We had a patient in our ER this evening who presented with dehiscence of a ventral hernia repair which was done at another facility several days ago. Patient and his family were adamant they did not want to return to that facility. The ER physicians called all the surgeons of our facility in an attempt to help this patient and all referred this patient back to the surgeon who did the original surgery. They even attempted to contact another facility who also referred him back to the original facility.
My question: I know we like to refer surgical cases back to the original surgeon, however, if we can perform the surgery here, and the patient does not wish to return to that surgeon, are we not obligated under EMTALA to provide those services?
ANSWER: You are correct. The fact that the patient is presenting with complications of prior surgery performed elsewhere is irrelevant under EMTALA. Your facility is required to render stabilizing care to patients who present at your facility. The only two exceptions would be if your facility lacked the capability to perform the necessary care which would require you to make an appropriate transfer, or if the patient requested transfer back to the original hospital and that hospital accepted the patient in transfer.
A secondary issue might be to question the refusal of transfer from the third hospital. In this case, since your facility could not declare this an EMTALA transfer because you had the capacity to render care and transfer would not be permitted by EMTALA, this was probably one of the few cases where the third hospital could refuse the transfer request without EMTALA compliance concerns.
At a minimum, I would require that my on-call surgeon come to the ED to evaluate the pt at the bedside, which is the clear obligation of on-call physicians per EMTALA law. I would, if necessary, involve senior leaders to “remind” the on call surgeon of/her/his EMTALA obligation vis a vis ED pts, and remind all parties that the patient is a patient of the hospital, not exclusively of the ED, so it is the obligation of the entire hospital to determine best care, and not the option of the on call surgeon to say, for all intents and purposes (to the ED staff), “You’re on your own.”
Secondary thought; the statute itself does note that the ED meets its EMTALA obligation if the pt is offered and declines transport (this pt refused transport to the hospital wherein the original surgery was done). Could one argue that EMTALA has been met? I realize that that stipulation presumes that the pt has a condition for which appropriate stabilizing care is not available at the putative sending hospital, but only at the putative receiving hospital, which is not the case here.
No, because #1 the hospital must have an EMTALA basis for the transfer and #2 even if the patient refuses a bona fide transfer, the current hospital must still render care within its capacity, which includes their own on-call physicians.
If a facility has a patient in their ED that they are requesting a transfer to a higher level of care because they don’t have a particular specialty service available and we do and we have beds available and they are requesting inpatient bed does this qualify as an EMTALA violation if we refuse. The basic question is: if we have an ED to inpatient transfer is that considered under the purview of EMTALA?
Stephen, thanks for your comments
Yes…that would be an EMTALA transfer to a higher level of care, as I understand your question.