A hospital was cited for failure to provide stabilizing treatment when an on-call Orthopedist declined to come in and ordered a hand case transferred. The receiving hospital questioned that transfer as a “lateral” move that could have been handled by the general Orthopedist on-call rather than triggering a 130 mile transfer. CMS concluded the transfer delayed debridement of the patient’s hand injuries and open wound contaminated with grass and gravel debris by several hours.
The young patient sustained injuries when the go-cart he was driving crashed and rolled over his hand and arm and initial exam revealed decreased range of motion, tenderness, bony tenderness, deformity, laceration, and swelling. There was significant debris in the crushed tissue wound. The deformity was near the wrist at the site of a greenstick fracture of the ulna.
The On-call was contacted:
When contacted by the ED, the on-call indicated that he was uncomfortable managing the case because he was not a hand surgeon. The PA indicated he was nervous about EMTALA compliance and requested the on-call orthopedist evaluate the patient in the ED prior to transfer. The on-call indicated that he was unable to manage the wound, and that his evaluation was not warranted. The hospital lacked an on-call hand surgeon and attempts to find a local Orthopedist willing to take the patient failed. Several hospitals denied the transfer as a lateral transfer. A hand surgeon at the destination hospital accepted transfer of the patient. The patient’s insurance was a Medicaid plan.
The on-call indicated to site investigators that he was not a hand surgeon and did not have privileges for the type of surgery that was potentially required. He also stated that his job was to discuss the case with the ED physician and then decide whether he needed to come in to evaluate the patient. A review of the physician’s privileges showed closed and open fracture reduction, upper extremity casting, strapping and splinting, incision and drainage of bone, tendon, muscle and joints. They also were noted to include tissue repair of tendon, muscle, skin and vascular but not hand surgery specifically.
Consistent with EMTALA, the hospital bylaws were found to require the on-call physician to respond in person when requested by the ED and specifically indicated that if the on-call disagreed with the need to come in, he or she was required to come in regardless and resolve the issue later within department channels.
COMMENT:
This case illustrates a number of well-established principles in EMTALA enforcement:
1. If the ED requests an on-call physician to come in, EMTALA is automatically triggered, and the on-call must respond in timely manner.
2. The on-call may not substitute their judgment for that of the ED on the need to respond. (Even if the on-call has reviewed tests or imaging remotely by computer, as in this case).
3. If the on-call does not have privileges for the specific procedure, they must still respond to evaluate within the scope of education and general privileges, to render stabilizing care within their capabilities, and to effect appropriate transfer where indicated.
4. Documentation of financial considerations prior to the completion of medical screening and stabilization creates a high degree of suspicion that the deficiencies were attributable to financial considerations. (No citation was issued for financial denial of care in this case, however.)
Another question that sometimes arises in the failure of on-call to respond cases is whether the ED physician properly activated the “chain of command” or “over-ride” procedures that hospitals are expected to have in place to prevent violations. In this case there is some indication that the PA was aware of the EMTALA issue, and no mention of “over-ride” attempts being made. The citation suggests that several other potential transfer destinations pointed out EMTALA issues and refused the transfer (at their own potential risk).
See pp 257-259; 271-274 EMTALA Field Guide 3rd Edition
A2407-2013-8-22-IA
Would like your input on a little different scenario. Physicians often don’t perceive hand injuries as “emergencies.” Scenario is a patient arriving with the tip of his finger left inside his glove after a work injury. Physician discharged the individual with written instructions of “Go to XXXhospital to see Dr. XXX today.” The nurse was told by the physician that it was not a transfer situation and so EMTALA paperwork and processes did not need to be completed. There has been a belief that the EMTALA definition of emergency medical condition including “serious injury to any bodily organ or part” is no longer enforced and the “lay person” definition is more applicable. In this case, I think even a lay person would have agreed that an emergency medical condition existed, but the physician did not see a smashed finger as an EMC. Could you respond, please, to current enforcement patterns in a situation like this? We are in the Midwest and under the jurisdiction of the KC office. Thanks.
The prudent lay person standard is an ADDITIONAL standard. The “serious injury to any bodily organ or part” has not been replaced, and citations for “minor” injuries are still the order of the day. An amputated finger tip would be an emergency — and having sustained one myself, it is typically addressed promptly, and would be considered an EMTALA injury under either standard. It is also considered an EMTALA transfer to discharge a patient with instructions to go to another facility for care. The physician was wrong.
there are many errors in your article.
1. The hospitals that refused the transfer claiming it was a lateral transfer WERE incorrect. It was a transfer to a higher lever of care to them simply by the fact that the transferring hospital’s Ortho was not coming in for whatever reason. When an on call MD doesn’t come it, it automatically means that this hospital at the moment does NOT “within the capability of the hospital” have the back up MD to stabilize. It was a “reverse EMTALA” for any of these potentially receiving hospitals not to take the patient even if the transferring hospital is violating EMTALA. The receiving hospital can still report the transferring hospital for an EMTALA violation. A receiving hospital cannot refuse a transferring hospital request for transfer for any reason if the transfer hospital says in a sense “I need your help for stabilization” that we cannot provide.
2. Many orthopedic MDs per the standard of care aren’t qualified to deal with hand problems and it could be malpractice for that Ortho to come in and as a result cause a further delay in the appropriate treatment of the patient. What the ER MD should have documented if s/he agreed with the Ortho that the patient needed a hand surgeon and it is the standard of care to transfer the patient and to also document in the chart the hospital did not “have the capability” to stabilize at that time.
Dr. EMTALA
First of all, thank you for your comments. Unfortunately, they don’t apply to the article facts that connect to this comment.
I do agree that a receiving hospital basically only has the option to accept a transfer for services which they are capable of providing, and then if situation justifies it, they are obligated to report the sending hospital.
As for ortho’s declining to respond to hand issues, CMS has repeatedly held that they are able to assess a patient and arrange transfer even if they are not qualified or privileged to do the required surgery. They are required to respond and assess and then make a transfer if appropriate. They are not allowed to turn down cases over the phone without laying eyes on the patient. The ED doc is entitled to request specialty assessment whether or not that doc will ultimately do the surgery.