EMTALA question

[PTPoeny]

This might be a stupid question but this thread has made me wonder if I am following EMTALA or not. What determines "capacity" to care for a patient? As a pediatric hospital we routinely ask OSHs to call the nearby adult hospitals if they call us for some reason on the otherwise healthy 20 year old patient. Technically we have adult sized equipment for our teenagers and there are certain conditions we admit up to age 25. So is this an EMTALA violation?

In the other direction, is it an EMTALA violation when the adult hospitals request to transfer drunk 17 year olds to us? I once received a call to transfer someone to me 4 hours before they turned 18...

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[Apollyon]

This might be a stupid question but this thread has made me wonder if I am following EMTALA or not. What determines "capacity" to care for a patient? As a pediatric hospital we routinely ask OSHs to call the nearby adult hospitals if they call us for some reason on the otherwise healthy 20 year old patient. Technically we have adult sized equipment for our teenagers and there are certain conditions we admit up to age 25. So is this an EMTALA violation?

In the other direction, is it an EMTALA violation when the adult hospitals request to transfer drunk 17 year olds to us? I once received a call to transfer someone to me 4 hours before they turned 18...

If it's ED to ED, you have "unlimited beds" for capacity. If it's ED to floor, there has to be a literal open, clean, staffed bed available.

As to having equipment or qualified docs, etc, that I don't know.

That makes me recall Kapi'olani Womens and Children's Hospital in Honolulu. As in the name, they cater to females and children, but, the ED also staffs an ED doc, for the not so rare homeless, drunk, or both, pt that wanders in.

And THAT reminds me of another story, this one from the EMS rolls. About 23 years ago, took a call on Broadway in Buffalo, NY, for a pedestrian struck. Closest Buffalo Fire Dept to that was the station that had Engine 31 and Ladder 14, at Bailey and Doat. When we get there, 31 and 14 were there, but, also Engine 33, which would be next due. And, some FF were standing around. Well, turns out this "kid" had ridden his bicycle into the side of Engine 31, who were on the air, but not responding to a call, and he went through the wheels. I was surprised he didn't pop. Anyways, we were closer to ECMC (Erie County Medical Center) than to CHOB (Children's Hospital of Buffalo), so, we took him to ECMC. One of the nurses b*tched because he was 12 - all 6' 3" and 250lbs of him. He took an 8.0 tube. I think he didn't make it, although I do not recall. My partner (who we called "Joker", because he looked like Pvt Joker from "Full Metal Jacket") tubed him right there on Broadway, because I made him, and encouraged him, and he got it. His first trauma tube.

 

[Boatswain2PA]

Had an on-call optho tell me that EMTALA doesn't apply to ophthalmology because "it's not life threatening".

Refused to consult patient, or see the pt tomorrow, because while he takes call for optho, he is only on call for HIS established patients.

Closest tertiary care has optho, but only takes call from THEIR ed. Required an ED to ED transfer.

Don't see how that isn't an EMTALA violation.

 

[southerndoc]

Had an on-call optho tell me that EMTALA doesn't apply to ophthalmology because "it's not life threatening".

Refused to consult patient, or see the pt tomorrow, because while he takes call for optho, he is only on call for HIS established patients.

Closest tertiary care has optho, but only takes call from THEIR ed. Required an ED to ED transfer.

Don't see how that isn't an EMTALA violation.

If he's listed on a call roster for the hospital, then he's on call for the ED and committed an EMTALA violation for refusing to see the patient.

 

[Dr Mantis Toboggan]

If he's listed on a call roster for the hospital, then he's on call for the ED and committed an EMTALA violation for refusing to see the patient.

Yeah if your hospital pays this guy to take call they should stop immediately and just drop the coverage. He’s not going to help you ever it sounds like and you are safer transferring EMTALA wise without a listed on call for opthy.

 

[RustedFox]

How does ophtho think they're so special?
I mean, I have zero ophtho coverage, but should be able to transfer a true ophtho emergency somewhere. I've heard EDs refuse transfer.

