interfacility transfer work flow team
DESCRIPTION
TRANSCRIPT
Interfacility Transfer Work Interfacility Transfer Work Flow TeamFlow Team
Saint Joseph HealthCareSaint Joseph HealthCareMarymount Medical CenterMarymount Medical Center
Our Lady of the Way HospitalOur Lady of the Way HospitalCHI-KentuckyCHI-Kentucky
September 24, 2007September 24, 2007
Team: Facilitator-Paula Keally, RN – Clinical Informatics Co-Facilitator- Katherine Hansen – Director Outpatient DiagnosticsKathy Williams – Admin Asst.
Marymount Medical Center: Dr. Jeff Violette - ED Medical Director Peggy Green, RN - CNOGrace (Libby) Campbell, RN -AVP NursingMary Lou Young, RN – Director EDNora Ross, RN – House ManagerLori M. Young, RN – Clinical Supervisor EDOur Lady of the Way Hospital:Billie Turner, RN – CNORobyn Johnson, RN – ED/House SupervisorSaint Joseph Healthcare:Dr. Scot Dunavant - ED PhysicianDr. Yaccoubagha – Physician with Ky. Inpatient Medicine Associates Chris Mays, RN – CNODebbie Bryant, RN – ED Manager – SJHPatti Sturt, RN – ED Manager – SJBMelanie Sanguigni, RN – House AdministratorDebra Lawrence, RN – Clinical Coordinator Patient Access
"I am personally convinced that one person can be a change catalyst, a 'transformer' in any situation, any organization. Such an individual is yeast that can leaven an entire loaf. It requires vision, initiative, patience, respect, persistence, courage and faith to be a transforming leader."
Steven R. Covey
To Develop an Algorithm to To Develop an Algorithm to be used for the Purpose of be used for the Purpose of
Improving and Standardizing Improving and Standardizing the process of: the process of:
"Pt Access – Inter-Facility "Pt Access – Inter-Facility Transfer of Patients"Transfer of Patients"
CHI KY – All Facility Transfers CHI KY – All Facility Transfers August 2007August 2007
Total Transfers: 320Total Transfers: 320 Transfers Excluding Transfers Excluding
Peds/Trauma/Psych: 204Peds/Trauma/Psych: 204 Transfers Within System: 81Transfers Within System: 81 Transfers Outside of System: 123Transfers Outside of System: 123
Our Lady of the WayOur Lady of the WayAugust 2007 - TransfersAugust 2007 - Transfers
Total Transfers: 29Total Transfers: 29 Total Transfers Excluding Peds/Trauma/Psych: Total Transfers Excluding Peds/Trauma/Psych:
2222 Transfers Within System: 2Transfers Within System: 2 Transfers Outside of System: 20Transfers Outside of System: 20
Our Lady of the WayOur Lady of the Way
August 2007 – total Transfers out - 29August 2007 – total Transfers out - 29
Facility Transferred To Transfer Category
# of Transfers
Facility Transferred To Transfer Category # of Transfers
University of Kentucky Pediatrics 1
Neuro 1 Hazard ARH Respiratory 2
Cardiac 1
Ortho 4 St Mary's Trauma 1
General Surgery 1 General Surgery 1
Kings Daughters Cardiac 8 Creekside Psych 1
Total Transfers: 29 Transfer Category # of Transfers
Pikeville Pediatrics 1 Cardiac 10
General Surgery 2 Neuro 2
Other 1 Ortho 4
Trauma 2
SJH Cardiac 1 Psych 2
General Surgery 3
SJE Neuro 1 Pediatrics 3
Other 3
Cabell Huntington Trauma 1
Pediatrics 1
Marymount Medical CenterMarymount Medical CenterAugust 2007 - TransfersAugust 2007 - Transfers
Total Transfers: 59Total Transfers: 59 Total Transfers Excluding Peds/Trauma/Psych: Total Transfers Excluding Peds/Trauma/Psych:
4444 Transfers Within System: 9Transfers Within System: 9 Transfers Outside of System: 35Transfers Outside of System: 35
Facility Transferred ToTransfer
Category
# of Transfers
Facility Transferred To Transfer Category # of Transfers
Saint Joseph Hospital Cardiac 1 UT Neuro 1
General
Surgery 2 General Surgery 2
Other 5
Manchester SOA 1
University of Kentucky Pediatrics 13
Trauma 1 Baptist Regional Ortho 1
Ortho 4 General Surgery 1
Neuro 2 Other 2
General
Surgery 4
Other 13 Good Samaritan -
UK SOB 1
Lake Cumberland Psych 1 Total Transfers: 59 Transfer Category # of Transfers
General
Surgery 1 Cardiac 1
Other 1 Trauma 1
Neuro 2
Central Baptist Ortho 1 Psych 1
