Ask any ER physician what ranks among the most painful 10 things he or she has to do and I am sure “transfer” ranks up there. Now, some are very lucky and have painless transfer agreements with a nearby academic centre where they basically take everything (especially if you work at a very small community ER with limited services – essentially the larger hospital realises that the small guy just don’t have people on staff that can handle really sick patients or lacks facilities such as a cath lab.),however, many docs are not so lucky. Like me, they work in a community hospital that DOES have good and extensive services – BUT because almost all the docs are “privates” (ie, they don’t take charity cases unless forced to, unlike salaried academicians), AND at night and on weekends, either no one is around or available or….well, see this post and you will see what I am talking about. Anyway, transferring a patient is not as easy as calling an ambulance and loading the patient in. There are laws, logistical considerations, inter-state regulations, insurance issues, paperwork, phone calls, reports by RN’s, consent forms, and pain-in-the-ass MD’s. URGHGH!!!.
First, in general you cannot transfer someone for monetary reasons – totally illegal to “dump” an uninsured patient at another hospital because they don’t have the ability to pay (this used to happen all the time before the EMTALA law). For practical purposes, to transfer someone (other than at a patient’s request – in which case, the onus falls on them to insure that the arrangements are legal and accepted), your hospital must lack the ability to care for the patient – ie. “we don’t have a hyperbaric chamber and the guy’s Carbon Monoxide level is off the charts”, or “We have no neurosurgeon on staff and the guy has an expanding epidural”. Sounds easy, right? Wrong. First, define ” Lack the ability to care for the patient”. One can POSSESS the prerequisite staff and facilities but for other reasons, cannot take care of the patient. Now, try convincing the doc on the other line to accept a transfer when some of the following occur: (and remember this is where the skills of “persuasion” come in)
1. “My neurosurgeon states that in his contract, he does not need to take care of Ventricular- Peritoneal shunts that were put in by other surgeons”
2. “My surgeon “can’t handle” a stab wound to the abdomen”
3. “His cardiologist is an hour and a half away”
4. “This case is too complicated for my surgeon”
5. “My orthopod states he has no resdents to help him in the OR”
Yet, these are the reasons we, as ER docs are given by our staff as to why we need to transfer a patient. Often, time is of the essence and threatening action with the medical staff is not a productive argument to have with an on call doc at the time. In these cases, I understand the annoyance of the doc on the other line.
Now, even in clearly established cases where a transfer is necessary, things are still not guaranteed to be smooth sailing. Here is the malarchy we have to listen to when the surgeon or other ER doc on the line starts in on us.
1. “I can’t take accept this transfer, you should be able to handle it yourself”
2. “I have been in the OR all day and am too tired to take another case”
3. “I refuse this transfer” ( I am thinking, “damn, why did I mention that this guy has no insurance”)
4. “Slam!!!” (the sound of a dial-tone…..)
5. ” We are too busy”
6. ” We can’t accept an uninsured transfer across State lines”
7. “Have your surgeon come in, examine the patient, and then have him call me back to explain why he can’t handle the case”.
Even after the transfer has been accepted, the pain does not end. How are you going to transfer the patient? If he or she is unstable, then you need a paramedic unit and often an RN and or doctor to ride over. Now try convincing one of your own staff to get in the bus when the accepting facility sends over a BLS unit with no ACLS training. If he or she is stable, it is easier but if a private ambulance comes, they may want a credit card of the patient’s to charge before they load ‘em up. Also, the RN has to give report to the accepting hospital’s RN – often the accepting RN is “too busy”, “on break” or asks our RN about a million useless questions during the report – further delaying the transfer. Finally, sometimes the ambulance takes an hour or more to arrive – and the accepting hospital is all of 10 minutes away – the patient could have gotten there faster if we simply pushed the stretcher down the street.
Here is the easiest solution of all (sad to say). If a patient is stable – and can be driven to the other hospital by family or friends, you can gently suggest they sign out AMA and just show up over in the other ER. Then the HAVE to take care of the patient. Ola! No transfer paperwork, calls, or legal issues.
This is what we had to do the other night after spending hours trying to find a hospital with a pediatric orthopaedist to accept a transfer of a 5 year old with a very complicated elbow injury that our on-call general orthopod could not fix (and I give him credit, he tried and tried to reduce it and honestly told the family that if he took the kid to the OR, he would be shooting blind). Now that “too tired” on call peds orthopod at Screw-U University Hospital has to just drink some more coffee, stop whining, and treat the patient.
