Interfacility Transfers: Pearls & Pitfalls for the Emergency Physician

Authors: Owais Durrani (EM Resident Physician, University of Texas Health Sciences Center San Antonio); Rachel Ely, DO, MHA, NRP (EM Attending Physician, EMS Fellow, San Antonio, TX);  and Nurani Kester, MD (Assistant Program Director, University of Texas Health Sciences Center San Antonio) // Reviewed by: Erica Simon, DO, MPH, MHA (@E_M_Simon), Alex Koyfman, MD (@EMHighAK), and Brit Long, MD (@long_brit)

Case 1

An 8-year-old female presents to your emergency department (ED) after spilling hot coffee on her chest and abdomen.  She has erythema and blistering to approximately 18% of her total body surface area (TBSA), but has no airway involvement. Her vital signs are normal, except for mild tachycardia.  You know that the American Burn Association recommends transfer to a burn center for all children with acute partial thickness burns with a TBSA > 10% or full thickness burns > 5% in a patient of any age1.

Case 2

While working in the ED of level I trauma center you receive a phone call from a free-standing ER requesting acceptance of a 35-year-old male who was assaulted and has significant left sided peri-orbital edema.  The transferring physician was unable to fully examine the eye given the localized edema, but noted an irregularity on CT scan suggesting an open globe injury.  Your hospital has an ophthalmologist on call.

 

Introduction

Each year 1.8 million patients are transferred from the ED to an acute care facility2. The American College of Emergency Physicians’ 2016 Appropriate Interfacility Patient Transfer guideline identifies the principle goals of patient transfer as ensuring the optimal health and well-being of the patient2.  ED patients from rural, non-teaching, and level III or IV trauma centers are more likely to be transferred, given facility lack of resources/specialists2. Furthermore, data has shown certain subsets of patients transferred to regional specialty care centers have improved outcomes3.  Pre-hospital EMS data indicates patients with myocardial infarcations have improved outcomes at PCI centers vs. non-PCI centers, the same trends have been shown with CVA patients transported to stroke centers and trauma patients to trauma centers.  The most common diagnoses of transferred patients are acute myocardial infarction or cardiac ischemia, stroke or intracranial hemorrhage, psychiatric related conditions, and trauma2.  Emergency medicine transfers are conducted on principles outlined in the 1986 Emergency Medical Treatment and Labor Act, or EMTALA4.  This law prevents patient dumping, which includes: discharging patients prematurely, denying medical screening exams, and transferring patients the inability to pay has been identified5.  EMTALA applies to Medicare participating hospitals, specifically to persons who present themselves on “hospital property”6.  Hospital property includes parking lots, sidewalks, and driveways within 250 yards of the hospital.  This also applies to urgent care centers operating under the umbrella of the hospital, and hospital owned/operated ambulances.  EMTALA does not apply to military and privately funded hospitals.

 

EMTALA and Hospital Duties

Hospital duties under EMTALA include6:

  1. EDs must post signs informing patients of their right to a medical screening exam, and provide this medical screening exam upon patient request. The exam must utilize all appropriate and available hospital resources, without delay or denial due to a patient’s ability to pay.
  2. If an emergent medical condition exists, then the emergency room and/or hospital must treat and stabilize the patient. If unable to stabilize the patient, then he/she must be transferred to a hospital with that capability.  CMS defines an emergent medical condition as “a condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in placing the individual’s health [or the health of an unborn child] in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of bodily organs”7.
  3. Hospitals with specialized capabilities must accept transfers from hospitals lacking those capabilities to treat unstable emergent conditions. The transferring hospital may transfer a patient for the purposes of overcrowding, or temporary lack of personnel.  If a facility does not have a dedicated ED, it must still screen and stabilize the patient to the best of its ability.
  4. Hospitals receiving patients are obligated to report inappropriate transfers within 72 hours.

 

Unique Situations

Am I required to perform a medical screening exam if a patient is brought to the ED by law enforcement?  What if the request is only for a blood alcohol test (BAT) for evidence?  Am I beholden to EMTALA?

If an individual is brought to the ED for the sole purpose of a BAT, and no request for examination or treatment for a medical condition is made, then the EMTALA medical screening requirement is not applicable since the request on behalf of the individual is for evidence only. If law enforcement requests examination or treatment for a potential emergent condition, or if a prudent layperson observer would believe that the individual is suffering from an emergent medical condition, then EMTALA applies6.

 

Can the EMTALA requirement be waived? 

EMTALA waivers can be issued by the government in disaster situations and public health emergencies.  These waivers allow the redirection of patients to an alternate location for a medical screening exam6.

 

What’s your role?

Emergency physicians are key actors in the patient transfer process as:

 

The Transferring Physician

Medicare-participating hospitals that offer emergency services are required to provide a medical screening exam according to the Social Security Act8.  The medical screening exam must be performed by a “qualified medical person” as identified in hospital bylaws.  In majority of cases, the ED physician will perform this exam and initiate transfer to a higher level of care9.

