how much do you consult

[DocEspana]

so question for the community.

I trained somewhere that we consulted the relevant fields for 'interesting' cases, largely so the residents could get a head start on seeing the case. OBVIOUSLY we consulted for strokes and STEMI and such that needed immediate admission and intervention.... but also would consult on cool stuff. Otherwise, we would most just admit and let the inpatient team do consultology. But because there were lots of residents who would benefit from seeing all the random wild medical stuff, I did place a decent amount of consults.

But since residency my consult frequency has severely dropped off. I've been comfortably employed (so more than a 2-3 month locums gig, long enough to 'know the vibes') at 4 different places and generally speaking at all four of them almost nobody consulted for *anything* except surgical cases that needed surgery to confirm capacity to fix, ortho/pods cases to check for admit vs follow up, and the aforementioned stroke/stemi needing immediate intervention. The very small number of ED docs who consulted a lot were outliers and everyone noticed and complained that they seemed to be slowing the whole ED down with them waiting on consultant opinions on obvious admissions or discharges that really only ever had one possible clinical disposition and didn't need any emergent intervention.

I'm now at my fifth place and all the admitting physicians are super nice and reasonable, but they dont take the admission call. Their PA/NPs do (the attendings are involved if I review the inpatient notes, but they dont write those initial H&Ps). And I am getting constant pushback that I should consult cardio, and neuro, and GI, and ENT, and everyone under the sun consults for whatever I want to admit for. I just had them push back on two different stone-cold-normal EKG NSTEMIs that they wouldn't accept until cardiology spoke *to me* and confirmed it wasn't actually a STEMI (we have a cath lab mind you, so outside of activating the team stat, it doesn't matter if it is). They also pushed back that a reported GI bleed that wasnt actually bleeding and had a negative stool occult but had that chronic on chronic anemia didnt have a GI consult in already. MOST recently that a binocular diplopia likely from mets to the brain needing neuro eval after an MRI (which wont be done until tomorrow) didn't have neurology consulted and already in agreement that MRI is the next step (what else could it be? I ordered all the CT studies in existence already).

Was I just blessed to dodge this in four consecutive jobs out of residency, or are you all placing consults for whatever the relevant field is from the ED? I obviously know what consults they *will* need, but when there isnt any acute intervention needed promptly, I don't see the point in holding up my workflow to place these consults and then take the subsequent calls. These midlevels are making me feel like I'm crazy. I ask my coworkers and they all just shrug and say thats how its always been and they dont try to fight it. But when I talk to the inpatient attendings they all tell me I don't have to do it and they will handle it (but they arent the ones doing the H&P, so I get the grief anyway until I call and bitch to them).

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[bky3c]

You're not crazy. They're trying to make you do their job.

 

[BoardingDoc]

so question for the community.

I trained somewhere that we consulted the relevant fields for 'interesting' cases, largely so the residents could get a head start on seeing the case. OBVIOUSLY we consulted for strokes and STEMI and such that needed immediate admission and intervention.... but also would consult on cool stuff. Otherwise, we would most just admit and let the inpatient team do consultology. But because there were lots of residents who would benefit from seeing all the random wild medical stuff, I did place a decent amount of consults.

But since residency my consult frequency has severely dropped off. I've been comfortably employed (so more than a 2-3 month locums gig, long enough to 'know the vibes') at 4 different places and generally speaking at all four of them almost nobody consulted for *anything* except surgical cases that needed surgery to confirm capacity to fix, ortho/pods cases to check for admit vs follow up, and the aforementioned stroke/stemi needing immediate intervention. The very small number of ED docs who consulted a lot were outliers and everyone noticed and complained that they seemed to be slowing the whole ED down with them waiting on consultant opinions on obvious admissions or discharges that really only ever had one possible clinical disposition and didn't need any emergent intervention.