Honestly, drug seekers are easier to deal with.
Thanks for the post. BTW, it’s MALARKEY, not MALARCHY.
here’s another side of this that makes you want to kill someone. After you talk with transfer centers, then the resident, then the on call attending to point you have this story in your memory forever, someone finally has a bed!! and accepts your patient!! you hang up and turn around and there’s the patient’s nurse waiting to talk with you. You KNOW what’s coming next!! Some A**Hole family memory has showed up or called at the last second to say ” we don’t want that hospital, we want to go to Mecca University Hospital”. Give me your drug seekers, any day, rather than deal with this crap everyday.
This post should be required reading for new ED residents … although now you’ve given all the specialists new ideas for how to refuse patients.
In all fairness, the on-call doc who wants to transfer the patient probably should be coming in to at least take a look at the patient before recommending transfer.
You can also try calling the administrator on call at Screw U., waking them up out of a sound sleep, and telling them what’s going on. Do that enough times and things will change.
If you sign out AMA ‘tho, your insurance often won’t cover anything…
Just FYI, discharging a patient with instructions on the sly to go to another hospital’s ER is a clear violation of EMTALA. The risk of getting busted is quite low, but you should know that it’s as much of a “bright line” as putting them in an ambulance and sending them. Yeah, yeah, I know, nobody ever gets punished for violating EMTALA, but if you are going to violate the law, you should at least do it knowingly.
One thing you can do, if your administration is willing to back you up, is to have a house-wide policy that transfers due to consultant preference need a dictated consult note in the chart, and the consultant needs to see the patient on request. If you request the consultant to see the patient and they refuse, document that refusal, and file your own EMTALA complaint with the HHS OIG. That will get their attention real quick!
I have been very close to reporting a few of our consultants for such violations – but have stopped short to avoid a giant broughaha. A few of them are so powerful in our hospital that they can essentially do no wrong (I have alse entertained letting the air out of their tyres….) As for the signing out AMA – in some of these cases, the patients have signed out on their own after getting digusted with the difficulty in transfer and/or the MD’s dodging the case. I know that if you “force or coerce” a patient to sign out, it is technically an EMTALA violation so one has to be careful. But in some cases, I would rather risk that then having the patient crap out in my shop.
well i know this is mostly er guys but being a specialist on the other side i heard a story of our ophthalmologists and psychiatrist the other day, basically they were getting consulted left and right from the er from non paying patients and basically said we are done, so now don’t have ophthamology or psychiatry at all.
I’m an obgyn and i cover the er but in 6 years I have had 3 patients total with insurance and I am on 3 or 4 times a month for 6 years.
And our er group gets a stipend for covering the er, hmm where’s my stipend for being a consultant.
Guy, our GYN on call is now paid a stipend by the hospital to cover the ER since most GYN patients we see seem to be uninsured or from the clinic. I think that is the way to go.
Hello webmaster I like your post
The problem is the ER docs at your facility. The problem: You guys continue to let this shit happen without contacting CMS and filing an EMTALA violation. Once you guys stop being nice guys and start filing EMTALA violations with CMS against these sorry bastards for refusing to accept patients that need a hire level of care than your facility can provide, they will get their act together. Their hospital will lose Medicare and Medicaid funding(Millions of dollars), pay a $50,000 fine, and each individual physician that refused to accept the patient will be fined $50,000. The offending hospital will have to come up with plan of action comply with EMTALA in the future.
So instead of writing on this blog, contact CMS (Center for Medicaid and Medicare Service) and report the EMTALA violation.
And there are people in your country trying to convince the rest of us you have the best medical system in the world? Per-lease!!!! You go to a hospital in GB and you are not going to have your poor ED dr spend all day trying to find a consultant who’ll take them because they are unemployed or the wrong insurer. If you are on-call in a GB hospital you have to live within 20 minutes of the hospital and be available when needed (unless you are already dealing with another patient but even then you are likely to be in the same building).
You have a system that is fantastic for those with money, lots of it. It seems to me it is a case of hang the rest. GB may not be perfect, no-one ever claimed it was. But no-one is excluded and the ED abuse level varies according to location, generally though it isn’t as bad as yours.