 

[Mount Asclepius]

To play devils advocate, what’s an ophtho emergency?

I’ll buy globe rupture, but more of an urgent condition. You also don’t need them to do a lateral canthotomy.

Pretty much everything else can follow up closely in clinic.

 

[bravotwozero]

To play devils advocate, what’s an ophtho emergency?

I’ll buy globe rupture, but more of an urgent condition. You also don’t need them to do a lateral canthotomy.

Pretty much everything else can follow up closely in clinic.

Orbital abscess, though they’ll usually turf that to oculo plastics…

 

[Apollyon]

To play devils advocate, what’s an ophtho emergency?

I’ll buy globe rupture, but more of an urgent condition. You also don’t need them to do a lateral canthotomy.

Pretty much everything else can follow up closely in clinic.

Acute closed angle glaucoma?

 

[GassYous]

To play devils advocate, what’s an ophtho emergency?

I’ll buy globe rupture, but more of an urgent condition. You also don’t need them to do a lateral canthotomy.

Pretty much everything else can follow up closely in clinic.

Foreign body

 

[thegenius]

Acute closed angle glaucoma?

Of course.

I had a lady with a red eye who was vomiting. She couldn't even open her eye. I finally doped her up and the pressure was 80. I gave a ton of drops, mannitol, called ophtho and he came right in, spent 2-3 hours giving drops, doing multiple anterior chamber paracenteses, and other stuff with fancy equipment. He said it was a very challenging case.

It was 2:00 AM.

Any acute vision loss (like literally they go blind in 5 minutes), markedly increased pressure, globe rupture, orbital cellulitis, severe chemical trauma, retinal injury, and I'm probably missing some and I will consult and expect to see the ophthalmologist with a few hours of calling.

Fact is eye emergencies are extremely high risk, litigious problems. It matters less that there is "nothing to do". These are very hard conversations to have with consultants, and we know there isn't much to do, and they know there isn't much to do, yet they still need to come in. Of course we can force them to come in but that's a pyrrhic victory. It's better to just have a collegial conversation and be nice about it. It's like a 48 yo man with acute no blood flow to the testicle. yes it's not torsion...torsion basically doesn't happen at that age, but there is no blood flow to the organ so you call the respective specialist. We do this all the time with heart, brain, limb, gut, etc.

 

[GassYous]

Of course.

I had a lady with a red eye who was vomiting. She couldn't even open her eye. I finally doped her up and the pressure was 80. I gave a ton of drops, mannitol, called ophtho and he came right in, spent 2-3 hours giving drops, doing multiple anterior chamber paracenteses, and other stuff with fancy equipment. He said it was a very challenging case.

It was 2:00 AM.

Any acute vision loss (like literally they go blind in 5 minutes), markedly increased pressure, globe rupture, orbital cellulitis, severe chemical trauma, retinal injury, and I'm probably missing some and I will consult and expect to see the ophthalmologist with a few hours of calling.

Fact is eye emergencies are extremely high risk, litigious problems. It matters less that there is "nothing to do". These are very hard conversations to have with consultants, and we know there isn't much to do, and they know there isn't much to do, yet they still need to come in. Of course we can force them to come in but that's a pyrrhic victory. It's better to just have a collegial conversation and be nice about it. It's like a 48 yo man with acute no blood flow to the testicle. yes it's not torsion...torsion basically doesn't happen at that age, but there is no blood flow to the organ so you call the respective specialist. We do this all the time with heart, brain, limb, gut, etc.

Time is testicle

 

[Apollyon]

Time is testicle

Well, that's just NUTS!!

 

[Apollyon]

Foreign body

Like a piece of concrete right in the middle of the globe. That was dramatic.

 

[Mount Asclepius]

I guess I just differ in my opinion that there are many ophthalmological emergencies. Perhaps our local practice patterns are different as we have decent next day follow up and our hospital doesn’t have the same resources in house that the ophthalmology clinic has. I haven’t seen Ophthalmology in the ED in about a decade.