I'm now at my fifth place and all the admitting physicians are super nice and reasonable, but they dont take the admission call. Their PA/NPs do (the attendings are involved if I review the inpatient notes, but they dont write those initial H&Ps). And I am getting constant pushback that I should consult cardio, and neuro, and GI, and ENT, and everyone under the sun consults for whatever I want to admit for. I just had them push back on two different stone-cold-normal EKG NSTEMIs that they wouldn't accept until cardiology spoke *to me* and confirmed it wasn't actually a STEMI (we have a cath lab mind you). They also pushed back that a reported GI bleed that wasnt actually bleeding and had a negative stool occult but had that chronic on chronic anemia didnt have a GI consult in already. MOST recently that a binocular diplopia likely from mets to the brain needing neuro eval after an MRI (which wont be done until tomorrow) didn't have neurology consulted and already in agreement that MRI is the next step (what else could it be? I ordered all the CT studies in existence already).

Was I just blessed to dodge this in four consecutive jobs out of residency, or are you all placing consults for whatever the relevant field is from the ED? I obviously know what consults they *will* need, but when there isnt any acute intervention needed promptly, I don't see the point in holding up my workflow to place these consults and then take the subsequent calls. These midlevels are making me feel like I'm crazy. I ask my coworkers and they all just shrug and say thats how its always been and they dont try to fight it. But when I talk to the inpatient attendings they all tell me I don't have to do it and they will handle it (but they arent the ones doing the H&P, so I get the grief anyway until I call and bitch to them).

I consult someone if I have a question or if I want them to do something.
- patient needs surgery
- patient needs egd for food impaction.
- I have a really weird EKG and I think it's X or some such and I want you to look at this (rare)
- neuro for a stroke if I'm considering lyrics (I don't call them at all if the patient is outside of any intervention window. I also don't have a neuro service to admit to which would obviously change things if I did)

That's basically it.

I've never had someone ask me to run an EKG by cardiology. I've had people ask me to call GI or cards for things before admitting. I usually ask precisely what it is that they want me to ask these people if I don't have an emergent question for them. If it isn't insane, I call. If it's something like "I want x to be aware of this patient, but no I don't need them to come in immediately to do something" I will generally refuse and say that they can do that upstairs as this will in no way change management of the patient in the ED. This scenario used to be somewhat common. It's now very rare.

 

[Siggy]

The only time I expect the ED to place consults are for stat consults (look, you caught the K of 8... call the nephrologist) or if the consult will determine whether the patient needs to be transferred (either because specialty is not on call or we might not have the equipment for that specific pathology even if we have the specialty). EMTALA doesn't apply inpatient. I can't submit a complaint because a hospital administratively refused a patient.

I don't need nor expect the ED consulting neprho just because the patient is ESRD or consulting ID for sepsis.

 

[painER]

This happens somewhat frequently at our ED. It's primarily by midlevels when they have the admission pager (which is about 50/50 with an attending). For me it comes down to how much I want to fight it vs play nice in the sandbox. I have no problem saying no if I really don't feel it's needed or I'm getting slammed, and they seem ok with that. But I also have the occasional borderline admit that I need them to help me out with too, so I try to make the calls if I have time and the consult is not totally unreasonable.

 

[pkwraith]

A lot of our consultations here are driven by systemic abuse of peer review system by consultants. One doc got peer reviewed for cardioverting an a fib patient without calling cardiology for permission. One doc got peer reviewed for admitting a patient that had >48 hours of stroke without talking to neurology. One doctor got peer reviewed for admitting an comfort care ischemic leg to hospice without consulting vascular surgery. Trauma is notorious for peer reviewing everyone for not activating traumas or consulting them for the ankle fracture admission. So, this results in everyone gets pan-consulted under the guise of "quality care". It drives insane bloat on every patient so every specialist can get their bite under threat of peer review process. And the normal consultants are like "why are you calling me for this?" Ask your colleagues.

 

[WhatJobDoIPick]

The midlevels (and hospitalists) likely don't have the knowledge, so depend on actual doctors to handle acute issues for them

 

[DocEspana]

Okay good. Because I was feeling like mugatu from Zoolander.

 

[southerndoc]

I consult when medically necessary.

I worked at a place like you described where the hospitalist wanted all kinds of unnecessary consults from specialists. This ended when we started talking to the specialists about it. They started calling the hospitalist every time we consulted them. The hospitalists stopped asking us to consult them.

 

[emergentmd]

I have worked in 4 hospital systems and I only consult when I need some input/help/close follow up. The rest just get hospitalist admission. What OP is describing is crazy to me.

But they are NPs so I understand why they do they. They don’t want responsibility for the pt without an MD involvement.

