Possible EMTALA violations

[DeadCactus]

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.

We're talking about different patients. I'm referring to the first patient in the original post.

"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."

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[CoolDoc1729]

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.



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.



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.



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.

I’m wondering how long it will take EMTALA to catch up with the current environment . These AMA pseudo transfers by private car are not going away.

I also wonder how long tort reform is going to take to catch up with waiting room medicine. I’m sure they could find a lot of er docs that retired 2-5 years ago that would say that 3/4 of what I’m currently forced to do is not “standard of care.” And while I don’t disagree I also don’t think making all of us uninsurable is the right answer.

 

[RoyBasch]

We're talking about different patients. I'm referring to the first patient in the original post.

"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."

Sorry, my mistake.

 

[RoyBasch]

I’m wondering how long it will take EMTALA to catch up with the current environment . These AMA pseudo transfers by private car are not going away.

I also wonder how long tort reform is going to take to catch up with waiting room medicine. I’m sure they could find a lot of er docs that retired 2-5 years ago that would say that 3/4 of what I’m currently forced to do is not “standard of care.” And while I don’t disagree I also don’t think making all of us uninsurable is the right answer.

I don't want to sound too cynical, but probably never?

I think the current stakeholders like it just the way it is now. The hospital/owners can continue razor-thin staffing at all levels thus maximizing profit and minimizing their expenses.

Any problems with bad outcomes that come up can be attributed to you (individual ER physician) "error in judgement" or "mistake in management." And all of the liability for institutional failure is passed on to you individually.

If you burn-out/don-t like it because of this moral injury and quit, here is the over-supply of 10,000 new ER grads all $250,000 in debt champing at the bit to take your place and not fall further in debt and maybe buy a small house for their long-suffering spouse who stayed with them for 4 years of med school and 3-4+ years of training.

The powers-that-be see this all as a "features" of the new normal, not "bugs." Our specialty is perfectly trapped at this point between administrative over-reach and excessive profit-seeking.

 

[TooMuchResearch]

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.

If a patient is really in a dire situation like that, it's best to work somewhere where you know people in the tertiary center EDs or have an understanding or transfer agreement...

 

[thegenius]

Just musing

are the routine lacerations we see in the ED medical emergencies? I'm not trying to trick everyone. I'm talking about the 1.5 cm eyebrow lac after a fall, the finger lac from cutting, etc.

Are we obligated under EMTALA to "stabilize" (e.g. repair) these minor lacerations?

 

[Apollyon]

Just musing

are the routine lacerations we see in the ED medical emergencies? I'm not trying to trick everyone. I'm talking about the 1.5 cm eyebrow lac after a fall, the finger lac from cutting, etc.

Are we obligated under EMTALA to "stabilize" (e.g. repair) these minor lacerations?

I'm just trying to channel @southerndoc , but, lac repair, I would venture, while not an "emergency", still need to be completed for EMTALA. I do recall him saying that fracture reduction was part of EMTALA.

 

[Vandalia]

Any problems with bad outcomes that come up can be attributed to you (individual ER physician) "error in judgement" or "mistake in management." And all of the liability for institutional failure is passed on to you individually.

Actually, no.

Particularly in these scenarios, the hospital and the CMG have the deep pockets, and that is who has the liability.

If you are employed, then your employer has all the liability. If care is provided in a hospital, the hospital is liable.

The trend is that the physicians are not even named as a defendant in malpractice suits.

 

[southerndoc]

Just musing

are the routine lacerations we see in the ED medical emergencies? I'm not trying to trick everyone. I'm talking about the 1.5 cm eyebrow lac after a fall, the finger lac from cutting, etc.

Are we obligated under EMTALA to "stabilize" (e.g. repair) these minor lacerations?

