Patient presented to Hospital 1 with chief complaint of pain in back and pain and numbness in right leg. A medical screening examination was conducted with a CT ordered. During the CT scan the patient had erratic blood pressures requiring fluid boluses. The CT scan revealed a massive ruptured AAA with no blood flow to the iliac or femoral arteries, COPD, coronary artery disease, and an abnormal kidney surrounded by blood.
The destination hospital, hospital 2, was contacted at 2:19 and a transfer request was made. At 2:28 the ED physician at hospital 2 reported speaking to the vascular surgeon on call at Hospital 2. Initial calls for transfer at Hospital 2 are directed to the ED physician per policy. The ED physician at hospital 2 felt that the distance involved (40 miles) was too great for a safe transfer and that there were capable hospitals closer to the sending facility. The ED physician from hospital 2 recommended contacting hospital 3, did not accept the patient, and instructed Hospital 1 to call back if the patient was not accepted at hospital 3. The ED physician from Hospital 1 reported advising that other hospitals had declined the transfer.
The ED physician at hospital 2 then had the vascular surgeon notified of the transfer request. The vascular surgeon spoke with the ED physician at Hospital 2, concurred in his reluctance to accept the patient, and said he would speak to the ED physician at Hospital 1 if he called back, but it does not appear that Hospital1 called back. The transfer log for Hospital 1 indicates that the transfer was “refused/other”.
Ultimately, the patient was transferred to Hospital 3 via helicopter for surgery.
Citation:
Hospital 2 was cited for violation of “Tag A2411 Recipient Hospital Responsibilities” for failure to have an effective system in place to accept transfers of individuals in need of the specialized services of the facility when the hospital had the capacity to accept the patient.
Comments:
While distance is a concern for transports, EMTALA specifically eliminates that as a ground for refusal of a transfer. The only criteria are:
1. Does the sending hospital make a request for transfer because the patient needs specialized care or specialty consult that is not available at the sending hospital at this time?
2. Does the receiving hospital have the capability to provide the needed specialized equipment, surgery, or specialists requested?
3. Does the receiving hospital have the capacity to accept the patient – i.e. the hospital has capacity if it has EVER had more patients in-house than it has right now
Many physicians on the receiving end of transfer requests are reluctant to accept “responsibility by accepting the patient” and are concerned about “potential malpractice claims.” EMTALA, however, places the responsibility for determining the patient’s emergency status and whether the patient needs transfer on the SENDING physician. EMTALA mandates acceptance at the receiving facility.
Anywhere in the US
Physicians responsible for ED or on-call transfer acceptance are subject to the EMTALA requirement that their hospitals must accept transfers from ANYWHERE in the US or its territories.
Hospital system must facilitate acceptance
In this case, hospital 2 personnel were not familiar with hospital policy or the EMTALA law applicable to transfers, and the system in hospital 2 failed to facilitate the prompt acceptance of the requested transfer. CMS expects that calls will go to those who have appropriate authority to accept transfers and that
multiple calls to achieve a transfer should not be required.
Hospitals may have calls go to the ED, designated transfer centers, on-call specialists (I do not recommend this approach) or may come up with other alternatives, but the approach must provide a prompt and reliable acceptance and hospital staff must follow the system.
More information regarding on-call requirements can be found in pages 249-277 of the EMTALA Field Guide.
A2411-GA-2012-11-15