 

[Mount Asclepius]

I just say, “I don't have a reason to talk to xyz speacialist emergently, but I’m happy to page them to your number for you if you’d like to talk to them. What number would you like me to have them paged to?” It puts an immediate end to it.

 

[sloh]

A lot of our consultations here are driven by systemic abuse of peer review system by consultants. One doc got peer reviewed for cardioverting an a fib patient without calling cardiology for permission. One doc got peer reviewed for admitting a patient that had >48 hours of stroke without talking to neurology. One doctor got peer reviewed for admitting an comfort care ischemic leg to hospice without consulting vascular surgery. Trauma is notorious for peer reviewing everyone for not activating traumas or consulting them for the ankle fracture admission. So, this results in everyone gets pan-consulted under the guise of "quality care". It drives insane bloat on every patient so every specialist can get their bite under threat of peer review process. And the normal consultants are like "why are you calling me for this?" Ask your colleagues.

Activate trauma for grandma who suffers ground level fall and hits her head and is on eliquis! Cash money baby

 

[DocEspana]

I just say, “I don't have a reason to talk to xyz speacialist emergently, but I’m happy to page them to your number for you if you’d like to talk to them. What number would you like me to have them paged to?” It puts an immediate end to it.

going to use this

 

[Groove]

Sounds like a whack institutional culture thing. Get your FMD to bring it up during a through put meeting where you've got all the relevant people going over ED metrics. Bring up how LOS and admit times are much higher than they need to be due to unnecessary consultations required by the admitting providers. Meet with medicine director to get them on board ("Hey, you realize all your APCs are requiring all these consults and that's killing your inpatient LOS....") and could even bring it up during MEC. That puts it on the hospital admin radar and who doesn't love the idea of cooking those ED metrics.

If your FMD just doesn't care and there isn't any sort of institutional interest in ED/inpatient metric enhancement (would be weird....) then you're just out of luck. I certainly don't think this is anything you can change by yourself.

But yeah...that's a weird shop. Like everybody else, I just consult the common sense stuff or if I need to throw some medicolegal "high risk" hot potatoes.

I haven't really had to consult specialists in order to brute force admissions since residency though that was a common tactic back then.

I most definitely don't consult for "interesting cases". Nobody wants to be interested these days in private practice/community. If I did something like that, I think I'd literally hear the specialists eyes rolling on the other end of the phone. "Interesting" would have to be something more along the lines of "Hey cards...I've got ST elevation in AVR and V1 and I think this is a proximal LAD STEMI though it doesn't meet formal criteria for STEMI. Would you check it out? Pretty 'interesting'. Want me to activate cath lab?", etc..

 

[southerndoc]

Activate trauma for grandma who suffers ground level fall and hits her head and is on eliquis! Cash money baby

You'd be surprised at the number of head bleeds we see from this. We don't fully activate, but have a Code CHIP process (Closed Head Injury Protocol) where patients are screened by the APP and go directly to CT. They do not get an activation charge like trauma activations do. We went from >2 hours waiting on CTs to <15 mins with time to reversal <40 mins 90% of the time. We're working on publishing it as we've seen a reduction in mortality.

 

[thegenius]

 

[thegenius]

Was I just blessed to dodge this in four consecutive jobs out of residency, or are you all placing consults for whatever the relevant field is from the ED? I obviously know what consults they *will* need, but when there isnt any acute intervention needed promptly, I don't see the point in holding up my workflow to place these consults and then take the subsequent calls. These midlevels are making me feel like I'm crazy. (1) I ask my coworkers and they all just shrug and say thats how its always been and they dont try to fight it. (2) But when I talk to the inpatient attendings they all tell me I don't have to do it and they will handle it (but they arent the ones doing the H&P, so I get the grief anyway until I call and bitch to them).

(1) largely a cultural issue. Some places have forged positive "ER" relationships and only will do consults if/when necessary and ER does only "emergency" consults.

(2) there is your out. "I'm sorry this is not an emergency consult. Please have a discussion with your attending. Thank you and have a good day."

 

[thegenius]

The only time I expect the ED to place consults are for stat consults (look, you caught the K of 8... call the nephrologist) or if the consult will determine whether the patient needs to be transferred (either because specialty is not on call or we might not have the equipment for that specific pathology even if we have the specialty). EMTALA doesn't apply inpatient. I can't submit a complaint because a hospital administratively refused a patient.