Peds 13
Saint Joseph Mt Sterling Ortho 1 Ortho 7
General Surgery 10
U of L Nosebleed 1 Other 24
Marymount Medical Center Marymount Medical Center August 2007 – Total Transfers Out - 59August 2007 – Total Transfers Out - 59
SJH Admissions Thru House Administrator - Marymount and Our Lady of the Way
02468
101214
Janu
ary
Mar
ch May
July
Septe
mber
Novem
ber
2007
Ad
mis
sio
ns
#
MarymountMedicalCenter -London
Our Lady ofthe WayHospital -Martin
Goals of the MeetingGoals of the Meeting Defined by team Defined by team
Simple ProcessSimple Process Patient Focused Process – “what is best Patient Focused Process – “what is best
for patient is guiding tenet of plan”for patient is guiding tenet of plan” One Call into systemOne Call into system Enhanced Relationships between Enhanced Relationships between
facilities and moves towards improving facilities and moves towards improving physician acceptance of transfersphysician acceptance of transfers
Current State: DefinedCurrent State: Defined Issues Identified –Issues Identified – Sometimes up to 5 calls from referring facility to
affect the transfer or find out that the physician would not accept.
Needs to be ‘One Call’ to trained personnel to initiate the transfer
Bed Availability issues – Peak times of discharge are not covered adequately to facilitate rapid turn around of room.
D/C process in ADT system needs to be monitored and expedited so bed control is aware of accurate bed availability
No consistent response time from Physicians on call for SJHC
Question raised by MMC and Question raised by MMC and OLOW:OLOW:
What is the incentive for us if our current referral center (UK [MMC] and King’s Daughters [OLOW]) has a seamless one call, 100% acceptance system in place and we can get our patients to higher levels of care without delays?
BenefitsBenefits: :
Improved Transfer Process for CHI – KYImproved Transfer Process for CHI – KY Improved Continuity of Care across the Improved Continuity of Care across the
system for the patient and their familiessystem for the patient and their families Keep CHI patients in one system in order Keep CHI patients in one system in order
to optimize electronic record sharing with to optimize electronic record sharing with development of Patient Keeper Physician development of Patient Keeper Physician PortalPortal
CHI referrals will stay in our Medical Staff CHI referrals will stay in our Medical Staff Network rather than us pushing them into Network rather than us pushing them into another Physician Networkanother Physician Network
Possible SolutionsPossible Solutions Transfer Center – Staffed with RN or have a second
House Administrator on to manage these transfers Bed Ahead System – already in place at SJHC but
could use optimizing One Transfer Number for All Transfers – Med Surg
and Critical Care 1-800-755-4344 is currently used for Critical Care transfers
Have SJHC – East and Main – Specialty call schedule available to outlying facilities for ED docs to use.
Network Building Initiatives with SJHC Medical Staff and Staff from MMC and OLOW.
Informational CME for All physicians related to EMTALA and the responsibilities of “On-Call” Physicians.
con’t Possible Solutionscon’t Possible Solutions Expedited admission to the receiving unit – no
stopping in ED Admitting Patient Transfer – Intake form for use by
Transport Coordinator in order to expedite transfer and collect all necessary information on one call
Three way phone call with Transfer Coordinator-Sending Physician and third party either bed control to assure bed availability or Receiving Facillity Physician on call in order to ascertain acceptance at time of initial call if possible and if not have the receiving physician call ED doc back (with defined acceptable response time)
Electronic Logs of all transfer related information - requested and actual for documentation as well as monitoring of progress with initiative.
Who? What? When?
