ARE YOU FRUSTRATED WORKING WITH YOUR EMERGENCY DEPARTMENT?
Marc Stern, MD, MPH
I’ve lost count of the number of jail managers and health care staff who’ve expressed to me their frustration dealing with their local hospital’s emergency department (ED). Some complain about how difficult it is to get usable medical records without arguing with hospital staff or waiting days for records to arrive. Others hate the long waits at the ED and the expenses required for staff overtime. Yet another problem occurs when the ED staff insists a patient is ready to be released and has been “medically cleared” for admission to the jail, but it may not be safe for the person to be admitted.
Having served as a jail medical director, I can sympathize. However, also having served as an ED medical director, I understand the “other side.” Most EDs are excellent partners with jails. But, because this isn’t always the case, I thought I’d offer a few suggestions, drawing on my jail, ED, and other experiences working with jails and prisons. There are ways to reduce frustration and increase the value of sending patients for emergency evaluation or treatment.
To better understand and apply the suggestions I’ve listed below, it helps to realize what goes on behind the scenes. First of all, most medical professionals, including the doctors and nurses who work in EDs, receive little or no formal education regarding health care delivery in correctional settings. So we can’t simply expect them to grasp the needs, realities, and medical capabilities of a jail. Fortunately, that is slowly changing as those of us in academic settings are providing medical, nursing, and social work staff as well other trainees with some basic orientation regarding this unique environment. After all, almost 3% of the community will pass it over the course of a year. For now, though, we are still a “black box” to them.
In addition, many EDs are forced to use temporary doctors (locum tenens) and nurses (traveling nurses) to fill vacant positions. This is especially true in rural communities. The effect is that any familiarity the ED professionals attain with local jail operations may be short-lived. Hence, system changes may be more effective in some EDs than those that rely on educating front-line ED staff; the same staff may not be there next week.
I’ve listed eight suggestions below that can be helpful in various ways, depending on the setting and the circumstances:
1 Find alternatives to using the ED.
EDs are complex organisms. They’re busy places where dedicated professionals are doing the best they can to save limbs and lives, often under challenging conditions. It can be difficult for them to understand the nuances of our settings and needs. There can also be long waits if jail patients are less critically ill than the people who were triaged ahead of them. While moving less-ill jail patients further back in the queue is legitimate, it places an additional staffing and financial burden on the jail that has one, two, or even three jail deputies cooling their heels at the hospital.
There are three effective alternatives to using the hospital ED as your go-to for all emergency care. One alternative is to bring the needed health care to the patient. Some—though certainly not all—emergency health care services can be provided at the jail by engaging a contract or full-time practitioner (such as a physician, nurse practitioner, or physician assistant) to respond to certain jail emergencies. For example, an on-call practitioner could suture many wounds and even set simple fractures. Some communities have mobile x-ray services that can provide the practitioner with necessary imaging services. A second alternative is to use an emergency telemedicine service. Optimally, this arrangement would be with a local or regional ED. But it can also be with a distant provider (as long as their practitioners are licensed in your state). Finally, you can seek out a relationship with an urgent care center. These centers are typically unable to handle the full spectrum of medical emergencies, but they can still be useful (and quicker) for lesser emergencies.
You may find the per-visit cost higher for one or two of these options. However, you may also find that the additional medical costs are more than covered by the savings in staff time and the reduction in other frustrations, such as increased responsiveness to your needs and better communication. None of these alternatives replaces the ED for the most serious emergencies, but most of your trips to the ED probably aren’t in that category.
2. Help the ED understand your setting.
A common understanding between two parties is always a great path to better cooperation. Assume ED leaders and staff know very little about our world but would be interested in learning. Many correctional administrators have reported immense improvement in operations after visiting the hospital for a meet-and-greet with key hospital and ED leaders and front-line ED staff. Better yet, invite them to tour your jail. (Remember, doctors and nurses love free food, so invite them for lunch.) Help them understand the limitations of your health services. Perhaps you have no night nurses and officers are the ones determining if the patient is responding to the ED discharge treatment.
Maybe your practitioner is the only person able to determine if the antibiotics that the ED physician-prescribed are working, and she only comes to the jail once a week. Or, you might not be staffed to administer all the doses of the pain medications the ED physician prescribed to be given every three to four hours.
