pratik7

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I had a case tonight i wanted to ask yall about.

On my shift tonight, i had a patient who happened to be a floor nurse at my hospital. He was sp gsw to chest with hemo/pneumo and liver injury. He was exlap'ed at a local trauma center with chest tubes and went home 2 weeks ago. Came to hospital to work tonight and was sent home for low volume on floors. Decided to come to ED due to drainage at chest tube site. Also had pleuritic cp and mildly tachy. Got a Ct angio which shows loculated effusion with gas consistant with empyema.

Call local trauma center and they accept in transfer. Pt wants to drive self to trauma hospital to avoid ambulance cost and figure out how to get to his car when he is diacharged. Normal vital, reading a book and even left the ED to get his lunchbox from the floor.

The accepting hospital refused to take him if he was driving himself. I spoke with the ER nurse, ER doc and transfer center and none agreed to take him by private vehicle.

Am i crazy for allowing him to drive himself? Do you all allow low risk patients to drive themself. We commonly do this with the local peds hospitals ( kids with appendicitis especially ). It sure does seem like a waste of resources if every transfer needs an ambulance ride...glorified taxi at that point
 

Dr.McNinja

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They can't refuse his transfer based on the type of transfer he chooses. They're basically saying "Nope, it's not safe to come here by your car, you should go home AMA by your car. You're much safer there."
Especially since the receiving hospital isn't on the hook for anything that happens.
F that noise.


Yes, I allow reasonable patients to transfer by POV. It's reasonable and rational.
 

Daedalus

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Pretty sure that's not a valid reason for them to refuse a transfer. Per EMTALA, it is the sending physician's responsibility to chose an appropriate mode of transport.
 
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southerndoc

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Daedalus is right. It's an EMTALA violation to create stipulations before accepting a transfer (exceptions are for stability issues, like asking for a chest tube be placed in a significant pneumothorax prior to transfer).

You cannot force the guy to go by ambulance. He has a right to go by car, and as long as you document the risks, then he can go by car. I wouldn't even make him sign an AMA form. Just document the risks.
 

n2b8me

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My opinion: if he leaves your hospital by car it's not a transfer. He is being discharged, then presenting to the other ER as a new patient.
For me all kids being transferred go by ambulance, all pregnant > 20 weeks go by ambulance. Otherwise they are being discharged (+/- AMA) and it is on them to get to the facility.
 

Venko

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I would have recommended ambulance and allowed him to refuse it given that he had capacity. I would have reminded the accepting facility of their obligations per emtala and sent the guy on his way


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The refusal is an EMTALA violation as others have said. That part is easy. Without knowing much more about the pt and being in front of him, it's hard for me to imagine sending an empyema POV. I hate saying it but I probably would have made him sign an AMA or at least documented refusal of transfer and understanding of risks/benefits with risks including death/perm disability. (My usual stuff.)

Color me paranoid in this day and age but you always have to remember it's not just the rational and reasonable pt in front of you that you're currently dealing with but all the irrational family members that you are potentially having to deal with and are the ones more likely to sue you if this guy suddenly decompensated and died. I mean, let's be real, we never transfer a post op empyemas POV. The standard of care in the region is most definitely not to transfer empyemas POV. Yes, it sounds reasonable given the education level and pt's wishes but I'd still encourage him to undergo proper transport and if he refused, I'd document the discussion just to cover myself. I'd probably legitimately worry about him driving across town with his chest tube and empyema too. It was def inappropriate for the receiving hospital to refuse based on mode of transport.

Plus, he's an employee of the hospital, right? How much of the ambulance ride is he actually going to have to pay in the first place? All these W2 hospital employee guys have better insurance than my 1099 bandaid policy self.
 

BAM!

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Here's a solution. Send him by ambulance. If he wants to go by private vehicle and has mental capacity, then have him sign out AMA. You are essentially discharging him. If he shows up at the other hospital, then he did so on his own accord. You're not violating EMTALA because you didn't transfer or discharge him. Besides, I understand professional courtesy, but he's a floor nurse. When are you ever going to see him again? Just have him sign AMA. He'll understand.

In my experience, the accepting facility doesn't decide how the patient is transferred. It's the transferring physician who decides. Often the accepting physician doesn't even know the method of transfer until they arrive. That said, if the accepting physician knows that a critical patient is being transferred via a unreasonable method and they said it was OK, then it seems pretty logical they'd also be on the hook if something bad happened.

I think it's reasonable for the accepting facility say something like, Given the clinical picture I do not advise transfer via private vehicle. I don't think that method of transfer is safe and recommend ambulance transfer. However because you are the treating physician and have seen the patient, then it is your decision how to transfer this patient.

