13 February 2009

That didn't take long

I wrote the other day about an interesting, innovative, and risky plan the University of Chicago is undertaking to decompress their overwhelmed ER. They are screening patients at triage and refusing some; sending patients to local community health centers or other local ERs.

As I wrote, three days ago, "it's a big gamble -- the first time a patient is inappropriately redirected away, or has a bad outcome, the media, the regulators, the lawyers, and Chuck Grassley will be all over them like flies on stink. So they had better be very careful in developing and adhering to their triage protocols, I think, to survive the extra scrutiny that this move will engender."


Via Symtym, the first bad case has already happened, and it simply couldn't be worse from a PR point of view:

University of Chicago ER sends kid mauled by pit bull home

Oh. My. God.

I mean, really? A child? Mauled by a dog? What karmic crime has U of C committed that the first bad case was this one? (Oh, yeah, they're sending patients away from the ER.) I suppose the article could have been worse if it had featured a photo of the child's mangled face, but that would just have been icing on the cake.

But it gets worse. (yes, worse!)

The child's mother alleges that she was pressured for insurance information, and the implication is that her medicaid status contributed to their decision not to perform surgery.

And when she was discharged, she was told to follow up "at Cook County."

I obviously cannot comment on whether it was a justifiable decision not to undertake a primary repair of this injury, having not seen it. But it sounds like bullshit to me, and the hospital's defense is unbelievably lame, "that sending Dontae into surgery too quickly would have created a risk for infection." WTF? A dog bite on the face? Folks, you just don't leave those open. On the arm, maybe, because scarring doesn't matter so much there, and infections are more common on the extremities. But facial wounds are less likely to get infected, due to the excellent blood supply, and due to their cosmetic importance, wounds there are generally better treated with a washout, primary closure, and antibiotics.

When she did (promptly) present at County, the child was operated on. This implies to me (though not conclusively) that this truly was a patient dump, that the University chose not to or did not have the resources to care for the child and just sent them away, hoping that they would become somebody else's problem.

It's arguable (and will be argued) whether this was a true EMTALA violation. The kid was screened, and there is an argument, albeit weak, that it is acceptable to pursue secondary closure in dog wounds. So the University may not be on the hook for a statutory violation. My experience with the CMS Quality Improvement Organizations, however, is that they will use this as an opening to delve into the records of U of C and find every single transfer and redirect and crucify the organization for this and possibly other transgressions. (I've been through the same experience for far far less, and no, the incident patient does not need to be a Medicare beneficiary to precipitate such an investigation.)

One other point, more relating to the Chicago Tribune than to U of C. I notice that the date of the injury was cited as "august." I wonder how long the Trib has known about this case, and whether they were sitting on it to maximize the political impact. Just sayin'.


  1. To be sure the Trib may have held onto the story; but they've published recently re: the policy, and it's also possible that the family contacted them after one of their recent stories. In any case, what a mess, that one shouldn't have happened.

  2. wait... that case is from last august though. was the diversion plan already in effect then?

  3. While I agree that this appears to be a clear case of a patient dump, I do not agree with you saying that U of C did not have the resources available to treat this child. It is U of C! They have more resources than King Richard.

    Unless of course you were being sarcastic, and in that case, I completely agree with your sarcasm.

    I just shake my head at U of C diverting people to County or other hospitals... as if the ERs are full enough there...

  4. If this is a new policy, but the injury happened in August, is there any connection?

    Did the injury happen in August, but they just came to the ED this week?

    It does appear to have been a poor decision in this case, regardless of what the hospital policy was at the time.

  5. Geez where is the humanity here? I would have thought that a child with dog bites to his face would be considered a honest to goodness emergency and be taken in for treatment. I'd love to follow thought processes that led to the conclusion 'refuse kid with dog bite to face'.

  6. It sounds like this kid would have been eligible for Medicaid, so reimbursement should have been available whether or not mom had insurance.

    Anyone know if U of C has a Plastic Surgery service?

  7. This case was probably totally unrelated to the policy to refer nonurgent cases.

    It was probably a matter of a lazy or stupid ER doctor perhaps combined with a lazy plastic surgeon on call or something. You know the scenario. ER doc calls plastics and plastics doesn't want to come in so he convinces ER doc that it should wait a week since its a dog bite.

    The fact that they told the mother to follow up in one week would lead one to believe that whomever saw this kid wasn't so much concerned with their ability to pay, but had no frigging idea how to treat a facial wound. If they were just trying to clear out the ER they'd have him f/u in the am.

    Idiot in the PR dept at the hospital should have said "we can't comment on a case due to pt confidentiality" instead of trying to defend this decision.

  8. wasn't it stuff like this (and worse) that led to EMTALA? Go ahead and dump....

  9. They did not have a dogbite service, so the patient had to be transferred, it was in the best interest of medical care


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