If it truly is a simple laceration and bleeding is controlled, then there is no risk of deterioration then the patient is stable. No EMTALA obligation applies after you perform a MSE. However, liability is a different story. If the patient is on a NOAC and goes home, bleeds excessively, and ends back in the ER, CMS may view your failure to repair the laceration as failure to stabilize the patient (because there was possible deterioration from them being on a NOAC).

 

[CoolDoc1729]

Here’s one for SDN EM to ponder..
in their infinite wisdom my hospital system administration has decided that if our freestanding half an hour away can’t find a peds/PICU bed they can transfer them to our main, non pediatric facility until the inevitable second transfer bed at a pediatric facility is available .. this seems like a cut and dried Emtala violation .. ED director is saying it isn’t ..?

 

[southerndoc]

Here’s one for SDN EM to ponder..
in their infinite wisdom my hospital system administration has decided that if our freestanding half an hour away can’t find a peds/PICU bed they can transfer them to our main, non pediatric facility until the inevitable second transfer bed at a pediatric facility is available .. this seems like a cut and dried Emtala violation .. ED director is saying it isn’t ..?

No, it's not an EMTALA violation.

 

[NYEMMED]

Here’s one for SDN EM to ponder..
in their infinite wisdom my hospital system administration has decided that if our freestanding half an hour away can’t find a peds/PICU bed they can transfer them to our main, non pediatric facility until the inevitable second transfer bed at a pediatric facility is available .. this seems like a cut and dried Emtala violation .. ED director is saying it isn’t ..?

Not an EMTALA violation.
Peds transfers are ridiculous lately

I wish ACEP would put out a PSA commercial telling parents to go to a pediatric hospital

 

[BoardingDoc]

Here’s one for SDN EM to ponder..
in their infinite wisdom my hospital system administration has decided that if our freestanding half an hour away can’t find a peds/PICU bed they can transfer them to our main, non pediatric facility until the inevitable second transfer bed at a pediatric facility is available .. this seems like a cut and dried Emtala violation .. ED director is saying it isn’t ..?

Agree with @southerndoc on this one. I don't see why you would think this would be an EMTALA violation. You are transferring a patient from a lower to a higher level of care. Regardless of whether your mothership hospital has peds, it's certainly a higher level of care than a freestanding ED.

 

[CoolDoc1729]

Agree with @southerndoc on this one. I don't see why you would think this would be an EMTALA violation. You are transferring a patient from a lower to a higher level of care. Regardless of whether your mothership hospital has peds, it's certainly a higher level of care than a freestanding ED.

I don’t know .. of course if it’s a 15 year old that needs an appy our surgeons will do those anyway … but if it’s a fever of unknown origin, or an asthmatic for ex .. the mothership doesn’t actually have any additional relevant services .. the freestanding has a well stocked Pyxis , a full lab and rads including mri

 

[southerndoc]

I don’t know .. of course if it’s a 15 year old that needs an appy our surgeons will do those anyway … but if it’s a fever of unknown origin, or an asthmatic for ex .. the mothership doesn’t actually have any additional relevant services .. the freestanding has a well stocked Pyxis , a full lab and rads including mri

It's not an EMTALA violation. Plain and simple.

 

[PTPoeny]

Not an EMTALA violation.
Peds transfers are ridiculous lately

I wish ACEP would put out a PSA commercial telling parents to go to a pediatric hospital

I would guess this won't happen because (some) parents are bad at recognizing when kids are sick versus peri-arrest. As a PICU doc I have unfortunately taken care of more than one kid who had a really bad outcome that probably could have been prevented if the parents went to the nearest ED instead of driving an hour with a kid who was barely breathing to a Children's hospital.

It also isn't any better at many Children's hospitals right now. Currently getting multiple calls per day from other children's hospital EDs looking for PICU beds, sometimes multiple states away 🤷

 

[DrDrummer]

I would guess this won't happen because (some) parents are bad at recognizing when kids are sick versus peri-arrest. As a PICU doc I have unfortunately taken care of more than one kid who had a really bad outcome that probably could have been prevented if the parents went to the nearest ED instead of driving an hour with a kid who was barely breathing to a Children's hospital.

It also isn't any better at many Children's hospitals right now. Currently getting multiple calls per day from other children's hospital EDs looking for PICU beds, sometimes multiple states away 🤷

Are you sending any change in PICU bed triage in light of the current situation? My previous experience was that pediatric floor and tele nurses were rarely if ever willing to take even marginally sick kids. Are you seeing more kids on stable on HFNC or whatever (who may have gone to the PICU during ordinary times) admitted to step down units, or any shifts like that? I always found it surprising at academic centers how little comfort with marginally ill kids the general peds teams seemed to have.

 

[PTPoeny]

Are you sending any change in PICU bed triage in light of the current situation? My previous experience was that pediatric floor and tele nurses were rarely if ever willing to take even marginally sick kids. Are you seeing more kids on stable on HFNC or whatever (who may have gone to the PICU during ordinary times) admitted to step down units, or any shifts like that? I always found it surprising at academic centers how little comfort with marginally ill kids the general peds teams seemed to have.

My hospital generally will take sicker kids on the floor than other places I have been before. So high flow went to the floor even before this. Maybe because of this but we have been running out of floor beds as often as PICU so we haven't had any shifts to send more kids to the floor because it wouldn't help with our local patterns of running out of beds.

When we previously had MISC surges that overwhelmed the PICU and not the floors the hospitalists definitely stepped up and worked to help the nurses feel comfortable taking kids they normally wouldn't.

 

[NYEMMED]

I would guess this won't happen because (some) parents are bad at recognizing when kids are sick versus peri-arrest. As a PICU doc I have unfortunately taken care of more than one kid who had a really bad outcome that probably could have been prevented if the parents went to the nearest ED instead of driving an hour with a kid who was barely breathing to a Children's hospital.

It also isn't any better at many Children's hospitals right now. Currently getting multiple calls per day from other children's hospital EDs looking for PICU beds, sometimes multiple states away 🤷

I guess it depends on distance, you are correct.

In my area there are 3 pediatric hospitals around the city, each would be a 30 min drive.
Obviously in distress they should go to the closest ED. But with admission waits for peds getting up to 3 day ED holds now, waiting for a transfer. I still think it is a better choice for parents to drive to the pediatric hospital. A decompensating kid in a pediatric ED waiting for a bed upstairs is much safer and has much more resources than a decompensating kid with no peds resources at all, waiting on a bed elsewhere

They are all better off waiting for a bed in a peds ED.

 

[thegenius]

Here’s one for SDN EM to ponder..
in their infinite wisdom my hospital system administration has decided that if our freestanding half an hour away can’t find a peds/PICU bed they can transfer them to our main, non pediatric facility until the inevitable second transfer bed at a pediatric facility is available .. this seems like a cut and dried Emtala violation .. ED director is saying it isn’t ..?

If the transfer happens within the same “hospital system”, e.g. they have the same tax ID or CMS ID, it’s not considered an EMTALA violation because the transfer is within the same hospital system. You can’t dump on yourself, so to speak. Well you can, but you are just hurting yourself over and over LOL

Is the FSED a real ED? Are FSEDs considered real EDs and are bound by federal statute?

 

[Apollyon]

Is the FSED a real ED? Are FSEDs considered real EDs and are bound by federal statute?

Not Federal, but state. Here in NY, for example, Article 28 of the public health law covers EDs. In short, if you receive ambulances, you are an ED.

 

[southerndoc]

Not Federal, but state. Here in NY, for example, Article 28 of the public health law covers EDs. In short, if you receive ambulances, you are an ED.

I think you meant if you do not receive ambulances you are not an ED?

 

[southerndoc]

If the transfer happens within the same “hospital system”, e.g. they have the same tax ID or CMS ID, it’s not considered an EMTALA violation because the transfer is within the same hospital system. You can’t dump on yourself, so to speak. Well you can, but you are just hurting yourself over and over LOL

Is the FSED a real ED? Are FSEDs considered real EDs and are bound by federal statute?

Sort of. Most hospitals have unique IDs per hospital and not the health system. That way if a hospital tanks it doesn't take its whole system down. If a transfer occurs within the same health system EMTALA still applies in nearly every case. Reporting your sister hospital will likely accelerate any alternative career options as I'm sure nearly every health system will have retaliatory behavior.

CMS has in the past held that some urgent cares are held to EMTALA.

 

[Apollyon]

I think you meant if you do not receive ambulances you are not an ED?

Correct. There is a standalone ED (which existed before the idea even did) that got into a little bind nearly 30 years ago.

I think we were saying the same thing, though. Mine was the positive, and yours the negative, but the same. If you don't take 911 ambulances, not an ED. If you take 911 buses, you're an ED.

 

[southerndoc]

Correct. There is a standalone ED (which existed before the idea even did) that got into a little bind nearly 30 years ago.

I think we were saying the same thing, though. Mine was the positive, and yours the negative, but the same. If you don't take 911 ambulances, not an ED. If you take 911 buses, you're an ED.

Yeah, we are. I think I misread your post and thought you said if you receive ambulances you're not an ED. Sleep, need more sleep. LOL

 

[turkeyjerky]

I don’t know .. of course if it’s a 15 year old that needs an appy our surgeons will do those anyway … but if it’s a fever of unknown origin, or an asthmatic for ex .. the mothership doesn’t actually have any additional relevant services .. the freestanding has a well stocked Pyxis , a full lab and rads including mri

I think you're saying that it's an emtala violation because it's essentially a lateral transfer of care, correct? If that's your reasoning, emtala doesn't forbade lateral transfers, just hospitals aren't required to accept. If you're saying it's a violation b/c the basically hasn't been adequately 'stabilized' and benefits of transfer don't exceed risks, than I think it's a matter of opinion but most would disagree w/ you.

 

[PTPoeny]

I guess it depends on distance, you are correct.

In my area there are 3 pediatric hospitals around the city, each would be a 30 min drive.
Obviously in distress they should go to the closest ED. But with admission waits for peds getting up to 3 day ED holds now, waiting for a transfer. I still think it is a better choice for parents to drive to the pediatric hospital. A decompensating kid in a pediatric ED waiting for a bed upstairs is much safer and has much more resources than a decompensating kid with no peds resources at all, waiting on a bed elsewhere

They are all better off waiting for a bed in a peds ED.

Normally I 100% agree with you. But there is a point where the resources of a peds ED don't help if no one can see the kid/the hospital is out of vents/Albuterol/whatever. During normal times we transfer kids from outside EDs to our ED all the time if a bed isn't quite open. Or just send our transport team to care for the kid where they are for an hour before leaving to make it work.

Most of the country is way more than 30 minutes from a children's hospital. Honestly the bad outcomes I have taken care of were parents driving 1-2 hours past many hospitals just to get to a children's hospital and they didn't realize their kid functionally stopped breathing in the backseat on the way.

In my city, the hospital within a hospital set up is the best-off place right now. We are sending tons of kids from our Children's hospital ED to the other hospital in town with peds capability. You have peds hospitalists, peds ICU, peds RNs, peds trained RTs and can pull RNs and RTs from the adult side and have them paired with peds people for support and still have all the peds sized supplies. They have adult units specified to overflow kids and the kids are still covered by peds docs and peds nurses (or adult/peds pairings). Plus with peds in house it is easier to convince the adult docs to take adult sized patients with adult problems that are just slightly underage. You know, maybe, just maybe, the 200lb otherwise healthy 17 year old admitted for intoxication with an ETT could be safely cared for in a MICU instead of PICU bed...

 

[evert1de101]

Reverse dumping is a new and increasingly important aspect of the law. EMTALA = YES. If your ED considers the freestanding to be an offsite extension of the hospital and/or has a history of accommodating peds transfers from the freestanding, then you have no legal basis to decline.

 

[CoolDoc1729]

Reverse dumping is a new and increasingly important aspect of the law. EMTALA = YES. If your ED considers the freestanding to be an offsite extension of the hospital and/or has a history of accommodating peds transfers from the freestanding, then you have no legal basis to decline.

The freestanding has ability to directly admit adults to our hospital but we have never accepted pediatric transfers from them (even simple ortho casting type transfers) because we are not a peds hospital.
Of course if it’s an adolescent that’s different. My hospital inpatient policy is 14+ can be admitted to our adults only hospital. I’m talking more a septic 2 month old or something along those lines.

 

[thegenius]

Bump
60 yo man p/w R facial swelling and CT shows parotiditis with an obstructing stone in the duct. No abscess. Vitals OK, WBC 17K. Started on IV Abx. Consult to ENT said that pt should be transferred because one needs special equipment to remove the stone that is not available at the hosptial. Multiple transfer requests are unsuccessful due to lack of capacity. One institution argued vociferously (the ENT attending) that this is in fact not a surgical case, no abscess to drain, and that pt can stay at home institution to get more IV antibiotics. Home hospitalist said they can't accept patient without ENT consultation, which was already recommended they be transferred. Meanwhile, pt is getting worse, swelling is getting worse and now creeping below the chin. This was told to ENT at the distal institution. Abx broadened. ENT at the distal institution again argued transfer is not necessary as this should be taken care of by internal medicine not ENT because it's not surgical. Pt somehow ultimately admitted, hours later, at home institution unclear how that happened.

Was the behavior of the accepting hospital in violation of EMTALA?

 

[ScepticSkeksis]

Bump
60 yo man p/w R facial swelling and CT shows parotiditis with an obstructing stone in the duct. No abscess. Vitals OK, WBC 17K. Started on IV Abx. Consult to ENT said that pt should be transferred because one needs special equipment to remove the stone that is not available at the hosptial. Multiple transfer requests are unsuccessful due to lack of capacity. One institution argued vociferously (the ENT attending) that this is in fact not a surgical case, no abscess to drain, and that pt can stay at home institution to get more IV antibiotics. Home hospitalist said they can't accept patient without ENT consultation, which was already recommended they be transferred. Meanwhile, pt is getting worse, swelling is getting worse and now creeping below the chin. This was told to ENT at the distal institution. Abx broadened. ENT at the distal institution again argued transfer is not necessary as this should be taken care of by internal medicine not ENT because it's not surgical. Pt somehow ultimately admitted, hours later, at home institution unclear how that happened.

Was the behavior of the accepting hospital in violation of EMTALA?

Yes, unless the ENT had examined the patient personally. He has to agree to examine the patient personally before concluding "it's not surgical".

 

[GonnaBeADoc2222]

I'm not an EMTALA expert, but man, what a weird stance from the accepting ENT.

I've never heard anything like that from any of our guys...

 

[southerndoc]

Bump
60 yo man p/w R facial swelling and CT shows parotiditis with an obstructing stone in the duct. No abscess. Vitals OK, WBC 17K. Started on IV Abx. Consult to ENT said that pt should be transferred because one needs special equipment to remove the stone that is not available at the hosptial. Multiple transfer requests are unsuccessful due to lack of capacity. One institution argued vociferously (the ENT attending) that this is in fact not a surgical case, no abscess to drain, and that pt can stay at home institution to get more IV antibiotics. Home hospitalist said they can't accept patient without ENT consultation, which was already recommended they be transferred. Meanwhile, pt is getting worse, swelling is getting worse and now creeping below the chin. This was told to ENT at the distal institution. Abx broadened. ENT at the distal institution again argued transfer is not necessary as this should be taken care of by internal medicine not ENT because it's not surgical. Pt somehow ultimately admitted, hours later, at home institution unclear how that happened.

Was the behavior of the accepting hospital in violation of EMTALA?

It is an EMTALA violation unless the receiving facility/physician uses one of three statements:
1. I do not have capacity to accept this patient. (Hospital has no room to accept patient; does not mean they have to be on diversion.)
2. I do not have the capability to care for this patient. (It is above the skill set of the particular physician.)
3. I will accept the patient.

There is no room to say that the patient doesn't need surgery or doesn't need transfer. If they call and ask your opinion of management, then they can give it to you. If you call and ask for a transfer, then the only EMTALA compliant statements are one of the 3 above whether it's in the best interest of the patient or not. If the patient truly doesn't need to be transferred, then CMS doesn't care. Only one of the three above will get you out of an EMTALA violation.

Now, having said that, the referring facility is likely to be non-compliant with EMTALA and could be subject to fines for delay in care for delay in admitting the patient. Making someone stay in an ED unnecessarily when inpatient beds are available is often viewed as an EMTALA violation. The fact that you had ENT on call means that he would need to personally evaluate the patient before he could say he did not have the equipment to adequately manage it. If he is credentialed to manage these, then whether he has the equipment or not is irrelevant in the eyes of CMS.

 

[thegenius]

If he is credentialed to manage these, then whether he has the equipment or not is irrelevant in the eyes of CMS.

Can you explain this further. So there are some procedures that do require specific equipment. Oh I think I see what you are getting at.

One should not be credentialed to take care of a specific problem within their field if you don’t have the tool. An example would be the following (however absurd). An ER doc transfers a PNX to another ER because the referring ER doc is not credentialed to do a thoracostomy. The reason is the ER doesn’t have and has never had chest tubes.

If the ER doc WAS credentialed to do chest tubes and the ER doesn’t have a chest tube, then that’s a problem on several fronts.

There are lots of cases where a specialist can do, say, 80-90% of their field but not all of it. Examples include GI can’t do ERCP, vascular can’t do a fenestration of an obstructing abdominal aortic dissection, NSGY doing coiling of a ruptured aneurysm. I guess what your saying is that they OUGHT not be credentialed to do those as well at the hospital. Then they are free and clear. If they are credentialed to do these, like an ERCP, and they say transfer because of equipment unavailability, then that is a violation?

 

[southerndoc]

Can you explain this further. So there are some procedures that do require specific equipment. Oh I think I see what you are getting at.

One should not be credentialed to take care of a specific problem within their field if you don’t have the tool. An example would be the following (however absurd). An ER doc transfers a PNX to another ER because the referring ER doc is not credentialed to do a thoracostomy. The reason is the ER doesn’t have and has never had chest tubes.

If the ER doc WAS credentialed to do chest tubes and the ER doesn’t have a chest tube, then that’s a problem on several fronts.

There are lots of cases where a specialist can do, say, 80-90% of their field but not all of it. Examples include GI can’t do ERCP, vascular can’t do a fenestration of an obstructing abdominal aortic dissection, NSGY doing coiling of a ruptured aneurysm. I guess what your saying is that they OUGHT not be credentialed to do those as well at the hospital. Then they are free and clear. If they are credentialed to do these, like an ERCP, and they say transfer because of equipment unavailability, then that is a violation?

Docs should not be credentialed for things they do not have equipment to do nor that they do not do routinely. One EMTALA violation centered around an ENT who was credentialed to do an EGD. An elderly lady with an esophageal food impaction was transferred because they had no GI on call. Lady vomited in the ambulance, aspirated, coded, and died. CMS found that the ENT was credentialed to do the procedure and fined the transferring hospital.

 

[DocEspana]

Related but also not question:

How do you guys handle NON-EMTALA requests for transfer? The exact example we run into a lot is that we opened a new affiliate hospital and its beautiful and new and has staffing for everything... but is mostly staffed by nurses and doctors from the older hospitals in the system and when they (or their family members) end up admitted there, they often request transfer from that ED to our ED to end up admitted at the home base hospital instead.