Paula Develop Electronic Version of Transfer Log <45days
IT/Paula Automate MD Call Schedule <30days
Debbie Lawrence/Chris
Develop and Optimize functionality of STAR to track Bed Capacity at both Campuses including UM support for reporting and d/c-ing in system ASAP upon Discharge from Unit <45 days
Chris/PaulaFinalize Form for Data needs when initial call for transfer occurs -
INTAKE REQUEST Form <45 days
Deb Bryant/Patti CreedFax # for CHI Participants Facilities - fax each night so is available
at 7 a.m. for Physicians - start with MM and OLOW <30 days
Patty Sturt/Chris Investigate possibity of Grant from CHI for funding of pilot <45 days
Billy Turner/Deb Bryant/Chris MaysInvestigate staffing of transfer center at UK/King's Daughters or use
of Back-up line if first number busy <45days
Debbie Lawrence/Pt access
Define Process of DA/Transfer Pt - notification to Pt Access and subsequent bedside verification of wristband and signing of consents <45 days
Paula Plan 60 day Mtg to Review <10days
Chris Mays/Sherry Tichenor Dr. Bitterman Visit for Med Staff CME meeting <45 days?
Chris Mays/Sherry Tichenor Networking / Relationship Building plan for SJHC, MM, OLOW staff <45 days
Jennie ChapmanCheck on 1-800 Number and capacity and hardware needs to do 3-
way call <30 days
IT/Paula/Jeana/MelanieDevelop Tracking tools for all facilities to use for measuring success
with Algorithm <45 days
Paula Document Algorithm Defined by Team 20070924 <10 days
Action Plan Action Plan
DECISION IS MADE TO TRANSFER A
PATIENT
CALL SJHC Transfer Line
1-800-755-4344
ACCESS CENTER
RECIEVES CALL AND
DOES FORM
BED AVAILABLE?
Add to SJHC Waiting List for next Available Bed -q4hr updates to
sending facility
PT DEEMED EMERGENT BY TRANSFERRING FACILITY – Another
Facility Contacted
LOCAL MD CALLED (VIA THREE WAY CALL IF
POSSIBLE)– RE; TRANSFER
ON-CALL MD CALLED (VIA
THREE WAY CALL IF POSSIBLE) RE:
TRANSFER
ACCEPT TRANSFER?
ACCESS CENTER HELPS
ARRANGE TRANSFER
HA NOTIFIED
TRANSFERRING FACILITY ARRANGES TRANSPORT/SEND
PT INFO/CALLS REPORT
NOTIFICATION OF FLOOR AND/
OR BED CONTROL
NO OR
YES
Patient Seen by SJHC Physician in past?
YES
NO ACCEPT
TRANSFER?
YES
At Point of Entry into SJHC – stop and let Pt. Access know you are
here and going to unit
YES
Intra-Facility Transfer Work Flow Team
September 24, 2007Proposed Algorithm
Patient not Transferred – Consulted Physician to Document as well as HA or Transfer Coordinator Documents in
Log reason for refussal
NO
See Comment below left endpt.
NO
Inter-facility Transfer Process Inter-facility Transfer Process defined in Algorithmdefined in Algorithm
Lateral Transfers Lateral Transfers Lateral transfers, that is, transfers between Lateral transfers, that is, transfers between
facilities of comparable resources, are not facilities of comparable resources, are not sanctioned by §489.24 because they would sanctioned by §489.24 because they would not offer enhanced care benefits to the not offer enhanced care benefits to the patient except where there is a mechanical patient except where there is a mechanical failure of equipment, no ICU beds available, failure of equipment, no ICU beds available, or similar situations. However, if the or similar situations. However, if the sending hospital has the capability but not sending hospital has the capability but not the capacity, the individual would most the capacity, the individual would most likely benefit from the transfer.likely benefit from the transfer.http://www.azcep.org/emtala/mc_trans.htmlhttp://www.azcep.org/emtala/mc_trans.html
Receiving Hospital’s Obligations – Receiving Hospital’s Obligations – Appropriate Appropriate TransfersTransfers
Recipient hospitals only have to accept the Recipient hospitals only have to accept the patient if the patient requires the specialized patient if the patient requires the specialized capabilities of the hospital in accordance with capabilities of the hospital in accordance with this section. If the transferring hospital wants to this section. If the transferring hospital wants to transfer a patient because it has no beds or is transfer a patient because it has no beds or is overcrowded, but the patient does not require overcrowded, but the patient does not require any "specialized" capabilities, the receiving any "specialized" capabilities, the receiving (recipient) hospital is not obligated to accept the (recipient) hospital is not obligated to accept the patient. If the patient required the specialized patient. If the patient required the specialized capabilities of the intended receiving (recipient) capabilities of the intended receiving (recipient) hospital, and the hospital had the capability and hospital, and the hospital had the capability and capacity to accept the transfer but refused, this capacity to accept the transfer but refused, this requirement has been violated. requirement has been violated.
