There has to be prior notice filed with most states before you can close an ER. If you close it, then you must go through another certificate of need to establish need to open it.
Bigger problem from my facility is the hospitalists. Nobody will touch a head bleed with a ten foot pole, and will only admit for meemaw that is on comfort care. Otherwise, we're told to ship them. For bleeds we know are minimal sometimes we can consult NSGY at the tertiary center and get recs to obs and rescan in 6 hours and can then sometimes convince our hospitalists to obs those, but they still don't like it and it really depends on who is working. A couple of times I've kept patients in the ED for the repeat scan but we don't have tons of beds and don't have an obs unit, so they sit for at least 6 (more realistically 7-8, since they don't get scanned minute one of being in the department) hours, and LOS goes to s***, as does the waiting room.
You're saying your LOS goes out the window, but what about tying up a bed at another facility, the cost of transfer, etc.? My LOS also increases from the unnecessary transfers.
Yeah. But to be fair to me, I've read this thread and replies over 3 different shifts so I didn't even recall you said that. Ha.
Yeah man I get it. I've been on the receiving end as well. I hate when patients ask questions about how much money a transfer will cost, because I know it will be many dollars. I don't like tying up beds, hence trying to angle for NSGY phone consults instead when I reasonably can, but sometimes that can't happen with any reasonable speed, and at some point, if my admitting docs/surgeons all say "send the patient" and I say "Nah we're just gonna chill here in the ED for 6 hours trust me patient bro" then I'll be asked why, and possibly open myself up to liability.
I don't disagree from a medical standpoint - these patients could be safely kept at community hospitals for observation, repeat imaging, disposition.
When I was in community hospitals without neurosurgery or trauma surgery coverage, and when I currently work in these facilities PRN, I have not had an issue with their disposition (repeat CT and home/hospitalist admitting).
Keep in mind the way EMS is in a lot of the country, there is no "quick transfer" process unless you are flying the patient. We've had critical head bleeds that needed emergent craniotomies wait 6+ hours for an ambulance when weather wouldn't permit a helicopter to fly the patient.
Yesterday a patient was being transferred to us for {non critical urgent surgical issue} and they told the patient there wouldn’t be an ambulance available for 12 hours. The patient decided to drive down instead (3-4 hour drive) and they made her sign out AMA! Also didn’t give her copies of anything 😠
Meh. Depends on the case. If the patient is completely stable (e.g. they could followup the next day just as easily) then I agree that's dumb. If the patient truly has an urgent surgical need which has the potential to decompensate en route, I'd do the same thing (but send them with the normal transfer paperwork).
I don’t blame people to sign out to facilitate their own care if we can’t get them where they need to go .. and I honestly was upset they sent her without her testing. Just a piece of paper that said “ama”. She had normal vitals and needed a chole.
This is a blatant EMTALA violation.
Definitely happened to me before and I’ve honestly made the effort to have them stay and be transferred per EMS etc. But I always give copies of their stuff and call the receiving hospital to tell them what happened. It’s not EMTALA in my opinion if the patient takes things into their own hands and leaves despite the transferring hospital’s best efforts.
If they leave AMA voluntarily it is *not* an EMTALA violation. But if the sending facility coerces or even suggests leaving AMA and taking a private vehicle this is a violation. Medical and actual advice are one and the same. Under EMTALA (and professional ethics) you have an obligation to either treat at your facility or stabilize and transfer if the medical presentation calls for it.
It's an EMTALA violation if they sign out AMA, you know they are leaving to go to the receiving facility, and you do not (1) notify the facility and (2) send records with the patient.
Even if the sending facility doesn't coerce the patient into leaving AMA, if they know they are leaving AMA with intent to go to the receiving facility, EMTALA requires that the sending facility notify the receiving facility of the patient leaving AMA and going on their own as well as sending records with the patient.
San Mateo Medical Center (CA, 2019) was found to be in EMTALA violation for allowing a patient to be transferred via private vehicle while presenting with abdominal pain, vaginal bleeding, and vaginal discharge while 25 weeks pregnant. The MSE was not performed because the ED physician did not perform a vaginal exam and failed to determine if the patient was in labor. Patient delivered in her car and the baby died. Settlement was $20,000.
I'm just going to go ahead and say that EMTALA sucks. The more I learn about it, the more pointlessly draconian it seems.
Right. I think it was safe though not ideal for the patient to get a private ride to my hospital, and honestly what I would have done myself. They knew she left ama because she had a paper that said ama. My issue was with them not spending the same amount of time and pieces of paper to print her labs and US results.
The land of Death Panels.
I was primarily discussing the AMA component of when you advise transfer with medical transport and the patient declines against your advice.
USC Medical Center in Los Angeles essentially does this. They have an “Evaluation and Treatment Clinic” that operates 24/7 and is staffed by USC’s EPs. Patients can only go there with a referral from their USC or private physician or after hours physician nurses line. Patients can also be brought there by private ambulance under the same circumstances. For many years the Cleveland Clinic operated in the same way but there was immense political pressure to open an actual ED and they now see 60k or so.
In this vein I remember taking a call as a resident rotating on the ortho spine service.
This transfer nonsense goes both ways. Case from few weeks ago:
Some of those people that work at the trauma center can be incredibly asinine.
Causing unnecessary delays or requesting additional studies to be done by the transferring facility can also be interpreted as an EMTALA violation by the receiving facility. In this case, patient has a clear reason to be transferred. Asking them to wait on CT results is an EMTALA violation. The other example with the scalp lac does not have a clear reason for transfer as any ER can handle that. There's no basis for transfer.
No real ER at their main campus. They have two ERs at community hospitals they own, though. LAC-USC, a public hospital they provide physician coverage for, is across the street from their medical center. Not having an ER is most likely an avoidance tool to keep indigent patients out of their hospital.
I do the same thing all the time from our freestanding. Agree 100%.
No, but I sometimes do ask "so let me get this straight, you have the capability to care for this patient but you're wanting to transfer because your hospitalist is refusing to admit the patient?"
Even if they fired the patient from their private practice, if the specialist is on call for the ED, they are obligated to provide care or arrange for alternate care themselves. So if they want someone not on call to deal with it, it is up to the specialist to arrange for such care.
