Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital

Applying Ethical Principles-Overuse of the Emergency Room in a Not-for-Profit Hospital

Healthcare professionals must ensure that the health needs of the populations they serve are timely met. They must also manage the available resources and ensure equity in healthcare access. However, in delivering their duties due to the dynamic nature of the healthcare settings, they meet various challenges that create ethical dilemmas. Regardless of the situation, healthcare providers’ decisions must be underpinned by the four fundamental ethical principles of healthcare: autonomy, beneficence, non-maleficence, and justice. This paper summarizes and analyses a case study presented in incident 2, Emergency Department Repeat Admissions Question of Resource Use. It will identify the ethical issues in the presented problem, the effectiveness of the communication approaches used in the case study, and how ethical principles can be used to resolve ethical dilemmas presented in the case study. Hire our assignment writing services in case your assignment is devastating you.

Summary of Case Study

The case study focuses on the overuse of the emergency room in a not-for-profit hospital and the moral problem surrounding resource management in a medical environment (“Incident 2: Emergency Department Repeat Admissions — A Question of Resource Use”, n.d.). The County General Hospital (CGH), the CEO, Matt Losinki, the CFO, Mary Scott, administrative resident Aniysha Patel, and the hospital’s executive committee are all involved in the case of the 300-bed acute care facility located in a mixed urban and suburban service area in the south-central United States.

After finishing a study-related article about excessive usage of emergency services at hospitals in central Texas, Matt Losinski reasoned that his hospital would experience a similar issue. He consistently sees issues at other hospitals as possible issues for the CGH. Losinski always perceived issues at other hospitals as having the potential to arise at CGH. Originally a county-owned facility, CGH’s assets were donated to a network of not-for-profit hospitals. CGH has maintained its strong commitment to providing public services even if it is no longer eligible for a tax subsidy. According to the published study, nine people in central Texas visited the ED 2,678 times over six years. If each visit to the ED costs $1,000, the frequent usage of resources will cost $2.7 million. Additionally, there were differences in ED use, with the bulk of frequent users being middle-aged, English-speaking men and women.

Losinski shared the article with Mary Scott on a priority basis; however, she did not understand why it was important. To help her comprehend, Losinski stated that for qualified ED users, Medicaid reimbursed 75% of expenditures. Cross-subsidies from privately insured and self-pay ED admissions covered most additional unpaid costs. Losinski requested Aniysha Patel to collect data on CGH’s ED utilization rates in two weeks. The results showed that utilization rates were not as extreme, but there were a few instances of repeated admissions to the ED, accounting for hundreds of visits in the past year. A brief analysis of the admissions data noted that most admissions were persons with minor, nonspecific medical problems with reimbursements of $200,000 not paid annually. This meant losing money for CGH. After presenting the report to the executive committee, Losinski requested recommendations from the senior management team to resolve the ED’s overuse.

Analysis and Justification of Ethical Issues in the Case Study

The ethical issue and dilemma in the case study develop from the overuse of the CGH’s ED and Losinski’s concerns over ED usage and admissions for minor health conditions and lack of reimbursements. Mr. Losinki wants to control the usage of the hospital’s ED as he is concerned that the continued department overuse will further impact the facility’s already dwindling finances. Controlling the overuse will include limiting the accessibility of the ED’s services to certain populations based on the seriousness of their health issue. This means adopting an emergency department triage system. However, ED triage within healthcare facilities has been linked to ethical concerns such as lack of patient privacy and confidentiality, poor communication between patients and physicians, and failure to provide needed care services (Dong & Bullard, 2022).

Additionally, triage systems risk leading to adverse outcomes in patients, especially elderly patients, as healthcare needs and symptom inconsistencies exist between the age groups (Brouns et al., 2019). The hospital’s management cannot determine who to attend to and when to attend to the patients, considering that all persons who present themselves to an ED receiving federal reimbursement must be attended to. However, the misuse and overuse of the ED are a leading cause of overcrowding in the ED, with a risk to patient safety, delayed service delivery, and compromise to the quality of care delivered (Rasouli et al., 2019). Either way, every decision will create an ethical challenge to the role of the ED and the quality of the hospital’s emergency care.

Application of Ethical Decision-Making Model to Analyze the Case Study

The Ethical Decision-Making Model uses moral awareness, judgment, and ethical behavior to guide decision-making processes. Moral awareness and judgment involve identifying a moral dilemma and choosing between what is perceived as wrong and right. Ethical behavior combines moral awareness and moral judgment to take the right actions toward resolving an ethical problem. Losinski’s moral awareness enables him to presume the overuse of the hospital’s ED. It expresses his moral judgment when he requests Aniysha Patel to review hospital ED data to determine his presumptions. He expresses his ethical behavior by delegating roles to resolve the ethical problem to the senior management team rather than acting impulsively.

Effectiveness of Communication Approaches in the Case Study

The approaches to communication presented in the case study are effective in helping achieve the intent of the communication. Losinski uses electronic communication to forward the article to Mrs. Scott, allowing information sharing before discussing it. Besides this, Mr. Losinski uses evidence on Medicaid reimbursements to convince his CFO why ED overuse is an issue of concern. Additionally, Losinski uses open communication to present the report to the executive committee and air his concerns. He also takes time to observe their response and then explains why ED overuse is an issue that concerns the hospital’s financial well-being. Through this, he can convince them why a solution is needed.

