Diversion…

[thegenius]

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Can't ER's just close down for a period of time and not accept anyone?

What law exists that they must be open 24 / 7?

 

[southerndoc]

Can't ER's just close down for a period of time and not accept anyone?

What law exists that they must be open 24 / 7?

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.

A hospital does not need an ER to be a hospital. However, they must make it clear that there is no emergency services offered.

 

[thegenius]

Do most hospitals get special dispensation to be an ER (meaning they get gov't subsidies)?

Seems to me they can opt to not have an "Emergency Department" - rather call it something else that's open when they want and under their own rules. They can advertise it to their community any way they way. It's not an urgent care...or maybe a glorified urgent care that is open most of the time but they have the right to close down whenever they want. Or refuse certain kinds of patients.

What advantage does a hospital have by running an ER? Besides the obvious that they get a source of income and can bill under emergency services?

 

[thegenius]

What if there's a fire in an ER and they can't operate for a period of time? Or everyone just leaves and it's not staffed? They should put a closed sign on the door. What would happen if EMS brought patients to an ER that isn't staffed?

Or if CT / Xray / MRI are down...or there is a strike and nobody operating the lab? There are all sorts of conditions I can see where an ER can't function as an ER.

I'm sure there are c-suite admin lawyers who have tried to figure this out at some point.

 

[gruemd]

In all seriousness, it does get frustrating when we have a ton of patients just waiting for SAR placement taking up inpatient beds, which clogs up the ER with people waiting on beds, which keeps us from accepting transfers that need to come to us. Not every head bleed needs to be transferred (brush up on BIG criteria), an elderly lady with 3 rib fractures needing pain control does not need a trauma center, etc. When people flood a tertiary referral center with that non-sense then no, we won't have room to take your stroke with 12 hours of symptoms who needs a thrombectomy, your subdural with impending herniation needing a crani, or your young person needing ECMO.

It drives me crazy to accept a trace subarachnoid hemorrhage from a trauma only to repeat their CT and discharge them from the ER without a neurosurgeon ever seeing them. This should be done by the transferring facility without ever involving me or my neurosurgeon, but you can't get some of them to man up. This literally happened the other day, and unfortunately, while the patient was sitting in the ER we became quite saturated and I had to turn down 2 transfers for things that needed to come here.

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.

 

[RustedFox]

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.

So, what I said.

 

[southerndoc]

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.

 

[gruemd]

So, what I said.

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.

 

[gruemd]

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 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.

 

[bravotwozero]

What if there's a fire in an ER and they can't operate for a period of time?

This exact scenario has happened in my ED. Twice. Both cases were psych patients managing to sneak in lighters past security and police (still don’t know how this happens) and set their rooms on fire.

We actually did shut down our ED for a few hours and declared were on internal disaster mode.

 

[bougiecric]

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.

I don't disagree from a medical standpoint - these patients could be safely kept at community hospitals for observation, repeat imaging, disposition.

But at the same time, the culture (and arguably the standard of care depending on location), is for them to have a face to face consult with a neurosurgeon. Every community site I've worked at that doesn't have neurosurgery coverage transfers these patients to a facility that does. Similarly with "trauma" patients (i.e. the elderly patient with rib fractures you've described).

I guess the umbrage I take is that your frustration seems directed at the community hospitals transferring these patients, as opposed to the larger cultural/systemic forces that have created the scenario in the first place. It's not fair to say "man up" when the standard of care at a given community hospital is to transfer out.

I'm all for changing the system, implementing BIG criteria, etc, but it has to be at a higher level than the individual doctors.

 

[emergentmd]

There are many reasons why transferring docs are trigger happy, and on the rare cases that I worked at a Critical access hospital I prefer a quick transfer including staff quality and quantity typically stinks. Its just better for the pt to be at a place that has more resources and I rather be sent to the mother ship than be in a rural ER where I have no idea about the quality of the staff or doc who very well could be family medicine trained who rarely works in the ER.

 

[southerndoc]

I don't disagree from a medical standpoint - these patients could be safely kept at community hospitals for observation, repeat imaging, disposition.

But at the same time, the culture (and arguably the standard of care depending on location), is for them to have a face to face consult with a neurosurgeon. Every community site I've worked at that doesn't have neurosurgery coverage transfers these patients to a facility that does. Similarly with "trauma" patients (i.e. the elderly patient with rib fractures you've described).