What if he was tachycardic at 150 and tachypneic at 35. If you were the accepting facility would you accept this transfer and say yes send him by private vehicle? No, you'd put up a stink too.
 

southerndoc

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My opinion: if he leaves your hospital by car it's not a transfer. He is being discharged, then presenting to the other ER as a new patient.
For me all kids being transferred go by ambulance, all pregnant > 20 weeks go by ambulance. Otherwise they are being discharged (+/- AMA) and it is on them to get to the facility.
EMTALA would disagree with you. Discharging a patient who is going to another facility is still considered a transfer.

There are a lot of little things with EMTALA that many people do not know. For instance, admitting a patient just to have a consultant see them is an EMTALA violation. Looking at a sister hospital's x-ray and saying it doesn't need transfer when the referring physician requested a transfer is an EMTALA violation. Stipulating that something must be done before transfer (unless it effects stability) is an EMTALA violation. If a sister hospital in your health system sends a patient to you that they can care for at the referring facility, they have committed an EMTALA violation. If your hospital doesn't report it to EMTALA and its discovered, BOTH have committed EMTALA violations. Someone presents with worst headache of life and gets a APP or physician screening exam, well they haven't fulfilled EMTALA requirements for an "adequate" screening exam without a CT. Of course if it's the worst headache of life and nothing comes of it, then no foul play. If they have a SAH and suffer an unfortunate outcome and complain, well the physician and ER have received an EMTALA violation.

Current fines are $104,000 per facility/physician. The DoJ/CMS has been fining people left and right lately due to unclear reasons. Maybe more lawyers are realizing lawsuits under standard of care or gross negligence are harder to win, so they have been pursuing more EMTALA violations for lawsuits (this has been occurring). It always helps their case when the DoJ fines the facility for an EMTALA violation.

Most EMTALA violations are published (usually in The Register), but you can also find them online. Some of the violations are unbelievable. I don't agree with them, but it is the way it is.
 
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BJJVP

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What if he was tachycardic at 150 and tachypneic at 35. If you were the accepting facility would you accept this transfer and say yes send him by private vehicle? No, you'd put up a stink too.
I may relay that I don't think it's a good idea to transfer the pt by private vehicle. But I wouldn't refuse the pt either.
 
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Rendar5

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If the patient leaves the ed on their own I still call ahead but the pt leaves AMA because I have no clue that they'll actually go there. Had a kid with suspected appy once and they never arrived. I don't make a big deal of the AMA though or go overboard to convince them to go by ambulance.
 

Daedalus

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If the patient leaves the ed on their own I still call ahead but the pt leaves AMA because I have no clue that they'll actually go there. Had a kid with suspected appy once and they never arrived. I don't make a big deal of the AMA though or go overboard to convince them to go by ambulance.
Doesn't matter - if your intention is to transfer them and they leave saying "yep, we're going to hospital X like you recommended", then it's a transfer and you need to call the receiving facility and the whole deal. If they leave saying "screw you buddy - we're going to the beach", then yeah it's an AMA haha.
 

dchristismi

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I had a similar case not too long ago - family from out of town traversing the state hitting the theme parks. Mom and dad both happen to be paramedics. Kiddo (little kid, not teenager) has a textbook appy.

I have no pediatric surgeon, and more importantly, no pediatric anesthesiologist. Mom and Dad are both not only reasonable, they completely get it, and actually brought up the idea of deliberately ama'ing to definitive care rather than us start the workup and transfer. We talked, they were in the room for maybe 10 minutes, and even though I offered a shot of pain medicine, etc, they were well aware that they could make the drive in half the time - if not faster because they knew what a transfer entailed, and had transferred patients before.

They were heading east to meet up with family on the coast. I listed the pediatric centers that direction, called ahead to the one they thought they'd go to (which happens to be the one I trained at) and the attending (who I knew) relayed that he'd "put it in the book" as this sort of thing happened more frequently that I'd realized.

I called to check on the kid the next day - Mom and Dad were appreciative, made it to the hospital quite fast and kiddo had her appendix removed uneventfully.
 
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Dr.McNinja

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My opinion: if he leaves your hospital by car it's not a transfer. He is being discharged, then presenting to the other ER as a new patient.
For me all kids being transferred go by ambulance, all pregnant > 20 weeks go by ambulance. Otherwise they are being discharged (+/- AMA) and it is on them to get to the facility.
Your opinion is wrong though.
 

Dr.McNinja

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People have to realize that EMTALA is pretty black and white. There aren't a lot of shades of grey there.
If you are the receiving hospital, and the other hospital wants to sent the unstable patient by car, or the completely stable patient by helicopter, it's not your decision. It's theirs. And if you refuse based on that, you're simply wrong.
You can offer advice, and you want to be on a recorded line if at all possible explaining why you think doing something a certain way is bad or good, but at the end of the day, it's on them as long as you accept it.
The only things I don't accept are the things I don't have capacity for, or the things I don't have coverage for. Those are all you're allowed to do based on the law.