Glaucoma follows up in clinic. Same with retinal detachment. Orbital cellulitis admitted to the hospitalist on antibiotics. Globe rupture usually in the setting of other trauma admitted to trauma for consultation in the hospital. Foreign bodies removed with burr drill with outpatient referral if remaining rust ring. Etc, etc.

In general, I think that sometimes in the ED we think certain things are more time sensitive than they really are. Many things can wait a bit longer without significant deterioration. I see somewhat high strung colleagues becoming irate with any push back and demanding specialists come see patients. I just shrug my shoulders. Sure, Urology needs to take the testicular torsion and OB needs to take the ruptured ectopic with hemoperitoneum to the OR. It really shouldn’t take much convincing for truly emergent conditions.

 

[RoyBasch]

Had an on-call optho tell me that EMTALA doesn't apply to ophthalmology because "it's not life threatening".

Refused to consult patient, or see the pt tomorrow, because while he takes call for optho, he is only on call for HIS established patients.

Closest tertiary care has optho, but only takes call from THEIR ed. Required an ED to ED transfer.

Don't see how that isn't an EMTALA violation.

This is a fairly clear cut violation by the ophthalmologist. The receiving center would be within their rights to file because you are transferring a patient that you do have capacity to take care of.

 

[RustedFox]

I guess I just differ in my opinion that there are many ophthalmological emergencies. Perhaps our local practice patterns are different as we have decent next day follow up and our hospital doesn’t have the same resources in house that the ophthalmology clinic has. I haven’t seen Ophthalmology in the ED in about a decade.

Glaucoma follows up in clinic. Same with retinal detachment. Orbital cellulitis admitted to the hospitalist on antibiotics. Globe rupture usually in the setting of other trauma admitted to trauma for consultation in the hospital. Foreign bodies removed with burr drill with outpatient referral if remaining rust ring. Etc, etc.

In general, I think that sometimes in the ED we think certain things are more time sensitive than they really are. Many things can wait a bit longer without significant deterioration. I see somewhat high strung colleagues becoming irate with any push back and demanding specialists come see patients. I just shrug my shoulders. Sure, Urology needs to take the testicular torsion and OB needs to take the ruptured ectopic with hemoperitoneum to the OR. It really shouldn’t take much convincing for truly emergent conditions.

I'm so glad you said this.
Before I say anything else: I'll say upfront that I'm not being adversarial. I can be on here. Because.

I'm not.

So, in my career, I've seen a few CRAOs and one true-blue acute angle closure glaucoma.
Luckily, I worked in a place where it was easy to transfer ophtho things (both big and small) to Big Memorial Hospital.
Its those "tweener" cases that give me this feeling of dis-ease.
I've also heard of the Jackpot! suits for eye stuff that "looks totally routine" but is totally not.
I'll freely admit that "ophtho" is not my best suit. Slit lamp? Pfft.

But "vision loss or damage" is super litigious and super contentious.
I don't see how a place can "refuse transfer" for an Ophtho case if they have legit ophtho coverage.

 

[Mount Asclepius]

I'm so glad you said this.
Before I say anything else: I'll say upfront that I'm not being adversarial. I can be on here. Because.

I'm not.

So, in my career, I've seen a few CRAOs and one true-blue acute angle closure glaucoma.
Luckily, I worked in a place where it was easy to transfer ophtho things (both big and small) to Big Memorial Hospital.
Its those "tweener" cases that give me this feeling of dis-ease.
I've also heard of the Jackpot! suits for eye stuff that "looks totally routine" but is totally not.
I'll freely admit that "ophtho" is not my best suit. Slit lamp? Pfft.

But "vision loss or damage" is super litigious and super contentious.
I don't see how a place can "refuse transfer" for an Ophtho case if they have legit ophtho coverage.

Not adversarial at all. Appreciate the preface though. Fair points.