Application of Ethical Principles to Solve Ethical Issues in the Case Study

The ethical issues and dilemmas presented in this case can be resolved if ethical principles of autonomy, beneficence, non-maleficence, and justice underpin the decisions. Autonomy requires patients to have control over their healthcare decisions; beneficence and non-maleficence principles ensure the delivery of beneficial care that causes no harm, while justice refers to fairness in care delivery regardless of the patient’s situation (Varkey, 2021). By adopting the four principles of healthcare ethics, Mr. Losinski and CGH’s senior management can resolve the current issue of ED overuse. For instance, ethical principles can guide the hospital in listening to the patient’s care needs, suggesting alternative care methods, or using other departments. Another way the principles of healthcare ethics can help resolve the issue is to guide the provision of truthful information on the state of the hospital’s ED and the status of their health to make an informed consent to seek alternative treatment methods and decongest the ED.

Conclusion

The right to emergency care and the concerns of overuse of the emergency department contribute to the various ethical issues and dilemmas common within the ED. Application of the Ethical Decision-Making Model can help identify such ethical issues and determine the right actions to take to resolve the ethical problems. Underpinning decisions on healthcare ethics ensures that healthcare providers have their moral obligation to deliver quality and safe care as needed when needed.

References

Brouns, S. H. A., Mignot-Evers, L., Derkx, F., Lambooij, S. L., Dieleman, J. P., & Haak, H. R. (2019). Performance of the Manchester triage system in older emergency department patients: a retrospective cohort study. BMC Emergency Medicine, 19(1). https://doi.org/10.1186/S12873-018-0217-Y

Dong, S. L., & Bullard, M. (2022). Emergency Department Triage. Evidence-Based Emergency Medicine, 58–65. https://doi.org/10.1002/9781444303674.ch7

Incident 2: Emergency Department Repeat Admissions — A Question of Resource Use. Ethical Case Studies. (n.d.). Retrieved November 9, 2022, from https://media.capella.edu/CourseMedia/nhs4000element18655/wrapper.asp#collapseOne.

Rasouli, H. R., Esfahani, A. A., Nobakht, M., Eskandari, M., Mahmoodi, S., Goodarzi, H., & Farajzadeh, M. A. (2019). Outcomes of Crowding in Emergency Departments; a Systematic Review. Archives of Academic Emergency Medicine, 7(1), e52. https://doi.org/10.22037/aaem.v7i1.332

Varkey, B. (2021). Principles of Clinical Ethics and Their Application to Practice. Medical Principles and Practice, 30(1), 17–28. https://doi.org/10.1159/000509119

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Introduction
Whether you are a nurse, a public health professional, a health care administrator, or in another role in the health care field, you must base your decisions on a set of ethical principles and values. Your decisions must be fair, equitable, and defensible. Each discipline has established a professional code of ethics to guide ethical behaviour. In this assessment, you will practice working through an ethical dilemma described in a case study. Your practice will help you develop a method for formulating ethical decisions.

Emergency Department Repeat Admissions — A Question of Resource Use

Matt Losinski finished reading an article that provided grim details of a study of the overuse of emergency services in hospitals in central Texas. He smiled that sardonic half-smile that meant there was a strong possibility that County General Hospital (CGH) might have the same problem. As chief executive officer (CEO), Losinski always saw the problems of other hospitals as potential problems at CGH, a 300–bed acute care hospital in a mixed urban and suburban service area in the south-central United States. CGH was established as a county–owned hospital; however, ten years ago, the county wanted to get out of the hospital business, and the assets were donated to a not–for–profit hospital system. The new owner has continued a strong public service orientation, even though CGH no longer receives the tax subsidy it did when it was county-owned; it must look to itself for fiscal health.

The study data showed that nine residents of a central Texas community had been seen in emergency departments (EDs) a total of 2,678 times over six years. One resident had been seen in an ED 100 times yearly for the past four years. Given that an ED visit can cost $1,000 or more, the nine residents had consumed $2.7 million in resources. These high users of ED services were middle-aged, spoke English, and were split between male and female. The problem seemed like a manifestation of Wilfredo Pareto’s classic 80/20 rule to Losinski.

Losinski forwarded the article on a priority basis to Mary Scott, his chief financial officer (CFO), and asked her to see him after she read it. Scott stopped by Losinski’s office late the next day and began the conversation by asking him why he thought the article was a priority. Scott reminded Losinski that Medicaid paid 75% of costs for eligible ED users and that the cross-subsidy from privately insured and self–pay ED admissions covered most of the unpaid additional costs. Losinski had a good working relationship with Scott, but he was annoyed by her rather indifferent response.

Losinksi wanted details on the use of the ED at CGH. He asked the administrative resident, Aniysha Patel, to gather data to identify use rates for persons repeatedly admitted to the ED. The findings that Patel gave to Losinski two weeks later were not as extreme as those reported from central Texas; however, they did show that a few persons were repeatedly admitted to the ED and accounted for hundreds of visits in the past year. The clinical details were not immediately available. However, a superficial review of the admitting diagnoses suggested that most admissions involved persons with minor, nonspecific medical problems, commonly known as the “worried well.” Although Scott was correct that Medicaid covered the majority of costs, the fact remained that over $200,000 each year was not reimbursed to CGH. Were that money available, it could go directly to the bottom line and enhance health initiatives for the community. In addition, repeated admissions to the ED contributed to crowding, treatment delays, and general dissatisfaction for other patients.

Losinski presented the data to his executive committee, which includes all vice presidents, the director of development, and the elected president of the medical staff. The responses ran the gamut from “So what?” to “Wow, this is worse than I imagined.” Losinski was bemused by the disparity of views. He had thought there would have been an almost immediate consensus that this problem needed a solution. The financial margins for CGH were already very thin, and the future for higher reimbursement was not bright. A concern echoed by several at the meeting was the requirement of the federal Emergency Medical Treatment and Active Labor Act (EMTALA) that all persons who present at an ED that receives federal reimbursement for services must be treated and stabilized.

Losinski asked his senior management team for recommendations to address the problem of ED overuse.