Another EMTALA question - transferring in labor

[Boatswain2PA]

New job at CAH in very remote area an hour drive from OB. Hospital admin says hospital was fined for EMTALA violation for transferring a pt dilated to 4 cm, so if I find that I have to go with her on transfer and thus leave the ED unstaffed (frequently difficult to find someone to backfill). So far I've been getting about one patient a week in first stages of labor.

I'm certainly no EMTALA expert, but from everything I've read/listened I've never heard anything like this. Any EMTALA experts here who can point me to some references refuting this? I would like to take something to admin to calm them down on the issue. Or am I wrong and this is what EMTALA requires?

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[BoardingDoc]

New job at CAH in very remote area an hour drive from OB. Hospital admin says hospital was fined for EMTALA violation for transferring a pt dilated to 4 cm, so if I find that I have to go with her on transfer and thus leave the ED unstaffed (frequently difficult to find someone to backfill). So far I've been getting about one patient a week in first stages of labor.

I'm certainly no EMTALA expert, but from everything I've read/listened I've never heard anything like this. Any EMTALA experts here who can point me to some references refuting this? I would like to take something to admin to calm them down on the issue. Or am I wrong and this is what EMTALA requires?

I can't answer your question satisfactorily, but I would imagine that there are far greater legal perils associated with abandoning the ED than with transferring a patient in early labor.

 

[southerndoc]

There are a couple of EMTALA cases for transferring someone in active labor, but generally, if you don't have the resources to care for the patient, then transfer is acceptable. You do not need to send a physician, but a nurse may be ideal. I will post more when I have time.

 

[AlmostAnMD]

There is a lot of missing information here. A cervical dilation of 4 cm is not an emtala violation! It can be that dilated for days and absolutely in many, if not most circumstances, would not preclude transfer. If hospital was fined it was for a reason not written here.

 

[GonnaBeADoc2222]

No physician at a CAH. Sounds safe!

 

[Boatswain2PA]

There is a lot of missing information here. A cervical dilation of 4 cm is not an emtala violation! It can be that dilated for days and absolutely in many, if not most circumstances, would not preclude transfer. If hospital was fined it was for a reason not written here.

I agree, I'm trying to figure that out, but that's what they are telling me.

There are a couple of EMTALA cases for transferring someone in active labor, but generally, if you don't have the resources to care for the patient, then transfer is acceptable. You do not need to send a physician, but a nurse may be ideal. I will post more when I have time.

That's my understanding as well. Would appreciate any resources you could send my way to calm admin down on this.

No physician at a CAH. Sounds safe!

Haters gonna hate.
Are you a doc yet Junior?

 

[GonnaBeADoc2222]

I agree, I'm trying to figure that out, but that's what they are telling me.

That's my understanding as well. Would appreciate any resources you could send my way to calm admin down on this.

Haters gonna hate.
Are you a doc yet Junior?

Been one for 10 years broski.

 

[Boatswain2PA]

Been one for 10 years broski.

Good for you. I hope you are one of the successful ones who is a multi-millioinaire by now who also loves their job. BTW - I would be more like your dad than your broski.

Any ideas on the topic at hand?

 

[turkeyjerky]

There is a lot of missing information here. A cervical dilation of 4 cm is not an emtala violation! It can be that dilated for days and absolutely in many, if not most circumstances, would not preclude transfer. If hospital was fined it was for a reason not written here.

Probably a typical example of reflexive admin overcompliance. They likely got fined for transferring a patient who delivered en route, so now any patient in active labor, eg cervical dilation to 4 cm combined w/ regular contractions (which emtala explicitely defines as an emergency medical condition) cannot be transferred via normal channels. They neglect to realize that we transfer 'unstable' patients all the time. Maybe somebody f'ed up the last time and marked the patient as 'stable'.

I'm not sure how putting a nurse, doc or pa in the back of an ambulance somehow negates emtala. This aspect is puzzling to me.

 

[thegenius]

Aren't ER doctors trained to deliver babies in emergency situations?

I had a woman come in who just discovered she was pregnant (about 34-5 wks, but at the time she NOR we didn't know how pregnant she was) and the fetus was breech and I could feel the knee or foot poking out of her cervix.

Luckily a hospital 5 minutes away with OB services accepted the woman for transfer, and she delivered within about 10 minutes of arrival to the other hospital.

 

[CoolDoc1729]

New job at CAH in very remote area an hour drive from OB. Hospital admin says hospital was fined for EMTALA violation for transferring a pt dilated to 4 cm, so if I find that I have to go with her on transfer and thus leave the ED unstaffed (frequently difficult to find someone to backfill). So far I've been getting about one patient a week in first stages of labor.

I'm certainly no EMTALA expert, but from everything I've read/listened I've never heard anything like this. Any EMTALA experts here who can point me to some references refuting this? I would like to take something to admin to calm them down on the issue. Or am I wrong and this is what EMTALA requires?