I guess the umbrage I take is that your frustration seems directed at the community hospitals transferring these patients, as opposed to the larger cultural/systemic forces that have created the scenario in the first place. It's not fair to say "man up" when the standard of care at a given community hospital is to transfer out.

I'm all for changing the system, implementing BIG criteria, etc, but it has to be at a higher level than the individual doctors.

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).

If EMTALA would allow, I would certainly decline these types of transfers even when we have zero patients.

One example from the other day was a 19 year old with a trace subarachnoid hemorrhage after a skateboard accident. He sat in the outside ER for 8 hours waiting on an ambulance to become available to transfer him to my facility. By the time he got here (a 2 hour trip), he was literally 12 hours post injury (he presented to outside ER after about 3-4 hours post injury). We did a head CT within an hour of his arrival and he was discharged. Length of stay in my ER was 90 mins. I never once spoke to neurosurgery. The father was mad that he was transferred and asked "why couldn't they have done this at (xxx) Hospital?" I told him "each hospital has their own protocols for how to handle this." I could've easily said "I dunno, they're just being obtuse and insisting the patient get transferred because it's the easiest way to dispo the patient for them."

 

[southerndoc]

There are many reasons why transferring docs are trigger happy, and on the rare cases that I worked at a Critical access hospital I prefer a quick transfer including staff quality and quantity typically stinks. Its just better for the pt to be at a place that has more resources and I rather be sent to the mother ship than be in a rural ER where I have no idea about the quality of the staff or doc who very well could be family medicine trained who rarely works in the ER.

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.

 

[CoolDoc1729]

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 😠

 

[BoardingDoc]

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).

 

[CoolDoc1729]

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.

 

[southerndoc]

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 😠

This is a blatant EMTALA violation.

 

[Dr Mantis Toboggan]

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 😠

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.

 

[p1acebo]

Med mal dude.. med mal. while you may be up to date on all the latest research and such those docs in smaller facilities dont know. The risk is real and lets also be real you can also "man up" and tell them how they should manage it and not accept them. Of course EMtala is a thing and most hospitals want the inpatient business. It goes both ways.

I say this as someone who works in both a well resourced hospital and others with little to no resources.

This in spades. The hospitalist doesn’t want to get stuck with a potential lawsuit (However exceedingly rare that might be) admitting a patient to a hospital that does have the sub specialist that MIGHT be needed. Definitely frustrating when it’s not practice to transfer.

This is a blatant EMTALA violation.

How is it an EMTALA violation if the patient decides they don’t want to wait and are capable of making their own decisions? You can’t force them to stay in your ED against their will. Hell I would probably do the same thing if it was going to be a +12 hour wait to transfer.. then again I wouldn’t go to a critical access hospital for care in the first place if I can avoid it.

 

[old_boy]

How is it an EMTALA violation if the patient decides they don’t want to wait and are capable of making their own decisions?

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.

I understand the complex and sometimes altruistic motivations behind it, but telling patients to leave AMA is poor form.

 

[Mount Asclepius]

I know this is an aside to the EMS diversion discussion, but it always bothers me how physicians use AMA inappropriately. It’s been discussed before, but is worth repeating given its continued misuse. Essentially it is your medical advice to transfer via ambulance even if there is a delay in obtaining. Otherwise you'd just recommend transfer via private auto and then this isn't a discussion. The patient elects to leave though against your advice to transfer via private auto. You still do what's right for the patient by providing them with records so that they can continue to receive care if they decide to self transfer. You don’t, ‘make them leave AMA and just leave it up to them since they didn’t do what you wanted.’ The AMA discussion is an actual conversation regarding risks/benefits with reflective charting. The form isn't that important. Patients frequently make testing, treatment or admission/transfer decisions against our advice. Documenting that is important. Not just classifying them broadly as AMA and using a form. The important thing is the risks/benefit discussion, as well as helping and doing what is right by the patient by providing them with records. Against your advice (i.e. officially AMA) doesn't mean you don't still help the patient with records, providing prescriptions or assisting with followup. Too many physicians have the poor assumption that leaving AMA completely nulls your obligation to the patient and provides full legal protection. AMA involves increased risk. Therefore you should take extra care to ensure the patient has the best outcome possible. In conclusion, if a patient decides to self transfer that is okay. You can document that it wasn't your advice to transfer that way. It isn't an EMTALA violation in my opinion. You also should be okay with self-transfer if it is reasonable.

