Possible EMTALA violations

[Jabbed]

How do you handle accepting transfers that you think might be EMTALA violations? Do you reject them? Do you notify your medical director afterwards? Recent examples with intentionally vague details

• Trauma transfers that you anticipate discharging from the ED without specialist involvement. This is along the lines of "ooh there may be a head bleed and we're not sure and the hospitalist won't take it" and they are discharged after negative MRI.
• Transfer where they have a specialist at the facility that is credentialed to perform the procedure but won't. As an example, orthopedist on-call predominantly does hand and refuses to manage a bimal ankle fracture.
• "The patient had a surgery there 5 years ago and our surgeon does not want to manage any complications"

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[thegenius]

I wouldn't reject any transfer request to your hospital if your hospital has the capability to handle the chief complaint AND you have the capacity to do so. I believe it's a violation on your part to reject.

I would escalate to your admin if it getting abused though.

Lastly...ER docs should never be accepting patients anyway, theoretically at least. A transfer from one ER to another ER (if they are both fully credentialed ERs) for the purpose of patient management doesn't make sense. ER Doc A has the same capabilities and training as ER Doc B. So usually all these transfers are because a specialist is needed, and I wouldn't accept a patient in transfer if another ER doc called me. I would say "Please call Ortho specialist or trauma specialist and discuss the case with them."

At my hospital, we accept trauma transfers from the community and they always come to the ER first, whether they are stable or not. The trauma surgeon is involved though and accepts all transfers, not the ER. Sometimes kind of frustrating as I'm not needed, but I guess I get to bill more RVUs as a result.

 

[southerndoc]

If you reject, then it's an EMTALA violation. If you accept and fail to report the sending facility, then BOTH facilities are in EMTALA violation.

It's best to accept these things. The last time I had a surgeon that didn't want to deal with another surgeon's problems, I explicitly said on a recorded line to the ER doc "so let me get this correct, you have a surgeon with the capability of treating this patient, you have the capacity to treat this patient, the patient is not wanting to be transferred to my facility for treatment, and your surgeon is refusing to take care of the patient? Have I summarized that correctly?"

 

[southerndoc]

At my hospital, we accept trauma transfers from the community and they always come to the ER first, whether they are stable or not. The trauma surgeon is involved though and accepts all transfers, not the ER. Sometimes kind of frustrating as I'm not needed, but I guess I get to bill more RVUs as a result.

Why do they come to the ER? Because your trauma service uses the ER as a destination in order to justify charging an activation fee. Yes, even a lower extremity fracture gets an activation fee.

 

[Janders]

(1) Your job is to accept these; if you reject them you may end up being the EMTALA violator
(2) It is also your job to report (through your leadership/hospital) transfers you receive that appear to be EMTALA violations.

As far as your examples—
(A) I don’t understand this transfer. Is their a small bleed on non-con CT they want NSUG input on, but you are comfortable handling yourself? Outlying uncomfortable small ERs asking big trauma centers to take trauma cases usually should get the benefit of the doubt IMO. One of my rules is if another ER Doc calls me asking for help, they get whatever help they need. Brotherhood etc etc.

(B) These are more sticky wickets to me. I work with orthopedists who literally have only done Hips and Knees for a decade. Its a small place. Yeah maybe they are “dumping” the tri-mail ankle on the trauma center up the street, but also they haven’t done one in 6 years and the best thing for the patient is to be transferred. Devil is in the details with these; as you know precisely what is in your credentialing packet isn’t necessarily what you should/can be doing. I certainly wouldn’t reject these If i were you, but I’d flag them to my transfer center or director as “there are a pattern of routine ortho cases being sent in from XXX, here are 4 examples I’ve collected, is this an issue?”

(C) Does the patient want to be transferred? If they do, then I’d take them, they have a relationship with your institution. If they don’t, and its the outside surgeon refusing to be involved… I would still accept, but I would 100% do as Southerndoc above and clarify on the recorded line that the reason for xfer is that the outside surgeon doesn’t want to be involved in a case that they have the capability and capacity to handle, DESPITE the fact the patient wants to stay there.

 

[thegenius]

(1) Your job is to accept these; if you reject them you may end up being the EMTALA violator
(2) It is also your job to report (through your leadership/hospital) transfers you receive that appear to be EMTALA violations.

As far as your examples—
(A) I don’t understand this transfer. Is their a small bleed on non-con CT they want NSUG input on, but you are comfortable handling yourself? Outlying uncomfortable small ERs asking big trauma centers to take trauma cases usually should get the benefit of the doubt IMO. One of my rules is if another ER Doc calls me asking for help, they get whatever help they need. Brotherhood etc etc.

It would be hard to argue effectively that traumatic head bleeds, no matter how small, shouldn't get a NSG consult. That is...I'm sure there would be thousands upon thousands of ED docs that would argue on the stand that it's standard of care to get a NSG consult for traumatic head bleeds.

 

[Janders]

It would be hard to argue effectively that traumatic head bleeds, no matter how small, shouldn't get a NSG consult. That is...I'm sure there would be thousands upon thousands of ED docs that would argue on the stand that it's standard of care to get a NSG consult for traumatic head bleeds.

Yeh we set up a teleNsurg system to allow us to do this without physical transfer for the small ones.

I think evolving standard of care will eventually be benign, small traumatic SAH / couple pixels of blood can be managed by EM alone without NSURG at all.

 

[turkeyjerky]

Yeh we set up a teleNsurg system to allow us to do this without physical transfer for the small ones.

I think evolving standard of care will eventually be benign, small traumatic SAH / couple pixels of blood can be managed by EM alone without NSURG at all.

A little afraid of that one. We might end up w/ a future where we're stuck w/ these patients and nobody to accept them. Few of these patients need a neurosurgeon, but many need more than a few hours in the ED and a pat on the bum.

 

[southerndoc]

A little afraid of that one. We might end up w/ a future where we're stuck w/ these patients and nobody to accept them. Few of these patients need a neurosurgeon, but many need more than a few hours in the ED and a pat on the bum.

More than a few hours in the ED. So if it doesn't need a neurosurgeon, you want to transfer it to another ED so it becomes that ED's length of stay to discharge them?

