Interfacility Transfer WorkInterfacility Transfer Work
Flow TeamFlow Team
Saint Joseph HealthCareSaint Joseph HealthCare
M...
Team:
Facilitator-Paula Keally, RN – Clinical Informatics
Co-Facilitator- Katherine Hansen – Director Outpatient Diagnosti...
"I am personally convinced that one person can be a change catalyst, a
'transformer' in any situation, any organization. S...
To Develop an Algorithm to beTo Develop an Algorithm to be
used for the Purpose ofused for the Purpose of
Improving and St...
CHI KY – All Facility TransfersCHI KY – All Facility Transfers
August 2007August 2007
 Total Transfers: 320Total Transfer...
Our Lady of the WayOur Lady of the Way
August 2007 - TransfersAugust 2007 - Transfers
 Total Transfers: 29Total Transfers...
Our Lady of the WayOur Lady of the Way
August 2007 – total Transfers out - 29August 2007 – total Transfers out - 29
Facili...
Marymount Medical CenterMarymount Medical Center
August 2007 - TransfersAugust 2007 - Transfers
 Total Transfers: 59Total...
Facility Transferred To
Transfer
Category
# of
Tran
sfers
Facility Transferred
To Transfer Category # of Transfers
Saint J...
SJH Admissions Thru House Administrator -
Marymount and Our Lady of the Way
0
2
4
6
8
10
12
14
JanuaryM
arch
M
ay
July
Sep...
Goals of the MeetingGoals of the Meeting
Defined by teamDefined by team
 Simple ProcessSimple Process
 Patient Focused P...
Current State: DefinedCurrent State: Defined
Issues Identified –Issues Identified –
 Sometimes up to 5 calls from referri...
Question raised by MMC and OLOW:Question raised by MMC and OLOW:
What is the incentive for us if our current
referral cent...
BenefitsBenefits::
 Improved Transfer Process for CHI – KYImproved Transfer Process for CHI – KY
 Improved Continuity of...
Possible SolutionsPossible Solutions
 Transfer Center – Staffed with RN or have a
second House Administrator on to manage...
con’t Possible Solutionscon’t Possible Solutions
 Expedited admission to the receiving unit – no
stopping in ED Admitting...
Who? What? When?
Paula Develop Electronic Version of Transfer Log <45days
IT/Paula Automate MD Call Schedule <30days
Debbi...
Inter-facility Transfer ProcessInter-facility Transfer Process
defined in Algorithmdefined in Algorithm
Lateral TransfersLateral Transfers
 Lateral transfers, that is, transfersLateral transfers, that is, transfers
between fa...
Receiving Hospital’s Obligations –Receiving Hospital’s Obligations – Appropriate TransfersAppropriate Transfers
 Recipien...
Three Principles of EMTALAThree Principles of EMTALA
 Medical Emergency ScreeningMedical Emergency Screening
 On-Call Ph...
First Principle of EMTALA
 Medical Screening ExamMedical Screening Exam
 Stable -Stable - Stable for Transfer when you c...
Second Principle of EMTALA
 On-Call Docs - These
Physicians are on-call for the hospital
not for the private practice and...
"On-call" duties come with the privilege of
practicing in a hospital. They are a covenant
between physician and hospital a...
Third Principle of EMTALA
 Obligation to Accept
Transfers -
If any hospital in the U.S. calls and says they have a
patien...
Exceptions to Acceptance:Exceptions to Acceptance:
Beds not available –Beds not available –
Some institutions define this ...
No Physician On-Call :No Physician On-Call :
--If we have a specialty on staff at our hospital, and we
have enough physici...
Under current HCFA policy andUnder current HCFA policy and
thinking, are “lateral” transfersthinking, are “lateral” transf...
A recipient hospital would notA recipient hospital would not
have to take a lateral transferhave to take a lateral transfe...
 IfIf the patient isthe patient is stablestable, as defined by law,, as defined by law,
EMTALA no longer applies and hosp...