 

[southerndoc]

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.

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.

 

[southerndoc]

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.

I understand the complex and sometimes altruistic motivations behind it, but telling patients to leave AMA is poor form.

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.

 

[southerndoc]

I know this is an aside to the EMS diversion discussion, but it always bothers me how physicians use AMA inappropriately. It’s been discussed before, but is worth repeating given its continued misuse. Essentially it is your medical advice to transfer via ambulance even if there is a delay in obtaining. Otherwise you'd just recommend transfer via private auto and then this isn't a discussion. The patient elects to leave though against your advice to transfer via private auto. You still do what's right for the patient by providing them with records so that they can continue to receive care if they decide to self transfer. You don’t, ‘make them leave AMA and just leave it up to them since they didn’t do what you wanted.’ The AMA discussion is an actual conversation regarding risks/benefits with reflective charting. The form isn't that important. Patients frequently make testing, treatment or admission/transfer decisions against our advice. Documenting that is important. Not just classifying them broadly as AMA and using a form. The important thing is the risks/benefit discussion, as well as helping and doing what is right by the patient by providing them with records. Against your advice (i.e. officially AMA) doesn't mean you don't still help the patient with records, providing prescriptions or assisting with followup. Too many physicians have the poor assumption that leaving AMA completely nulls your obligation to the patient and provides full legal protection. AMA involves increased risk. Therefore you should take extra care to ensure the patient has the best outcome possible. In conclusion, if a patient decides to self transfer that is okay. You can document that it wasn't your advice to transfer that way. It isn't an EMTALA violation in my opinion. You also should be okay with self-transfer if it is reasonable.

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.

Research Medical Center (MO, 2016) settled for $360,000 for an EMTALA violation for a psychiatric patient who was transferred by private vehicle and decided to exit the vehicle enroute to the psychiatric facility causing their death.

There are currently 3 cases I'm aware of that are from 2021/2022 that involve patients being transferred by private vehicle who decompensated enroute. I'm not at liberty to discuss these cases due to ongoing issues, but I can try to circle back around when the issues are settled with CMS/OIG. One is only very very recent and just had their Entrance Conference with CMS.

For the record, CMS does NOT consider private vehicle transportation an appropriate mode of transportation for an EMTALA transfer. If a patient refuses on his or her own accord, then that is different and should be clearly documented.

In order to be in compliance with 42 CFR §489.24, the CMS SOM Interpretative Guidelines specifically state: "Ensure that the transfer of an unstabilized individual is effected through qualified personnel and transportation equipment, including the use of medically appropriate life support measures." Keep in mind, you're pretty much NEVER transferring a stabilized patient in the eyes of CMS. Stable by us and stable by CMS are on totally different concepts.

On another note, the interpretive guidelines also state: "A hospital is required to report to CMS or the State survey agency promptly when it suspects it may have received an improperly transferred individual. Notification should occur within 72 hours of the occurrence. Failure to report improper transfers may subject the receiving hospital to termination of its provider agreement." In other words, if a transferring facility violates EMTALA and the receiving facility doesn't report it, the receiving facility could risk termination of its CMS participation if CMS finds out about it. This is even more important now that patients can report EMTALA violations.

 

[BoardingDoc]

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.

Research Medical Center (MO, 2016) settled for $360,000 for an EMTALA violation for a psychiatric patient who was transferred by private vehicle and decided to exit the vehicle enroute to the psychiatric facility causing their death.

There are currently 3 cases I'm aware of that are from 2021/2022 that involve patients being transferred by private vehicle who decompensated enroute. I'm not at liberty to discuss these cases due to ongoing issues, but I can try to circle back around when the issues are settled with CMS/OIG. One is only very very recent and just had their Entrance Conference with CMS.

For the record, CMS does NOT consider private vehicle transportation an appropriate mode of transportation for an EMTALA transfer. If a patient refuses on his or her own accord, then that is different and should be clearly documented.

In order to be in compliance with 42 CFR §489.24, the CMS SOM Interpretative Guidelines specifically state: "Ensure that the transfer of an unstabilized individual is effected through qualified personnel and transportation equipment, including the use of medically appropriate life support measures." Keep in mind, you're pretty much NEVER transferring a stabilized patient in the eyes of CMS. Stable by us and stable by CMS are on totally different concepts.