 

Responsibilities of the transferring physician include:

  • The transferring physician must determine if the patient is stable for transfer. Patients must be stabilized to the best of the facility’s ability prior to transfer. Any life-threatening process that requires immediate management must be treated prior to transfer. Stable is understood as the patient having a low probability of material deterioration during transfer7,10.
  • Transferring a patient that has a moderate to high risk of decompensation during transportation requires additional consideration: basic life support ambulance vs. advance life support ambulance vs. ground or airborne critical care specialty team transport. If an unstable patient requires continued medication and/or infusion of blood products during transfer, this should be communicated to the transferring team and their medical director.  Organizational protocols may prohibit transport personnel from taking direct orders from physicians.

 

It is the responsibility of the transferring physician to confirm that the accepting hospital can treat the condition for which the patient is to be transferred, to ensure that the contacted facility is willing to accept patient, to arrange for transport with appropriate equipment and personnel, and to send all medical documentation to the accepting facility.

 

The Accepting Physician

Medicare requires that hospitals have a physician on call for the initial evaluation of patients presenting with emergency medical conditions9.  Transferred patients may be accepted by the specialist on call and directly admitted, or sent to the ED for evaluation and treatment.  In either case, consultation between the accepting specialist and emergency physician (if ED to ED transfer) is advised.  Larger hospital systems and academic centers commonly utilize transfer centers4 to consolidate transfer requests from outlying hospitals, and confirm hospital and specialist availability.

 

Can you ever refuse a patient transfer?

You can only refuse a patient transfer if your facility is unable to provide the necessary patient care.  Examples of this include maximum bed capacity, and the absence of the specialty care requested.  If specialty consultation is required, it is important that as the ED physician accepting a transfer, you ensure the specialist has agreed to accept and see the patient.  If your facility is unable to provide the required level of care, you can suggest transfer to alternate facilities, clinics, or specialty hospitals11.

 

Can transferred patients be discharged from the ED?

Sometimes patients are transferred for specialist evaluation.  The specialist may complete their evaluation and recommend discharge from the ED.  When this occurs, the hospital has met EMTALA obligations, but the specialist has a responsibility to continue outpatient follow-up9.   Frequently, patients are transferred long distances, which may make discharge difficult if there is limited social support.  Engage case workers and discharge planners to address these unique situations.

 

What if a patient is transferred inappropriately to your hospital?

As a receiving physician, you have an obligation to report inappropriate transfers (EMTALA violations) within 72 hours8 – not doing may result in facility termination of Medicare participation9.  In many cases, the patient may have been accepted to your facility by another physician, but as the treating ER physician, you will need to ensure the patient was transferred to achieve patient care goals.

 

Considerations for Transferring Patients with Common Diagnoses

Acute Coronary Syndrome is the most common diagnosis requiring patient transfer.  Patients with STEMI who present to a non-PCI center must be identified and transported with a goal of 120 minutes from door to PCI (including transfer time)12, 13.  Pre-established protocols are key to minimizing door to PCI times in STEMI patients.  After acceptance by a PCI center, discuss the reason for transfer with the transporting team.  Local protocols will most commonly dictate a “lights and sirens” transport for this patient population.  If door to PCI time is anticipated to greater than 120 minutes, then thrombolytic therapy should be administered within 30 minutes of patient arrival.

Patients with an acute stroke have improved morbidity and mortality if treated at a certified stroke center.  Current literature has identified endovascular thrombectomy (EVT) as reducing disability following a large vessel occlusion (LVO)14. The National Institute of Health Stroke Scale (NIHSS) and Vision, Aphasia, Neglect (VAN) scales have been utilized in the prehospital setting used to activate an LVO alert.  The VAN scale, which is currently undergoing external validation, assesses for visual disturbance, aphasia, and neglect.  In patients with large vessel occlusion, EVT within 6 hours of symptom onset is optimal, but benefits have been shown if performed within 24 hours14.  As the transferring physician, document the patient’s NIH Stroke Scale, last known “well time,” imaging results, and therapies administered at your facility.  If you are unsure of your community’s resources, contact the local EMS director or transfer facility to identify an appropriate patient destination.

 

Case 1, Continued

You call the inter-facility transfer line to reach the regional burn center.  You discuss the case with the accepting burn surgeon on call.  He directs you to send the patient to their ED to be assessed by the burn team.  The patient is transferred to the ED, evaluated by the burn team, and admitted to the burn service.

 

Case 2, Continued

After you confirm that the ophthalmologist on call is aware of the patient, and that she agrees to evaluate the patient, you accept the transfer.  Upon arrival, the patient is evaluated by ophthalmology and determined not to have and emergent medical condition.  The ophthalmologist recommends discharge from the ED.