Understanding can go both ways. You may discover things you can do to improve the relationship. Getting your county, city, or tribal accounts payable department to expedite payment to EDs could heighten the desirability of dealing with jail patients the next time.
3 Have your medical staff call ahead.
As a physician in the ED, I know it’s immensely helpful to hear from my practitioner colleagues about the patients I’m about to care for. Although they do their best, it isn’t fair to rely upon officers to relay the complexity, detail, and nuance of a patient’s medical situation. Further, the transport officer is not always the staff member who is most informed about what happened to the patient. Even if you have a medical staff member who sends a written transfer form with the patient, that isn’t always enough. Nothing replaces a practitioner-to-practitioner phone call. Admittedly, the practitioner may not be in the jail when all of this is happening. He may not even know the patient. Still, the jail practitioner knows the jail, the staff, and the right questions to ask and of whom to ask them.
All of this—even sharing with the ED practitioner what he might not know—can translate into incredibly valuable information for the ED. If you don’t have an on-call practitioner (and even if you do), a parallel call from the jail nurse to the ED nurse can provide the whole ED team with valuable information.
This initial communication not only provides the ED with the information they can use at the front end to better care for your patient, but it also provides a mechanism at the back end for a smoother transfer back to the jail. When calling the ED as the sending physician, I always provide my phone number and ask the ED practitioner to call me when a diagnosis and plan have been determined. That way, if the plan includes sending the patient back to the jail, (a) I now know what’s going on, even if medical records lag behind, and (b) I can determine if the jail can handle the patient.
Lastly, if this suggestion fits well for your jail, and you have contract medical staff, consider including these activities as part of the performance requirements in the contract.
4 Make HIPAA work for you, not against you.
Have you vowed to throw the next person who says, “I’m sorry, I can’t give you those records. It’s a HIPAA violation.” in disciplinary segregation forever? If so, I have good news. They’re probably wrong. HIPAA has two provisions granting access to ED (or hospital) medical
records to jail staff who are responsible for providing health care to jail residents. One provision is not specific to corrections. With some rare exceptions, it applies generally to exchanges among providers taking care of the same patient; 45 CFR 164.506(c)(2) states, “A covered entity [in this case, the ED or hospital] may disclose protected health information for treatment activities of a health care provider [in this case, your jail’s medical provider].” No consent is needed. The second provision is specific to corrections; 45 CFR 164.512 Uses and Disclosures for which an authorization or opportunity to agree or object is not required, subsection (k)(5)(i) says: “A covered entity [again, the ED or hospital] may disclose to a correctional institution or a law enforcement official having lawful custody of an inmate or other individual protected health information about such inmate or individual, if the correctional institution or such law enforcement official represents that such protected health information is necessary for: (A) the provision of health care to such individuals;….”
In other words, jail staff responsible for providing health care to a jail resident is entitled to the resident’s ED medical records (and patient consent is not needed) under two different HIPAA provisions. (Note: Your state might have regulations that are stricter than HIPAA.) Unfortunately, knowing that you
have a right to the medical records and getting the records are two different things. You could, of course, have a legal argument with the graveyard hospital medical records technician. Better yet, arrange a meeting with the hospital’s administrator. Consider bringing your jail’s attorney. Share the above HIPAA provisions. Ask the administrator to generate a letter, on hospital letterhead, signed by the hospital administrator and ED administrator, addressed to the hospital’s own ED and medical records staff. Inform them that it’s okay to release any medical records of care provided by the hospital, at the jail’s request, at the time of service, or afterward—without patient consent—unless, in the opinion of the attending physician, a HIPAA exception applies. Then, place a copy of the letter as the coversheet for the medical transfer paperwork you send with the patient whenever you send them to the ED. (If the administrator agrees with the principle but is unwilling to provide a letter, ask to have the instructions incorporated in hospital policy and inform you of the policy number. Then, if you encounter resistance from ED staff, you can direct them to the policy.) Most EDs recognize the need for continuity of care and cooperate with jails to provide necessary medical records. But, for those few that don’t, you have other ways to handle the situation.
