June 26, 2008

Child’s Plight, Hospital Fines Expose Holes in ER Care

By Phil Galewitz, The Palm Beach Post, Fla.

Jun. 24--Palms West Hospital and St. Mary's Medical Center agreed to pay a combined $17,500 to the state following a 2006 incident in which the hospitals failed to appropriately treat a child bleeding into the brain after being hit by a softball.

Both have since changed how their ERs handle emergencies.

Although the settlement is a minor expense to HCA Inc. and Tenet Healthcare Corp., the billion-dollar parent companies of Palms West and St. Mary's, respectively, it carries the biggest state penalties levied against any hospital in this region in the past two years.

The penalties underline a continuing problem: the lack of specialists available to local emergency rooms.

"It is a disgrace for every citizen of Palm Beach County, and as a community we should be able to get together to solve this problem," said Dr. Jose Arrascue, an Atlantis kidney specialist who has served for four years on a community task force trying to address the issue. "It may be my kid or your kid that's affected next time." State regulators fined Palms West Hospital in Loxahatchee $10,000 and West Palm Beach-based St. Mary's Medical Center $7,500 after the Sept. 30, 2006, incident.

One day after being hit in the head by a softball, a child arrived at the Palms West ER, complaining of head and jaw pain and nausea.

A CT scan revealed a skull fracture. Doctors concluded there was bleeding in the brain. Palms West did not have a pediatric neurologist on call to treat the child.

The ER physician tried to transfer the patient to St. Mary's, which has a trauma center, but a doctor there refused to take the patient "due to the fact that the trauma to the patient was a day old," according to state inspection records.

The St. Mary's trauma surgeon also failed to refer the patient to the hospital's on-call neurologist.

At 11 p.m., the child was transferred to a Broward County hospital. Despite the eight-hour delay, a source close to the case says the youngster recovered.

After investigating the incident, state inspectors fined St. Mary's for failing to adequately document how it handles emergency transfers from other hospitals. The hospital also was fined for not having emergency neurology services available.

Under state and federal "patient dumping" laws, hospitals that offer a specific service to elective cases, such as neurosurgery, also must offer the service for emergency patients.

The reasoning is that hospitals that benefit financially from offering such services in-house cannot refuse to provide them to ER patients, some of whom may lack insurance coverage. The law is intended to prevent patients from being "dumped" onto other hospitals.

Since 2006, St. Mary's has hired two neurologists. The hospital also has started a telemedicine radiology service, ensuring its specialists will be available for a consultation around the clock.

Bland Eng, who took over as CEO at Palms West last year, said the Loxahatchee hospital was fined because it did not adequately document why the benefit of transferring the patient outweighed the risk of keeping the patient. Eng said the hospital also failed to get approval from a doctor at the receiving facility before the transfer was made.

"We didn't follow all the rules and failed to document," Eng said.

Both hospitals told the state that they retrained their physicians and administrators regarding patient dumping laws.

Several local hospitals have been cited over the past five years for similar problems.

In 2004, for instance, St. Mary's paid a $40,000 fine to the federal government for a patient-dumping violation. In 2006, three Palm Beach County hospitals refused to treat an uninsured man bleeding internally in what the state ruled was a violation of its patient-dumping law.

Key to the problem is a shortage of ER specialists that dates to at least 2004.

In addition to neurologists, local hospitals have struggled to provide emergency care by hand surgeons, gastroenterologists and neurosurgeons.

The specialists, many of whom have dropped their medical malpractice insurance coverage due to escalating premiums, are reluctant to provide ER services because of the risk of being sued.

That has led to local ERs' transferring patients to hospitals in such far-flung locations as Tampa and Gainesville.

Local health leaders have spent years trying to solve the problem. Area hospitals have been unable to agree on a solution, and it remains unclear who would pay for a revised emergency system.

Another issue is the overall lack of specialists.

According to data released last year by the Palm Beach County Medical Society, the county should have 18 neurosurgeons but has only 13 today.

Arrascue, the Atlantis physician, said his time on the community task force addressing the issue has convinced him that "the problem cannot be solved alone by doctors and hospitals. This is a community problem that every citizen should be upset over."


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