An alleged failure to call in an on-call orthopedic surgeon and an apparent disagreement on what constitutes “Trauma” for transfer to a Trauma Center ultimately was resolved with $20,000 Office of Inspector General (OIG) settlement on charges against a Critical Access (fewer than 25 beds) hospital in Tennessee (December 2014). Maximum fines for violations by small hospitals is $25,000 per violation. An OIG settlement does not involve any admission of fault.
The OIG report indicates a patient came to the ED with severe pain in his feet, ankles, and right shin after jumping from a 20-foot wall onto concrete. Although the hospital did have an orthopedic surgeon on call, they transferred the patient to a Trauma Center without consulting with their on-call surgeon and without providing stabilizing care to the legs before transferring the patient to the trauma center. The federal Emergency Medical Treatment and Active Labor Act (EMTALA – 1986) requires the hospital to provide care within its capabilities and only transfer for services beyond their capabilities. EMTALA also requires hospitals to provide care, such as splinting and specialty examination, to reduce risks of transfer before sending the patient to a higher level of care.
Editors comment: An interesting aspect of this case is that the Trauma Center ultimately determined that the case was not a “trauma” case, which may have led directly or indirectly to the incident being reported under EMTALA. The law requires receiving hospitals that receive transfers that are possible EMTALA violations to report them to federal authorities, although no indication is included in the OIG report whether the receiving hospital was the source of the report.
If the Trauma Center was the source of the report, I would have to agree with the report but disagree for the reason, if they did not consider the initial basis for sending the patient to be “trauma”. Most trauma systems consider the “mechanism of injury” or how the injury occurred to be one of the reasons to consider a patient a “trauma” patient based on the potential for serious injury. A 20-foot fall onto concrete would typically qualify as a potential trauma patient that would justify transport to a trauma center in most systems.
The EMTALA regulations, however, specifically indicate that EMTALA is not supplanted by Trauma Center designations, so the initial hospital must fully comply with EMTALA and provide all of the care they are capable of and follow EMTALA procedural rules regardless of whether a patient would otherwise qualify to be sent to a Trauma Center.
See page 290 EMTALA Field Guide 3rd Edition.