That being said, this empyema is perfectly safe to drive. For God's sake he was at his house, and he drove his car to the hospital. If he's unstable, then sure, let him take the bus. Everybody is potentially unstable, and no, you aren't on the hook for him getting in a car accident if he's driving any more than you are if the ambulance gets in a wreck or the helicopter crashes. (Caveat, if you've blasted him with opiates, then yes, yes you are).
 

irJanus

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I deal with this alot... I never say no, but I strongly recommend safer mechanisms and I always ensure they have someone driving for them. A recent example was a 500lb person, concern for Pe, they needed our scanner due to weight. Doc wanted to send by private car, no HD instability. I thought that dangerous, made my case, and then advised someone else drive. I don't need the person syncopizing and crashing hurting someone else.
I try to offer solutions, and better mechanisms, but I never say no.
Lady never showed up... Hope she did well
 

Rendar5

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Doesn't matter - if your intention is to transfer them and they leave saying "yep, we're going to hospital X like you recommended", then it's a transfer and you need to call the receiving facility and the whole deal. If they leave saying "screw you buddy - we're going to the beach", then yeah it's an AMA haha.
I do call the receiving hospital to let them know the whole deal, but that is because they are leaving AMA and I'm doing everything I can to arrange for the patients best possible care given the circumstances.

if I'm not arranging transfer and have no way of confirming that they're going where I'm telling them to go it's a discharge against medical advice. If I feel like calling the place to make sure they got there I'll change my note to a transfer.if you want to know the basis for my opinion on this,
Per emtala.com, criteria for an appropriate transfer include:
  • "the transfer is effected with the use of qualified personnel and transportation equipment, as required by the circumstances, including the use of necessary and medically appropriate life support measures during the transfer."
Now if you consider the family or person driving to be qualified personnel with appropriate transportation equipment then you're right it's a transfer. I don't. if you still want to debate the semantics of the word transfer, and the word discharge against medical advice, be my guest. But at that point it's semantics because the exact same thing happened in both scenarios. The potential receiving facility was called, the patient left by car, and they were stabilized to the best of my ability.
 

Tenk

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We transfer people by private car all the time so long as stable and non cardiac/respiratory, haven't given anything sedating and also aren't on any drips. It's a big bill and you just document that you recommended ambulance and have patient sign an AMA form where you write that you want them to go by ambulance.

The other hospital cannot refuse based on this.
 

Dr.McNinja

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Now if you consider the family or person driving to be qualified personnel with appropriate transportation equipment then you're right it's a transfer. I don't. if you still want to debate the semantics of the word transfer, and the word discharge against medical advice, be my guest. But at that point it's semantics because the exact same thing happened in both scenarios. The potential receiving facility was called, the patient left by car, and they were stabilized to the best of my ability.
So consider these hypotheticals. You've got someone with a broken hand. They're 25. If you call an ambulance for transfer, that ambulance then proceeds to do nothing for the patient except act as a taxi. No ALS or BLS given. What is the difference between that and their own car?

A second one. In many places a bimal can be discharged. However, you call the orthopod, who is new, and he wants the patient transferred to his facility to up his numbers. So the patient that you would normally feel safe to let go home in their own car and sleep in their own house, suddenly can't use their own car to drive to another hospital for faster definitive care?

I'm not talking about people driving while titrating their own levophed drips and giving themselves blood here. Simple, stable patients who aren't actively receiving anything can go by their own car.

Also, as a receiving physician, the number of times somebody gets transferred to my hospital, 30+ miles from home (and sometimes >100), and then is discharged to the lobby to wait hours for family to show up is entirely too common. Especially when the condition didn't actually warrant transfer to begin with but the receiving doc can't see the patient on the other end of the phone.
 

Dr.McNinja

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Per emtala.com, criteria for an appropriate transfer include:
  • "the transfer is effected with the use of qualified personnel and transportation equipment, as required by the circumstances, including the use of necessary and medically appropriate life support measures during the transfer."
Also per emtala.com
The author of this FAQ is M. Sean Fosmire, an attorney practicing in Marquette, Michigan with 29 years' experience in defending hospitals and physicians in professional liability litigation, both in Detroit and in Northern Michigan.
It's not part of the law.
Per ACEP
  • The mode of transportation used for transfers should be at the discretion of the treating provider and based on the individual clinical situation, available options, needed equipment and patient preference. Options for transport include but are not limited to ambulance, air-transport and private vehicle. Regardless of the method of transfer, intravenous access may remain in place if deemed appropriate by the referring provider.
If they're going specifically from your hospital A to their hospital B, by any means, they need the transfer agreement including the accepting physician's name, and any relevant documentation. Discharging the patient AMA generally doesn't give them those things (specifically the transfer page).

