EMTALA Question

[pollyspockets]

If you have a service available at your hospital and they refuse to consult on a patient and recommend transfer to another facility is this an EMTALA violation?

For example you are at a community hospital and you have an MVA patient with an isolated injury (say hip fracture or minor SAH) without any need for a trauma surgery. Can ortho or neurosurgery refuse the patient based on mechanism when they are credentialed for the appropriate procedure and management does not change based on pattern of injury? They would agree to consult if it was a fall, but not a car accident and refuse to see the patient in the ER and demand transfer to trauma center.

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[Dr Mantis Toboggan]

If you have a service available at your hospital and they refuse to consult on a patient and recommend transfer to another facility is this an EMTALA violation?

For example you are at a community hospital and you have an MVA patient with an isolated injury (say hip fracture or minor SAH) without any need for a trauma surgery. Can ortho or neurosurgery refuse the patient based on mechanism when they are credentialed for the appropriate procedure and management does not change based on pattern of injury? They would agree to consult if it was a fall, but not a car accident and refuse to see the patient in the ER and demand transfer to trauma center.

I’m no expert but seems to me to be a no brainer EMTALA violation.

 

[Jball43]

If you have a service available at your hospital and they refuse to consult on a patient and recommend transfer to another facility is this an EMTALA violation?

For example you are at a community hospital and you have an MVA patient with an isolated injury (say hip fracture or minor SAH) without any need for a trauma surgery. Can ortho or neurosurgery refuse the patient based on mechanism when they are credentialed for the appropriate procedure and management does not change based on pattern of injury? They would agree to consult if it was a fall, but not a car accident and refuse to see the patient in the ER and demand transfer to trauma center.

I’ve always found EMTALA to be deceptively confusing. I’ve done some conference work to residents as an attorney on the subject. I try to make sure people know EMTALA mandates that hospitals provide *appropriate* medical screening examinations and *necessary* stabilizing treatment for emergency medical conditions. If the refusal to consult and the recommendation for transfer are not based on the patient's medical condition but rather on the mechanism of injury, it could be considered a violation of EMTALA. So if a service within a hospital refuses to consult based solely on the mechanism of injury and recommends transfer without considering the patient's medical needs (making sure the patient is actually stable to not just flat out die and also stable enough to transfer), the violation would likely involve both the individual healthcare provider that refused or the service refusing the consultation and potentially the hospital itself. EMTALA violations can actually involve both providers and hosptials.

When speaking to one of the attending surgeons about a specific, “hypothetical case,” he finished confessing his sins to which I responded, “yeah that sounds like a problem you should hypothetically talk to risk management.”

His response? “The patients family is probably too stupid to report anything anyways.”

So there’s that factor I suppose.

 

[JacobMcCandles]

His response? “The patients family is probably too stupid to report anything anyways.”

So there’s that factor I suppose.

No, but the hospital you call (or the ED doctor) isn't.

 

[valianteffort]

The only reason you can legitimately call to transfer a patient is if you or your hospital is clearly not able to provide the necessary care (i.e. no ICU beds at your hospital or you are already truly involved in another emergency situation that will prohibit you from providing the care). Otherwise, if the services are available you must make them available to any patient that needs them. EMTALA generally uses the “if you have ever before” principle: That is, “If your hospital has ever taken care of such a patient under similar conditions before you must treat them now unless the capacity is saturated.” Similarly, you can not refuse to accept a patient in transfer because they have no insurance or because they are a non-contracted health plan.

 

[Tenk]

The ortho is EMTALA but what exactly is the problem with NS and minor SAH though? None of them are surgical because it’s traumatic and not due to aneurysm and it’s not massive requiring a shunt. It’s just an obs -> repeat ct -> dc. We hardly even admit these to the hospital anymore.

 

[southerndoc]

Sounds like your hospital has capability to treat the patient. If the orthopedic surgeon is credentialed to treat the injury (and likely he/she is), then transferring to another hospital is most likely an EMTALA violation.