 

[Jabbed]

I didn’t want to give specifics on any cases, but as this one example has derailed the thread quite a bit I’ll clarify further. Patient had a small ditzel on CT head that was ready as potentially a punctate ICH. NSG was consulted by outside facility and said no need to transfer, fine for floor admit and am CT head. Hospitalist refused admission. Patient was transferred to my ED. I ordered an MR which was read as negative for ICH and patient was discharged. The sending facility had the ability to perform the imaging study and had phone access to a consultant that said that there was no reason to transfer the patient.

**please do not quote me in reply**

 

[turkeyjerky]

More than a few hours in the ED. So if it doesn't need a neurosurgeon, you want to transfer it to another ED so it becomes that ED's length of stay to discharge them?

I think you misunderstood me, likely b/c I was unclear. I just worry about a future scenario where everyone else involved abdicates their role and we're left holding a patient who's unsafe to go home but most community hospitalists will refuse.

 

[Janders]

I think you misunderstood me, likely b/c I was unclear. I just worry about a future scenario where everyone else involved abdicates their role and we're left holding a patient who's unsafe to go home but most community hospitalists will refuse.

Well yeah the entire concept would be predicated on a wide spread adoption of evidence based guidelines to define precisely whom amongst these various “ditzel” headbleeds can be sent right home, watched for 4-8hr, or admitted to your non-Neurosurgical hospital for OTHER reasons.

I suspect in 5-10 years this will be typical clinical practice around most of the US.

 

[DrDrummer]

Well yeah the entire concept would be predicated on a wide spread adoption of evidence based guidelines to define precisely whom amongst these various “ditzel” headbleeds can be sent right home, watched for 4-8hr, or admitted to your non-Neurosurgical hospital for OTHER reasons.

I suspect in 5-10 years this will be typical clinical practice around most of the US.

Just since I don't think this has been posted yet in this thread: Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications -- I know some centers are already using this, but I think this is useful as an emerging standard of care and if you can get your local neurosurgeon's support/buy-in I think it's very safe/reasonable to follow these. (Note: One of the major punchlines of BIG is that you *don't* need a neurosurgery consult for every traumatic brain bleed.)

I see a lot of fear of litigation driving dispositions/transfer decisions, but using evidence + gestalt seems very reasonable to me. Still a six hour LOS for the repeat scan but I hope that more places will move towards this. Good use of an obs unit if you have one.

 

[southerndoc]

Just since I don't think this has been posted yet in this thread: Multicenter assessment of the Brain Injury Guidelines and a proposal of guideline modifications -- I know some centers are already using this, but I think this is useful as an emerging standard of care and if you can get your local neurosurgeon's support/buy-in I think it's very safe/reasonable to follow these. (Note: One of the major punchlines of BIG is that you *don't* need a neurosurgery consult for every traumatic brain bleed.)

I see a lot of fear of litigation driving dispositions/transfer decisions, but using evidence + gestalt seems very reasonable to me. Still a six hour LOS for the repeat scan but I hope that more places will move towards this. Good use of an obs unit if you have one.

For clarification, our protocol excludes any epidural hematoma from BIG1 criteria. All epidural hematomas get neurosurgery consults.

 

[turkeyjerky]

Well yeah the entire concept would be predicated on a wide spread adoption of evidence based guidelines to define precisely whom amongst these various “ditzel” headbleeds can be sent right home, watched for 4-8hr, or admitted to your non-Neurosurgical hospital for OTHER reasons.

I suspect in 5-10 years this will be typical clinical practice around most of the US.

I don't have high hopes.

My previous site used the BIG criteria. I think the following two examples are representative:
1. Young homeless guy seen at the level 1 center after getting beat up. Signs of head trauma and ?seizure per EMS. CT head w/ small SAH. Persistently confused. I consult trauma to admit, they refuse. The attending trauma surgeon then lost his **** when he read my note documenting that they recommended discharge, "you're the one discharging. I just said he didn't need to be admitted!"
2. Old guy seen at affiliated critical access hospital after a fall. In no condition to go home, has tiny SDH on CT. Hospitalist refuses to admit. Fine, w/e. Trauma at Level 1 refuses transfer, "it's a BIG 1--doesn't need anything". Local hospitalist still refuses patient "dude, I would love to help you out. But I really have no idea how to manage these patients". Pt ends up getting transferred to hospitalist at level 1 w/ NSG on consult.

 

[southerndoc]

I don't have high hopes.

My previous site used the BIG criteria. I think the following two examples are representative:
1. Young homeless guy seen at the level 1 center after getting beat up. Signs of head trauma and ?seizure per EMS. CT head w/ small SAH. Persistently confused. I consult trauma to admit, they refuse. The attending trauma surgeon then lost his **** when he read my note documenting that they recommended discharge, "you're the one discharging. I just said he didn't need to be admitted!"
2. Old guy seen at affiliated critical access hospital after a fall. In no condition to go home, has tiny SDH on CT. Hospitalist refuses to admit. Fine, w/e. Trauma at Level 1 refuses transfer, "it's a BIG 1--doesn't need anything". Local hospitalist still refuses patient "dude, I would love to help you out. But I really have no idea how to manage these patients". Pt ends up getting transferred to hospitalist at level 1 w/ NSG on consult.

#1 is a misrepresentation of what the trauma surgeon said. I get that saying that he doesn't need admission is basically saying to discharge the patient, but the trauma surgeon didn't recommend you discharge since you're documenting what he said. It's appropriate to say "contacted trauma surgeon who advised admission isn't necessary" or "contacted trauma surgeon who stated admission to his service isn't required," but to say "contacted trauma surgery who recommended discharging the patient" is going a little too far. For one, he's not telling you to discharge the patient immediately and that's what is implied with your documentation.

 

[emergentmd]

99% of my shifts were at a receiving hospital and I would never call an EMTALA violation on anyone and the hospital hated this. Paperwork, piss off transferring hospital that they actively catered to, and plus its job security. Most of these pts were easy dispositions.

To Ops scenarios
#1 - I have to remember that these small transferring hospitals typically have FM/IM docs, old timers, or resident moonlighting who just do not feel comfortable discharging these pts without a specialist within 100 miles. Someone needs to follow these pts up and their PCPs many times don't want to deal with it.