On another note, the interpretive guidelines also state: "A hospital is required to report to CMS or the State survey agency promptly when it suspects it may have received an improperly transferred individual. Notification should occur within 72 hours of the occurrence. Failure to report improper transfers may subject the receiving hospital to termination of its provider agreement." In other words, if a transferring facility violates EMTALA and the receiving facility doesn't report it, the receiving facility could risk termination of its CMS participation if CMS finds out about it. This is even more important now that patients can report EMTALA violations.

I'm just going to go ahead and say that EMTALA sucks. The more I learn about it, the more pointlessly draconian it seems.

 

[CoolDoc1729]

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.

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.

 

[southerndoc]

What's worse is CMS seems to want the patient to wait in an ER waiting on an ambulance for 6+ hours instead of taking a car for something like a testicular torsion. It doesn't make sense, but since when has government ever made sense?

 

[xaelia]

The Land of No Lawyers?

The land of Death Panels.

It's also usually fairly well-established, once folks get to the level of chronic, disabling illness, to have very frank Goals of Care discussions.

 

[Mount Asclepius]

For the record, CMS does NOT consider private vehicle transportation an appropriate mode of transportation for an EMTALA transfer. If a patient refuses on his or her own accord, then that is different and should be clearly documented.

I was primarily discussing the AMA component of when you advise transfer with medical transport and the patient declines against your advice.

Transfer via private auto occurs fairly frequently regardless of whether or not CMS considers it appropriately. For the right patient it can be completely medical appropriate and the risk of CMS cracking down is low. There are rural facilities where ground transport isn’t always available and flight is unavailable due to weather. The right thing for the right patient is transfer via private auto in those scenarios.

Good information. Thanks for sharing.

 

[Apollyon]

Going by POV, in my mind, was ALWAYS "rolling the dice", because, in their words, "I didn't think that was important". One example is telling them to remain NPO. Mom is smarter than we are, "and he was so hungry", and, when they do get to the hospital with Ortho, they just send them home, because they can't do the procedure then. The cherry on top is the blatant lie, "the doctor didn't tell us that!"

 

[benem]

Seems to me they can opt to not have an "Emergency Department" - rather call it something else that's open when they want and under their own rules. They can advertise it to their community any way they way. It's not an urgent care...or maybe a glorified urgent care that is open most of the time but they have the right to close down whenever they want. Or refuse certain kinds of patients.

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.

 

[alpinism]

In all seriousness, it does get frustrating when we have a ton of patients just waiting for SAR placement taking up inpatient beds, which clogs up the ER with people waiting on beds, which keeps us from accepting transfers that need to come to us. Not every head bleed needs to be transferred (brush up on BIG criteria), an elderly lady with 3 rib fractures needing pain control does not need a trauma center, etc. When people flood a tertiary referral center with that non-sense then no, we won't have room to take your stroke with 12 hours of symptoms who needs a thrombectomy, your subdural with impending herniation needing a crani, or your young person needing ECMO.

It drives me crazy to accept a trace subarachnoid hemorrhage from a trauma only to repeat their CT and discharge them from the ER without a neurosurgeon ever seeing them. This should be done by the transferring facility without ever involving me or my neurosurgeon, but you can't get some of them to man up. This literally happened the other day, and unfortunately, while the patient was sitting in the ER we became quite saturated and I had to turn down 2 transfers for things that needed to come here.

I regularly will take OSH transfer requests for our ED trauma center while on shift.

I'd say on average its 1/3 legitimate, 1/3 questionable, 1/3 complete waste of resources.

I'll usually accept without any pushback but I've also refused if its a definite EMTALA violation.

Example of a request from last week:

Transfer hospital - Hey I've got a trauma patient I want to send you guys

Me - Hey okay what have you got?

Transfer hospital - Teenage girl fell with a posterior scalp laceration

Me - Hmm okay so what did her imaging show?

Transfer hospital - We did a full body pan scan but don't have the results

Me - Hmm okay so why does she need to be transferred?

Transfer hospital - So we're not a trauma center and she could have a bleed

Me - Hmm but if the imaging is all normal she can be discharged?

Transfer hospital - Ohh I guess so if you think thats safe

Me - Yeahhh I think she'll be fine at your hospital

 

[BoardingDoc]

I regularly will take OSH transfer requests for our ED trauma center while on shift.

I'd say on average its 1/3 legitimate, 1/3 questionable, 1/3 complete waste of resources.

I'll usually accept without any pushback but I've also refused if its a definite EMTALA violation.