 

[pollyspockets]

The ortho is EMTALA but what exactly is the problem with NS and minor SAH though? None of them are surgical because it’s traumatic and not due to aneurysm and it’s not massive requiring a shunt. It’s just an obs -> repeat ct -> dc. We hardly even admit these to the hospital anymore.

No BIG buy in locally + anti platelets in this particular case

 

[NYEMMED]

Yes it is a EMTALA violation.
Also likely a hospital bylaws/rules and regs violation. Typically all require a bedside consult when requested by the ED doc

 

[gro2001]

If you have a service available at your hospital and they refuse to consult on a patient and recommend transfer to another facility is this an EMTALA violation?

For example you are at a community hospital and you have an MVA patient with an isolated injury (say hip fracture or minor SAH) without any need for a trauma surgery. Can ortho or neurosurgery refuse the patient based on mechanism when they are credentialed for the appropriate procedure and management does not change based on pattern of injury? They would agree to consult if it was a fall, but not a car accident and refuse to see the patient in the ER and demand transfer to trauma center.

It seems those are two very different situations. The hip fracture will surely need an operative repair, either at the sending or receiving hospital. The minor traumatic SAH will probably not need anything surgical, at either hospital.

 

[WorkNoteEmergency]

I’ve never been sure if It’s addressed specifically in EMTALA refs, but trauma is a different can of worms and once a patient gets the ”Trauma” label, I found it nearly impossible to keep at a non trauma center. I think it opens up a lot of liability issues for the hospital when that happens. I worked at a semi rural non trauma ER for several years. We had a general surgeon on call 24/7 but they didn’t “do” trauma and I was on my own for all management of that and then if they needed admission, I was expected to ship them out.

A lot of my non trauma transfers were driven by nursing limitations and frequently would be considered EMTALA violations. “I know you got that afib rate controlled in the ER, but if it gets worse and the pt needs a drip, we don’t have ICU availability”, If that BiPap patient gets worse and needs a vent, we won’t have intensivist tomorrow” - that kind of crap

 

[Mount Asclepius]

Certain trauma center designations only allow for management of some types of trauma and require transfer of more significant trauma to a higher level of care. Doesn’t completely exclude some degree of stabilization prior to transfer though.

 

[DocEspana]

Or your hospital can do this little fun maneuver:

All branch hospitals are actually extensions of the main hospital. AKA County General is legally the same facility as County South, County West, County East, and County North even though all of these are miles apart with entirely different staffing for various specialties. Since you can *always* consult the main campus, we provide every service possible. and if the orthopod or obgyn at your branch campus doesnt feel like doing the consult you asked for, you can always just consult the "backup" specialty (aka main campus ortho/obgyn) who will accept the patient and continue to fulfill your hospital's (which is - again - five different actual places) duty to EMTALA. You just 'internally relocate' them to where the specialist is.

No one is transferred, its all the same hospital legally and it just happens to have multi-mile stretches between its various ERs and the standard way to get between them is ambulance. no further questions.

There is *always* a workaround.

 

[ScepticSkeksis]

No one is transferred, its all the same hospital legally and it just happens to have multi-mile stretches between its various ERs and the standard way to get between them is ambulance. no further questions.

There is *always* a workaround.

The fact that we move these non-emergent patients between hospitals for specialist consultation using expensive ambulances has always felt like a scam to me. The same as charging for multiple ED visits for a transfer. I've never understood why insurers agree to pay for all this wasteful nonsense.

 

[DocEspana]

The fact that we move these non-emergent patients between hospitals for specialist consultation using expensive ambulances has always felt like a scam to me. The same as charging for multiple ED visits for a transfer. I've never understood why insurers agree to pay for all this wasteful nonsense.

technically they dont get multiple ED visits in this system. But it does allow the local consultant to just fall into complete dereliction of duty without consequence.