Ophtho isn’t my thing either. I suspect it isn’t for most EPs due to lack of regularity/familiarity, low likelihood of emergent conditions, lack of many interventions we can provide, and our preference for camping headlamps over slit lamps.

I have no doubt that a missed diagnosis or bad care that leads to serious disability such as blindness can lead to litigation. I just question whether or not follow up in clinic within a few to 24 hours (or perhaps even slightly longer) leads to significant deterioration for many ophthalmological conditions leading to successful litigation. I don’t know much of the prior ophthalmological medicolegal case history, but I suspect most involved dismissiveness or misdiagnosis, and lack of adequate close follow up. I’m skeptical an Opthalmology consultation in the ED is all it would have taken to mitigate the liability in most cases. I don’t doubt though that rarely a case or two might have necessitated ED in person consultation.

Eye complaints are infrequent. Serious eye pathology rare. Litigation for bad care of ophthalmological emergencies even rarer. It takes a bad outcome plus an angry patient to lead to liability (and should include bad medical care, but you can do everything right and still lose - that’s the messed up system). I’ll focus on good patient care where they are satisfied with close Ophthalmology follow up over fighting Ophthalmology to consult in the ED unless I get burned or am convinced otherwise.

@southerndoc or others: When I rarely receive calls from small outlying hospitals trying to transfer eye complaints to our ED, I ask them to speak with our Ophthalmologist on call first. I don’t refuse the transfer and state that I’m happy to accept, but request that the case be discussed with our Opthalmologist on call since they would likely be involved. I almost always find the patient isn’t transferred. I suspect the patient is set up for close follow up in clinic instead. Is there any potential EMTALA violation for not immediately accepting patients in general versus instead asking the transferring facility to speak to a specialist on call?

 

[DrSnips]

For those interested here is an article Acute Glaucoma Outcomes in BMJ Ophthalmology about outcomes in acute angle closure glaucoma.

They found that for those presenting and starting treatment in under 24 hours of symptoms, 45 of 52 patients (87%) were cured* a year later. For those presenting after 24 hours, only 20 of 42 (48%) were cured* a year later.

*cured here means not requiring further medical / surgical treatment for glaucoma AND not having lasting damage to visual acuity from glaucoma

 

[southerndoc]

@southerndoc or others: When I rarely receive calls from small outlying hospitals trying to transfer eye complaints to our ED, I ask them to speak with our Ophthalmologist on call first. I don’t refuse the transfer and state that I’m happy to accept, but request that the case be discussed with our Opthalmologist on call since they would likely be involved. I almost always find the patient isn’t transferred. I suspect the patient is set up for close follow up in clinic instead. Is there any potential EMTALA violation for not immediately accepting patients in general versus instead asking the transferring facility to speak to a specialist on call?

I don't know of a case where an EM physician received a fine for requesting they contact a consultant. In fact, I think this is prudent advice. If you accept something like an aortic dissection and the cardiovascular surgeon is already doing one for the next 5 hours, you've basically accepted something on their behalf when you do not have the capacity to handle it (no available surgeon). Of course aortic dissections and eye "emergencies" are two different things.

I routinely ask EM docs to speak to a specialist if it needs their expertise. Now I cannot comment on the ophthalmologist causing an EMTALA violation to your facility. It's all in how the transferring facility words in. "Hey, I'd like to transfer a patient to you" can only be answered with "yes" or "we don't have capacity or the services to accept this patient at this time." It's a lot different if you preface it with "I'd like to run something by you" instead of "I'd like to transfer a patient to you."

 

[gutonc]

I don't know of a case where an EM physician received a fine for requesting they contact a consultant. In fact, I think this is prudent advice. If you accept something like an aortic dissection and the cardiovascular surgeon is already doing one for the next 5 hours, you've basically accepted something on their behalf when you do not have the capacity to handle it (no available surgeon). Of course aortic dissections and eye "emergencies" are two different things.

