EMTALA: the basics

The Emergency Medical Treatment and Active Labor Act (EMTALA) is the federal legislation governing the transfer of patients. This law is often confusing for healthcare providers. For this reason, it is often difficult for providers to understand what elements of this law apply to their practice. This article outlines the EMTALA requirements to clearly relay the critical elements of this important piece of legislation and to illustrate how EMTALA applies to hospital nursing practice. All nurses in administrative and management roles need to be aware of the requirements of this law in order to educate and guide their nursing staff so that the facility remains in compliance.

La sécurité transfusionnelle à l'échelle internationale : le rôle de l'OMS

Blood safety is an international public health challenge, particularly since the emergence of HIV AIDS. Recognizing the gross disparities between countries in the adequacy of national blood supplies and the risks arising from poorly organized services, particularly in developing countries, the World Health Organization has developed a global strategy for blood safety and availability. Dr N. Dhingra, coordinator, blood transfusion safety, WHO Headquarters, and Dr V. Hafner, focal point for blood safety in the WHO regional office for Europe, present the main features of this strategy: well-organized, nationally coordinated blood transfusion services with quality systems in all areas; the collection of blood only from voluntary non-remunerated blood donors from low-risk populations; the quality-assured testing of all donated blood; the safe and appropriate use of blood and blood products; and global collaboration for blood safety. WHO's programs, some difficulties encountered and outcomes are also described in this article.

Expert Consensus Conference. The screening for hepatitis C virus infection in adults in Italy, May 5-6, 2005

A Consensus Conference was convened by the Italian National Institute of Health on May 5-6, 2005, to address the issue of the screening for hepatitis C virus infection in adults in Italy. It was concluded that a mass screening for hepatitis C virus infection is inappropriate. It was recommended that the following high-risk groups be tested for hepatitis C virus infection, particularly if they are potentially eligible for antiviral treatment: subjects with history of intravenous drug use; haemodialysis patients; subjects who received blood coagulation factors before 1987; subjects who received blood transfusions or organ transplantation before 1992; households of hepatitis C virus-infected individuals; subjects with multiple sexual partners which have or have had a sexually transmitted disease. A screening for hepatitis C virus infection was considered unjustified for persons who are scheduled for an invasive procedure (e.g. surgery, endoscopy) and during pregnancy.

Screening mammography, public perceptions, and medical liability

PURPOSE

To outline the most common sources of raising malpractice claims in screening mammography and to discuss the related medical litigation issues in the light of the evidence-based medicine.

METHODS AND MATERIAL

Electronic and manual search of the relevant literature.

RESULTS

The most common cause of malpractice is the delayed diagnosis of breast cancer. The plaintiff must establish that the radiologist was negligent and the delay in diagnosis caused injury to the patient. Literature shows that mammography does not always detect breast cancer, and even skilled radiologists may periodically miss malignant lesions. Also, delay in diagnosis does not always affect treatment and prognosis. Over-promotion of screening mammography has made disproportionately difficult for a defendant radiologist to prevail in a malpractice lawsuit. Thus, screening mammography is at stake, although it saves lives. The public and legal system should be educated about biological processes, medical practice, and the limitations of screening mammography.

CONCLUSION

If mammography is to survive medical litigation and continue to save lives a major reform in public perception, in the stance of the mass media, and in the ability of legal system to understand medicine is required. Physicians and medical associations have an important role to play.

Using Cost and Health Impacts to Prioritize the Targeted Testing of Tuberculosis in the United States

PURPOSE

Evaluation improves efficiency and effectiveness. Current U.S. tuberculosis (TB) control policies emphasize the treatment of latent TB infection (LTBI). However, this policy, if not targeted, may be inefficient. We determined the efficiency of a state-law mandated TB screening program and a non state-law mandated one in terms of cost, morbidity, treatment, and disease averted.

METHODS

We evaluated two publicly funded metropolitan TB prevention and control programs through retrospective analyses and modeling. Main outcomes measured were TB incidence and prevalence, TB cases averted, and cost.

RESULTS

A non state-law mandated TB program for homeless persons in Tarrant County screened 4.5 persons to identify one with LTBI and 82 persons to identify one with TB. A state-law mandated TB program for jail inmates screened 109 persons to identify one with LTBI and 3274 persons to identify one with TB. The number of patients with LTBI treated to prevent one TB case was 12.1 and 15.3 for the homeless and jail inmate TB programs, respectively. Treatment of LTBI by the homeless and jail inmate TB screening programs will avert 11.9 and 7.9 TB cases at a cost of 14,350 US dollars and 34,761 US dollars per TB case, respectively.