Example of a request from last week:

Transfer hospital - Hey I've got a trauma patient I want to send you guys

Me - Hey okay what have you got?

Transfer hospital - Teenage girl fell with a posterior scalp laceration

Me - Hmm okay so what did her imaging show?

Transfer hospital - We did a full body pan scan but don't have the results

Me - Hmm okay so why does she need to be transferred?

Transfer hospital - So we're not a trauma center and she could have a bleed

Me - Hmm but if the imaging is all normal she can be discharged?

Transfer hospital - Ohh I guess so if you think thats safe

Me - Yeahhh I think she'll be fine at your hospital

In this vein I remember taking a call as a resident rotating on the ortho spine service.

Transfer hospital: Patient fell and has severe neck pain.

Me: What imaging did you do?

Them: CT C-spine. That was normal. So we did an MRI.

Me: Ok, cool. What did it show?

Them: It was normal.

Me: So, you want to transfer because why?

Them: We don't have a spine surgeon so we can't clear their collar.

Me: So you have a normal CT and a normal MRI of the neck and you want to transfer the patient here so that someone can remove their collar?

Them: Yes.

Me: No.

 

[turkeyjerky]

I regularly will take OSH transfer requests for our ED trauma center while on shift.

I'd say on average its 1/3 legitimate, 1/3 questionable, 1/3 complete waste of resources.

I'll usually accept without any pushback but I've also refused if its a definite EMTALA violation.

Example of a request from last week:

Transfer hospital - Hey I've got a trauma patient I want to send you guys

Me - Hey okay what have you got?

Transfer hospital - Teenage girl fell with a posterior scalp laceration

Me - Hmm okay so what did her imaging show?

Transfer hospital - We did a full body pan scan but don't have the results

Me - Hmm okay so why does she need to be transferred?

Transfer hospital - So we're not a trauma center and she could have a bleed

Me - Hmm but if the imaging is all normal she can be discharged?

Transfer hospital - Ohh I guess so if you think thats safe

Me - Yeahhh I think she'll be fine at your hospital

This transfer nonsense goes both ways. Case from few weeks ago:

Me--I've got a young guy who came in w/ what looks like a self-inflicted GSW to the face. History is limited. I've intubated him for airway protection. CT head/max-face are pending.

Transfer Center--What do they show?

Me--They're not back yet, he's only been here for 10 minutes. He'll require transfer regardless as we don't have NSG, Plastics and don't admit trauma.

Transfer Center--Can you call back once you have the imaging results?

Me--I was hoping to get him accepted early on to facilitate rapid care. You see, he likely has intracranial extension. It usually takes about 45 min to get the out of here once they're accepted, plus a 30 min flight, and we can't call the flight team in until the patient is officially accepted. Moreover, it's 1am in the morning and the teleradiology service has been slow recently, so I'd prefer not to sit on this patient for another 3-4 hours waiting for an inevitable transfer. Your physicians are able to access our imaging, and I'm more than happy to call w/ updates.

Transfer Center---....

Me--Maybe I could just talk to the trauma surgeon on call?

 

[bravotwozero]

This transfer nonsense goes both ways. Case from few weeks ago:

Me--I've got a young guy who came in w/ what looks like a self-inflicted GSW to the face. History is limited. I've intubated him for airway protection. CT head/max-face are pending.

Transfer Center--What do they show?

Me--They're not back yet, he's only been here for 10 minutes. He'll require transfer regardless as we don't have NSG, Plastics and don't admit trauma.

Transfer Center--Can you call back once you have the imaging results?

Me--I was hoping to get him accepted early on to facilitate rapid care. You see, he likely has intracranial extension. It usually takes about 45 min to get the out of here once they're accepted, plus a 30 min flight, and we can't call the flight team in until the patient is officially accepted. Moreover, it's 1am in the morning and the teleradiology service has been slow recently, so I'd prefer not to sit on this patient for another 3-4 hours waiting for an inevitable transfer. Your physicians are able to access our imaging, and I'm more than happy to call w/ updates.

Transfer Center---....

Me--Maybe I could just talk to the trauma surgeon on call?

Some of those people that work at the trauma center can be incredibly asinine.