 

Take Home Points

  • Emergency medicine transfers are conducted on principles outlined in the 1986 Emergency Medical Treatment and Labor Act, or EMTALA4.
  • Patients must be stabilized to the best of the facility’s ability prior to transfer. Any life-threatening process that requires immediate management must be treated prior to transfer.
  • If specialty consultation is required, it is important that as the ED physician accepting a transfer, you ensure the specialist has agreed to accept and see the patient.
  • As a receiving physician, you have an obligation to report inappropriate transfers (EMTALA violations) within 72 hours8 – not doing may result in facility termination of Medicare participation9.
  • A common pitfall for ED physicians is to perform an extensive evaluation on a trauma patient that requires transfer. Recognize the resource limitations of your facility early. Avoid workups that won’t change patient management17.
  • Frequently, patients are transferred long distances, which may make discharge difficult if there is limited social support. Engage case workers and discharge planners to address these unique situations.

 

References/Further Reading

  1. UC San Diego School of Medicine. (2019). Criteria for Referral – Regional Burn Center – UC San Diego Department of Surgery. [online] Available at: https://medschool.ucsd.edu/som/surgery/divisions/trauma-burn/about/burn-center/Pages/referral.aspx [Accessed 13 Sep. 2019].
  2. Kindermann D. Emergency Department Transfers to Acute Care Facilities, 2009. HCUP. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb155.pdf. Published May 2013. Accessed September 2019.
  3. Fiorilli, P. and Kolansky, D. (2018). Getting to the Right Place at the Right Time. Circulation: Cardiovascular Interventions, 11(5).
  4. Bitterman, R. (2017). Feds Increase EMTALA Penalties against Physicians and Hospitals – Emergency Physicians Monthly. [online] Emergency Physicians Monthly. Available at: https://epmonthly.com/article/feds-increase-emtala-penalties-physicians-hospitals/ [Accessed 3 Sep. 2019].
  5. The National Law Review. (2019). Patient Dumping and the Emergency Medical Treatment and Labor Act (EMTALA). [online] Available at: https://www.natlawreview.com/article/patient-dumping-and-emergency-medical-treatment-and-labor-act-emtala [Accessed 13 Sep. 2019].
  6. gov. (2010). CMS Manual System. [online] Available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R60SOMA.pdf [Accessed 11 Dec. 2019].
  7. Appropriate Interfacility Patient Transfer. ACEP. https://www.acep.org/patient-care/policy-statements/appropriate-interfacility-patient-transfer/. Published December 1, 2018. Accessed September 3, 2019.
  8. Emergency Medical Treatment & Labor Act (EMTALA). CMS.gov Centers for Medicare & Medicaid Services. https://www.cms.gov/Regulations-and-Guidance/Legislation/EMTALA/index.html. Published March 26, 2012. Accessed September 3, 2019.
  9. Frequently Asked Questions about the Emergency Medical Treatment and Active Labor Act (EMTALA). EMTALA. http://www.emtala.com/faq.htm. Published October 10, 2009. Accessed September 3, 2019.
  10. EMTALA (Emergency Medical Treatment and Labor Act). American College of Emergency Physicians | News Room. http://newsroom.acep.org/2009-01-04-emtala-fact-sheet. Published 2015. Accessed September 3, 2019.
  11. EMTALA and The On-Call Physician. EB Medicine. https://www.ebmedicine.net/content.php?action=showPage&pid=27. Published August 29, 2000. Accessed September 3, 2019.
  12. Sahini L. Texas ST-Elevation Myocardial Infarction (STEMI) and Heart Attack System of Care Report, 2018.
  13. Brown, M. (2017). Clinical Policy: Emergency Department Management of Patients Needing Reperfusion Therapy for Acute ST-Segment Elevation Myocardial Infarction. [online] Acep.org. Available at: https://www.acep.org/globalassets/new-pdfs/clinical-policies/reperfusion-acute-stemi-2017.pdf [Accessed 11 Oct. 2019].
  14. Grotta JC. Interhospital Transfer of Stroke Patients for Endovascular Treatment. Circulation. 2019;139(13):1578-1580. doi:10.1161/circulationaha.118.039425.
  15. Weingart S, Himmel W. Emergency Management of Intracerebral Hemorrhage: EM Cases. Emergency Medicine Cases. https://emergencymedicinecases.com/intracerebral-hemorrhage-golden-hour/. Published December 2017. Accessed October 2019.
  16. Ovens H, Dawe I, Steinhart B. Medical Clearance of the Psychiatric Patient: EM Cases. Emergency Medicine Cases. https://emergencymedicinecases.com/medical-clearance-psychiatric-patient/. Published August 2016. Accessed October 2019.
  17. American College of Surgeons. (2019). ATLS 10th edition offers new insights into managing trauma patients | The Bulletin. [online] Available at: http://bulletin.facs.org/2018/06/atls-10th-edition-offers-new-insights-into-managing-trauma-patients/#Chapter_13_Transfer_to_Definitive_Care [Accessed 13 Sep. 2019].
  18. Walls, R. (2019). Rosen’s Emergency Medicine: Concepts and Clinical Practice. 9th ed. p. Chapter 191.

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