EM By the Book

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Director’s Corner
You may think that your hospital and departmental rulebooks don’t apply to you, but nothing could be further from the truth.

Dear Director,
I’ve been an attending for 2 years and recently I was asked to sign a contract addendum saying that I’ll be compliant with the hospital bylaws, rules and regulations, and all hospital policies. How can I be compliant with something I barely know exists?
Many physicians come to work, see their patients and go home without ever thinking about the rules and regs that are required to run a department, a medical staff, and a hospital. Some even genuinely believe that these policies don’t impact them on a daily basis. In fact, these rules and regs can have a great impact on your clinical practice. So, what are they and how well do you need to know them?

1. The Bylaws
You’ll care about them when…
One of the surgeons tells you he has lost his privileges to operate at your hospital. You start wondering: could it happen to me?


Hospital bylaws are like the Constitution, the underlying, big picture laws of the hospital. They outline the responsibilities of department chairmen and medical staff officers as well as things like membership on the medical executive committee (MEC). Hospital bylaws address credentialing, insuring that competent physicians have privileges in the hospital, but they also protect physicians’ rights and privileges at the hospital with due process. As long as you are a private physician, that is. These same bylaws may offer little protection to EPs, who are typically contracted physicians, and whose hospital privileges are given based on having an active contract with our ED group. You would need to refer to your individual contract to see what due process you’re afforded.

2. Hospital & Department Rules and Regulations
You’ll care about them when…
Your orthopedist, who operates on femurs regularly, refuses a femur fracture trauma case at 2am, citing inexperience and requesting a transfer. 

While the underlying mission of your hospital’s rules and regs is to insure high standards of medical care, the reality is that they’re there to keep you within Joint Commission standards. Through bylaws departmental rules and regulations, each of us is granted certain clinical privileges. Hospital privileges range from the use of bedside ultrasound to taking a patient to the OR.

The good news for EPs is that in the big picture, the delineation of privileges can help us with specialty coverage or EMTALA. That fully-credentialed orthopedist who refuses to take care of the uninsured femur fracture at 2 am? He’s setting himself and the hospital up for an EMTALA violation. This would then start the discussion with your VPMA about ED specialty coverage or if the orthopedic chief needs to better evaluate the privileges that his doctors carry.


On the flip side, these rules and regs can come back to bite you if you are not careful. For instance, many hospitals require EPs to be certified in ACLS to perform conscious sedation. If your ACLS lapses and you perform conscious sedation, you run the risk of undergoing a formal punishment. Worse, if there is a bad outcome and the plaintiff’s attorney sees your rules and regs (which they will), you could lose a malpractice case.

3. The Department Manual
You’ll care about it when…
The police bring an uninjured, uncooperative patient into the ED for a blood alcohol level. Does the patient need a screening exam? Can the nurse help the police by drawing the blood?

Your department policy book is your way of knowing the ED’s official policy in sticky situations. It can also be a clue into potential liability risks. For instance, psychiatric patients in the ED for 24 -36 hours probably don’t get the q-shift evaluation and documentation that your psych policy spells out. If there is a bad outcome, lawyers will cling to this. So get a copy of your department rules and regs – usually available in an electronic format – and have a basic understanding. Know that hospital bylaws exist and that you may be held to their standards. Your charge nurse is probably the most familiar with them and will know how to access them if you have a question that needs an immediate answer. However, policies and rules are never a replacement for practicing good, standard-of-care and state-of-the-art medicine.

Mike Silverman, MD is the chairman of emergency medicine at Harbor Hospital in Baltimore and is on the faculty at the TeamHealth Leadership Academy


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