I don't need nor expect the ED consulting neprho just because the patient is ESRD or consulting ID for sepsis.

FYI, more than one decision in the past by CMS/OIG says EMTALA applies until the patient is stabilized, whether in the ED or as an inpatient.

 

[thegenius]

This happens somewhat frequently at our ED. It's primarily by midlevels when they have the admission pager (which is about 50/50 with an attending). For me it comes down to how much I want to fight it vs play nice in the sandbox. I have no problem saying no if I really don't feel it's needed or I'm getting slammed, and they seem ok with that. But I also have the occasional borderline admit that I need them to help me out with too, so I try to make the calls if I have time and the consult is not totally unreasonable.

This is the correct answer.
It all depends, depends on how busy I am, depends if I like the consultant, depends on the time of day, depends on the question (or perceived question), depends on several things.

I generally consult less than the avg doc in my group, I push back more than the average ER doc. But I'm not militant about it. Sometimes I know the hospitalist has gotten 10 admits in the past 2-3 hours, and I'll call the consultant to make their job easier and more likely to take the admit - especially if it's close to the end of their shift.

 

[thegenius]

You'd be surprised at the number of head bleeds we see from this. We don't fully activate, but have a Code CHIP process (Closed Head Injury Protocol) where patients are screened by the APP and go directly to CT. They do not get an activation charge like trauma activations do. We went from >2 hours waiting on CTs to <15 mins with time to reversal <40 mins 90% of the time. We're working on publishing it as we've seen a reduction in mortality.

Interesting we see so few traumatic head bleeds on DOAC. Probably 2-3% (that don't meet trauma activation criteria). If they meet activation that's a different story.

 

[TooMuchResearch]

so question for the community.

I trained somewhere that we consulted the relevant fields for 'interesting' cases, largely so the residents could get a head start on seeing the case. OBVIOUSLY we consulted for strokes and STEMI and such that needed immediate admission and intervention.... but also would consult on cool stuff. Otherwise, we would most just admit and let the inpatient team do consultology. But because there were lots of residents who would benefit from seeing all the random wild medical stuff, I did place a decent amount of consults.

But since residency my consult frequency has severely dropped off. I've been comfortably employed (so more than a 2-3 month locums gig, long enough to 'know the vibes') at 4 different places and generally speaking at all four of them almost nobody consulted for *anything* except surgical cases that needed surgery to confirm capacity to fix, ortho/pods cases to check for admit vs follow up, and the aforementioned stroke/stemi needing immediate intervention. The very small number of ED docs who consulted a lot were outliers and everyone noticed and complained that they seemed to be slowing the whole ED down with them waiting on consultant opinions on obvious admissions or discharges that really only ever had one possible clinical disposition and didn't need any emergent intervention.

I'm now at my fifth place and all the admitting physicians are super nice and reasonable, but they dont take the admission call. Their PA/NPs do (the attendings are involved if I review the inpatient notes, but they dont write those initial H&Ps). And I am getting constant pushback that I should consult cardio, and neuro, and GI, and ENT, and everyone under the sun consults for whatever I want to admit for. I just had them push back on two different stone-cold-normal EKG NSTEMIs that they wouldn't accept until cardiology spoke *to me* and confirmed it wasn't actually a STEMI (we have a cath lab mind you, so outside of activating the team stat, it doesn't matter if it is). They also pushed back that a reported GI bleed that wasnt actually bleeding and had a negative stool occult but had that chronic on chronic anemia didnt have a GI consult in already. MOST recently that a binocular diplopia likely from mets to the brain needing neuro eval after an MRI (which wont be done until tomorrow) didn't have neurology consulted and already in agreement that MRI is the next step (what else could it be? I ordered all the CT studies in existence already).

Was I just blessed to dodge this in four consecutive jobs out of residency, or are you all placing consults for whatever the relevant field is from the ED? I obviously know what consults they *will* need, but when there isnt any acute intervention needed promptly, I don't see the point in holding up my workflow to place these consults and then take the subsequent calls. These midlevels are making me feel like I'm crazy. I ask my coworkers and they all just shrug and say thats how its always been and they dont try to fight it. But when I talk to the inpatient attendings they all tell me I don't have to do it and they will handle it (but they arent the ones doing the H&P, so I get the grief anyway until I call and bitch to them).