Sending hospital is not inSending hospital is not in
compliance. Once again, though,compliance. Once again, though,
hospit...
In the past the patient has receivedIn the past the patient has received
all of their medical care andall of their medical...
Sending hospital is not inSending hospital is not in
compliance. Once again, though,compliance. Once again, though,
hospit...
Can the emergency physician &/orCan the emergency physician &/or
the on-call neurosurgeon after EDthe on-call neurosurgeon...
NO!NO!
The hospital has a duty to provide theThe hospital has a duty to provide the
neurosurgeon; when on-call to the ED, thatneu...
This is why the real fight with on-This is why the real fight with on-
call physicians will be over thecall physicians wil...
Assuming the above transfer isAssuming the above transfer is
NOT legal, what is the bestNOT legal, what is the best
course...
1) Notify the on-call administrator1) Notify the on-call administrator
or chief of staff STATor chief of staff STAT
2) Mai...
Appropriate agreements must beAppropriate agreements must be
reached between the medical staffreached between the medical ...
How do you handle the rogueHow do you handle the rogue
physician who refuses tophysician who refuses to
follow the rules a...
Policy should specificallyPolicy should specifically
address what the EP shouldaddress what the EP should
do in this situa...
If everything fails, the only optionIf everything fails, the only option
for the EP is to transfer thefor the EP is to tra...
Hospital administratorsHospital administrators
must understand that themust understand that the
actions of the on-callacti...
Patient requires acute care andPatient requires acute care and
the sole reason for denial isthe sole reason for denial is
...
Assume the patient has a moreAssume the patient has a more
imminently serious problem and itimminently serious problem and...
Act to save the patient. NotifyAct to save the patient. Notify
administration. Transfer ifadministration. Transfer if
nece...
If the patient needs immediate attention, then theIf the patient needs immediate attention, then the
hospital must do ever...
Under these circumstancesUnder these circumstances
does the hospital being called todoes the hospital being called to
arra...
Under the general rule, if the EDUnder the general rule, if the ED
truly can’t obtain the services oftruly can’t obtain th...
If a patient is legally stable, butIf a patient is legally stable, but
has a medical condition thathas a medical condition...
...requires the tertiary facility to accept...requires the tertiary facility to accept
an “appropriate” transfer. The mean...
Presently, both HCFA andPresently, both HCFA and
the OIG take the positionthe OIG take the position
that anything the pati...
Try your best to reach anTry your best to reach an
acceptable solution holding theacceptable solution holding the
patient’...
Under EMTALA there is noUnder EMTALA there is no
requirement for physicians torequirement for physicians to
take hospital ...
The medical staff by-laws orThe medical staff by-laws or
policies and procedures mustpolicies and procedures must
define t...
If hospitals and physiciansIf hospitals and physicians
don't solve the problem,don't solve the problem,
government and pol...
Emergency Department on-callEmergency Department on-call
coverage issues will be the finalcoverage issues will be the fina...
“Money is the root of all evil” but
unfortunately is not the entire
solution for the on-call issue. Fully
funding on-call ...
The ED: A “Besieged”The ED: A “Besieged”
Work EnvironmentWork Environment
Causes of Increase in ProviderCauses of Increase in Provider
Dissatisfaction coming to ED?Dissatisfaction coming to ED?
 ...
Solutions to this?Solutions to this?
 ““Hand holding” practices to meet on callHand holding” practices to meet on call
ph...