I routinely ask EM docs to speak to a specialist if it needs their expertise. Now I cannot comment on the ophthalmologist causing an EMTALA violation to your facility. It's all in how the transferring facility words in. "Hey, I'd like to transfer a patient to you" can only be answered with "yes" or "we don't have capacity or the services to accept this patient at this time." It's a lot different if you preface it with "I'd like to run something by you" instead of "I'd like to transfer a patient to you."

I'll be honest here and say that I don't understand the need for most ED-->ED transfers.

If acute inpatient management is needed, then the transfer should be ED-->floor/ICU/OR/Cath lab and should bypass the ED completely other than as an after hours entrance to the hospital.

if urgent outpatient f/u is needed, or there's a question of whether this needs to be managed inpatient vs outpatient, the conversation should be with referring ED doc and the appropriate specialist at "Big Referral Hospital". As the person who answers the pages at BRH, if I feel that it can be managed as an outpatient, I will always say (on the recorded line), "I will ensure this patient is seen in X days (where X depends on the acuity of the issue), but if you, as the person currently looking at this patient, feels they need inpatient evaluation, go ahead and admit them locally with a transfer request, or stay on the line and bed control will take it from there and we'll see them on arrival".

ED to ED transfer seems like straight-up passive-aggressive BS on somebody's part.

 

[Mount Asclepius]

For those interested here is an article Acute Glaucoma Outcomes in BMJ Ophthalmology about outcomes in acute angle closure glaucoma.

They found that for those presenting and starting treatment in under 24 hours of symptoms, 45 of 52 patients (87%) were cured* a year later. For those presenting after 24 hours, only 20 of 42 (48%) were cured* a year later.

*cured here means not requiring further medical / surgical treatment for glaucoma AND not having lasting damage to visual acuity from glaucoma

Thanks for sharing. This article is 37 years old though and I would be curious if applicable today or if treatment modalities have significantly changed. Just for clarification in case not clear, I always initiate treatment in the ED for glaucoma, but patients may receive more definitive management in the Ophthalmology clinic.

 

[Siggy]

Fact is eye emergencies are extremely high risk, litigious problems. It matters less that there is "nothing to do". These are very hard conversations to have with consultants, and we know there isn't much to do, and they know there isn't much to do, yet they still need to come in. Of course we can force them to come in but that's a pyrrhic victory. It's better to just have a collegial conversation and be nice about it. It's like a 48 yo man with acute no blood flow to the testicle. yes it's not torsion...torsion basically doesn't happen at that age, but there is no blood flow to the organ so you call the respective specialist. We do this all the time with heart, brain, limb, gut, etc.

1. Never go to the gallows alone.

2. Never have to explain why you didn't call a stat consult on something that needs a stat consult. Sure, if there is more blood in the cranial vault than brain, there's nothing that neurosurgery is going to do... but I'm going to make neurosurgery say there's nothing to do. Similarly, it's amazing how things get done once people know that they're going to be put in the chart. I had to call podiatry at 10 PM because the primary wanted to upgrade a patient to the ICU... because of a band count of 17 and a WBC count of 29. MRI from that day showed gas throughout the foot. It was amazing how quick it went from, "We'll reeval the patient in the morning" to "yep... I/D and bedside debridement at 11:30pm."

 

[Siggy]

I'll be honest here and say that I don't understand the need for most ED-->ED transfers.

If acute inpatient management is needed, then the transfer should be ED-->floor/ICU/OR/Cath lab and should bypass the ED completely other than as an after hours entrance to the hospital.

I've seen the difficulty my hospital's ED has with getting a hold of their own hospitalists... I can't imagine the special kind of hell required to coordinate with a direct admission and figuring out and getting a hold of an admitting team at a different, possibly out of network (i.e. something like Tenet to HCA) admission. Sure, there's a transfer center, but that's still a lot of coordinating with systems you're not familiar with.

 

[gutonc]

I've seen the difficulty my hospital's ED has with getting a hold of their own hospitalists... I can't imagine the special kind of hell required to coordinate with a direct admission and figuring out and getting a hold of an admitting team at a different, possibly out of network (i.e. something like Tenet to HCA) admission. Sure, there's a transfer center, but that's still a lot of coordinating with systems you're not familiar with.