CONCLUSIONS

Mandated TB screening programs should be risk-based, not population-based. Non mandated targeted testing for TB in congregate settings for the homeless was more efficient than state-law mandated targeted testing for TB among jailed inmates.

[Assessment of mammographic units in Poland in the view of current requirements of radiation protection regulations]

The aim of mammography examination is to discover as soon as possible any structural changes in a breast tissue. Every X-ray examination exposure the patient to the radiation as it takes place in mamnography images might be a cause of cancer. In this publication the dynamics growth of mammnography units number in Poland in years 1995,1997 and 2002 has been analyzed. The distribution of mammography units in Poland has been examined. The places of mammography units exploitation in regard to the type of health service institution has been determined. In this publication the manufacturers and the age of mammography units as a prerequisite to determine whether the specified mammography unit complies with the actual requirements in radiation protection regulations have been taken into consideration. The mammography laboratory equipment for providing quality control and the method of developing X-ray films has been also analyzed. It has been ascertained that about 25 % of mammography units do not comply with current technical requirements and they should be withdrawn from exploitation. However, it should be pointed out that there were only 554 mammography units in Poland at the end of year 2002. Their unequal distribution do not provide satisfactory availability to examinations for patients. As a result of this, the principal method of withdrawing them from exploitation should be replacing the time-worn the X-ray apparatuses with the new ones.

Medical and legal issues in the cardiovascular evaluation of competitive athletes

Healthy-appearing competitive athletes may harbor unsuspected cardiovascular disease with the potential to cause sudden death. This fact raises issues of physician responsibility in preparticipation screening and eligibility/disqualification decisions. A number of medical-legal cases now represent a framework for screening and eligibility decision making in high school and college athletes. Physicians screening competitive athletes should strictly adhere to recommendations from the American Heart Association. Precedent exists for disqualifying athletes with heart disease from competition to prevent unnecessary exposure to risk of injury or death. By virtue of the court decision in Larkin v Archdiocese of Cincinnati, high school students with heart disease have no compelling right to participate in interscholastic sports without medical clearance. In Knapp v Northwestern University, an appellate court ruled that college athletes can be medically disqualified from sports and supported the use of national association medical guidelines by team physicians in formulating eligibility/disqualification decisions. This medical-legal analysis provides guidelines for physicians participating in medical evaluations of competitive athletes by clarifying the standard of care, potential pitfalls, and the evolving liability associated with this clinical practice.

Residual risk of transfusion-transmitted human immunodeficiency virus, hepatitis C virus, and hepatitis B virus infections in Italy

BACKGROUND

Estimating the risk of transfusion-transmitted infections (TTIs) is essential for monitoring blood safety. The residual risk of TTI was estimated for nearly 90 percent of the blood supply in Italy.

STUDY DESIGN AND METHODS

Data were analyzed from 1,079,281 repeat donors, corresponding to 5,361,000 donations made in blood transfusion centers throughout Italy in the period 1999 through 2001. The residual risk of transfusion-transmitted human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV) infections was estimated with the incidence rate-window period model. The denominator for the incidence rate (i.e., the number of person-years at risk) was estimated on a sample of 5850 donors.

RESULTS

The risk of an infectious donation entering the blood supply, per 1 million donations, was 1.91 (probable range, 0.52-3.32) for HIV, 16.74 (9.57-24.01) for HCV, and 69.16 (43.12-102.70) for total HBV (adjusted for vaccination and hepatitis B surface antigen transience).

CONCLUSION

In Italy, the estimated residual risk of TTI is apparently low, particularly for HIV infection. Although the estimated risks are higher for HCV and HBV, the introduction of mandatory viral detection tests for HCV in 2002 should account for an 80 percent reduction in the HCV risk. Moreover, the ongoing HBV vaccination program will contribute to reducing the risk of transfusion-transmitted HBV.

Findings from mental health screening of newly arrived refugees in Colorado

States are required to provide a public health screening for all newly arrived refugees in the United States. In 1997, a comprehensive program was created to include both a physical examination and a mental health screening. This article provides a complete description of the mental health screening process, including two illustrative cases, and reports information about the refugees who participated in the program. Ten percent of screened refugees were offered mental health referrals; of those, 37% followed up. Refugees who presented for treatment reported a higher number of symptoms upon screening compared with those who were offered referrals but did not follow up. Psychiatric evaluation confirmed that those who screened positive and presented for treatment were experiencing a high level of suffering and qualified for mental health diagnoses. The findings support inclusion of a mental health screening as part of the public health screening.