They're tricking you into doing the entire job. Some days I think they'd be happy if we did the entire thing i.e. full hospital admission and discharge without involving them.

 

[TooMuchResearch]

A lot of our consultations here are driven by systemic abuse of peer review system by consultants. One doc got peer reviewed for cardioverting an a fib patient without calling cardiology for permission. One doc got peer reviewed for admitting a patient that had >48 hours of stroke without talking to neurology. One doctor got peer reviewed for admitting an comfort care ischemic leg to hospice without consulting vascular surgery. Trauma is notorious for peer reviewing everyone for not activating traumas or consulting them for the ankle fracture admission. So, this results in everyone gets pan-consulted under the guise of "quality care". It drives insane bloat on every patient so every specialist can get their bite under threat of peer review process. And the normal consultants are like "why are you calling me for this?" Ask your colleagues.

Wtf.

 

[Siggy]

FYI, more than one decision in the past by CMS/OIG says EMTALA applies until the patient is stabilized, whether in the ED or as an inpatient.

That's good to know... I may need to start using this.

 

[Rekt]

Almost never. I trained at a place with no other residents essentially. Our consultants wanted nothing to do with the ED even though our volume was >100k/yr. So we were trained to only call when we had a clinical question that we couldn’t answer or reached the end of our treatment options. Got comfortable with pretty much doing anything without talking to anyone. Hospitalist pretty much never ask me to call anyone anymore. “What is their emergent need to come in?” Shuts that question down.

On the other hand I also work with a lot of new grads and they consult constantly for everything it’s insane. It makes me cringe on the inside when I hear them talking to a consultant and I can tell they’re not even sure why they’re calling them.

DocE, for your specific scenario I’d just say “I don’t have any emergent need to contact them. They can see the patient on their list. If you have management questions you can contact them or ask your attending. Thanks.” Hang up. Not your fault you’re admitting to clueless PLPs

 

[Zebra Hunter]

I work at an institution where hospitalists admit everything, and ask us to call consults for every. single. thing. It’s a culture that is set in stone and our weak group leadership just never pushed back on it. Patient needs non-emergent dialysis tomorrow? Call nephro. Patient being admitted for syncope? Call cards. TIA? Neuro. Pelvis fx that just needs rehab? Ortho. I think the most consults I have ever had in a shift was 30, and that was in an 8 hour shift. I once had a patient I was asked to make 6 separate consultations on. I told them to **** off and make those calls themselves outside of the two that were necessary, which got me in trouble.

 

[thegenius]

☝️
good grief.

 

[DocEspana]

☝️
good grief.

what you said.

I suddenly feel much better in comparison

 

[Jabbed]

Whenever someone asks me to put in a non-emergent consult I say “absolutely” and then put in a routine consult order.

No additional phone calls, the consultant is consulted, and they’re admitted.

 

[The Knife & Gun Club]

When I’m working the inpatient side I have one hospital where we consult heavily from the ED and both ICU and Hospitalist are unfortunately put in the position for asking for a lot of these “no emergency but need onboard” consults.

The reason we ask for the ED consult at this specific hospital is because it’s a small community hospital with limited resources and if we admit someone overnight only to find out our GI doesn’t feel comfortable scoping for XYZ reason and wants them transferred to the tertiary center the admitting team is up a creek without a paddle because EMTALA no longer applies and these transfers can take days.

Let me tell you sitting for 3 days waiting for a tertiary bed on someone with an EF of 5% who’s actively having an MI and needs urgent PCI with mechanical support but we don’t have that capability absolutely stinks.

So if you’re at a smaller shop that would be the only reasonable explanation for why these consults have to happen in the ED.

 

[WhatJobDoIPick]

Once I had a complex surgical patient come to the ED at the behest of the surgical attending for a non-emergent admission for a chronic surgical issue.

Why this was not a direct admission I don't know.

The patient arrived with the reasonable expectation that the surgical service would be admitting him.

PGY2 consult resident to me, the attending: "Admit to Medicine, and consult ID for us."

Me: "I won't be consulting anyone. Feel free to make the call if you want the consult."