#2 - Having a specialist able to care for the pt doesn't mean that they have the support staff to take care of it. Even if the orthopedic doc does care for the specific body part, they may be taking call 100 miles away, may not have nursing staff, may not have anesthesiologist, etc. If a transferring doc tells me they are not comfortable then I just take it.

#3 - If I were an on call surgeon and the ER doc calls me, I would try to find any way to get out of it. Its human nature. Even if it was 5 yrs ago, the doc who did the surgery has all the records, know the pt, etc.

TLDR - receiving hospitals love to receive pts to fill up beds to make more money. I get to make more $$$ if RVU based for little work. Transferring doc, no matter the reason, is not comfortable and thus I am better equipped. I have drained peritonsillar abscesses all the time for pts transferred from a sister hospital 10 miles away b/c the EM boarded doc was not comfortable. I just take it, drain it, send them home. Really nothing off my back.

 

[emergentmd]

My previous site used the BIG criteria. I think the following two examples are representative:
1. Young homeless guy seen at the level 1 center after getting beat up. Signs of head trauma and ?seizure per EMS. CT head w/ small SAH. Persistently confused. I consult trauma to admit, they refuse. The attending trauma surgeon then lost his **** when he read my note documenting that they recommended discharge, "you're the one discharging. I just said he didn't need to be admitted!"
2. Old guy seen at affiliated critical access hospital after a fall. In no condition to go home, has tiny SDH on CT. Hospitalist refuses to admit. Fine, w/e. Trauma at Level 1 refuses transfer, "it's a BIG 1--doesn't need anything". Local hospitalist still refuses patient "dude, I would love to help you out. But I really have no idea how to manage these patients". Pt ends up getting transferred to hospitalist at level 1 w/ NSG on consult.

#1 - I tell Trauma guy I do not feel comfortable to D/C this homeless pt without chance for follow up. I then tell him, I will have hospitalist admit if he will drop by and put in a note. Then I call Hospitalist tell them Trauma will consult if you put the pt in. This typically solves the issue as I for sure would not send this guy home. If this fails, I tell them both they are consulted and come put a note stating they do not need admission. If this fails, I call admin on call and let them duke it out. I will not be the only doc holding the bag when this guy comes back dead

 

[turkeyjerky]

#1 is a misrepresentation of what the trauma surgeon said. I get that saying that he doesn't need admission is basically saying to discharge the patient, but the trauma surgeon didn't recommend you discharge since you're documenting what he said. It's appropriate to say "contacted trauma surgeon who advised admission isn't necessary" or "contacted trauma surgeon who stated admission to his service isn't required," but to say "contacted trauma surgery who recommended discharging the patient" is going a little too far. For one, he's not telling you to discharge the patient immediately and that's what is implied with your documentation.

Exactly my point. I wouldn’t expect improved healthcare system functionality or better patient care through mechanisms designed to enable abdication of responsibility.

 

[EdEmEr]

Hola!

Can anyone direct me to a canned and vetted statement to put in the chart when the higher level of care facility has decline/deferred/refused acceptance due to X reason?

Or would someone versed give a list of the elements to include in such a statement?

Thanks in advance. Everywhere is full always and is sorry they can’t help. But call us back.

 

[CliveStaples]

Hola!

Can anyone direct me to a canned and vetted statement to put in the chart when the higher level of care facility has decline/deferred/refused acceptance due to X reason?

Or would someone versed give a list of the elements to include in such a statement?

Thanks in advance. Everywhere is full always and is sorry they can’t help. But call us back.

Is the concern that you'll be sued because something bad happened to somebody you couldn't transfer out? I am curious if there is a precedent for that. Obviously if a negative outcome occurs and somebody decides to sue, everybody involved gets served, but I do wonder if there is any precedent for it being more or less defensible that you didn't transfer somebody out due to charting.

I always just chart that I called X Hospital for Y subspecialty or higher level of care or whatever and that the transfer request was denied due to lack of capacity at the accepting institution.

 

[Jabbed]

#1 - I tell Trauma guy I do not feel comfortable to D/C this homeless pt without chance for follow up. I then tell him, I will have hospitalist admit if he will drop by and put in a note. Then I call Hospitalist tell them Trauma will consult if you put the pt in. This typically solves the issue as I for sure would not send this guy home. If this fails, I tell them both they are consulted and come put a note stating they do not need admission. If this fails, I call admin on call and let them duke it out. I will not be the only doc holding the bag when this guy comes back dead

Catch 22: If you admit a trauma patient to the hospitalist service it jeopardizes your hospital’s trauma center accreditation. 90% of traumas need to be admitted to a surgical service in order to maintain accreditation.

 

[RoyBasch]

#1 is a misrepresentation of what the trauma surgeon said. I get that saying that he doesn't need admission is basically saying to discharge the patient, but the trauma surgeon didn't recommend you discharge since you're documenting what he said. It's appropriate to say "contacted trauma surgeon who advised admission isn't necessary" or "contacted trauma surgeon who stated admission to his service isn't required," but to say "contacted trauma surgery who recommended discharging the patient" is going a little too far. For one, he's not telling you to discharge the patient immediately and that's what is implied with your documentation.

If I call a specialist and they say "admission is not necessary" without further elaboration, they are telling me to the discharge the patient. If they mean something different, they should say so. If they mean "I will consult and hospitalist should admit;" say that. If they mean "Observe them for 6 hours in the ER and reassess and call me if worse;" say that. If they mean "I would like to see the patient in consultation myself in the ER prior to disposition;" say that.

I take tremendous umbrage at consultants who now have a new plan--lo and behold a more cautious and conservative plan--when I make it clear they will be held accountable for their recommendations and I fully intend to document their professional advice verbatim.

When I call a consultant, this is not a curbside. I am asking for their professional opinion in their capacity as a specialist on call. They should feel comfortable with me documenting what they tell me, and if they don't like the way their own recommendation sounds on paper, they should make a different one.

 

[southerndoc]

If I call a specialist and they say "admission is not necessary" without further elaboration, they are telling me to the discharge the patient. If they mean something different, they should say so. If they mean "I will consult and hospitalist should admit;" say that. If they mean "Observe them for 6 hours in the ER and reassess and call me if worse;" say that. If they mean "I would like to see the patient in consultation myself in the ER prior to disposition;" say that.

