23 February 2009

Univ of Chicago vs ACEP

This one just won't go away.

So, to summarize for those keeping score at home:
  • U of C starts a program to redirect non-emergent patients away from the ER to community health centers and other hospitals.
  • The Chicago Tribune and community activists suggest that U of C is engaging in patient dumping.
  • A case is published by the Trib in which a child with a dog bite to the face is discharged from the UCMC ER with instructions to "follow up at Cook County."
  • ACEP releases a press release strongly condemning the UCMC program.
New development: University of Chicago fires back.

I have received (from multiple sources) documents in which UCMC strongly defends itself, the care provided to the child with the dog bite, and criticizes ACEP president Nick Jouriles for the "reckless and uninformed" press release sent out by ACEP. Their key points include a complaint that ACEP did not contact UCMC prior to releasing its statement, which essentially accuses UCMC of patient dumping, and a contention that delayed primary closure is within the standard of care for this sort of injury.

As far as the ACEP release, I admit to ambivalence. Standard journalistic practice is to contact the subject of an article for comment prior to press, but ACEP is an advocacy organization, and not subject to the same constraints that bind media organizations. I suppose it would have been polite to call the UCMC ED chair for insight prior to jumping on the bandwagon. On the other hand, I note that the ACEP release called for congressional hearings, which without doubt would have been used not to condemn UCMC but as a platform to advocate for strengthening the safety net that is the nation's emergency departments. So I would say that the ACEP release, while perhaps rude, fits neatly within the general mission of the college, of improving access to emergency care.

The contention that the care provided to the child, Dontae Adams, was "appropriate" is in my mind highly suspect, despite the joint statement (PDF) from the Chairs of Plastic Surgery at both UCMC and County, and the citation of the ACEP "policy" on wound management. Again, I qualify this in that I did not see the child or review the record. But the statement from the plastic surgeons "we believe Dontae would have been well served either with delayed surgery, as the University of
Chicago team recommended, or with the immediate surgery performed by the physicians at Stroger Hospital. Both options are acceptable..." is weak tea, my friends. Similarly, a commenter cites an "ACEP recommendation" that "Delayed primary closure is ... best used for wounds at high risk of infection, such as heavily contaminated wounds, wounds from animal or human bites."

First of all, note that a seven year old opinion in a non-peer-reviewed publication (PDF) is not a clinical policy. ACEP has plenty of clinical policies which reflect consensus opinion on important topics as informed by the current evidence. None address this injury. Secondly, note that the cited opinion is actually contradictory to the incident case. I and the evidence agree that infected wounds and wounds at risk for suppuration should not be closed at the initial presentation. However, dog bites to the face, presenting promptly, are not at particularly high risk for infection when washed out and debrided appropriately. The excellent blood flow to the facial structures make it a very low risk area for infections, even for dog bites. Given the importance of cosmesis in this area of the body, unless there is a high degree of devitalized tissue present, there is no good reason to delay closure of the wound.

The real test here is "what would you want for your child?" Or, since parental preference clearly did not drive care at UCMC, what would be the common practice for an insured patient in a "normal" hospital for a disfiguring facial dog bite? Primary closure, that's what. This is what makes University of Chicago look so bad -- the deviation from the common practice, and the diversion of an indigent patient elsewhere.

The University of Chicago team could make a good case to a jury in a malpractice trial that their care was within the standards of care. I'll buy that. Delayed primary closure is, technically, a persmissible option. I'd vote to acquit. But the real-world question here in the court of public opinion is not malpractice, but patient dumping. And on that front, UCMC is guilty, guilty, guilty! Had they referred Dontae to their own plastic surgery clinic, I would be much more charitable in my conclusions here. You take care of your own, right? But that is not what happened. They turned the child away with the instruction to "go somewhere else," on the thin pretext that it's (barely) within the standard of care.

And make no mistake, the Cook County plastics guys signed on to the extremely tepid defense of Dontae's care out of courtesy alone. You may note that they did the right thing: they repaired the child's injuries on initial presentation. Because it's the right thing to do medically, and it's the right thing to do as a humanitarian. They were not about to throw University of Chicago under the bus, but in this case their actions speak much louder than their words. They knew bad care and an unavoidable patient dump when they saw it, and the County guys stepped up and took care of the patient.

Ultimately, I have sympathy for UCMC: they are overwhelmed, and they are looking for creative solutions to decompress their ER. They took a risk with this program, and I respect creative thinking in trying to make scarce resources stretch farther than they are capable of. My advice (had they asked me which of course nobody ever does) would have been to admit that in this case an error was made and that policies would be improved and it would not happen again. By persisting in a futile defense of bad care, they just wind up making themselves look worse and inviting tighter scrutiny of a policy which is controversial even in the best of circumstances.


  1. I must have missed the "what would you want for your own child" provision of EMTALA.

    Technically, the cosmetic outcome of delayed primary closure is comparable to that of immediate closure, btw. The key point is that any outpatient clinic other than one associated with a county facility is unlikely to (and certainly not obligated to) provide free or reduced rate indigent treatment. The kid might well have been turned away at the front desk of the private clinic without even seeing a physician, then be forced to go back to the ER again. The referral to the county facility was therefore not necessarily inappropriate.

    Most of our local Ortho groups don't take Medicaid, so any closed fracture other than a hip gets splinted and referred to County, even if the patients would rather get admitted and operated on right away.

  2. Is it true that Michelle Obama was responsible for designing and implementing the policy for University of Chicago?

  3. I'm still unsure why this Dontae Dog Bite Case keeps getting lumped in with the 'triage out' stuff.

    'Triage out' is not new, people. Here's a little article (abstract only--boo) that might be interesting.

  4. This may not be an EMTALA violation but I think it is unethical--EP scope of practice includes acute injury and we consider cosmesis in our patients and attempt good outcomes. This isn't someone who brings in a well-appearing 4 year old with a runny nose and no fever for four hours, who could be triaged away IMHO. The program is brave but it was inelegantly applied to a kid that could've used some care. I'm sure there were people in the same waiting room with BS complaints they could've turfed to make room for the dog bite to the face.

  5. Scalpel,

    I did not say it was an EMTALA violation; I said it was a dump.

    The interesting/galling thing is that this is an inner-city university hospital doing the dumping. More typically, these facilities are the receiving hospitals, not the dumpers.

  6. Indigent patients should be treated at County facilities whenever possible. Michelle even says so!

    I had a long reply that I decided to post at my place instead.

  7. I agree with those who said that while not an EMTALA violation, this was probably a "dump" in the spirit of things.

    What slays me is this piece of ACEP's statement, where the president argues that the ED has an obligation to take care of the indigent because "[m]any primary care providers are simply not taking Medicare patients, let alone the uninsured or the underinsured. Most clinics don’t have same-day laboratory or X-ray resources needed to determine whether patients have emergency medical conditions." Isn't that an arguement for increasing Medicare/Medicaid payouts and resources toward primary care physicians so they can provide the kind of care necessary to those who are ill or injured, but not emergently so?

  8. Right. Probably a dump but not an EMTALA violation. I bet I could have convinced a plastics guy to come in for the kid. One has to just phrase it right and I am sure if the wound was bad, he would realise once he saw it that it was best that he close it.


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