 

[The Knife & Gun Club]

I work at an institution where hospitalists admit everything, and ask us to call consults for every. single. thing. It’s a culture that is set in stone and our weak group leadership just never pushed back on it. Patient needs non-emergent dialysis tomorrow? Call nephro. Patient being admitted for syncope? Call cards. TIA? Neuro. Pelvis fx that just needs rehab? Ortho. I think the most consults I have ever had in a shift was 30, and that was in an 8 hour shift. I once had a patient I was asked to make 6 separate consultations on. I told them to **** off and make those calls themselves outside of the two that were necessary, which got me in trouble.

This is absolutely preposterous what on earth are these consultants going to do during non business hours? It’s also a massive efficiency time sink making these non-emergent calls.

Your hospital needs a reliable way to put in routine consults where you click one button in the computer and can be sure the consult will get seen within 24 h. I trained at a place like the one you describe and the time sink of making so many calls in a shift was devastating to efficiency.

 

[thegenius]

When I’m working the inpatient side I have one hospital where we consult heavily from the ED and both ICU and Hospitalist are unfortunately put in the position for asking for a lot of these “no emergency but need onboard” consults.

The reason we ask for the ED consult at this specific hospital is because it’s a small community hospital with limited resources and if we admit someone overnight only to find out our GI doesn’t feel comfortable scoping for XYZ reason and wants them transferred to the tertiary center the admitting team is up a creek without a paddle because EMTALA no longer applies and these transfers can take days.

Let me tell you sitting for 3 days waiting for a tertiary bed on someone with an EF of 5% who’s actively having an MI and needs urgent PCI with mechanical support but we don’t have that capability absolutely stinks.

So if you’re at a smaller shop that would be the only reasonable explanation for why these consults have to happen in the ED.

This isn't true. EMTALA starts in the ED, but it is active until the patient is stabilized. The obligation to stabilize doesn't end once the ED clicks on "Admit".

There was a hospital in the Southeast part of the US that would admit psych patients on a hold, and then immediately drop the hold and discharge the patient while they still had SI. They felt that once admitted, EMTALA no longer applies. People found out about it, and this might have even gone to trial. Hospital was charged $100,000s for their actions by the OIG.

 

[southerndoc]

This isn't true. EMTALA starts in the ED, but it is active until the patient is stabilized. The obligation to stabilize doesn't end once the ED clicks on "Admit".

There was a hospital in the Southeast part of the US that would admit psych patients on a hold, and then immediately drop the hold and discharge the patient while they still had SI. They felt that once admitted, EMTALA no longer applies. People found out about it, and this might have even gone to trial. Hospital was charged $100,000s for their actions by the OIG.

There are two sides to this.

For the hospital that admits the patient, EMTALA obligation doesn't end just by admitting and can be found at fault if they try to admit to obviate need to satisfy stabilization for EMTALA.

However, if a hospital admits a patient and they are a true admission and not observation status, then a receiving facility has no EMTALA obligation to accept the patient.

 

[Siggy]

However, if a hospital admits a patient and they are a true admission and not observation status, then a receiving facility has no EMTALA obligation to accept the patient.

All the more reason for ER to ER transfers instead of admit and transfer.

 

[HemeOncHopeful19]

There are two sides to this.

For the hospital that admits the patient, EMTALA obligation doesn't end just by admitting and can be found at fault if they try to admit to obviate need to satisfy stabilization for EMTALA.

However, if a hospital admits a patient and they are a true admission and not observation status, then a receiving facility has no EMTALA obligation to accept the patient.

So what happens if there is a patient that gets admitted (a "true admit") and then suddenly develops a condition that can't be fully "stabilized" (say, a head bleed with no NSGY coverage) in their facility?

 

[Rendar5]

So what happens if there is a patient that gets admitted (a "true admit") and then suddenly develops a condition that can't be fully "stabilized" (say, a head bleed with no NSGY coverage) in their facility?

Then you transfer it out…

 

[thegenius]

However, if a hospital admits a patient and they are a true admission and not observation status, then a receiving facility has no EMTALA obligation to accept the patient.

ED admits a STEMI because their one and only cardiologist is on-call and available to take care of the pt.
Then the Cardiologist isn't able to take care of the patient for some reason.