I take tremendous umbrage at consultants who now have a new plan--lo and behold a more cautious and conservative plan--when I make it clear they will be held accountable for their recommendations and I fully intend to document their professional advice verbatim.

When I call a consultant, this is not a curbside. I am asking for their professional opinion in their capacity as a specialist on call. They should feel comfortable with me documenting what they tell me, and if they don't like the way their own recommendation sounds on paper, they should make a different one.

Just saying you can't quote him as saying to discharge the patient when he said patient doesn't need admission. It won't hold up in litigation. You call a cardiologist for a chest pain and he says the patient doesn't need admission, but you only check one troponin, it won't be your consultant who will be named in litigation. It will only be you. If they depose the consultant, he's not going to testify to say he told you to discharge the patient. He'll say something like "I told him patient didn't need admission. I thought he would be up on the research saying that the patient needed a repeat troponin."

 

[p1acebo]

Is the concern that you'll be sued because something bad happened to somebody you couldn't transfer out? I am curious if there is a precedent for that. Obviously if a negative outcome occurs and somebody decides to sue, everybody involved gets served, but I do wonder if there is any precedent for it being more or less defensible that you didn't transfer somebody out due to charting.

I always just chart that I called X Hospital for Y subspecialty or higher level of care or whatever and that the transfer request was denied due to lack of capacity at the accepting institution.

100% you can be sued for a delay in care if a patient can’t be transferred out. Like you said a bad outcome is a bad outcome, a lawyer isn’t going to care about the circumstances if the “standard of care” is not met.

 

[Jabbed]

Just saying you can't quote him as saying to discharge the patient when he said patient doesn't need admission. It won't hold up in litigation. You call a cardiologist for a chest pain and he says the patient doesn't need admission, but you only check one troponin, it won't be your consultant who will be named in litigation. It will only be you. If they depose the consultant, he's not going to testify to say he told you to discharge the patient. He'll say something like "I told him patient didn't need admission. I thought he would be up on the research saying that the patient needed a repeat troponin."

Okay. Sure. Technically.

Should he instead document: “Consulted Dr. NSGY who refused to examine patient or offer any recommendations beyond ‘the patient does not need to be admitted.’”?

 

[thegenius]

Is this a violation?

Pt presents to ER with pain around his lower extremity wound vac. It was put on by another hospital in the past. T 100.0, HR 135, BP 124/96, RR 20, SpO2 95%. ED doc notes are of fluctuance over around the wound vac on the lower extremity with crepitus. Notable labs are (and no priors for comparison) WBC 17 w/ left shift, platelets 400, Lactate 1.3, Na 132, Glucose 300, Cr 1.31. CT of lower extremity shows an "elongated rim enhancing collection in the lower extremity (calf) which is in and around the muscle and achilles tendon, with soft tissue changes of cellulitis. There are some foci of soft tissue gas in the region. There is a bypass graft in the region from a prior PFTP". ED doc thinks the differential includes deep space tissue infection (e.g. nec fasc), abscess with cellulitis, and sepsis. Pt given 2L IVF, vanc, zosyn, and clindamycin.

ED doc calls general surgery who says, in a nutshell "I do not operate on abscesses in extremity muscles." Refuses to come in. ED doc calls Ortho who says "this pt needs to be transferred back to the original facility who performed the procedure" despite being told he has an emergency medical condition right now in the ED. Refuses to come in. Finally after multiple conversations, Ortho finally comes in and evaluates the patient. Again says pt needs to be transferred out to another hospital. Ortho does not leave a note in the system. ED doc calls the other hospital who performed the wound vac and they not have bed space. In the meantime, pt's vital signs remain wishy-washy - HR comes down to 98...BP drops to 98/65, but an hour later HR again is 130, BP is 119/79.

I for one know that the hospital system can manage deep space tissue infections e.g. nec fasc because I've admitted it before to the same doc pool. Not sure what happened to the patient I need to look that up.

This is a violation, no?

 

[Dr Mantis Toboggan]

Is this a violation?

Pt presents to ER with pain around his lower extremity wound vac. It was put on by another hospital in the past. T 100.0, HR 135, BP 124/96, RR 20, SpO2 95%. ED doc notes are of fluctuance over around the wound vac on the lower extremity with crepitus. Notable labs are (and no priors for comparison) WBC 17 w/ left shift, platelets 400, Lactate 1.3, Na 132, Glucose 300, Cr 1.31. CT of lower extremity shows an "elongated rim enhancing collection in the lower extremity (calf) which is in and around the muscle and achilles tendon, with soft tissue changes of cellulitis. There are some foci of soft tissue gas in the region. There is a bypass graft in the region from a prior PFTP". ED doc thinks the differential includes deep space tissue infection (e.g. nec fasc), abscess with cellulitis, and sepsis. Pt given 2L IVF, vanc, zosyn, and clindamycin.

ED doc calls general surgery who says, in a nutshell "I do not operate on abscesses in extremity muscles." Refuses to come in. ED doc calls Ortho who says "this pt needs to be transferred back to the original facility who performed the procedure" despite being told he has an emergency medical condition right now in the ED. Refuses to come in. Finally after multiple conversations, Ortho finally comes in and evaluates the patient. Again says pt needs to be transferred out to another hospital. Ortho does not leave a note in the system. ED doc calls the other hospital who performed the wound vac and they not have bed space. In the meantime, pt's vital signs remain wishy-washy - HR comes down to 98...BP drops to 98/65, but an hour later HR again is 130, BP is 119/79.

I for one know that the hospital system can manage deep space tissue infections e.g. nec fasc because I've admitted it before to the same doc pool. Not sure what happened to the patient I need to look that up.

This is a violation, no?

No brainer violation in my opinion.

 

[RustedFox]

Is this a violation?

