Transfer Ethics

Every ER doc HATES to transfer a patient for the most part.  They are generally time consuming, and very difficult.  They are fraught with potential legal pitfalls as well as by obstructions by receiving hospitals/doctors.  Why?  Because usually, a receiving facility (usually another ER)  does not usually want to accept a transfer (more on this in a minute).  This is amplified at night since during the day, you are more likely to have a receiving doctor readily accept a transfer to the inpatient unit (such as a trauma ICU, a Burn unit, or a hyperbaric chamber).  At night it usually goes to the ER. 

So, here is the deal with transfers.  First, you cannot legally transfer from ER to ER unless the receiving hospital possesses some capability in patient care that the sending facility does not.  An example is a trauma centre accepting a badly injured patient from a small non-trauma designated hospital.  Other examples abound – including some very specific things – such as “bloodless medicine”(for Johova’s Witnesses), neuroangiography, specialised pediatric care, or even an on call Dentist.  Now, if a patient just wants to go to another place for their own personal reasons, they cannot be legally transferred unless there is an accepting physician who will take the patient on his or her service (and an inpatient bed available).   The reason this law was created was to prevent “patient dumping” where in the past one hospital would just randomly transfer an “undesirable” patient – usually uninsured, drunk, or otherwise difficult or nonprofitable. 

Things are more complicated (or you might say less so) for the uninsured regardless of their medical condition.  They can generally NOT be transferred to any old hospital that possess the facilities to take care of them (that the transferring hospital does not have – like a PICU).  They cannot be transferred across state lines in general.  They can usually only be legally sent to a regional centre – usually state-supported and urban. 

On top of all this complication is the fact that no one really wants more work – at least not a busy ER especially in the middle of the night.   ER docs dread the call “so and so is calling from such and such hospital – they want to transfer someone”.   Often even if it is a legal ER to ER transfer, the patient arrives unstable, inadequately worked up, with  limited paperwork, thrashing around, etc.  Not fun – then they have to convince a usually unenthusiastic doctor to admit them.  Administrators MAY want well insured patients who are coming for expensive (and well -reimbursing) procedures but obviously they are not so enthusiastic for an uninsured patient who will cost them a ton of money.   I remember a scam a local hospital used to pull – when a drunk person would show up in the ER (this was a private urban hospital where drunks often walked in), a waiting ambulance would casually pick them up and drive the guy across town to another hospital – and then claim they were dispatched to some random place where they found him – (no mention of where he really had just been!)

Last night I had a difficult transfer drama.  A patient had a high chance of having an intracerebral aneurysm (based on a very abnormal eye and pupil exam) . The head CT showed nothing but what she really needed was an angiogram (both for diagnosis and treatment) and the only place I could transfer her was about 45 minutes away and in a large, poor city (because she was uninsured).  Both the patient and the family refused to go to this “crappy” place and wanted to go to a closer, nicer place.  I told them I could not do it legally so they signed her out AMA and then marched over there.  I had to call the other ER and make sure they knew she signed AMA and that I did not tell her to go there – or else we could face a “dumping” fine.   Seems to me, any hospital should be able to accept charity transfers and then apply for governmental reimbursement – instead of having to have us  jump through insurance hoops, angry doctor hoops, dissatisfied patient hoops, etc.