Setting aside the reason why, are other hospitals not obligated to take the transfer?

 

[Siggy]

Then you transfer it out…

Depends.

If the patient has insurance... then the outside hospital accepts the transfer.

If the patient doesn't have insurance or is medicaid... then everyone magically doesn't have space and "the administrator declined the transfer." So you get to watch the patient die in front of you. I know this from watching patients die in front of me. My favorite was when the 1 liver transplant center/hepatology center in the county said "no," refused to let me talk to the hepatologist (because all ICU patients had to be approved by transplant, not hepatology). Meanwhile I'm being told by my facility that we can't transport across county lines.


Acute liver failure is tricky because you often don't need a hepatologist. However when you do, everyone will say no.

 

[Siggy]

ED admits a STEMI because their one and only cardiologist is on-call and available to take care of the pt.
Then the Cardiologist isn't able to take care of the patient for some reason.

Setting aside the reason why, are other hospitals not obligated to take the transfer?

If it's ED to ED, then yes. It doesn't matter the reason. It's an EMTALA violation to say no.

From my understanding, if the patient isn't as advertised or it's for someone not meeting their call obligation, then the accepting facility can complain later. It doesn't relieve their requirement to accept the transfer.

 

[thegenius]

If it's ED to ED, then yes. It doesn't matter the reason. It's an EMTALA violation to say no.

From my understanding, if the patient isn't as advertised or it's for someone not meeting their call obligation, then the accepting facility can complain later. It doesn't relieve their requirement to accept the transfer.

I'm just trying to come up with a scenario whereby a patient has an emergency medical condition, is admitted because that hospital has the capability to take care of it, and then something happens and the hospital can no longer stabilize the patient. For whatever reason.

It's a different thing all together if a pt is admitted, then 3 days into their stay they develop a new emergency medical condition unrelated to the original admission that the hospital cannot manage. I think in this case EMTALA doesn't apply because 1395dd(a) only describes an "...individual comes to the emergency department and a request is made..."


The problem I have with

The reason we ask for the ED consult at this specific hospital is because it’s a small community hospital with limited resources and if we admit someone overnight only to find out our GI doesn’t feel comfortable scoping for XYZ reason and wants them transferred to the tertiary center the admitting team is up a creek without a paddle because EMTALA no longer applies and these transfers can take days.

is I'm presuming GI is on call, they are on the call schedule, they will continue to be on the call schedule for the coming days, and they are credentialed to do the procedure. So we are calling them to ask "will you consult?" is just kind of silly and redundant. It's not like I can force them to consult and the admitting team cannot. If they are on the call schedule

And I get that there is nuance. We all get it. There are fringe cases where I have no problem calling the consultant. But it's not the fringe cases that bother us, it's the lack of consideration from the inpatient folks to "get them on board." How do we get them on board? They are on board because they are on call.

 

[southerndoc]

If the patient is admitted and becomes unstable or develops a new condition, then EMTALA still doesn't apply. EMTALA only applies to ED to ED transfers on non-admitted patients. Observation status isn't considered a true admission and EMTALA has been ruled to apply.

The right thing to do is to accept the transfer of an unstable patient if you have the capacity and capability to care for them. However, there is no law requiring it since EMTALA doesn't apply. Becomes more difficult with admitted patients as well because inpatient-to-ED transfers bring up regulatory issues and most facilities will not accept this. If it is a critical patient that needs intervention, we accept inpatient-to-ED transfers if we have capacity to take them. Usually it's floor patients that develop a stroke, head bleed, chest pain obs patient that they finally CT and they have an aortic dissection, etc.

 

[hoot504]

I feel like I consult quite a bit but by and large only in the following situations.

Surgical specialties: patient needs a procedure
Neurology: tPA candidate
Nephrology: emergent HD needed
Cards: STEMI/NSTEMI, significant dysrhythmias that I appreciate their input on
GI: pretty much exclusively UGIBs that I think will get a scope within 12 - 24 hours
OB: patient needs a procedure. Or when the patient post-workup is still technically a rule-out ectopic and I want to secure good follow-up

The iffy cases are mostly bad radiology reads where I appreciate the specialist weighing in with their insight. I don't think that's unreasonable and I don't get paid any more to soak up 100% of the liability.