Interfacility Transfer Work Flow Team
Interfacility Transfer Work Flow Team
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Interfacility Transfer Work Flow Team

  1. 1. Interfacility Transfer WorkInterfacility Transfer Work Flow TeamFlow Team Saint Joseph HealthCareSaint Joseph HealthCare Marymount Medical CenterMarymount Medical Center Our Lady of the Way HospitalOur Lady of the Way Hospital CHI-KentuckyCHI-Kentucky September 24, 2007September 24, 2007
  2. 2. Team: Facilitator-Paula Keally, RN – Clinical Informatics Co-Facilitator- Katherine Hansen – Director Outpatient Diagnostics Kathy Williams – Admin Asst. Marymount Medical Center: Dr. Jeff Violette - ED Medical Director Peggy Green, RN - CNO Grace (Libby) Campbell, RN -AVP Nursing Mary Lou Young, RN – Director ED Nora Ross, RN – House Manager Lori M. Young, RN – Clinical Supervisor ED Our Lady of the Way Hospital: Billie Turner, RN – CNO Robyn Johnson, RN – ED/House Supervisor Saint Joseph Healthcare: Dr. Scot Dunavant - ED Physician Dr. Yaccoubagha – Physician with Ky. Inpatient Medicine Associates Chris Mays, RN – CNO Debbie Bryant, RN – ED Manager – SJH Patti Sturt, RN – ED Manager – SJB Melanie Sanguigni, RN – House Administrator Debra Lawrence, RN – Clinical Coordinator Patient Access
  3. 3. "I am personally convinced that one person can be a change catalyst, a 'transformer' in any situation, any organization. Such an individual is yeast that can leaven an entire loaf. It requires vision, initiative, patience, respect, persistence, courage and faith to be a transforming leader." Steven R. Covey
  4. 4. To Develop an Algorithm to beTo Develop an Algorithm to be used for the Purpose ofused for the Purpose of Improving and StandardizingImproving and Standardizing the process of:the process of: "Pt Access – Inter-Facility"Pt Access – Inter-Facility Transfer of Patients"Transfer of Patients"
  5. 5. CHI KY – All Facility TransfersCHI KY – All Facility Transfers August 2007August 2007  Total Transfers: 320Total Transfers: 320  Transfers Excluding Peds/Trauma/Psych:Transfers Excluding Peds/Trauma/Psych: 204204  Transfers Within System: 81Transfers Within System: 81  Transfers Outside of System: 123Transfers Outside of System: 123
  6. 6. Our Lady of the WayOur Lady of the Way August 2007 - TransfersAugust 2007 - Transfers  Total Transfers: 29Total Transfers: 29  Total Transfers Excluding Peds/Trauma/Psych: 22Total Transfers Excluding Peds/Trauma/Psych: 22  Transfers Within System: 2Transfers Within System: 2  Transfers Outside of System: 20Transfers Outside of System: 20
  7. 7. Our Lady of the WayOur Lady of the Way August 2007 – total Transfers out - 29August 2007 – total Transfers out - 29 Facility Transferred To Transfer Category # of Trans fers Facility Transferred To Transfer Category # of Transfers University of Kentucky Pediatrics 1 Neuro 1 Hazard ARH Respiratory 2 Cardiac 1 Ortho 4 St Mary's Trauma 1 General Surgery 1 General Surgery 1 Kings Daughters Cardiac 8 Creekside Psych 1 Total Transfers: 29 Transfer Category # of Transfers Pikeville Pediatrics 1 Cardiac 10 General Surgery 2 Neuro 2 Other 1 Ortho 4 Trauma 2 SJH Cardiac 1 Psych 2 General Surgery 3 SJE Neuro 1 Pediatrics 3 Other 3 Cabell Huntington Trauma 1 Pediatrics 1
  8. 8. Marymount Medical CenterMarymount Medical Center August 2007 - TransfersAugust 2007 - Transfers  Total Transfers: 59Total Transfers: 59  Total Transfers Excluding Peds/Trauma/Psych: 44Total Transfers Excluding Peds/Trauma/Psych: 44  Transfers Within System: 9Transfers Within System: 9  Transfers Outside of System: 35Transfers Outside of System: 35
  9. 9. Facility Transferred To Transfer Category # of Tran sfers Facility Transferred To Transfer Category # of Transfers Saint Joseph Hospital Cardiac 1 UT Neuro 1 General Surgery 2 General Surgery 2 Other 5 Manchester SOA 1 University of Kentucky Pediatrics 13 Trauma 1 Baptist Regional Ortho 1 Ortho 4 General Surgery 1 Neuro 2 Other 2 General Surgery 4 Other 13 Good Samaritan - UK SOB 1 Lake Cumberland Psych 1 Total Transfers: 59 Transfer Category # of Transfers General Surgery 1 Cardiac 1 Other 1 Trauma 1 Neuro 2 Central Baptist Ortho 1 Psych 1 Peds 13 Saint Joseph Mt Sterling Ortho 1 Ortho 7 General Surgery 10 U of L Nosebleed 1 Other 24 Marymount Medical CenterMarymount Medical Center August 2007 – Total Transfers Out - 59August 2007 – Total Transfers Out - 59