Pt presents to ER with pain around his lower extremity wound vac. It was put on by another hospital in the past. T 100.0, HR 135, BP 124/96, RR 20, SpO2 95%. ED doc notes are of fluctuance over around the wound vac on the lower extremity with crepitus. Notable labs are (and no priors for comparison) WBC 17 w/ left shift, platelets 400, Lactate 1.3, Na 132, Glucose 300, Cr 1.31. CT of lower extremity shows an "elongated rim enhancing collection in the lower extremity (calf) which is in and around the muscle and achilles tendon, with soft tissue changes of cellulitis. There are some foci of soft tissue gas in the region. There is a bypass graft in the region from a prior PFTP". ED doc thinks the differential includes deep space tissue infection (e.g. nec fasc), abscess with cellulitis, and sepsis. Pt given 2L IVF, vanc, zosyn, and clindamycin.

ED doc calls general surgery who says, in a nutshell "I do not operate on abscesses in extremity muscles." Refuses to come in. ED doc calls Ortho who says "this pt needs to be transferred back to the original facility who performed the procedure" despite being told he has an emergency medical condition right now in the ED. Refuses to come in. Finally after multiple conversations, Ortho finally comes in and evaluates the patient. Again says pt needs to be transferred out to another hospital. Ortho does not leave a note in the system. ED doc calls the other hospital who performed the wound vac and they not have bed space. In the meantime, pt's vital signs remain wishy-washy - HR comes down to 98...BP drops to 98/65, but an hour later HR again is 130, BP is 119/79.

I for one know that the hospital system can manage deep space tissue infections e.g. nec fasc because I've admitted it before to the same doc pool. Not sure what happened to the patient I need to look that up.

This is a violation, no?

0/10 wouldn't defy EMTALA again.

 

[evert1de101]

Is this a violation?

Pt presents to ER with pain around his lower extremity wound vac. It was put on by another hospital in the past. T 100.0, HR 135, BP 124/96, RR 20, SpO2 95%. ED doc notes are of fluctuance over around the wound vac on the lower extremity with crepitus. Notable labs are (and no priors for comparison) WBC 17 w/ left shift, platelets 400, Lactate 1.3, Na 132, Glucose 300, Cr 1.31. CT of lower extremity shows an "elongated rim enhancing collection in the lower extremity (calf) which is in and around the muscle and achilles tendon, with soft tissue changes of cellulitis. There are some foci of soft tissue gas in the region. There is a bypass graft in the region from a prior PFTP". ED doc thinks the differential includes deep space tissue infection (e.g. nec fasc), abscess with cellulitis, and sepsis. Pt given 2L IVF, vanc, zosyn, and clindamycin.

ED doc calls general surgery who says, in a nutshell "I do not operate on abscesses in extremity muscles." Refuses to come in. ED doc calls Ortho who says "this pt needs to be transferred back to the original facility who performed the procedure" despite being told he has an emergency medical condition right now in the ED. Refuses to come in. Finally after multiple conversations, Ortho finally comes in and evaluates the patient. Again says pt needs to be transferred out to another hospital. Ortho does not leave a note in the system. ED doc calls the other hospital who performed the wound vac and they not have bed space. In the meantime, pt's vital signs remain wishy-washy - HR comes down to 98...BP drops to 98/65, but an hour later HR again is 130, BP is 119/79.

I for one know that the hospital system can manage deep space tissue infections e.g. nec fasc because I've admitted it before to the same doc pool. Not sure what happened to the patient I need to look that up.

This is a violation, no?

This is an institutional issue. Your institute has bad culture. Only way to fix this behavior is to document well and anonymously call CMS.

 

[NYEMMED]

Typical surgeon “That’s somebody else’s issue, send them there”

“We can’t, we have to stabilize here first, and continuity of care isn’t a reason to not treat here”

I really think the EMTALA training EM docs need at many facilities should actually go to all the non-EM physicians….

 

[wareagle726]

Why do they come to the ER? Because your trauma service uses the ER as a destination in order to justify charging an activation fee. Yes, even a lower extremity fracture gets an activation fee.

I think this is probably true from the C-suite level to a point. We have fantastic trauma surgeons and great relationships with them and I asked one of them about this and why we don't direct admit them. He basically said he trusts us a lot more than sending facilities' docs because who knows what other injuries they missed. I think there is merit to both.

 

[DeadCactus]

None of those patients sound unstable. I would argue EMTALA doesn't even apply and these are just frustrating transfers that come down to a community hospital being uncomfortable managing the patient (i.e. feeling they don't have the capacity to manage the patient). Advanced imaging, a more competent surgeon, and continuity of care all sound beneficial to the patient. EMTALA is meant to keep patients from dying through denial of stabilizing treatments, not limit their care if transfer would benefit them.

 

[pkwraith]

What EMTALA is meant to do has very little to do with how EMTALA is interpreted by those enforcing it

 

[southerndoc]

Is this a violation?

Pt presents to ER with pain around his lower extremity wound vac. It was put on by another hospital in the past. T 100.0, HR 135, BP 124/96, RR 20, SpO2 95%. ED doc notes are of fluctuance over around the wound vac on the lower extremity with crepitus. Notable labs are (and no priors for comparison) WBC 17 w/ left shift, platelets 400, Lactate 1.3, Na 132, Glucose 300, Cr 1.31. CT of lower extremity shows an "elongated rim enhancing collection in the lower extremity (calf) which is in and around the muscle and achilles tendon, with soft tissue changes of cellulitis. There are some foci of soft tissue gas in the region. There is a bypass graft in the region from a prior PFTP". ED doc thinks the differential includes deep space tissue infection (e.g. nec fasc), abscess with cellulitis, and sepsis. Pt given 2L IVF, vanc, zosyn, and clindamycin.

ED doc calls general surgery who says, in a nutshell "I do not operate on abscesses in extremity muscles." Refuses to come in. ED doc calls Ortho who says "this pt needs to be transferred back to the original facility who performed the procedure" despite being told he has an emergency medical condition right now in the ED. Refuses to come in. Finally after multiple conversations, Ortho finally comes in and evaluates the patient. Again says pt needs to be transferred out to another hospital. Ortho does not leave a note in the system. ED doc calls the other hospital who performed the wound vac and they not have bed space. In the meantime, pt's vital signs remain wishy-washy - HR comes down to 98...BP drops to 98/65, but an hour later HR again is 130, BP is 119/79.