 

[Torsion]

I've got a (somewhat) related question. Say a patient needs admission for cardiac work-up to my hospital in health system A. Health System A is perfectly able to care for that patient's needs. The patient then asks to be admitted to health system B because "all my records are there." Two questions:

1) Am I obligated to attempt to transfer away from my own healthcare system to another knowing full well that the transfer process will be lengthy and complicated.
2) Health System B can theoretically refuse transfer given Health System A is fully capable of managing the problem, correct?

What I've done in the past is point out that my hospital if fully capable of handing the problem, we can access the other system's records (both on Epic), and not admitting to my hospital would result in a lengthy delay in care and the risks associated with that. Normally patients have been agreeable after that and I haven't needed to transfer for routine things.

Post surgical complications and obstetric stuff I will admit to whoever was previously managing without hesitation.

 

[DocEspana]

I've got a (somewhat) related question. Say a patient needs admission for cardiac work-up to my hospital in health system A. Health System A is perfectly able to care for that patient's needs. The patient then asks to be admitted to health system B because "all my records are there." Two questions:

1) Am I obligated to attempt to transfer away from my own healthcare system to another knowing full well that the transfer process will be lengthy and complicated.
2) Health System B can theoretically refuse transfer given Health System A is fully capable of managing the problem, correct?

What I've done in the past is point out that my hospital if fully capable of handing the problem, we can access the other system's records (both on Epic), and not admitting to my hospital would result in a lengthy delay in care and the risks associated with that. Normally patients have been agreeable after that and I haven't needed to transfer for routine things.

Post surgical complications and obstetric stuff I will admit to whoever was previously managing without hesitation.

Part 2) is definitely correct.
I also believe you are not obligated to try very hard, but are supposed to do the minimum to make 1) happen.

 

[Dr Mantis Toboggan]

I've got a (somewhat) related question. Say a patient needs admission for cardiac work-up to my hospital in health system A. Health System A is perfectly able to care for that patient's needs. The patient then asks to be admitted to health system B because "all my records are there." Two questions:

1) Am I obligated to attempt to transfer away from my own healthcare system to another knowing full well that the transfer process will be lengthy and complicated.
2) Health System B can theoretically refuse transfer given Health System A is fully capable of managing the problem, correct?

What I've done in the past is point out that my hospital if fully capable of handing the problem, we can access the other system's records (both on Epic), and not admitting to my hospital would result in a lengthy delay in care and the risks associated with that. Normally patients have been agreeable after that and I haven't needed to transfer for routine things.

Post surgical complications and obstetric stuff I will admit to whoever was previously managing without hesitation.

1) don’t know you if *have* to transfer them but if they refuse to stay at your shop, what are you gonna do, sign them out AMA? It’s a bad look for sure.

2) 100% they don’t have to take the patient, usually I find they do though especially since they generally have insurance and they all about that $. What sucks is when they accept but don’t give you a bed for forever.

All in all I agree that this scenario is super annoying. I hate it too.

 

[ScepticSkeksis]

For #1 I make one call to the "Transfer Center". If accepted, then great. If refused, I document this, explain to patient, and they can choose to get admitted or sign out AMA. Literally takes no brain processing power.

 

[CliveStaples]

I think I disagree in the case of #2; I believe you can still only refuse a transfer on the grounds of insufficient capability or insufficient capacity, even if it is a lateral transfer at the patient's request.

 

[WorkNoteEmergency]

“Patient requests transfer“ - EMTALA doesn’t apply. I also let them know they might be on the hook for ambulance transfer bill.

 

[prolene60]

I feel like this is just the culture of community medicine. This seems to happen all the time at my place. Board certified orthopedist feels like something is “too complicated” or he/she only deals with one or 2 anatomical segments so we transfer to another hospital with board certified Otho who is willing to do the other anatomical part. It’s so common. Nobody ever mentions EMTALA.

 

[Dr Mantis Toboggan]

I think I disagree in the case of #2; I believe you can still only refuse a transfer on the grounds of insufficient capability or insufficient capacity, even if it is a lateral transfer at the patient's request.

I thought if the referring facility admits that they have capacity and capability to treat the patient/EMC that you were safe to decline. I am no EMTALA expert however.