  10. 10. SJH Admissions Thru House Administrator - Marymount and Our Lady of the Way 0 2 4 6 8 10 12 14 JanuaryM arch M ay July Septem ber N ovem ber 2007 Admissions# Marymount Medical Center - London Our Lady of the Way Hospital - Martin
  11. 11. Goals of the MeetingGoals of the Meeting Defined by teamDefined by team  Simple ProcessSimple Process  Patient Focused Process – “what is bestPatient Focused Process – “what is best for patient is guiding tenet of plan”for patient is guiding tenet of plan”  One Call into systemOne Call into system  Enhanced Relationships between facilitiesEnhanced Relationships between facilities and moves towards improving physicianand moves towards improving physician acceptance of transfersacceptance of transfers
  12. 12. Current State: DefinedCurrent State: Defined Issues Identified –Issues Identified –  Sometimes up to 5 calls from referring facility to affect the transfer or find out that the physician would not accept.  Needs to be ‘One Call’ to trained personnel to initiate the transfer  Bed Availability issues – Peak times of discharge are not covered adequately to facilitate rapid turn around of room.  D/C process in ADT system needs to be monitored and expedited so bed control is aware of accurate bed availability  No consistent response time from Physicians on call for SJHC
  13. 13. Question raised by MMC and OLOW:Question raised by MMC and OLOW: What is the incentive for us if our current referral center (UK [MMC] and King’s Daughters [OLOW]) has a seamless one call, 100% acceptance system in place and we can get our patients to higher levels of care without delays?
  14. 14. BenefitsBenefits::  Improved Transfer Process for CHI – KYImproved Transfer Process for CHI – KY  Improved Continuity of Care across the systemImproved Continuity of Care across the system for the patient and their familiesfor the patient and their families  Keep CHI patients in one system in order toKeep CHI patients in one system in order to optimize electronic record sharing withoptimize electronic record sharing with development of Patient Keeper Physician Portaldevelopment of Patient Keeper Physician Portal  CHI referrals will stay in our Medical StaffCHI referrals will stay in our Medical Staff Network rather than us pushing them intoNetwork rather than us pushing them into another Physician Networkanother Physician Network
  15. 15. Possible SolutionsPossible Solutions  Transfer Center – Staffed with RN or have a second House Administrator on to manage these transfers  Bed Ahead System – already in place at SJHC but could use optimizing  One Transfer Number for All Transfers – Med Surg and Critical Care 1-800-755-4344 is currently used for Critical Care transfers  Have SJHC – East and Main – Specialty call schedule available to outlying facilities for ED docs to use.  Network Building Initiatives with SJHC Medical Staff and Staff from MMC and OLOW.  Informational CME for All physicians related to EMTALA and the responsibilities of “On-Call” Physicians.
  16. 16. con’t Possible Solutionscon’t Possible Solutions  Expedited admission to the receiving unit – no stopping in ED Admitting  Patient Transfer – Intake form for use by Transport Coordinator in order to expedite transfer and collect all necessary information on one call  Three way phone call with Transfer Coordinator-Sending Physician and third party either bed control to assure bed availability or Receiving Facillity Physician on call in order to ascertain acceptance at time of initial call if possible and if not have the receiving physician call ED doc back (with defined acceptable response time)  Electronic Logs of all transfer related information - requested and actual for documentation as well as monitoring of progress with initiative.