I for one know that the hospital system can manage deep space tissue infections e.g. nec fasc because I've admitted it before to the same doc pool. Not sure what happened to the patient I need to look that up.

This is a violation, no?

Definitely a violation unless the patient requested to be transferred.

 

[southerndoc]

I think this is probably true from the C-suite level to a point. We have fantastic trauma surgeons and great relationships with them and I asked one of them about this and why we don't direct admit them. He basically said he trusts us a lot more than sending facilities' docs because who knows what other injuries they missed. I think there is merit to both.

My point was the facility charging a trauma activation fee for a simple hip fracture or extremity fracture that is transferred to the ER for a trauma admission.

 

[wareagle726]

My point was the facility charging a trauma activation fee for a simple hip fracture or extremity fracture that is transferred to the ER for a trauma admission.

Well then yes, you're absolutely correct with those patients. Simply a billing grab.

 

[TooMuchResearch]

Well yeah the entire concept would be predicated on a wide spread adoption of evidence based guidelines to define precisely whom amongst these various “ditzel” headbleeds can be sent right home, watched for 4-8hr, or admitted to your non-Neurosurgical hospital for OTHER reasons.

I suspect in 5-10 years this will be typical clinical practice around most of the US.

I work in a system in which I can see the standard becoming teleneurology or neuro ICU consult in ED, admit to hospitalist in small hospital, teleneurology next day again

 

[TooMuchResearch]

We're told they just need trauma consults. Our level 18 trauma certification hospitals let us admit to hospitalist.

Catch 22: If you admit a trauma patient to the hospitalist service it jeopardizes your hospital’s trauma center accreditation. 90% of traumas need to be admitted to a surgical service in order to maintain accreditation.

 

[RoyBasch]

Typical surgeon “That’s somebody else’s issue, send them there”

“We can’t, we have to stabilize here first, and continuity of care isn’t a reason to not treat here”

I really think the EMTALA training EM docs need at many facilities should actually go to all the non-EM physicians….

I agree with this 100%. I have had this conversation with too many surgeons now to count. I really think the hospital should require EMTALA training as part of their onboarding.

None of those patients sound unstable. I would argue EMTALA doesn't even apply and these are just frustrating transfers that come down to a community hospital being uncomfortable managing the patient (i.e. feeling they don't have the capacity to manage the patient). Advanced imaging, a more competent surgeon, and continuity of care all sound beneficial to the patient. EMTALA is meant to keep patients from dying through denial of stabilizing treatments, not limit their care if transfer would benefit them.

You are completely wrong.

EMTALA applies in the case of ANY transfer.

The term "unstable" has a different legal meaning in the context of EMTALA than it does medically. A patient is not "stable" in EMTALA terms until their medical problem is completely ruled out, diagnosed, and treated to the point where patient can be safely discharged. Yes, this is DIFFERENT than what we would consider medically unstable (immediate threats to ABCs, unstable vital signs, etc.) A patient with a severe soft tissue wound infection after surgery is considered "unstable" in the eyes of EMTALA until the problem is definitively treated well enough the patient is safe for discharge (which in this case, they seem very far from).

Transferring this patient to maintain "continuity of care" is not considered a higher level of care in the eyes of EMTALA (please refer to the previous posts in this thread.)

There are two ways to satisfy EMTALA in this particular case:

One, you explain to the patient that you do have an available surgeon, but you offer transfer as an option to the patient to maintain continuity of care. If the the PATIENT ELECTS to transfer after you have offered care at your facility, then you are covered, as patients can initiate a transfer for any reason at anytime, higher level of care or no. Patient preference always over-rides.

OR

You request your surgeon consult on the patient. If they see the patient (and leave a written consult note) that the patient exceeds their level of care, at that point you can initiate the transfer for a higher level of care.

It gets a little bit sticky if your consulting surgeons refuse to see the patient. "I won't" is a little different than "I can't." If your surgeon "won't" see a patient then they indeed could be subject to an EMTALA violation. You need to document your conversation with said surgeon very carefully, to make clear who is refusing to see the patient. If they say without seeing the patient they can't manage the problem because its beyond their scope, then all you can do is document it.

The receiving hospital can decide if that is legit or not, and if they feel it is in the scope of the surgeon, again they could file a violation against the surgeon. The key piece here is documenting the conversation you have with your available consultant very clearly and that your consultant (not you the ER physician) is initiating and requesting the transfer.

There is a spirit of these rules, but it is immaterial. It's naive to believe you are "safe" because you "did the right thing for the patient." People are slammed with violations all the time because of technical violations even if the transfer is clearly in the best interest of the patient. Meticulous documentation of conversations, clear description of who is initiating the transfer (you, the patient, the consultant, etc.) and fastidious completion of the hospital's paperwork and checking the right boxes to reflect the decisions is essential to negotiating these hazards.

If I do not have excellent certainty in a transfer I have a very low threshold to consult my medical director and administrator on call and document their opinion as well in the chart.

 

[DeadCactus]

You are completely wrong.

EMTALA applies in the case of ANY transfer.

The term "unstable" has a different legal meaning in the context of EMTALA than it does medically. A patient is not "stable" in EMTALA terms until their medical problem is completely ruled out, diagnosed, and treated to the point where patient can be safely discharged.

"EMTALA does not apply to the transfer of stable patients. Under the law, a patient is considered stable for transfer if the treating physician determines that no material deterioration will occur during the transfer between facilities."

"An emergency medical condition is defined as 'a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.'"

Understanding EMTALA

Emergency departments are unique— anyone who has an emergency must be treated or stabilized, regardless of their insurance status or ability to pay. The patient protection that makes this possible is a federal law known as the Emergency Medical Treatment and Labor Act (EMTALA).

www.acep.org

 

[turkeyjerky]

With regard to the above example, I think both DC and RB are right in a sense. This is most likely not an Emtala violation, however, if things play out a certain way, there is a small chance that it ultimately could turn out to be one.

Consider the two following scenarios:
a) Surgical site infection guy comes in to my ED, I transfer him back to his original hospital. He gets admitted to the floor at original hospital, goes to the OR the next day and does fine.
b) Surgical site infection guy comes in to my ED, I consult our surgeons, get told to transfer him and make arrangements to do so. However, by the time of arrival to the original hospital, he's moribound and expires shortly after arrival.