 

[JacobMcCandles]

I've got a (somewhat) related question. Say a patient needs admission for cardiac work-up to my hospital in health system A. Health System A is perfectly able to care for that patient's needs. The patient then asks to be admitted to health system B because "all my records are there." Two questions:

1) Am I obligated to attempt to transfer away from my own healthcare system to another knowing full well that the transfer process will be lengthy and complicated.
2) Health System B can theoretically refuse transfer given Health System A is fully capable of managing the problem, correct?

What I've done in the past is point out that my hospital if fully capable of handing the problem, we can access the other system's records (both on Epic), and not admitting to my hospital would result in a lengthy delay in care and the risks associated with that. Normally patients have been agreeable after that and I haven't needed to transfer for routine things.

Post surgical complications and obstetric stuff I will admit to whoever was previously managing without hesitation.

If it's just a patient request and not a higher level of care then they don't have to accept for basically any reason they want, although I think we can all agree the patient typically gets better care where all their specialists are at.

 

[NITRAS]

If it's just a patient request and not a higher level of care then they don't have to accept for basically any reason they want, although I think we can all agree the patient typically gets better care where all their specialists are at.

Some patients are complicated and benefit from their panel of specialists. .. but most don’t. Most are too ignorant to realize that their precious spancy cardiologist isn't going to see them in the hospital if they aren’t on call. That most of their speciality decisions are going to be made by a first year fellow. . .. and that maybe patients should take some responsibility for their health and know what medicines they actually take and why. . .

 

[JacobMcCandles]

Some patients are complicated and benefit from their panel of specialists. .. but most don’t. Most are too ignorant to realize that their precious spancy cardiologist isn't going to see them in the hospital if they aren’t on call. That most of their speciality decisions are going to be made by a first year fellow. . .. and that maybe patients should take some responsibility for their health and know what medicines they actually take and why. . .

I'm not sure if you work in academics or a large tertiary care center but most places we'd transfer to don't have fellows or residents. And I would always encourage patients to seek care under one hospital system, especially if they have multiple specialists or just had a procedure done.

 

[southerndoc]

“Patient requests transfer“ - EMTALA doesn’t apply. I also let them know they might be on the hook for ambulance transfer bill.

To add to this... Transfer by insurance preference can be an EMTALA violation. We deal with a lot of Kaiser patients. I always tell patients they're welcome to be admitted at my facility, but if Kaiser doesn't approve it will be an out-of-network admission. Almost all of them request transfer. It's a patient requested transfer to an in-network facility and not a physician transfer even if you are required to call the insurer to get "permission" to admit there.

 

[thegenius]

Can accepting hospitals refuse to accept transfer based on reviewing imaging, and then saying "it's not an emergency?"
We've had quite a few of these recently, especially when we are trying to transfer patients to an academic center.

Possible invasive sinusitis - the academic center somehow reviewed the our CT scan and refused to accept patient (our ENT recommended transfer although I'm not sure if there was a formal consult note)
Orbital cellulitis - local Ophtho said should be transferred for oculoplastics consult, academice center again somehow reviewed our CT scan and said this can be managed locally and only transfer if it's getting worse.

 

[pkwraith]

Based on how Emtala is enforced, the accepting hospital is not supposed to respond to any transfer request except variations of "Yes" or "we don't have capacity or specialty service". But, this in fact ****tier for patients, because patient will get there and be discharged immeidately because they didn't need to be transferred.

 

[thegenius]

Based on how Emtala is enforced, the accepting hospital is not supposed to respond to any transfer request except variations of "Yes" or "we don't have capacity or specialty service". But, this in fact ****tier for patients, because patient will get there and be discharged immeidately because they didn't need to be transferred.

Yea I'm aware of that. They can't decide too if a patient is stable or unstable, or has an emergency or doesn't have one. It's up to the transferring doctor who has examined the patient to make that decision.

The fact is that the two patients above were not "unstable", and didn't even need immediate Ophtho or ENT surgery, but should be at an institution where that can be done if it's needed. It's just frustrating.