  17. 17. Who? What? When? Paula Develop Electronic Version of Transfer Log <45days IT/Paula Automate MD Call Schedule <30days Debbie Lawrence/Chris Develop and Optimize functionality of STAR to track Bed Capacity at both Campuses including UM support for reporting and d/c- ing in system ASAP upon Discharge from Unit <45 days Chris/Paula Finalize Form for Data needs when initial call for transfer occurs -INTAKE REQUEST Form <45 days Deb Bryant/Patti Creed Fax # for CHI Participants Facilities - fax each night so is available at 7 a.m. for Physicians - start with MM and OLOW <30 days Patty Sturt/Chris Investigate possibity of Grant from CHI for funding of pilot <45 days Billy Turner/Deb Bryant/Chris Mays Investigate staffing of transfer center at UK/King's Daughters or use of Back-up line if first number busy <45days Debbie Lawrence/Pt access Define Process of DA/Transfer Pt - notification to Pt Access and subsequent bedside verification of wristband and signing of consents <45 days Paula Plan 60 day Mtg to Review <10days Chris Mays/Sherry Tichenor Dr. Bitterman Visit for Med Staff CME meeting <45 days? Chris Mays/Sherry Tichenor Networking / Relationship Building plan for SJHC, MM, OLOW staff <45 days Jennie Chapman Check on 1-800 Number and capacity and hardware needs to do 3- way call <30 days IT/Paula/Jeana/Melanie Develop Tracking tools for all facilities to use for measuring success with Algorithm <45 days Paula Document Algorithm Defined by Team 20070924 <10 days Action PlanAction Plan
  18. 18. Inter-facility Transfer ProcessInter-facility Transfer Process defined in Algorithmdefined in Algorithm
  19. 19. Lateral TransfersLateral Transfers  Lateral transfers, that is, transfersLateral transfers, that is, transfers between facilities of comparablebetween facilities of comparable resources, are not sanctioned byresources, are not sanctioned by §489.24 because they would not offer§489.24 because they would not offer enhanced care benefits to the patientenhanced care benefits to the patient except where there is a mechanicalexcept where there is a mechanical failure of equipment, no ICU bedsfailure of equipment, no ICU beds available, or similar situations. However,available, or similar situations. However, if the sending hospital has the capabilityif the sending hospital has the capability but not the capacity, the individual wouldbut not the capacity, the individual would most likely benefit from the transfer.most likely benefit from the transfer. http://www.azcep.org/emtala/mc_trans.htmlhttp://www.azcep.org/emtala/mc_trans.html
  20. 20. Receiving Hospital’s Obligations –Receiving Hospital’s Obligations – Appropriate TransfersAppropriate Transfers  Recipient hospitals only have to accept theRecipient hospitals only have to accept the patient if the patient requires the specializedpatient if the patient requires the specialized capabilities of the hospital in accordance withcapabilities of the hospital in accordance with this section. If the transferring hospital wants tothis section. If the transferring hospital wants to transfer a patient because it has no beds or istransfer a patient because it has no beds or is overcrowded, but the patient does not requireovercrowded, but the patient does not require any "specialized" capabilities, the receivingany "specialized" capabilities, the receiving (recipient) hospital is not obligated to accept(recipient) hospital is not obligated to accept the patient. If the patient required thethe patient. If the patient required the specialized capabilities of the intendedspecialized capabilities of the intended receiving (recipient) hospital, and the hospitalreceiving (recipient) hospital, and the hospital had the capability and capacity to accept thehad the capability and capacity to accept the transfer but refused, this requirement has beentransfer but refused, this requirement has been violated.violated.   