And before anyone argues about the patient going to the wrong hospital, I have that happen with ambulances about once a month. Nobody is immune to it. The worst part is once the error is discovered, some hospitals think that because the patient arrived by EMS that they therefore have an EMTALA obligation to the patient.
 

e30ftw

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If the patient has medical decision making capacity they can absolutely drive themselves to the receiving hospital. I use the same documentation in these cases as I do discharging an 85 y/o CHF'er with syncope who refuses OBS. Advise the patient to be transferred by ambulance, explained reasoning including possible reduced cost (via insurance bundling multiple visits into one admission) and fact that they may have to wait in the other ER waiting room for 5 hours (this is most effective) and if the patient refuses, document all of the above and discharge them.

The "receiving" hospital in this case has no authority or ability to refuse "transfer" as the patient is just going to show up at their ER and you are doing them a courtesy of even calling..
 

Dr.McNinja

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Advise the patient to be transferred by ambulance, explained reasoning including possible reduced cost (via insurance bundling multiple visits into one admission) and fact that they may have to wait in the other ER waiting room for 5 hours (this is most effective) and if the patient refuses, document all of the above and discharge them.
If they're going to wait in the ED for 5 hours, it's the same for EMS as it is for POV. If they have a ready bed and show up by POV, they go to that just like they would if it's a direct admit for day surgery.
Trying to convince them otherwise is similar to telling them that leaving AMA will result in them being on the hook for the bill. They aren't, and it's foolhardy to do so.
 

e30ftw

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Interfacility transport protocol in my area is via EMS.

I have transported a few via private vehicle directly to an inpatient bed (usually stable chemo patients with an attentive oncologist) but the vast majority of patients I transfer would not be appropriate as POV (due to IV, meds) and if they refuse EMS I would document it as an AMA (although not make the patient sign) and inform them that they would have to check in to the ER rather than go to a bed as they are going against my advice. Anyone else stable enough to be transferred as a direct admit via POV I would just keep at my hospital..

Foolhardy is a rather strong term for you to use in the context of this thread.
 

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If they're going to wait in the ED for 5 hours, it's the same for EMS as it is for POV. If they have a ready bed and show up by POV, they go to that just like they would if it's a direct admit for day surgery.
Trying to convince them otherwise is similar to telling them that leaving AMA will result in them being on the hook for the bill. They aren't, and it's foolhardy to do so.
And I had a guy with a new creatinine of 5 that the hospitalist accepted, but, when I told him the patient wanted to go POV, he rescinded his acceptance, and said the pt would have to present to the ED.

Had I known that that was an EMTALA thing, I would have said something. I had always thought, though, that POV=discharge.

I raised the same question with the SANE nurse - that the SA victim going by POV is an easy dismissal for the defense attorney.
 

BJJVP

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Every time I think that I understand EMTALA, someone brings up a special case or situation that makes me wonder. At this point, I have resigned to the fact that I will never understand EMTALA and I have basically refused to try anymore. I even skip that section on my board review materials. I will simply do what I think is best for the patient, or at least what I would like to have done for myself or a family member.
 

Dr.McNinja

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Anyone else stable enough to be transferred as a direct admit via POV I would just keep at my hospital.
So, you've got peds ortho? 24/7 hand? Ophtho? Any other specialty where they might need a very small part of them examined by a person but aren't in extemis?
If you can keep them at your hospital, you aren't allowed to transport them to another faclity unless they request it. That's also part of EMTALA. Any transfer is due to higher level of care, not just "level of sickness".

Your protocol is fine, but you can't force people to not go by POV, and discharging them so they can go to another ER might actually end up with you not getting paid for their visit, as most insurers will only pay one ER visit for a DRG. They can certainly go to the registration desk (which might be the ER desk 16 hours of the day, I agree), without taking up an ER bed.

Again, we aren't talking about people driving to the hospital while a LUCAS device pounds their chest.

I mean, there's a reason ACEP has it listed in their recommendations. And yes, telling them that if they don't go by EMS that they have to wait in the ER is by definition placing them under duress, or coercion, and puts you in iffy legal standing. Similar to your nurses telling htem that if they leave AMA they are on the hook for the bill (also not true). POV transports are accepted legally every single day.
 

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People have to realize that EMTALA is pretty black and white.
This is something I just don't get. There are repeated conversations on this forum and other places regarding EMTALA, HIPPA, capacity, etc. where people chime in with opinions like it's a medical decision rather than a legal issue with clearly written rules.

You can't force a patient to go by ambulance and you can't abandon them because they disagree with one part of your plan. You can pad your chart with whatever documentation lets you sleep at night but ultimately it is the patient's (assuming intact capacity) decision to transfer by POV or ambulance.
 
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