 

[southerndoc]

As @pkwraith said, the only answers are "yes," "we don't have capability," or "we don't have capacity" if you request transfer. If you call for advice then you aren't formally requesting a transfer. It's all in how you word it. "I have a patient with orbital cellulitis and would like to talk to ophthalmology" is a lot different than "I have a patient with orbital cellulitis that I would like to transfer to your facility."

It's in the best interest of the patient (even though not EMTALA compliant) for the consultant to say you can manage it there instead of transferring and then them discharging. I get it that some hospitalists/consultants are outside their comfort zone at the transferring facility, but if you tie up all the beds at the receiving facility, then they're on diversion or don't have capacity when you truly need something transferred there.

 

[Apollyon]

facility, but if you tie up all the beds at the receiving facility, then they're on diversion or don't have capacity when you truly need something transferred there.

That's end-stage possibility. Sounds like admin speak. Remember, if the sending faculty is sending from the ED, the receiving facility has literally infinite beds in the ED, per the law. (To clarify, to send from ED to ED, unlike on the floor, there doesn't need to be a bed assigned in the receiving ED to accept the transfer.)

 

[TooMuchResearch]

Based on how Emtala is enforced, the accepting hospital is not supposed to respond to any transfer request except variations of "Yes" or "we don't have capacity or specialty service". But, this in fact ****tier for patients, because patient will get there and be discharged immeidately because they didn't need to be transferred.

Sure, but it gets a little ridiculous when they're asking me to keep bilateral acute subdural hematomas at my rural ED, reimage in 6 hours and call them back. I know for a fact the level 1 trauma center ED isn't discharging these patients without surgery seeing them and signing off.

Once they develop a policy that involves ED seeing the patient alone at their center and filter the policy to all the surrounding hospitals, and the surrounding hospitals accept the policy, then maybe. Until then, I'm not volunteering to keep these patients.

 

[CliveStaples]

That's end-stage possibility. Sounds like admin speak. Remember, if the sending faculty is sending from the ED, the receiving facility has literally infinite beds in the ED, per the law. (To clarify, to send from ED to ED, unlike on the floor, there doesn't need to be a bed assigned in the receiving ED to accept the transfer.)

Are you saying that no EDs are allowed to state that they do not have capacity to accept a patient? I don't think this is the practice of most tertiary care centers that do go on ED transfer diversion.

 

[Apollyon]

Are you saying that no EDs are allowed to state that they do not have capacity to accept a patient? I don't think this is the practice of most tertiary care centers that do go on ED transfer diversion.

Correct. The ED is never "full". They might not have capability, but, the ED always has capacity.

Facilities on "diversion" (which is local or state, not federal) do so because there are more patients than they can safely treat. It's not that they literally have nowhere to put them. Likewise, if someone literally walks in, versus BIBA, they can't stop them.

And who goes on "transfer diversion" without being on "EMS diversion"? Were that so, I would guess that would be close to, or at, MCI level.

 

[southerndoc]

Correct. The ED is never "full". They might not have capability, but, the ED always has capacity.

Facilities on "diversion" (which is local or state, not federal) do so because there are more patients than they can safely treat. It's not that they literally have nowhere to put them. Likewise, if someone literally walks in, versus BIBA, they can't stop them.

And who goes on "transfer diversion" without being on "EMS diversion"? Were that so, I would guess that would be close to, or at, MCI level.

@Apollyon ED doesn't always have capacity. If we have more patients than beds, we are not obligated to accept a transfer to the ED. If that were the case, tertiary care facilities would be accepting transfers from inability to deny them which would saturate the ED even more and place patients in the waiting room at risk. There is precedent to establish that the ED doesn't have to accept if they do not have capacity to treat.

