EMTALA / JCAHO violation?

[Aidey]

The reading I did indicated that if the benefits outweighed the risks then transfer was allowable. Basically the patient has to have been treated/stabilized to the maximum ability of the sending facility.

 

[jwk]

The reading I did indicated that if the benefits outweighed the risks then transfer was allowable. Basically the patient has to have been treated/stabilized to the maximum ability of the sending facility.

Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians. They decide, you transport. If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.

 

[RocketMedic]

In my system, establishing physical doctor-patient contact at an ER is even constituted as asking for on-line medical control, which means that they have to go to my base hospital. Obviously, there's a problem with this, since my base hospital has no specialty capabilities.

Ideally, a paramedic could initiate transport, even to out-of-area facilities, entirely based on what's needed for the patient, to include BLS downgrades and alternate transport arrangements.

 

[Aidey]

Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians. They decide, you transport. If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.

Oh dear, I'm sorry. I didn't realize that as a medic who has no say in the decision making process I couldn't respond to a MD asking a question. Pardon me for attempting to provide clarification. I'll just go stand in the corner and wait for the paperwork to be filled out.

 

[Aidey]

For the record:

2. If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized.If the hospital does not have the capability to treat the emergency medical condition, an "appropriate" transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.

3. Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medial conditions.

and

7. What is an appropriate transfer?
An "appropriate transfer" (a transfer before stabilization which is legal under EMTALA) is one in which all of the following occur:

• The patient has been treated at the transferring hospital, and stabilized as far as possible within the limits of its capabilities;
• The patient needs treatment at the receiving facility, and the medical risks of transferring him are outweighed by the medical benefits of the transfer;

Sources

http://www.acep.org/content.aspx?id=25936 and http://www.emtala.com/faq.htm

 

[Handsome Robb]

Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians. They decide, you transport. If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.

You are correct but they also cannot "dump" an "unstable" patient on an EMS crew. I guess I shouldn't say the cannot do it, they certainly could but any medic worth their salt will refuse the transport. The sending physician is responsible for that patient until that patient reaches the receiving facility correct? Why would the sending physician not do everything they could to get that patient in a state fit for the transport environment before sending them out? I'm not willing to take someone who will likely code en route because of inadequate "stabilization" at the sending facility.

If that physician has set up a transfer to a facility that bypasses other capable facilities where does that fall? Example: an active STEMI being transfered from a facility incapable of providing PCI to another facility which will result in bypassing another facility capable of providing that patient definitive care. If it's within reason I'm perfectly OK with it but if they are asking me to drive a long distance past the facility being bypassed would it be wrong for the medic to chime in? I know being out of insurance coverage comes into play but in a situation like this what's more important, ease for the insurance company or patient care?

I know stable is controversial term at best, Dr. Jeffrey Guy has a good quote: "A stable is a place for horses, patients are compensated or decompensated". Why wouldn't the sending facility do everything in their power to keep that patient in a compensated state. I know patient care is dynamic and constantly changing but that just seems silly to me to "dump" a decompensated patient on a transport crew.

 

[Veneficus]

You are correct but they also cannot "dump" an "unstable" patient on an EMS crew. I guess I shouldn't say the cannot do it, they certainly could but any medic worth their salt will refuse the transport.

I do not agree with that.

If a facility has no possibility of helping or even stabizing a patient, a transport on compassionate grounds is absolutely in order.

Not to you in particular, but I want to point out people die in ambulances. It is not a place where death is officially put on hold until at a hospital.

Taking an unstable patient from one hospital to another might be the best chance that patient has.

I think there are times it is appropriate for the medic to deny sitting the transfer. But that is a different thread.

The sending physician is responsible for that patient until that patient reaches the receiving facility correct? Why would the sending physician not do everything they could to get that patient in a state fit for the transport environment before sending them out? I'm not willing to take someone who will likely code en route because of inadequate "stabilization" at the sending facility.

So your plan is to let them die without help as opposed to try and get them somewhere that can help, simply because they might die on the trip?

Does that sound logical or reasonable to you?

If that physician has set up a transfer to a facility that bypasses other capable facilities where does that fall? Example: an active STEMI being transfered from a facility incapable of providing PCI to another facility which will result in bypassing another facility capable of providing that patient definitive care. If it's within reason I'm perfectly OK with it but if they are asking me to drive a long distance past the facility being bypassed would it be wrong for the medic to chime in? I know being out of insurance coverage comes into play but in a situation like this what's more important, ease for the insurance company or patient care?

Finanacial considerations are absolutely part of good patient care.

From not ordering unwarrented tests to making sure the pt isn't forced into bankruptcy from the needed treatment when possible.

I know stable is controversial term at best, Dr. Jeffrey Guy has a good quote: "A stable is a place for horses, patients are compensated or decompensated". Why wouldn't the sending facility do everything in their power to keep that patient in a compensated state. I know patient care is dynamic and constantly changing but that just seems silly to me to "dump" a decompensated patient on a transport crew.