Emtala technically says that patient requests more or less relieve everyone of their EMTALA duties, but also... like... some of my coworkers get really puritanical about the idea that we shouldn't accept these. I judge it based on the volume of our hospital and say yes if we arent already backlogged.

 

[CliveStaples]

Related but also not question:

How do you guys handle NON-EMTALA requests for transfer? The exact example we run into a lot is that we opened a new affiliate hospital and its beautiful and new and has staffing for everything... but is mostly staffed by nurses and doctors from the older hospitals in the system and when they (or their family members) end up admitted there, they often request transfer from that ED to our ED to end up admitted at the home base hospital instead.

Emtala technically says that patient requests more or less relieve everyone of their EMTALA duties, but also... like... some of my coworkers get really puritanical about the idea that we shouldn't accept these. I judge it based on the volume of our hospital and say yes if we arent already backlogged.

I believe that this is incorrect, and the patient transfer (even if it is by patient request) is still governed by EMTALA.

Meaning, even if a facility has capability and capacity to manage a patient, if the patient requests a transfer, the receiving hospital cannot decline the transfer on the basis of the sending hospital having capability and capacity - the receiving hospital still must accept the patient if it has capability and capacity.

Edit: I am capable of being incorrect on this, but this has been my understanding of transfers of ED patients by request. I suppose the only limitation would be if the patient does not have an emergency medical condition that needs to be stabilized.

 

[DocEspana]

I believe that this is incorrect, and the patient transfer (even if it is by patient request) is still governed by EMTALA.

Meaning, even if a facility has capability and capacity to manage a patient, if the patient requests a transfer, the receiving hospital cannot decline the transfer on the basis of the sending hospital having capability and capacity - the receiving hospital still must accept the patient if it has capability and capacity.

Edit: I am capable of being incorrect on this, but this has been my understanding of transfers of ED patients by request. I suppose the only limitation would be if the patient does not have an emergency medical condition that needs to be stabilized.

Considering EMTALA considers "stabilization" nearly everything until discharge - so including the entire admission stay until DC from inpatient - it is extremely few patients (barring some social admits that linger forever) that count as being stabilized. We all just sort of use the term way more loosely than the lawyers view it. I learned that from my extremely aggressive yearly corporate CME just a week ago. That **** had mandatory knowledge checks every 4th or 5th slide.

 

[CoolDoc1729]

We’ve recently had a smattering of patients decide they’re sick of waiting after 24+hours and ask to be transferred from ER to another hospital despite being in an ER room and already having seen 2-4 consultants etc. I don’t know how they handle “dissatisfaction” type transfers from the floor but I don’t think it’s my job and so far just ignoring it has worked lol

 

[southerndoc]

Patient requests for transfer haven't really been tested. In general, if the patient is requesting transfer, and the transferring physician believes their facility has both capacity and capability to treat the patient, then you are under no obligation to accept the patient. EMTALA only applies if the transferring facility makes a request to transfer based on medical need and not based on patient preference. Again, this hasn't been tested to my knowledge so who knows how CMS would interpret such a complaint. I'll dig through my database to see if I can find a case, but I do not believe it's ever been tested.

With regard to the last post, if the patient is admitted, then EMTALA usually does not apply to transfers. However, keep in mind that CMS does not consider observation admissions as admissions and EMTALA has been deemed to be applicable to observation admissions on several cases.

 

[JacobMcCandles]

We’ve recently had a smattering of patients decide they’re sick of waiting after 24+hours and ask to be transferred from ER to another hospital despite being in an ER room and already having seen 2-4 consultants etc. I don’t know how they handle “dissatisfaction” type transfers from the floor but I don’t think it’s my job and so far just ignoring it has worked lol

That sounds like an admitting team problem.