[Evaluation of the organization of pre and post transfusion screening of viral infection markers in blood recipients in France in 2001]

In France, data collection related to blood recipient's viral infectious disease markers pre and post-transfusion is a legal requirement for hospitals. Our study aimed to evaluate the actual modalities of this extensive screening in 2001, six years after the Ministry of health issued recommendations. A questionnaire was sent to the haemovigilance correspondents in hospitals having transfused labile blood products (LBP) in 2001. A total of 1463 hospitals having transfused 85% of LBP in France responded. 82.4% of hospitals have written guidelines for pre-transfusion screening of viral markers, mainly for HIV and hepatitis C. A frozen repository storage is held by 23.9% of hospitals with storage durations between 1 to 40 years. 84% of hospitals have written guidelines for post-transfusion screening. The test prescriptions are mostly done by physicians from clinical services and they include in more than 80% of cases, HIV and HCV markers. Only 12% of hospitals recontact the patient in case of a no show. Even though 77.5% of responding hospitals have labile blood products recipients follow up processes, their effectiveness remains quite low, only 16% of recipients having test results available at the hospital.

[Influences of the adoption of new tuberculosis mass-examination system for school children on tuberculosis in school age]

TB mass screening for elementary and junior-high school pupils was revised in 2003 in Japan. Interview sheet with questionaires about past history of TB and BCG has been applied for all pupils to choose high risk groups for TB infection or TB diseases since 2003 April replacing previous mass-screening method with tuberculin test for first-grade pupils. We compare results of case-finding of school-children in 2001, 2002 and 2003 by the data of national TB surveillance system. Total number of latent TB infection (LTBI) subjected to preventive treatment decreased from 2920 (2001), 2173 (2002) to 1087 (2003). Number of LTBI detected by school mass-examination decreased markedly from 1310, 933 to 99. In addition, two peaks of LTBI in 6-7 years old and 12-13 years old children disappeared. Number of LTBI by contact examination gradually decreased from 881, 742 to 687. Number of LTBI detected by medical facilities also decreased from 199, 121 to 76. Total number of TB patients among school-children also decreased from 122, 72 to 46. TB patients found by school mass-examination showed a marked decrease from 23, 21, to 6. TB patients detected by medical facilities decreased from 68, 29 to 19. Number of TB cases detected by the contact examinations did not change. The reduction in the number of LTBI and disappearance of two peaks in 6-7 years old and 12-13 years old children are assumed to be mainly due to the revision of TB mass screening method in elementary and junior-high schools.

[Training, practice and the increasing dominance of legal aspects in ultrasound in obstetrics and gynecology in Austria]

During the past few years, the Austrian Supreme Court has hanged down two landmark rulings concerning the use of ultrasound in obstetrics and gynecology. After a woman had died of ovarian carcinoma, her family sued the doctor for not having diagnosed the carcinoma by transvaginal ultrasound she had performed 8 months before the tumor was diagnosed. The plaintiffs won the case at the supreme court level, this making Austria the first country with implicit court-ordered ovarian cancer screening. A wrongful life case concerning a baby that had been born with bone deformities was also decided in favor of the plaintiffs, declaring ultrasound in pregnancy to be an instrument intended to help women decide whether or not to have an abortion. The impact of these two cases on the teaching and clinical application of ultrasound in obstetrics and gynecology in Austria is discussed.

[Sudden cardiac death in athletes is usually caused by undiagnosed heart disease. Cardiac screening of young athletes under discussion]

Sudden death during exercise in young athletes is usually caused by previously undiagnosed heart disease. The most frequent underlying diseases are hypertrophic cardiomyopathy, coronary artery anomalies and arrhythmogenic right ventricular cardiomyopathy. The possibility of carrying out screening to prevent these tragic cardiac deaths in young athletes has been discussed. A history of sudden cardiac death at a young age among relatives and/or the occurrence of exercise related symptoms in the active sportsperson may identify some of the individuals at risk. A pathological ECG is also a risk factor, especially in combination with a history of abnormal findings upon physical examination. For a correct evaluation of the young athlete, it is important to be aware of the normal variation of cardiac findings in athletes ("athlete's heart").

Screening for mental illness: the merger of eugenics and the drug industry

The implementation of a recommendation by the President's New Freedom Commission (NFC) to screen the entire United States population--children first--for presumed, undetected, mental illness is an ill-conceived policy destined for disastrous consequences. The "pseudoscientific" methods used to screen for mental and behavioral abnormalities are a legacy from the discredited ideology of eugenics. Both eugenics and psychiatry suffer from a common philosophical fallacy that undermines the validity of their theories and prescriptions. Both are wed to a faith-based ideological assumption that mental and behavioral manifestations are biologically determined, and are, therefore, ameliorated by biological interventions. NFC promoted the Texas Medication Algorithm Project (TMAP) as a "model" medication treatment plan. The impact of TMAP is evident in the skyrocketing increase in psychotropic drug prescriptions for children and adults, and in the disproportionate expenditure for psychotropic drugs. The New Freedom Commission's screening for mental illness initiative is, therefore, but the first step toward prescribing drugs. The escalating expenditure for psychotropic drugs since TMAP leaves little doubt about who the beneficiaries of TMAP are. Screening for mental illness will increase their use.