Regarding what @TooMuchResearch mentioned regarding bilateral subdurals getting repeat CTs and discharged, that's extreme. If it meets BIG1 criteria, then yes, you can do a 6-hour CT and discharge these patients safely. My facility does NOT contact neurosurgery for BIG1 patients. We aren't required to do a repeat CT. If their neuro exam is stable, then the repeat CT is optional. About 75% of the providers still do a repeat CT. If they are on 81 mg aspirin, then a repeat CT is recommended. BIG2/3 patients get repeat CTs but also get neurosurgery consultations.

 

[CliveStaples]

I will echo the above. BIG 1 and BIG 2 criteria at my shop do not get Neurosurgery consultation even though they are available. BIG 2 and 3 do get repeat head CTs. Our BIG 1s just get watched and discharged.

 

[Apollyon]

@Apollyon ED doesn't always have capacity. If we have more patients than beds, we are not obligated to accept a transfer to the ED. If that were the case, tertiary care facilities would be accepting transfers from inability to deny them which would saturate the ED even more and place patients in the waiting room at risk. There is precedent to establish that the ED doesn't have to accept if they do not have capacity to treat.

I'm talking on the paperwork. You need a room upstairs, an actual bed - 735A - but not needed, by law, for ED to ED, not required.

 

[TooMuchResearch]

@Apollyon ED doesn't always have capacity. If we have more patients than beds, we are not obligated to accept a transfer to the ED. If that were the case, tertiary care facilities would be accepting transfers from inability to deny them which would saturate the ED even more and place patients in the waiting room at risk. There is precedent to establish that the ED doesn't have to accept if they do not have capacity to treat.

Regarding what @TooMuchResearch mentioned regarding bilateral subdurals getting repeat CTs and discharged, that's extreme. If it meets BIG1 criteria, then yes, you can do a 6-hour CT and discharge these patients safely. My facility does NOT contact neurosurgery for BIG1 patients. We aren't required to do a repeat CT. If their neuro exam is stable, then the repeat CT is optional. About 75% of the providers still do a repeat CT. If they are on 81 mg aspirin, then a repeat CT is recommended. BIG2/3 patients get repeat CTs but also get neurosurgery consultations.

Where I work, we don't even know those criteria. Once the big trauma centers locally make it their standard and filter down to us, I'll learn it.

 

[Janders]

Correct. The ED is never "full". They might not have capability, but, the ED always has capacity.

Facilities on "diversion" (which is local or state, not federal) do so because there are more patients than they can safely treat. It's not that they literally have nowhere to put them. Likewise, if someone literally walks in, versus BIBA, they can't stop them.

And who goes on "transfer diversion" without being on "EMS diversion"? Were that so, I would guess that would be close to, or at, MCI level.

MA doesn’t allow ems diversion unless you are code black due to something like loss of water / fire in progress.

So in MA during respiratory season every single tertiary hospital is on xfer divert due to “lack of capacity” but oddly their post op dat 2 complex surgical disasters keep landing in random community EDs…

 

[southerndoc]

Where I work, we don't even know those criteria. Once the big trauma centers locally make it their standard and filter down to us, I'll learn it.

It's there. It's been validated.

Here's a primer: The Brain Injury Guidelines: Can we avoid talking to neurosurgeons? - First10EM

 

[thegenius]

That's end-stage possibility. Sounds like admin speak. Remember, if the sending faculty is sending from the ED, the receiving facility has literally infinite beds in the ED, per the law. (To clarify, to send from ED to ED, unlike on the floor, there doesn't need to be a bed assigned in the receiving ED to accept the transfer.)

But I'm not sending to the ED. That's a lateral transfer. Their ED can't help me at all except board the patient. If I were on the receiving end, I would say no. The sending ED has already done the standard of care. Pt needs to be admitted to inpatient.

 

[southerndoc]

But I'm not sending to the ED. That's a lateral transfer. Their ED can't help me at all except board the patient. If I were on the receiving end, I would say no. The sending ED has already done the standard of care. Pt needs to be admitted to inpatient.

This is what some facilities don't want to deal with. Have a hip fracture that your ortho isn't comfortable handling (why I don't know), well let's try to send it to the ER instead of the patient waiting 24 hours and going directly from the sending ER to pre-op.