So in scenario (a), I highly doubt anyone's arguing that the receiving hospital is obligated to file an EMTALA violation against me for the transfer. But scenario (b) is pretty obviously a violation, unless my surgeon truly could not have handled that patient.

 

[southerndoc]

"EMTALA does not apply to the transfer of stable patients. Under the law, a patient is considered stable for transfer if the treating physician determines that no material deterioration will occur during the transfer between facilities."

"An emergency medical condition is defined as 'a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs.'"

Understanding EMTALA

Emergency departments are unique— anyone who has an emergency must be treated or stabilized, regardless of their insurance status or ability to pay. The patient protection that makes this possible is a federal law known as the Emergency Medical Treatment and Labor Act (EMTALA).

www.acep.org

As someone who does expert witness work regarding EMTALA, I can assure you that your text is entirely misleading.

As @RoyBasch pointed out, stable is not what you think. In the eyes of CMS and OIG, stable refers to definitively treating the problem at hand. If a patient comes in with appendicitis, stability does not occur until the patient has his/her appendix taken out.

So no, EMTALA doesn't apply to transfer of stable patients. However, stable does not mean normal vital signs. It means their medical emergency has been treated.

 

[DeadCactus]

As someone who does expert witness work regarding EMTALA, I can assure you that your text is entirely misleading.

As @RoyBasch pointed out, stable is not what you think. In the eyes of CMS and OIG, stable refers to definitively treating the problem at hand. If a patient comes in with appendicitis, stability does not occur until the patient has his/her appendix taken out.

So no, EMTALA doesn't apply to transfer of stable patients. However, stable does not mean normal vital signs. It means their medical emergency has been treated.

Well it’s not my text, it’s ACEP's guidance.

I think even appendicitis has some room to argue given the evidence for antibiotic only treatment but I think we can agree it's generally considered a time sensitive disease where hours count and material decompensation could occur with delays in definitive treatment. In contrast, the cases in the original post are described as a liability dump that needed discharge rather than stabilizing treatment, a non-emergent surgery with a reasonable argument for lacking capacity, and a case too vague to really know either way. You're the paid expert; you would be excited to testify that these are EMTALA cases?

 

[southerndoc]

Well it’s not my text, it’s ACEP's guidance.

I think even appendicitis has some room to argue given the evidence for antibiotic only treatment but I think we can agree it's generally considered a time sensitive disease where hours count and material decompensation could occur with delays in definitive treatment. In contrast, the cases in the original post are described as a liability dump that needed discharge rather than stabilizing treatment, a non-emergent surgery with a reasonable argument for lacking capacity, and a case too vague to really know either way. You're the paid expert; you would be excited to testify that these are EMTALA cases?

I'm retained to help defend hospitals and physicians from EMTALA violations. There is no expert witness testifying against you. It's OIG basically fining you ("entered into settlement agreement") putting you on notice to lose your CMS funding if you don't come up with an action plan. I help come up with those action plans.

I have a very large database of all EMTALA actions since 2004. You'd be surprised at what hospitals are fined for.

With regards to ACEP's language, I'm just saying it's misleading. EMTALA applies to all patients, and "stable" is not what we normally think of. However, even if they are stable in the CMS sense, it still 100% applies. You transfer a patient without an accepting physician and with inappropriate mode of transportation, and you could be staring down at an EMTALA violation. One I'm representing right now is a hospital that discharged a patient and told them to drive straight to the receiving hospital because they didn't have the specialist on call at the sending facility. Not looking good for the hospital even if it was in the best interest of the patient (ambulances were tied up, transfer immediately preceding this patient's discharge took 8.5 hours to get an ambulance to transport the patient, no on-call specialist to deal with this patient's emergency, receiving facility was on diversion and would not take phone calls from transferring facilities, etc.). Patient ended up presenting to the receiving facility, went immediately to the OR, and had a good outcome. Had the patient waited at the sending facility 8.5 hours like the preceding patient, it's likely the patient would have died. Can share more details when things are finalized and action plan is accepted by CMS/OIG.

The expert witness part is solely in defense work for those unlucky physicians or hospitals who are sued by patients with EMTALA allegations (often after they have "entered into agreement" with OIG).

 

[thegenius]

You request your surgeon consult on the patient. If they see the patient (and leave a written consult note) that the patient exceeds their level of care, at that point you can initiate the transfer for a higher level of care.

Surgeons (or other specialists) can't get out of their duties if they claim it's out of their level of care, which it really isn't. For instance, we had a huge problem when a Urologist refused to come to the ED for a traumatic penis laceration. It's within his care because he's a board certified Urologist. If he can't take care of it then who can?

We get all sorts of nonsense stuff that board certified specialists within their specialty can't handle things within their specialty. I guess there might be extenuating circumstances in extreme cases, but it's mostly bollocks.

If I were CMS I would, if I could, get all surgical charts from this Urologist over the past 8 years and investigate if he has ever repaired any penis trauma ever. They cut open penises for a living!

 

[thegenius]

As someone who does expert witness work regarding EMTALA, I can assure you that your text is entirely misleading.

As @RoyBasch pointed out, stable is not what you think. In the eyes of CMS and OIG, stable refers to definitively treating the problem at hand. If a patient comes in with appendicitis, stability does not occur until the patient has his/her appendix taken out.

So no, EMTALA doesn't apply to transfer of stable patients. However, stable does not mean normal vital signs. It means their medical emergency has been treated.

Why can't all specialists get trained in this?

 

[thegenius]

With regards to ACEP's language, I'm just saying it's misleading. EMTALA applies to all patients, and "stable" is not what we normally think of. However, even if they are stable in the CMS sense, it still 100% applies. You transfer a patient without an accepting physician and with inappropriate mode of transportation, and you could be staring down at an EMTALA violation. One I'm representing right now is a hospital that discharged a patient and told them to drive straight to the receiving hospital because they didn't have the specialist on call at the sending facility. Not looking good for the hospital even if it was in the best interest of the patient (ambulances were tied up, transfer immediately preceding this patient's discharge took 8.5 hours to get an ambulance to transport the patient, no on-call specialist to deal with this patient's emergency, receiving facility was on diversion and would not take phone calls from transferring facilities, etc.). Patient ended up presenting to the receiving facility, went immediately to the OR, and had a good outcome. Had the patient waited at the sending facility 8.5 hours like the preceding patient, it's likely the patient would have died. Can share more details when things are finalized and action plan is accepted by CMS/OIG.