Accuracy of alcohol diagnosis among DWI offenders referred for screening

BACKGROUND

Most US courts use screening programs to evaluate substance-abuse problems of convicted driving while impaired (DWI) offenders. Typically self-report information determines need for treatment. However, little is known about the accuracy of self-reports of alcohol-use problems in this population.

METHODS

DSM-III-R alcohol abuse and dependence diagnoses from an initial, court-ordered screening evaluation of 583 female and 495 male convicted DWI offenders were compared with diagnoses and other self-reported information from a voluntary, noncoerced interview 5 years after the screening referral.

RESULTS

At initial screening, 16.8% of offenders were diagnosed with alcohol abuse and 20.1% with alcohol dependence. At the 5-year interview, 19.9 and 60.1% received a retrospective diagnosis of alcohol abuse or dependence at the age at which they were screened. Significantly fewer of those with a retrospective alcohol diagnosis reported that their alcohol use self-reports at screening were "very accurate" compared to those with no retrospective diagnosis.

CONCLUSIONS

Although many DWI offenders undergoing screening have diagnosable alcohol-related problems, underreporting is common, leading to inaccurate diagnosis and, therefore, a missed treatment opportunity. The research community and policymakers should review and reform the current screening system for alcohol-impaired drivers to better address this serious public health problem.

[Public health, prevention and federalism: insights from the implementation of the federal law on health insurance]

OBJECTIVES

In 1996, the new Swiss law on health care insurance (KVG) introduced the coverage of certain preventive measures. This provided an opportunity to include research-based public health issues in federal health policy. The present article examines the problems with which the realization of those goals in a Federalist health care system with strong cantonal autonomy as it is found in Switzerland was confronted.

METHOD

Comparative qualitative case studies design (vaccination of school age children and screening-mammography).

RESULTS

Switzerland's federalist health care system strongly hinders the realisation of the Confederation's public health goals. Prevention falls into the cantons' autonomy and the federal KVG (Krankenversicherungsgesetz; Health insurance law) only regulates the coverage of the services provided, but does not contain any instruments to assure implementation in consistency with the policy goals. Under those circumstances, conflicts of interest between the implementing actors, varying cantonal preferences, and scarce resources block the implementation of public health goals.

CONCLUSIONS

The results imply stronger leadership of the Confederation in prevention policy and an improved consideration of implementation aspects in approving new measures to obligatory insurance coverage.

Screening and Identifying Children with Autism Spectrum Disorders in the Public School System: The Development of a Model Process

Heightened public awareness of autism and increased prevalence estimates of autism spectrum disorders (ASDs) has generated a sense of urgency within the public school system to identify children with these disorders for targeted intervention. Two multidisciplinary groups of professionals, one each from two separate school districts, were identified and trained to provide diagnostic and consultative services. This paper outlines a model process for school personnel to develop a basic level of training and competence in recognizing and serving students who have an ASD by (1) providing an overview of the legal and clinical issues involved in screening for children with ASD within the school system, (2) defining a school-based professional training process and (3) outlining a school-based ASD screening process.

Risk management. Discussing benefits and risks with patients. PSA testing

Obtaining valid consent from patients is good medical practice and a legal necessity. The process of obtaining consent involves shared decision making and a discussion of benefits and risks with patients. This article uses the example of PSA screening to explore the issue of shared decision making and outlines some strategies for general practitioners to use when discussing risks with patients.

A survey of compliance: Medicaid's mandated blood lead screenings for children age 12-18 months in Nebraska

BACKGROUND

To determine the frequency of Medicaid mandated blood lead level (BLL) screening compliance rates by clinical site.

METHODS

Retrospective chart review for evidence of BLLs. Data analyses were conducted using frequencies, percentages & chi-square.

RESULTS

The overall incidence of documented BLLs was 78.9% with one clinic demonstrating 100% BLLs while the others had 72%. Screening rates differed significantly by clinical site (X2 = 18.460, df = 3, p < 0.001).

CONCLUSION

Although universal blood lead screening is mandated, there were missed opportunities to obtain BLLs in 21.1% of the records reviewed. Only one clinic had 100% documentation of BLLs when children on Medicaid were seen between the ages of 12-18 months.