  21. 21. Three Principles of EMTALAThree Principles of EMTALA  Medical Emergency ScreeningMedical Emergency Screening  On-Call PhysiciansOn-Call Physicians  Obligation to Accept TransfersObligation to Accept Transfers http://www.pitt.edu/~kconover/ftp/emtala-draft.pdfhttp://www.pitt.edu/~kconover/ftp/emtala-draft.pdf
  22. 22. First Principle of EMTALA  Medical Screening ExamMedical Screening Exam  Stable -Stable - Stable for Transfer when you can state about the patient, within reasonable clinical confidence, that there will be no material deterioration in his/her medical condition during transport  Unstable -Unstable - You shouldn’t transfer unstable patients, unless the benefits of transfer outweigh risks
  23. 23. Second Principle of EMTALA  On-Call Docs - These Physicians are on-call for the hospital not for the private practice and are agents of the hospital so anything they do or don’t do as related to EMTALA reflects directly on the hospital and therefore implies liability for the entire institution.
  24. 24. "On-call" duties come with the privilege of practicing in a hospital. They are a covenant between physician and hospital as part of their mutual responsibility to all patients who come to the hospital door. Physicians who break that covenant call into question their medical staff privileges. … Hospitals and physicians, including on-call physicians, who violate EMTALA may face stiff penalties. They could include civil fines of up to $50,000 per violation or exclusion from participating in the Medicare and Medicaid program.
  25. 25. Third Principle of EMTALA  Obligation to Accept Transfers - If any hospital in the U.S. calls and says they have a patient they can’t take care of, for whatever reason, and it’s something we can take care of, we have to take the patient. No ifs, ands, or buts, we have to take the patient. We shouldn’t even ask about insurance, lack of insurance, or HMO status—unless we have already agreed to take the patient.
  26. 26. Exceptions to Acceptance:Exceptions to Acceptance: Beds not available –Beds not available – Some institutions define this asSome institutions define this as Beds, Staff or equipmentBeds, Staff or equipment If it is an emergent medicalIf it is an emergent medical condition and requires care notcondition and requires care not available at transferringavailable at transferring hospital and a bed is availablehospital and a bed is available they must take the patient.they must take the patient.
  27. 27. No Physician On-Call :No Physician On-Call : --If we have a specialty on staff at our hospital, and we have enough physicians in that specialty to reasonably cover an on-call schedule, we have to have an ED on-call list for that specialty. -All docs on Active Staff have to participate in call if requested by their department (and Courtesy Staff may have to take call). -Whoever is on call has to come to see a patient within a “reasonable time” (30-60 minutes is generally considered “reasonable” in an urban or suburban area) whenever the ED calls with a request for the on-call doctor to come see the patient. No exceptions, unless the consult is just to admit, or just to discuss a case.
  28. 28. Under current HCFA policy andUnder current HCFA policy and thinking, are “lateral” transfersthinking, are “lateral” transfers (hospitals of equal capacity and(hospitals of equal capacity and capability) for admission after EDcapability) for admission after ED work up done strictly forwork up done strictly for managed care (economic)managed care (economic) reasons permissible?reasons permissible?
  29. 29. A recipient hospital would notA recipient hospital would not have to take a lateral transferhave to take a lateral transfer based on this issue. My generalbased on this issue. My general advice, however, is "when itadvice, however, is "when it doubt take it, then sort it out anddoubt take it, then sort it out and report if necessary."report if necessary." Stephen Frew, JDStephen Frew, JD <sfrew@medlaw.com><sfrew@medlaw.com>
  30. 30.  IfIf the patient isthe patient is stablestable, as defined by law,, as defined by law, EMTALA no longer applies and hospitalsEMTALA no longer applies and hospitals can transfer patients for any reason,can transfer patients for any reason, including economic reasonsincluding economic reasons  Only the patient can request to beOnly the patient can request to be transferredtransferred  If the patient isIf the patient is unstableunstable, and the, and the transferring hospital has both thetransferring hospital has both the capability and capacity to stabilize thecapability and capacity to stabilize the patient, then a “lateral transfer” would bepatient, then a “lateral transfer” would be illegal unless the patient demanded theillegal unless the patient demanded the transfer (essentially leaving the facilitytransfer (essentially leaving the facility against medical advice).against medical advice).