Three Principles of EMTALAThree Principles of EMTALA
Medical Emergency ScreeningMedical Emergency Screening On-Call PhysiciansOn-Call Physicians Obligation to Accept Obligation to Accept
TransfersTransfers
http://www.pitt.edu/~kconover/ftp/emtala-draft.pdfhttp://www.pitt.edu/~kconover/ftp/emtala-draft.pdf
First Principle of EMTALA
Medical Screening ExamMedical Screening Exam Stable - Stable - Stable for Transfer when you
can state about the patient, within reasonable clinical confidence, that there will be no material deterioration in his/her medical condition during transport
Unstable - Unstable - You shouldn’t transfer unstable patients, unless the benefits of transfer outweigh risks
Second Principle of EMTALA
On-Call Docs - These Physicians are on-call for the hospital not for the private practice and are agents of the hospital so anything they do or don’t do as related to EMTALA reflects directly on the hospital and therefore implies liability for the entire institution.
"On-call" duties come with the privilege of practicing in a hospital.
They are a covenant between physician and hospital as part of their mutual responsibility to all patients
who come to the hospital door. Physicians who break that covenant call into question their medical staff
privileges. … Hospitals and physicians, including on-call physicians, who
violate EMTALA may face stiff penalties. They could include civil fines
of up to $50,000 per violation or exclusion from participating in the Medicare and Medicaid program.
Third Principle of EMTALA
Obligation to Accept Transfers -
If any hospital in the U.S. calls and says they have a patient they can’t take care of, for whatever reason, and it’s something we can take care of, we have to take the patient. No ifs, ands, or buts, we have to take the patient. We shouldn’t even ask about insurance, lack of insurance, or HMO status—unless we have already agreed to take the patient.
Exceptions to Acceptance:Exceptions to Acceptance:
Beds not available – Beds not available – Some institutions define this Some institutions define this
as Beds, Staff or equipmentas Beds, Staff or equipment If it is an emergent medical If it is an emergent medical
condition and requires care condition and requires care not available at transferring not available at transferring hospital and a bed is hospital and a bed is available they must take the available they must take the patient.patient.
No Physician On-Call :No Physician On-Call :--If we have a specialty on staff at our hospital, and we have enough physicians in that specialty to reasonably cover an on-call schedule, we have to have an ED on-call list for that specialty. -All docs on Active Staff have to participate in call if requested by their department (and Courtesy Staff may have to take call). -Whoever is on call has to come to see a patient within a “reasonable time” (30-60 minutes is generally considered “reasonable” in an urban or suburban area) whenever the ED calls with a request for the on-call doctor to come see the patient. No exceptions, unless the consult is just to admit, or just to discuss a case.
Under current HCFA policy and Under current HCFA policy and thinking, are “lateral” thinking, are “lateral” transfers (hospitals of equal transfers (hospitals of equal capacity and capability) for capacity and capability) for admission after ED work up admission after ED work up done strictly for managed care done strictly for managed care (economic) reasons (economic) reasons
permissible?permissible?
A recipient hospital would A recipient hospital would not have to take a lateral not have to take a lateral
transfer based on this issue. transfer based on this issue. My general advice, My general advice,
however, is "when it doubt however, is "when it doubt take it, then sort it out and take it, then sort it out and
report if necessary." report if necessary." Stephen Frew, JD Stephen Frew, JD
IfIf the patient is the patient is stablestable, as defined by , as defined by law, EMTALA no longer applies and law, EMTALA no longer applies and hospitals can transfer patients for any hospitals can transfer patients for any reason, including economic reasons reason, including economic reasons
Only the patient can request to be Only the patient can request to be transferred transferred
If the patient is If the patient is unstableunstable, and the , and the transferring hospital has both the transferring hospital has both the capability and capacity to stabilize the capability and capacity to stabilize the patient, then a “lateral transfer” would patient, then a “lateral transfer” would be illegal unless the patient demanded be illegal unless the patient demanded the transfer (essentially leaving the the transfer (essentially leaving the facility against medical advice).facility against medical advice).