We've started accepting patients with commitments to allow a return transfer once stabilized. If not, then the complicated stroke patient needing thrombectomy and then inpatient rehab ties up a hospital bed for weeks.

 

[Mount Asclepius]

The BIG criteria have been out for 10 years. Validated and modified. It’s worth being familiar. I’m in the community, albeit a regional referral and small trauma center, and it’s now become standard to utilize. Also not that risky. Although we don’t tie up an ED bed for 6 hours. Admit to trauma surgery for observation.

 

[Mount Asclepius]

I never mind if a sub-specialist at a tertiary/quaternary referral center declines transfer. It makes my own hospital’s specialists have to buck up and do their job even if they aren’t subspecialty trained. I’m not a fellowship trained EP, but I still have to take care of patients that arrive in an ambulance, have pain, have a sports injury, need an ultrasound, or are critically ill. The sub-specialization of all of medicine has become a little absurd. The old generalist ortho docs can deal with a hand complaint every now and then. Just because you recently did a fellowship in joint replacement doesn’t mean you can’t consult on a patient admitted to the hospitalist with a hand wound or infection. Not picking just on ortho, as it’s become rampant across medicine. Sure it’s ideal patient care if you are niche trained and an expert in that field. Many times patients don’t really need that though. Just a specialty trained physician (not even a PLP) that knows just enough. Transfer takes a lot more work and makes more work for lots of people.

 

[skougess]

It's there. It's been validated.

Here's a primer: The Brain Injury Guidelines: Can we avoid talking to neurosurgeons? - First10EM

This article actually points out a lot of flaws in using it in the community…

This is a great tool if you are at a trauma center. In the community, your hospitalists will say “lol, I’m not ****ing admitting that for obs”

 

[southerndoc]

This article actually points out a lot of flaws in using it in the community…

This is a great tool if you are at a trauma center. In the community, your hospitalists will say “lol, I’m not ****ing admitting that for obs”

We don't admit ours. We observe them in the ED and then discharge home. No reason to admit. Unlikely for a patient to get a bed in 6 hours anyhow, and it's really a waste to admit them when they're perfectly stable to go home.

 

[skougess]

We don't admit ours. We observe them in the ED and then discharge home. No reason to admit. Unlikely for a patient to get a bed in 6 hours anyhow, and it's really a waste to admit them when they're perfectly stable to go home.

All I’m saying is this wasn’t standard of care at the trauma center I trained at 2 years ago. None of the other doctor’s in my group practice this way.

Until it is more accepted as a hospital based protocol, or I at least see peers doing this, and other hospitals saying they won’t accept my transfers for this, I’m going to err on the side of being conservative. It doesn’t matter what the evidence says when there’s a bad outcome and you can find 90% of the doctors around you to take the stand and say “well I definitely wouldn’t have discharged that…”

 

[southerndoc]

All I’m saying is this wasn’t standard of care at the trauma center I trained at 2 years ago. None of the other doctor’s in my group practice this way.

Until it is more accepted as a hospital based protocol, or I at least see peers doing this, and other hospitals saying they won’t accept my transfers for this, I’m going to err on the side of being conservative. It doesn’t matter what the evidence says when there’s a bad outcome and you can find 90% of the doctors around you to take the stand and say “well I definitely wouldn’t have discharged that…”

My general philosophy is never to be too early nor too late to adopt something. This is middle of the road now and should be adopted. Our experience with >200 patients has had no bad outcome.

 

[skougess]

My general philosophy is never to be too early nor too late to adopt something. This is middle of the road now and should be adopted. Our experience with >200 patients has had no bad outcome.

I’m not saying it’s not good practice. My region sounds like it’s behind the curve a bit. I stand by my practice pattern for liability reasons. There are other local patterns I buck against (our cardiologists/hospital has a culture of admitting every new afib, which I think is ridiculous.) Head bleeds are not where I’m gonna lay it on the line. I’ll wait for the local trauma centers to catch up at least.