  31. 31. Sending hospital is not inSending hospital is not in compliance. Once again, though,compliance. Once again, though, hospital 2 may be safer to take thehospital 2 may be safer to take the patient for the patient's safety, andpatient for the patient's safety, and turn it in. I would suggest: "We willturn it in. I would suggest: "We will take your patient, but this soundstake your patient, but this sounds like a COBRA violation, and welike a COBRA violation, and we may have to report it. But we willmay have to report it. But we will take your patient if you want us to."]take your patient if you want us to."]  Steven Frew Steven Frew
  32. 32. In the past the patient has receivedIn the past the patient has received all of their medical care andall of their medical care and necessary hospital admissions at thenecessary hospital admissions at the sending hospital, whose attendingsending hospital, whose attending primary care physician and hospitalprimary care physician and hospital are still contracted with the managedare still contracted with the managed care plan, BUT for this admissioncare plan, BUT for this admission there is no “contracted” specialistthere is no “contracted” specialist willing to provide the necessarywilling to provide the necessary services (i.e. neurosurgeon) despiteservices (i.e. neurosurgeon) despite having a neurosurgeon on-call for thehaving a neurosurgeon on-call for the sending ED.sending ED.
  33. 33. Sending hospital is not inSending hospital is not in compliance. Once again, though,compliance. Once again, though, hospital 2 may be safer to take thehospital 2 may be safer to take the patient for the patient's safety, andpatient for the patient's safety, and turn it in. I would suggest: "We willturn it in. I would suggest: "We will take your patient, but this soundstake your patient, but this sounds like a COBRA violation, and welike a COBRA violation, and we may have to report it. But we willmay have to report it. But we will take your patient if you want us to."]take your patient if you want us to."]   
  34. 34. Can the emergency physician &/orCan the emergency physician &/or the on-call neurosurgeon after EDthe on-call neurosurgeon after ED evaluation, transfer this patient toevaluation, transfer this patient to another hospital of similar or equalanother hospital of similar or equal capacity for admission simplycapacity for admission simply because the neurosurgeon refusesbecause the neurosurgeon refuses to contract with the patient’sto contract with the patient’s particular managed care plan andparticular managed care plan and does not wish to take care of thedoes not wish to take care of the patient simply for this reason.patient simply for this reason.
  35. 35. NO!NO!
  36. 36. The hospital has a duty to provide theThe hospital has a duty to provide the neurosurgeon; when on-call to the ED, thatneurosurgeon; when on-call to the ED, that duty attaches to the neurosurgeon. Heduty attaches to the neurosurgeon. He becomes an agent of the hospital and asbecomes an agent of the hospital and as such represents the hospital and not hissuch represents the hospital and not his private practice any more. If a hospitalprivate practice any more. If a hospital called a neurosurgeon who was not on-called a neurosurgeon who was not on- call, that neurosurgeon can accept orcall, that neurosurgeon can accept or reject any transfer as he would accept orreject any transfer as he would accept or reject any person in the capacity of hisreject any person in the capacity of his private practice. No EMTALA duty attachesprivate practice. No EMTALA duty attaches to him unless he is on-call and thus anto him unless he is on-call and thus an agent of the hospitalagent of the hospital
  37. 37. This is why the real fight with on-This is why the real fight with on- call physicians will be over thecall physicians will be over the definition of “stabilized”. If thedefinition of “stabilized”. If the patient is stable, the law does notpatient is stable, the law does not apply and the on-call physician hasapply and the on-call physician has no EMTALA duty to accept theno EMTALA duty to accept the patient (though he may have a dutypatient (though he may have a duty to accept under other legal theoriesto accept under other legal theories or contractual relationships).or contractual relationships).   