Sending hospital is not in Sending hospital is not in compliance. Once again, compliance. Once again,
though, hospital 2 may be though, hospital 2 may be safer to take the patient for the safer to take the patient for the patient's safety, and turn it in. patient's safety, and turn it in. I would suggest: "We will take I would suggest: "We will take your patient, but this sounds your patient, but this sounds
like a COBRA violation, and we like a COBRA violation, and we may have to report it. But we may have to report it. But we
will take your patient if you will take your patient if you want us to."]want us to."] Steven Frew Steven Frew
In the past the patient has In the past the patient has received all of their medical care received all of their medical care and necessary hospital admissions and necessary hospital admissions at the sending hospital, whose at the sending hospital, whose attending primary care physician attending primary care physician and hospital are still contracted and hospital are still contracted with the managed care plan, BUT with the managed care plan, BUT for this admission there is no for this admission there is no “contracted” specialist willing to “contracted” specialist willing to provide the necessary services provide the necessary services (i.e. neurosurgeon) despite having (i.e. neurosurgeon) despite having a neurosurgeon on-call for the a neurosurgeon on-call for the sending ED.sending ED.
Sending hospital is not in Sending hospital is not in compliance. Once again, compliance. Once again,
though, hospital 2 may be though, hospital 2 may be safer to take the patient for the safer to take the patient for the patient's safety, and turn it in. patient's safety, and turn it in. I would suggest: "We will take I would suggest: "We will take your patient, but this sounds your patient, but this sounds
like a COBRA violation, and we like a COBRA violation, and we may have to report it. But we may have to report it. But we
will take your patient if you will take your patient if you want us to."]want us to."]
Can the emergency physician Can the emergency physician &/or the on-call neurosurgeon &/or the on-call neurosurgeon after ED evaluation, transfer after ED evaluation, transfer
this patient to another hospital this patient to another hospital of similar or equal capacity for of similar or equal capacity for admission simply because the admission simply because the
neurosurgeon refuses to neurosurgeon refuses to contract with the patient’s contract with the patient’s
particular managed care plan particular managed care plan and does not wish to take care and does not wish to take care of the patient simply for this of the patient simply for this
reason.reason.
NO!NO!
The hospital has a duty to provide the The hospital has a duty to provide the neurosurgeon; when on-call to the ED, neurosurgeon; when on-call to the ED,
that duty attaches to the that duty attaches to the neurosurgeon. He becomes an agent of neurosurgeon. He becomes an agent of the hospital and as such represents the the hospital and as such represents the
hospital and not his private practice hospital and not his private practice any more. If a hospital called a any more. If a hospital called a
neurosurgeon who was not on-call, that neurosurgeon who was not on-call, that neurosurgeon can accept or reject any neurosurgeon can accept or reject any transfer as he would accept or reject transfer as he would accept or reject
any person in the capacity of his any person in the capacity of his private practice. No EMTALA duty private practice. No EMTALA duty
attaches to him unless he is on-call and attaches to him unless he is on-call and
thus an agent of the hospitalthus an agent of the hospital
This is why the real fight with This is why the real fight with on-call physicians will be over on-call physicians will be over the definition of “stabilized”. If the definition of “stabilized”. If the patient is stable, the law the patient is stable, the law
does not apply and the on-call does not apply and the on-call physician has no EMTALA duty physician has no EMTALA duty to accept the patient (though to accept the patient (though he may have a duty to accept he may have a duty to accept under other legal theories or under other legal theories or contractual relationships).contractual relationships).
Assuming the above Assuming the above transfer is NOT legal, what transfer is NOT legal, what is the best course of action is the best course of action
for the emergency physician for the emergency physician who has been placed in a who has been placed in a
situation where NO situation where NO neurosurgeon at the neurosurgeon at the
presenting facility will care presenting facility will care for the patient?for the patient?