5 Tell the ED exactly what you need.
ED physicians and nurses are trained to recognize and treat emergencies. When you send them a patient, they assume you want them to do just that. When you send a patient with an obvious life-threatening problem, there is seldom any confusion. However, when the situation is less emergent or less clear, the ED may not be good at figuring out the exact reason you have sent the patient to the ER nor what your limitations are if the patient is released back to jail. The most common situation that creates confusion and frustration (and risk for poor patient outcomes) is when you send a patient to the ED for “clearance” to admit the patient to jail. Unfortunately, clearance means different things to different people. Further, a patient “cleared” for admission to one jail might not be safe for admission to a different jail.
So, instead of sending the patient to the ED with just a description of what happened to them and their medical information, or even instead of asking for clearance, send patients with a transfer form that includes a specific question or request. The form might have a place to check off the most common requests. For example, one request might be, “Please evaluate and treat the patient for _____. Also, please determine if the patient is safe to return to jail. Be aware that they will be without access to medical staff or medical monitoring until 8 a.m. on the next business day. If not safe, please call the jail before release.”
6 Know ahead of time how to contact the hospital Administrator on Duty.
Be sure to get this contact information as part of your meet-and-greet (see suggestion #2). If things don’t go smoothly, the Administrator on Duty is the person you want to reach out to in the middle of the night.
7 Train transport deputies regarding your expectations.
Along with your medical staff, the transport deputy is an invaluable agent for making sure you get what you need from an ED visit. The officer is in the prime position to observe how things are going and communicate jail needs to the ED staff. For example, when the deputy observes ED staff starting to wrap things up, the deputy can ask the ED physician, “Have you discussed your findings with our jail practitioner yet?” When receiving the sealed envelope with medical records, the deputy can ask for assurance that ED staff have provided the actual patient medical record, not just the take-home information and instruction sheets typically given directly to patients.
Try the “nuclear option.”
You are ultimately responsible for your residents’ safety, so when common sense tells you that placing a particular resident back in the
jail is simply dangerous, you don’t want to fall back on an excuse of, “The ED said it was okay.” There are two “sub-nuclear” options when you think admission is unsafe. If the patient has already returned to the jail and just doesn’t seem to be doing well, take them back to the ED, regardless of the ED’s diagnosis or treatment instructions. Or, if the patient was released but you’re still at the ED, consider taking them to a different hospital ED (if there is one nearby). For both of these options, it’s always best to check with your medical staff first, if you have medical staff.
In the “nuclear option,” your transport team stays put (in the ED, or even in the ED waiting room) with the patient, despite having been discharged. Say, for example, during the booking process you discovered, upon body scanning, that the individual appears to have swallowed drug-filled balloons. Although the individual appears to be doing well, you transport them immediately to the ED. After evaluation, the ED physician informs the transport deputy that the patient is released and can return to the jail, with instructions to wait for the balloons to pass through. As an experienced jailer, you know that is patently dangerous. A balloon could rupture at any time, and if it ruptures while the patient is in the jail, there is a high likelihood that the patient will suffer a massive overdose and die before you can get them back to the hospital. You are well aware that the patient cannot safely leave the hospital.
Despite your best efforts, including direct communication between your medical director and the ED physician, and despite contacting the hospital Administrator on Call, the ED might still insist on discharging the patient. If there is no other nearby hospital ED, your best option may be to have the transport team decline to depart. Then, even if they have to sit with the patient in the waiting room, if the patient takes a sudden turn for the worse, help is just a few feet away. It’s an important option to keep in your toolkit.
Reduce the frustration you might be having with your local ED by improving the lines of communication and incorporating some of these suggestions. You might be pleasantly surprised at how smoothly the process of working with ED staff can be.
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Dr. Marc F. Stern, MD, MPH: Teacher, researcher, and consultant in correctional health care and a former jail medical director and Health Services Director for the Washington State Department of Corrections. He teaches at the University of Washington School of Public Health in Seattle, and chairs the Education committees of the American College of Correctional Physicians and the Academic Consortium on Criminal Justice Health. Dr. Stern serves as a consultant to federal courts and agencies and as medical advisor to the National Sheriffs Association and the Washington State Association of Sheriffs and Police Chiefs.