Which speaks directly to my last statement. I should have been more clear that I didn't mean the passive-aggressive BS was necessarily on the part of the transferring ED doc.

 

[RoyBasch]

I'll be honest here and say that I don't understand the need for most ED-->ED transfers.

If acute inpatient management is needed, then the transfer should be ED-->floor/ICU/OR/Cath lab and should bypass the ED completely other than as an after hours entrance to the hospital.

if urgent outpatient f/u is needed, or there's a question of whether this needs to be managed inpatient vs outpatient, the conversation should be with referring ED doc and the appropriate specialist at "Big Referral Hospital". As the person who answers the pages at BRH, if I feel that it can be managed as an outpatient, I will always say (on the recorded line), "I will ensure this patient is seen in X days (where X depends on the acuity of the issue), but if you, as the person currently looking at this patient, feels they need inpatient evaluation, go ahead and admit them locally with a transfer request, or stay on the line and bed control will take it from there and we'll see them on arrival".

ED to ED transfer seems like straight-up passive-aggressive BS on somebody's part.

ED to ED transfer is sometimes appropriate when the patient requires a service of the receiving hospital but won't ultimately require admission afterwards. Typical examples would be cases where a procedure needs to be done but the patient is anticipated to be stable for discharge afterwards.

For example, if you have an esophageal food bolus impaction but no endoscopist at your hospital. Patient will transfer ED to ED. And when the endoscopist and team are ready at the receiving hospital they will take the patient for procedure and can usually discharge directly from PACU after procedure complete (or as I have frequently experienced, the patient is sent BACK to the ER for 'discharge') because 'reasons.'

 

[RoyBasch]

Thanks for sharing. This article is 37 years old though and I would be curious if applicable today or if treatment modalities have significantly changed. Just for clarification in case not clear, I always initiate treatment in the ED for glaucoma, but patients may receive more definitive management in the Ophthalmology clinic.

The ophtho one is interesting because not infrequently I have an ophtho 'emergency' and when I talk to our on call ophthalmologist they advise sending the patient directly to their clinic, which is technically a discharge from the ER not a transfer.

I do believe they CAN provide a higher level of eye care in their clinic where they have all their necessary tools and medications. It always feels weird though 'discharging' a patient with an unstabilized emergency. That being said, I've worked in enough different systems that I get the impression this is the 'standard of care' in the community and probably IS in the best interest of the patient.

In the case of acute angle closure glaucoma, I have been told on several occasions to just send the patient to their clinic right away during business hours. On one occasion (and this was when I was working at an academic center with an ophtho residency mind you--not a community shop) an ophtho resident came to the ER to consult and then worked over a few hours at bedside lowering the patients IOP with various drops and taking serial IOP measurements.

I encounter this same issue a little bit in a few other cases such as with some OMFS issues.

 

[thegenius]

The ophtho one is interesting because not infrequently I have an ophtho 'emergency' and when I talk to our on call ophthalmologist they advise sending the patient directly to their clinic, which is technically a discharge from the ER not a transfer.

I do believe they CAN provide a higher level of eye care in their clinic where they have all their necessary tools and medications. It always feels weird though 'discharging' a patient with an unstabilized emergency. That being said, I've worked in enough different systems that I get the impression this is the 'standard of care' in the community and probably IS in the best interest of the patient.

In the case of acute angle closure glaucoma, I have been told on several occasions to just send the patient to their clinic right away during business hours. On one occasion (and this was when I was working at an academic center with an ophtho residency mind you--not a community shop) an ophtho resident came to the ER to consult and then worked over a few hours at bedside lowering the patients IOP with various drops and taking serial IOP measurements.

I encounter this same issue a little bit in a few other cases such as with some OMFS issues.

Yes I'm ok with sending an Ophtho patient to their clinic if they recommend it.