1) Notify the on-call 1) Notify the on-call administratoradministrator or chief of staff STAT or chief of staff STAT2) Maintain stabilizing efforts2) Maintain stabilizing efforts3) Transfer if necessary and 3) Transfer if necessary and document the name and document the name and address of the refusing on-call address of the refusing on-call physician in the transfer physician in the transfer documentation per statutedocumentation per statute
Appropriate agreements must be Appropriate agreements must be reached between the medical staff reached between the medical staff
and the hospital about what it and the hospital about what it means to be on-call. The hospital means to be on-call. The hospital must provide physicians, it must must provide physicians, it must monitor and Q/A their behavior, monitor and Q/A their behavior, and it must discipline physicians and it must discipline physicians who violate EMTALA and their on-who violate EMTALA and their on-call duties. Failure to monitor and call duties. Failure to monitor and enforce the EMTALA requirements enforce the EMTALA requirements is itself a violation of the law, and, is itself a violation of the law, and,
as one hospital in New Jersey as one hospital in New Jersey discovered, can be reason enough discovered, can be reason enough
for HCFA to literally close down for HCFA to literally close down the hospital’s ED.the hospital’s ED.
How do you handle the How do you handle the rogue physician who rogue physician who
refuses to follow the rules refuses to follow the rules and carry out his on-call and carry out his on-call
responsibilities?responsibilities?
Policy should specifically Policy should specifically address what the EP should address what the EP should do in this situation: call the do in this situation: call the
chief of the physician’s chief of the physician’s department for resolution, department for resolution, failing that call the chief of failing that call the chief of
the medical staff, and the medical staff, and failing there, call the failing there, call the
administrator on-call to administrator on-call to resolve the problemresolve the problem
If everything fails, the only If everything fails, the only option for the EP is to transfer option for the EP is to transfer the patient to a hospital that the patient to a hospital that
can manage the patient’s EMC. can manage the patient’s EMC. In that case, the EP must send In that case, the EP must send the name and address of the the name and address of the on-call physician who refused on-call physician who refused
to help to the receiving to help to the receiving hospital. In turn, the receiving hospital. In turn, the receiving
hospital is required by hospital is required by Medicare law to report the Medicare law to report the
transferring hospital to HCFA.transferring hospital to HCFA.
Hospital administrators Hospital administrators must understand that must understand that
the actions of the on-call the actions of the on-call physician are directly physician are directly
attributed to the hospitalattributed to the hospital
Patient requires acute care Patient requires acute care and the sole reason for and the sole reason for
denial is financial -- I would denial is financial -- I would not permit it in a hospital I not permit it in a hospital I represented. The on-call represented. The on-call rule should be simple and rule should be simple and
unequivocal: The on-unequivocal: The on-specialist takes all patients specialist takes all patients -- PERIOD. – Steven Frew-- PERIOD. – Steven Frew
Assume the patient has a more Assume the patient has a more imminently serious problem imminently serious problem and it is felt further delay in and it is felt further delay in
obtaining appropriate obtaining appropriate consultation at the sending consultation at the sending
facility might place the facility might place the patient’s health in jeopardy. Is patient’s health in jeopardy. Is
transfer OK under these transfer OK under these circumstances &/or what is the circumstances &/or what is the
best course of action for the best course of action for the emergency physician?emergency physician?
Act to save the patient. Act to save the patient. Notify administration. Notify administration.
Transfer if necessary. List Transfer if necessary. List the refusing physician in the the refusing physician in the transfer reports as required transfer reports as required
by law. Complete an by law. Complete an incident report. incident report.
If the patient needs immediate attention, If the patient needs immediate attention, then the hospital must do everything it can then the hospital must do everything it can
within its capabilities and capacity within its capabilities and capacity (resources) to stabilize the patient. If there is (resources) to stabilize the patient. If there is
disagreement between the emergency disagreement between the emergency physician and an on-call physician regarding physician and an on-call physician regarding
whether the patient is stable for transfer, whether the patient is stable for transfer, then hospital policy should require the on-then hospital policy should require the on-
call physician to come into the ED, call physician to come into the ED, personally examine the patient, and assume personally examine the patient, and assume care of the patient. This includes arranging care of the patient. This includes arranging
the transfer if the on-call physician still the transfer if the on-call physician still insists on transferring the patient, and insists on transferring the patient, and obtaining the patient’s consent to the obtaining the patient’s consent to the
transfer.transfer.
Under these circumstances Under these circumstances does the hospital being does the hospital being
called to arrange transfer called to arrange transfer (receiving hospital B) have (receiving hospital B) have an obligation to accept the an obligation to accept the
patient in transfer?patient in transfer?