How do you suggest sending hospitals/ERs deal with this situation where the pt has a real emergency, could end up dying in hours, needs transfer, and you can't find a facility to accept? I'm not being sarcastic I'm actually being serious here.

We could d/c and have them go straight to the other facility, they survive, then we get fined and maybe lose our license or the hospital loses CMS funding.

tough condition to be in. You save a life and *uck yourself at the same time.

 

[Janders]

How do you suggest sending hospitals/ERs deal with this situation where the pt has a real emergency, could end up dying in hours, needs transfer, and you can't find a facility to accept? I'm not being sarcastic I'm actually being serious here.

We could d/c and have them go straight to the other facility, they survive, then we get fined and maybe lose our license or the hospital loses CMS funding.

tough condition to be in. You save a life and *uck yourself at the same time.

Funny how occasionally these patients and their families decide to leave AMA and self-present elsewhere. Not sure the logistics of that.

The bigger issue is when they are too unstable for a private car ride, but the best you can do is keep them alive for a while, and you KNOW definitive management with a specialist/hospital that can handle their issue will likely save their life. And then you spend 6-8-12hr begging and calling and texting every connection you have in a tri-state area to get it done. Its peak burnout for me, its absolutely a systemic failure that is passed down to the pit doc, and its bull****.

 

[RoyBasch]

With regard to the above example, I think both DC and RB are right in a sense. This is most likely not an Emtala violation, however, if things play out a certain way, there is a small chance that it ultimately could turn out to be one.

Consider the two following scenarios:
a) Surgical site infection guy comes in to my ED, I transfer him back to his original hospital. He gets admitted to the floor at original hospital, goes to the OR the next day and does fine.
b) Surgical site infection guy comes in to my ED, I consult our surgeons, get told to transfer him and make arrangements to do so. However, by the time of arrival to the original hospital, he's moribound and expires shortly after arrival.

So in scenario (a), I highly doubt anyone's arguing that the receiving hospital is obligated to file an EMTALA violation against me for the transfer. But scenario (b) is pretty obviously a violation, unless my surgeon truly could not have handled that patient.

A bad outcome is not necessary to make it a violation. I think you are confusing potential malpractice due to delay in care, with EMTALA violation. They are two separate processes of medico-legal liability.

Well it’s not my text, it’s ACEP's guidance.

I think even appendicitis has some room to argue given the evidence for antibiotic only treatment but I think we can agree it's generally considered a time sensitive disease where hours count and material decompensation could occur with delays in definitive treatment. In contrast, the cases in the original post are described as a liability dump that needed discharge rather than stabilizing treatment, a non-emergent surgery with a reasonable argument for lacking capacity, and a case too vague to really know either way. You're the paid expert; you would be excited to testify that these are EMTALA cases?

EMTALA aside you would consider the patient from the original question a "liability dump that needed discharge?" The patient has by the description sepsis secondary to a potentially necrotizing wound infection with a large abscess. I mean even if they are not crumping right this second with hypotension and altered mental status I would still consider that a potentially "sick" patient. I would think surgical debridement is fairly emergent in this case.

Surgeons (or other specialists) can't get out of their duties if they claim it's out of their level of care, which it really isn't. For instance, we had a huge problem when a Urologist refused to come to the ED for a traumatic penis laceration. It's within his care because he's a board certified Urologist. If he can't take care of it then who can?

We get all sorts of nonsense stuff that board certified specialists within their specialty can't handle things within their specialty. I guess there might be extenuating circumstances in extreme cases, but it's mostly bollocks.

Well, I agree, this is where it gets really hard. The "Text book" answer is you demand an in person consult by the specialist in question, and IF after they see the patient they say it requires a higher level of care, so be it. Or you call them on their bull **** and demand they do what needs to be done.

But in reality, you are going to burn a bridge with a surgeon/specialist the hospital probably esteems more highly than you the ER physician (viewed to be a very replaceable cog), and you may ultimately piss away a lot of social capital with your hospital. That may blow back on you in problematic ways down the line.

Ultimately I feel it's not up to us (ER docs) to tell specialists what they can and cannot do. We merely have a duty to notify the most relevant specialist we have. I would say in the exception of exceedingly obvious examples (general surgeon says they cannot manage acute appendicitis, gynecologist says cannot manage an ectopic pregnancy) if the physician says they "can't do it" I kind of have to take that statement at face value, and all I can do is document that. If the receiving hospital wants to file a violation against me for "allowing" the transfer, I'm kinda stuck. All I can hope is they recognize in my documentation that the impetus to transfer was initiated by the specialist who said they were incapable, and the OIG and CMS can decide if that was appropriate behavior from the specialist or not.

You transfer a patient without an accepting physician and with inappropriate mode of transportation, and you could be staring down at an EMTALA violation. One I'm representing right now is a hospital that discharged a patient and told them to drive straight to the receiving hospital because they didn't have the specialist on call at the sending facility. Not looking good for the hospital even if it was in the best interest of the patient (ambulances were tied up, transfer immediately preceding this patient's discharge took 8.5 hours to get an ambulance to transport the patient, no on-call specialist to deal with this patient's emergency, receiving facility was on diversion and would not take phone calls from transferring facilities, etc.). Patient ended up presenting to the receiving facility, went immediately to the OR, and had a good outcome. Had the patient waited at the sending facility 8.5 hours like the preceding patient, it's likely the patient would have died. Can share more details when things are finalized and action plan is accepted by CMS/OIG.

A classic ER "lose-lose."

Send the patient POV to hospital for appropriate timely care: EMTALA violation.

Keep the patient awaiting appropriate space and transportation to be mindful of EMTALA, patient dies due to "delay in care:" medical malpractice suit.

Do any of the enforcing entities care that the healthcare system has collapsed and does not have appropriate resources to provide the care they require? No. This is why moral injury in this specialty is so pervasive and burnout exists.