I’ve often wondered what I would do as a pregnant woman in a critical access area. Especially a resource limited pregnant woman. Live in a hotel in a populated area from 34 weeks? I had one of my kids at 33 weeks and required NICU/intubation for him and icu for me. I’m fortunate I live in an area with specialist physicians or we truly might not all be here.
I think leaving the ER unattended is a hard stop no. Emtala requires you to stabilize to the best of your abilities. I think how I would play your situation would to tell the woman look, i technically can deliver your baby but I don’t have a nicu, anesthesia for epidural, etc etc and get them to request transfer, then check the patient request box on the paperwork. Unless the head is literally already halfway out and then they’re clearly not going to make it to Shiny Memorial Hospital

 

[Boatswain2PA]

Aren't ER doctors trained to deliver babies in emergency situations?

Sure, but the best outcomes for mom/baby would be to deliver in a resource-rich center with an OB, anesthesia, pediatrics, and NICU/PICU/ICU; as long as she doesn't deliver enroute, which would be rude to do to the basic EMT's who do most of our transports.

Apparently we deliver several babies a year in this ED, and I'm averaging one laboring mom a week. So far I've gotten them all to Shiny Memorial on time.

Emtala requires you to stabilize to the best of your abilities. I think how I would play your situation would to tell the woman look, i technically can deliver your baby but I don’t have a nicu, anesthesia for epidural, etc etc and get them to request transfer, then check the patient request box on the paperwork.

That's been my MO so far. Haven't shipped anyone who I felt would be questionable for making it, but I've made admin a little nervous.

Probably a typical example of reflexive admin overcompliance.

That's my feeling about the situation, but I don't know enough yet to say for sure.

cervical dilation to 4 cm combined w/ regular contractions (which emtala explicitely defines as an emergency medical condition)

Can you point me to exactly where to find this? Looking for something to abate the reflexive admin overcompliance (I'm stealing that phrase).

 

[gutonc]

I’ve often wondered what I would do as a pregnant woman in a critical access area. Especially a resource limited pregnant woman.

I am not a woman and will mercifully never be in this particular position, but having taken (IM, not EM or surgery) transfers from "good" CAH's I have decided that I will never live more than a 30 minute drive at rush hour from "Shiny Memorial".

 

[HemeOncHopeful19]

There are a couple of EMTALA cases for transferring someone in active labor, but generally, if you don't have the resources to care for the patient, then transfer is acceptable. You do not need to send a physician, but a nurse may be ideal. I will post more when I have time.

I've read you post before that if a physician is credentialed to perform a service then CMS can determine that they "have the capacity" to perform that service at said hospital. Would that not be the case if OP is credentialed for deliveries?

 

[Boatswain2PA]

I am not a woman and will mercifully never be in this particular position, but having taken (IM, not EM or surgery) transfers from "good" CAH's I have decided that I will never live more than a 30 minute drive at rush hour from "Shiny Memorial".

Quality of life issues of living in the city vs country aside, I can understand this sentiment. I have seen some absolutely horrible medical care in CAH's, and with the explosion of NP programs churning out licenses with massive student loan debt I think the overall quality of rural EM is terrible.
That being said, I've also seen terrible care at tertiary centers. From the wait time in the EDs to understaffed nurses in the ICU, that's not exactly a pretty picture for patients either.

The medically literate can navigate through and know where to get the best medical care. Got a minor problem? Can be seen/treated quickly (and hopefully well) at a small hospital. Are you 6 weeks s/p whipple, gained 30 pounds since d/c with protuberant belly, SOB and febrile? Yeah....don't go to the local 5 bed ED. BEST case scenario we just delay your care while making phone calls to transfer you, WORST case scenario you get a poorly trained new grad who has no idea what to do. Unfortunately most of our patients are not medially literate.

 

[southerndoc]

I've read you post before that if a physician is credentialed to perform a service then CMS can determine that they "have the capacity" to perform that service at said hospital. Would that not be the case if OP is credentialed for deliveries?

OP is a PA, and not many PAs are credentialed for deliveries.

Having said that, if delivery is imminent, then yes, it would be an absolute EMTALA violation to transfer that patient. However, by fact that someone is in active labor, it doesn't in itself define imminent delivery. The patient, however, is still considered unstable by CMS EMTALA standards. Therefore, it prevents discharge or transfer unless the transferring hospital has absolutely no capability to deliver the baby safely. If the referring facility believes that the transport to a receiving facility with OB and neonatal capability would be beneficial to the patient, and if delivery is thought to not be imminent, then you can transfer the patient.

The problem is if the patient suddenly delivers in the ambulance during transport, then it's likely that CMS can say that delivery was imminent when you transferred the patient and OIG will fine the referring facility and the referring physician. It's a catch-22 with the situation. A shorter transfer is unlikely to result in a delivery vs a 90-minute transfer to a receiving facility with OB capability.