Under the general rule, if the Under the general rule, if the ED truly can’t obtain the ED truly can’t obtain the
services of the on-call services of the on-call physician, for whatever the physician, for whatever the reason, then yes, Hospital B reason, then yes, Hospital B must accept the patient in must accept the patient in
transfer. However, Hospital B transfer. However, Hospital B does not have to accept any does not have to accept any patient in transfer if Hospital patient in transfer if Hospital A has the necessary on-call A has the necessary on-call
services and resources services and resources available to manage the available to manage the
patient’s EMC.patient’s EMC.
If a patient is legally stable, If a patient is legally stable, but has a medical condition but has a medical condition that requires the care of a that requires the care of a
tertiary facility, does tertiary facility, does EMTALA require the tertiary EMTALA require the tertiary facility to accept the patient facility to accept the patient
in transfer?in transfer?
...requires the tertiary facility to ...requires the tertiary facility to accept an “appropriate” transfer. accept an “appropriate” transfer. The meaning of appropriate here The meaning of appropriate here could refer back to the definition could refer back to the definition of an “appropriate transfer,” for of an “appropriate transfer,” for
purposes of transferring an purposes of transferring an unstable patient, or it could be just unstable patient, or it could be just
the common language meaning the common language meaning that the patient needs the service, that the patient needs the service,
the tertiary facility has that the tertiary facility has that service, and therefore the facility service, and therefore the facility
must accept the patient in must accept the patient in transfer.transfer.
Presently, both HCFA Presently, both HCFA and the OIG take the and the OIG take the
position that anything position that anything the patient needs that the patient needs that
you got, and the you got, and the transferring facility does transferring facility does not, you must accept in not, you must accept in
transfertransfer
Try your best to reach an Try your best to reach an acceptable solution holding acceptable solution holding the patient’s best interest at the patient’s best interest at
a premium. If your a premium. If your reasonable efforts fail, reasonable efforts fail,
document them, and call document them, and call other hospitals until you find other hospitals until you find
one that will accept the one that will accept the patient.patient.
Under EMTALA there is no Under EMTALA there is no requirement for physicians requirement for physicians
to take hospital ED call, to take hospital ED call, unlessunless the medical staff the medical staff
bylaws or hospital rules & bylaws or hospital rules & regulations state that duty. regulations state that duty. http://www.azcep.org/emtala/on_call.hthttp://www.azcep.org/emtala/on_call.ht
mlml
The medical staff by-laws or The medical staff by-laws or policies and procedures policies and procedures
must define the must define the responsibility of on-call responsibility of on-call physicians to respond, physicians to respond,
examine and treat patients examine and treat patients with emergency medical with emergency medical
conditions.conditions.
If hospitals and If hospitals and physicians don't solve the physicians don't solve the problem, government and problem, government and politicians certainly will.politicians certainly will.
Emergency Department on-Emergency Department on-call coverage issues will be call coverage issues will be the final EMTALA hurdle for the final EMTALA hurdle for
hospitals. hospitals.
“Money is the root of all evil” but unfortunately is not the entire
solution for the on-call issue. Fully funding on-call coverage would
bankrupt most hospitals and divert funding sorely needed in
other areas of healthcare. It also sets up a perverse system that rewards physicians for doing as
little as possible and builds resentment from those on-site
doing the bulk of the work.
The ED: A “Besieged” The ED: A “Besieged” Work EnvironmentWork Environment
Causes of Increase in Provider Causes of Increase in Provider Dissatisfaction coming to ED?Dissatisfaction coming to ED?
Critical Shortage of Qualified Nursing Critical Shortage of Qualified Nursing StaffStaff
30-60 minute waits for Nurses to 30-60 minute waits for Nurses to help help
Needed Equipment to evaluate Needed Equipment to evaluate patients either not available or patients either not available or inadequate or in ill repairinadequate or in ill repair
Solutions to this?Solutions to this?
““Hand holding” practices to meet on Hand holding” practices to meet on call physicians needs when in to call physicians needs when in to evaluate ED patientsevaluate ED patients
Increase Training and Retention Increase Training and Retention programs for seasoned ED nurses in programs for seasoned ED nurses in order to reduce turnover and order to reduce turnover and improve staff satisfactionimprove staff satisfaction