I had a patient who was seen at the main trauma center after an MVC and had a femur fracture that was repaired there. She showed up at our ED a few weeks after discharge with extremity pain and has a large hematoma on CT. Transfer center declines my transfer without even allowing a conference due the Hospital being ‘at capacity’

I knew though even in those situations that hospital will still take traumas so I request to speak with the trauma team and actually get connected. When the trauma resident hears the transfer center has declined transfer on their patient without notifying them, he was quite livid and demanded to speak to the transfer centers supervisor. Of course the transfer was accepted without conference afterwards.

 

[thegenius]

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 😠

I regularly transfer pts by private car to another hospital. It's all kosher, I get an accepting physician and tell them they are coming by private car. Everyone is in agreement (even parents). For instance this happens regularly with peds.

I write everything up, they are discharged (not AMA) and Igive him my finished chart and CD disc.

 

[thegenius]

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.

Does USC also have an actual ER too? Or just the Evaluatoin and Treatment clinic?

 

[southerndoc]

This transfer nonsense goes both ways. Case from few weeks ago:

Me--I've got a young guy who came in w/ what looks like a self-inflicted GSW to the face. History is limited. I've intubated him for airway protection. CT head/max-face are pending.

Transfer Center--What do they show?

Me--They're not back yet, he's only been here for 10 minutes. He'll require transfer regardless as we don't have NSG, Plastics and don't admit trauma.

Transfer Center--Can you call back once you have the imaging results?

Me--I was hoping to get him accepted early on to facilitate rapid care. You see, he likely has intracranial extension. It usually takes about 45 min to get the out of here once they're accepted, plus a 30 min flight, and we can't call the flight team in until the patient is officially accepted. Moreover, it's 1am in the morning and the teleradiology service has been slow recently, so I'd prefer not to sit on this patient for another 3-4 hours waiting for an inevitable transfer. Your physicians are able to access our imaging, and I'm more than happy to call w/ updates.

Transfer Center---....

Me--Maybe I could just talk to the trauma surgeon on call?

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.

 

[benem]

Does USC also have an actual ER too? Or just the Evaluatoin and Treatment clinic?

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.

 

[CoolDoc1729]

I regularly transfer pts by private car to another hospital. It's all kosher, I get an accepting physician and tell them they are coming by private car. Everyone is in agreement (even parents). For instance this happens regularly with peds.

I write everything up, they are discharged (not AMA) and Igive him my finished chart and CD disc.

I do the same thing all the time from our freestanding. Agree 100%.

 

[thegenius]

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.

When you are on calls with other hospitals, do you ever say to them "your action is an EMTALA violation?"

 

[southerndoc]

When you are on calls with other hospitals, do you ever say to them "your action is an EMTALA violation?"

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?"

 

[thegenius]

When did patients get the right to report EMTALA violations? What there recent law passed or was there a ruling indicating they could do so? And can they report EMTALA violations anonymously?

 

[gruemd]

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?"

Who would take the fall for this? For example, totally 100% not real, just theoretical case here, but say I had a patient who was in clear need of a service, but when I call the relevant specialist up, they say "No, we have fired that patient, and do not provide services to that patient" and refused to even see them, and then the hospitalist won't admit, because "Well if the specialist won't do [x] then we shouldn't admit them here" and then I'm forced to transfer the patient. The receiving hospital points out this sounds like a clear EMTALA violation and all I can say in this hypothetical scenario is "I understand where you are coming from, and all I can say is that I don't have a specialist or hospitalist willing to accept." Patient is accepted and transferred.

 

[Mr. Vandemar]

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?"

This scenario happens to me literally every shift I work. The hospitalist refusing to admit because we don’t have some unnecessary subspeciality back up, that is.

 

[southerndoc]

Who would take the fall for this? For example, totally 100% not real, just theoretical case here, but say I had a patient who was in clear need of a service, but when I call the relevant specialist up, they say "No, we have fired that patient, and do not provide services to that patient" and refused to even see them, and then the hospitalist won't admit, because "Well if the specialist won't do [x] then we shouldn't admit them here" and then I'm forced to transfer the patient. The receiving hospital points out this sounds like a clear EMTALA violation and all I can say in this hypothetical scenario is "I understand where you are coming from, and all I can say is that I don't have a specialist or hospitalist willing to accept." Patient is accepted and transferred.

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.

Georgia has a specific rule with the Composite Medical Board that patients must continue to be treated for six months after they are fired from a practice and indefinitely in emergency situations. CMS will rule in favor of the patient in this situation and the specialist and hospital will get fined. The ED doc will be off the hook because he can't provide definitive care that the specialist can (hence the reason he's contacting the specialist).