Sorry I was going to post more on this, but I haven't had the time to devote to it yet. This is the gist of OB transfers. And yes, you are absolutely correct, CMS has held specialists to procedures they are credentialed in without regard to how frequently they perform them.

 

[HemeOncHopeful19]

OP is a PA, and not many PAs are credentialed for deliveries.

Having said that, if delivery is imminent, then yes, it would be an absolute EMTALA violation to transfer that patient. However, by fact that someone is in active labor, it doesn't in itself define imminent delivery. The patient, however, is still considered unstable by CMS EMTALA standards. Therefore, it prevents discharge or transfer unless the transferring hospital has absolutely no capability to deliver the baby safely. If the referring facility believes that the transport to a receiving facility with OB and neonatal capability would be beneficial to the patient, and if delivery is thought to not be imminent, then you can transfer the patient.

The problem is if the patient suddenly delivers in the ambulance during transport, then it's likely that CMS can say that delivery was imminent when you transferred the patient and OIG will fine the referring facility and the referring physician. It's a catch-22 with the situation. A shorter transfer is unlikely to result in a delivery vs a 90-minute transfer to a receiving facility with OB capability.

Sorry I was going to post more on this, but I haven't had the time to devote to it yet. This is the gist of OB transfers. And yes, you are absolutely correct, CMS has held specialists to procedures they are credentialed in without regard to how frequently they perform them.

Sorry I did not catch that OP was a PA, but it gives me even more questions. I'm having difficulty wording them at the moment... but couldn't we assume that OP may be credentialed to deliver if he is being left alone on solo coverage and the hospital feels it would be an EMTALA violation for him to ship someone out? Also, how would OP "going with her" lessen the EMTALA risk?

I obviously don't work in the ER but I always find your EMTALA discussions interesting.

 

[Boatswain2PA]

Credentialing in small hospitals can be very different than larger hospitals. Some tiny hospitals only have one doc, and a couple of midlevels (or PLPs as RustedFox affectionately call us), and the "credentialing meeting" is someone signing the credentialing paperwork thrown on their desk. I have literally had credentialing paperwork returned to me signed within 5 minutes of me handing it to the credentialing person

Most of the time the credentialing request form is generic, and lists everything from checking blood pressure to doing c-sections (etc ad nauseum), with the applicant just checking whatever they feel comfortable with. It ain't right, but it's common. I've probably worked in 20 small hospitals like this. I usually check off the EM related stuff (no pap smears, etc), and then at the end write in "all emergency procedures".

SouthernDoc (et al)- that is all my understanding as well and how I practice. I am looking for something to take to admin to settle them down on this issue. I really don't want to sit on a mom for 10 hours as she is slowly progressing from a 4 to delivery. Looking forward to your (and others) thoughts/advice.

 

[emergentmd]

What is technically EMTALA correct vs what is practical/best for the pt is different story. When faced with this, I go towards what is best for the pt.

4cm dilated could mean delivery in 10 min vs delivery in 5 hrs. Our 1st child delivered 6 hrs after my wife was 4cm dilated.

So if I were the pt, I would ask to be flown to the nearest hospital. Now if head is coming out or imminent, then Im there to catch.

I am neither an OB doc or NICU doc so best risk EMTALA if only 4cm dilated.

Also, thank God I have always worked at hospitals with OB/Specialists in house.

 

[southerndoc]

So if I were the pt, I would ask to be flown to the nearest hospital. Now if head is coming out or imminent, then Im there to catch.

Air medical (HEMS at least) almost always will not fly someone in active labor. The thought of delivering a baby in an H-135 is terrifying, but can't even imagine a pilot wanting to deliver the baby in an H125. LOL Bell 206 and 407 are the same configuration as the H125 (feet next to the pilot), so wouldn't imagine those pilots would want to deliver either.

You'd need at least an S-76, H-145, AW109, Bell 412, etc. to have access to the feet to deliver a baby in a helicopter.

 

[EMhawkeye]

Speaking as a physician who has practiced OB, 4 cm is not active labor. New diameter for purposes of emtala is 6 cm or greater than 1 cm increase in one hour.

 

[Boatswain2PA]

Speaking as a physician who has practiced OB, 4 cm is not active labor. New diameter for purposes of emtala is 6 cm or greater than 1 cm increase in one hour.

Can you point me to a reference for this? 6 cm is much more reasonable, and the progression is probably even better.

 

[RustedFox]

Speaking as a physician who has practiced OB, 4 cm is not active labor. New diameter for purposes of emtala is 6 cm or greater than 1 cm increase in one hour.

Good. To. Know.

I now know one number. 4.

 

[maxxor]

Can you point me to a reference for this? 6 cm is much more reasonable, and the progression is probably even better.

A lot of patient focused education websites say 6 cm. Here’s Mayo clinic

Stages of labor and birth: Baby, it's time!

Find out what happens during the different stages of labor and birth.

www.mayoclinic.org