Because emergency rooms ad even the full capabilities of some hospitals cannot restore homeostasis with what they have.

Many people think stabilizing a few numbers or lab values actually saves patients.

That is just wrong.

I can stabilize normal vitals on a corpse. That doesn't mean it will live again.

 

[Handsome Robb]

I'll withdraw my statement seeing as Vene just shot it to pieces.

 

[FLdoc2011]

You are correct but they also cannot "dump" an "unstable" patient on an EMS crew. I guess I shouldn't say the cannot do it, they certainly could but any medic worth their salt will refuse the transport. The sending physician is responsible for that patient until that patient reaches the receiving facility correct? Why would the sending physician not do everything they could to get that patient in a state fit for the transport environment before sending them out? I'm not willing to take someone who will likely code en route because of inadequate "stabilization" at the sending facility.

From above:

2. If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized.If the hospital does not have the capability to treat the emergency medical condition, an "appropriate" transfer of the patient to another hospital must be done in accordance with the EMTALA provisions.

3. Hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medial conditions.

If that physician has set up a transfer to a facility that bypasses other capable facilities where does that fall? Example: an active STEMI being transfered from a facility incapable of providing PCI to another facility which will result in bypassing another facility capable of providing that patient definitive care. If it's within reason I'm perfectly OK with it but if they are asking me to drive a long distance past the facility being bypassed would it be wrong for the medic to chime in? I know being out of insurance coverage comes into play but in a situation like this what's more important, ease for the insurance company or patient care?

You can certainly chime in as you group may have specific transport protocols or regs that need to be addressed but probably not going to make a difference in most instances, by that time the receiving place has accepted the patient and report has been given. A lot goes into the process behind the scenes that you may not have been aware of..... maybe a closer facility refused to accept the pt or didnt have any available rooms or didn't have that specific specialty on call that night.... Any number of factors play in and by the time we get an accepting facility we may have already called a few different places.

I think you're example is a little extreme, a STEMI with goal door to balloon times is not knowingly going to bypass a closer facility for one significantly further away for now good reason.

We get a bunch of neuro transfers (bleeds) from hospitals in the region who are in our "network" since they have agreements in place to keep patient "in network" when I'm sure they are technically closer hospitals with similar capability. I think in some of these instances one big advantage is they keep the money "in network" but these aren't necessary critically time sensitive issues. We certainly wouldn't be getting a STEMI from a sister hospital an hour away.

All that to say there are a number of factors in play that get sorted through before you have become involved.
In this specific case the patient certainly doesn't seem unstable. I don't consider being on a heparin drip unstable.

 

[NYMedic828]

varying junctional to Accerated junctional w/ RBBB; Initially onscene the ECG showed ST segment changes in Inferior; 15 lead performed without any Right sided involvement; Third ECG and subsequent ECG's show no signs of STEMI. Our protocol states we are unable to call a STEMI with QRS duration greater than 0.12ms. Initial vitals are 40-60 HR; 70/40 BP; 90%SAO2; 28 RR; ETCO2 32.

Was pacing the patient an option?

 

[jwk]

Correct me if I'm wrong - but the decision to transfer from one facility to another is not a decision made by the medic, but between the transferring and receiving facilities/physicians. They decide, you transport. If you refuse to transport, for whatever reason that might be (good or bad), I assume there are other services that will.

Oh dear, I'm sorry. I didn't realize that as a medic who has no say in the decision making process I couldn't respond to a MD asking a question. Pardon me for attempting to provide clarification. I'll just go stand in the corner and wait for the paperwork to be filled out.

Lighten up there dude. Am I wrong that the decision that a patients needs to be transferred from one hospital to another is one that is made by physicians at the two facilities? Clearly nobody can force you personally to transport a patient, but again, if you don't, someone else will. You aren't the one that decides the patient should be transferred - that's a simple fact. I'm not arguing that you shouldn't know the reason, but simply that it's not you who decides if, where, and when.

FLdoc has pointed out several things that do into the rationale of why a patient should be transferred to a given facility. The reasons for transfer are up to someone other than you. In-network, out-of-network, actual availabilty of needed services (maybe the only interventional cardiologist on duty already has more cardiac cath's lined up than he can handle), availability of an ICU bed, availability of an OR or anesthesia personnel at the receiving facility - whatever. Maybe the family wants the patient at a specific facility - for example, if it were my family member getting transferred, I'd want them to go to MY hospital assuming the necessary services were available and the time issues weren't deleterious.

 

[Aidey]

I did not say it was the medic's decision. I really have no idea where you got that from anything I have said. All I did was answer a question someone else asked and you started lecturing on how it wasn't the medic's decision.

 

[ffemt8978]

Do I really need to get involved in another thread this week?

 

[STXmedic]

Do I really need to get involved in another thread this week?

:nosoupfortroll: