EMTALA Question

[TrailRun]

I get the premise, but what if they are worse in 6 hours? How is that defensible? I would suggest they need to be at a place with the capability to intervene, or else you’re trying to facilitate transfer perhaps too late (however long that will take; maybe it’s a snowstorm and no one is flying, etc)

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[Apollyon]

I get the premise, but what if they are worse in 6 hours? How is that defensible? I would suggest they need to be at a place with the capability to intervene, or else you’re trying to facilitate transfer perhaps too late (however long that will take; maybe it’s a snowstorm and no one is flying, etc)

Right - it's not a problem - until it is. Then, what do you do??

 

[southerndoc]

I get the premise, but what if they are worse in 6 hours? How is that defensible? I would suggest they need to be at a place with the capability to intervene, or else you’re trying to facilitate transfer perhaps too late (however long that will take; maybe it’s a snowstorm and no one is flying, etc)

You reassess them, and if they're worse, then you repeat head CT. You don't just say "oh 6 hours" and ignore them. If it worsens to a point that they need surgery, then you transfer. BIG1's by definition are extremely small bleeds and rarely - if ever - worsen.

 

[larpleston]

Those who work work at academic centers often don’t understand the realities of transferring. In 6 hours if their CT worsens you then have to initiate a transfer process that depending on where you are could take hours. So you keep a patient in your 8 bed ER for 6 hours while the waiting room is full and then have to board them 3 more hours while you reach out to the transfer center, wait to hear back, set up transport, etc. These guidelines also have not been validated outside of the center where they were devised, unless there is some new study out that I’m unaware of. It might be good medicine but at the end of the day if you are an EBM adherent you cannot honestly say that a single center study and then some retrospective studies (which have not been in agreement - some small ones have shown worsening of BIG1 patients while much larger ones have shown none - that should raise eyebrows), is enough for implementation in rural ERs that lack neurosurgery, ICUs, etc. That is an easy point to make from a large academic hospital, much harder to sell it to those of us who have no backup when their bleed is bigger and we sat on it for half a day.

 

[CoolDoc1729]

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.

My hospital is not a big quaternary center but it is the flagship of the system of ~30 EDs, including several ~30K community hospitals, several rural 10K CAHs, and a bunch of suburban 15-20K FSEDs. As such, we are often getting all of the systems NS, urology, GI, etc consults over the weekend due to them not having call coverage until Monday ….

Can you speak to how the return transfer agreement works? Is that just within your system or is it governed by state or local law?

A lot of our folks get transferred for something like “widely metastatic cancer, but now has a brain met, and we don’t have NS this weekend” where they arrive and the NS basically signs off immediately and they languish in the hospital for a couple weeks and in the rehab unit for a couple more …patiwnts get frustrated trying to find transport back to BFE or our case mgmt isn’t familiar with BFEs rehab facilities … and my understanding was that they can’t be transferred *back* because it has to go to a higher level of care.

 

[southerndoc]

My hospital is not a big quaternary center but it is the flagship of the system of ~30 EDs, including several ~30K community hospitals, several rural 10K CAHs, and a bunch of suburban 15-20K FSEDs. As such, we are often getting all of the systems NS, urology, GI, etc consults over the weekend due to them not having call coverage until Monday ….

Can you speak to how the return transfer agreement works? Is that just within your system or is it governed by state or local law?

A lot of our folks get transferred for something like “widely metastatic cancer, but now has a brain met, and we don’t have NS this weekend” where they arrive and the NS basically signs off immediately and they languish in the hospital for a couple weeks and in the rehab unit for a couple more …patiwnts get frustrated trying to find transport back to BFE or our case mgmt isn’t familiar with BFEs rehab facilities … and my understanding was that they can’t be transferred *back* because it has to go to a higher level of care.

It's within our system. We are approaching hospitals outside our system to get similar agreements.

 

[TooMuchResearch]

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”

Bingo.

 

[TooMuchResearch]

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.

My experience in my geographic area is that no one is doing it, including the local level one centers.

I'm happy to do it once I'm not the only person in the group and within 100 miles doing it.

 

[skougess]

My experience in my geographic area is that no one is doing it, including the local level one centers.

I'm happy to do it once I'm not the only person in the group and within 100 miles doing it.

That’s my position as well. The merits of the evidence are neither here nor there because following it falls well outside standard of care for my region. It’s not “middle of the road” where I practice. It’s one bad outcome away from a local trauma surgeon and neurosurgeon taking the stand against me wondering “why didn’t you call??” and $2m settlement.

This reminds me of the TNK debate. As long as the experts (neurologists) say it’s standard of care, then it’s standard of care. End of story.