  38. 38. Assuming the above transfer isAssuming the above transfer is NOT legal, what is the bestNOT legal, what is the best course of action for thecourse of action for the emergency physician who hasemergency physician who has been placed in a situation wherebeen placed in a situation where NO neurosurgeon at theNO neurosurgeon at the presenting facility will care forpresenting facility will care for the patient?the patient?
  39. 39. 1) Notify the on-call administrator1) Notify the on-call administrator or chief of staff STATor chief of staff STAT 2) Maintain stabilizing efforts2) Maintain stabilizing efforts 3) Transfer if necessary and3) Transfer if necessary and document the name and address ofdocument the name and address of the refusing on-call physician in thethe refusing on-call physician in the transfer documentation per statutetransfer documentation per statute
  40. 40. Appropriate agreements must beAppropriate agreements must be reached between the medical staffreached between the medical staff and the hospital about what it meansand the hospital about what it means to be on-call. The hospital mustto be on-call. The hospital must provide physicians, it must monitorprovide physicians, it must monitor and Q/A their behavior, and it mustand Q/A their behavior, and it must discipline physicians who violatediscipline physicians who violate EMTALA and their on-call duties.EMTALA and their on-call duties. Failure to monitor and enforce theFailure to monitor and enforce the EMTALA requirements is itself aEMTALA requirements is itself a violation of the law, and, as oneviolation of the law, and, as one hospital in New Jersey discovered,hospital in New Jersey discovered, can be reason enough for HCFA tocan be reason enough for HCFA to literally close down the hospital’s ED.literally close down the hospital’s ED.
  41. 41. How do you handle the rogueHow do you handle the rogue physician who refuses tophysician who refuses to follow the rules and carry outfollow the rules and carry out his on-call responsibilities?his on-call responsibilities?
  42. 42. Policy should specificallyPolicy should specifically address what the EP shouldaddress what the EP should do in this situation: call thedo in this situation: call the chief of the physician’schief of the physician’s department for resolution,department for resolution, failing that call the chief offailing that call the chief of the medical staff, and failingthe medical staff, and failing there, call the administratorthere, call the administrator on-call to resolve the problemon-call to resolve the problem
  43. 43. If everything fails, the only optionIf everything fails, the only option for the EP is to transfer thefor the EP is to transfer the patient to a hospital that canpatient to a hospital that can manage the patient’s EMC. Inmanage the patient’s EMC. In that case, the EP must send thethat case, the EP must send the name and address of the on-callname and address of the on-call physician who refused to help tophysician who refused to help to the receiving hospital. In turn,the receiving hospital. In turn, the receiving hospital is requiredthe receiving hospital is required by Medicare law to report theby Medicare law to report the transferring hospital to HCFA.transferring hospital to HCFA.
  44. 44. Hospital administratorsHospital administrators must understand that themust understand that the actions of the on-callactions of the on-call physician are directlyphysician are directly attributed to the hospitalattributed to the hospital
  45. 45. Patient requires acute care andPatient requires acute care and the sole reason for denial isthe sole reason for denial is financial -- I would not permit itfinancial -- I would not permit it in a hospital I represented. Thein a hospital I represented. The on-call rule should be simpleon-call rule should be simple and unequivocal: The on-and unequivocal: The on- specialist takes all patients --specialist takes all patients -- PERIOD. – Steven FrewPERIOD. – Steven Frew
  46. 46. Assume the patient has a moreAssume the patient has a more imminently serious problem and itimminently serious problem and it is felt further delay in obtainingis felt further delay in obtaining appropriate consultation at theappropriate consultation at the sending facility might place thesending facility might place the patient’s health in jeopardy. Ispatient’s health in jeopardy. Is transfer OK under thesetransfer OK under these circumstances &/or what is the bestcircumstances &/or what is the best course of action for the emergencycourse of action for the emergency physician?physician?
  47. 47. Act to save the patient. NotifyAct to save the patient. Notify administration. Transfer ifadministration. Transfer if necessary. List the refusingnecessary. List the refusing physician in the transfer reportsphysician in the transfer reports as required by law. Complete anas required by law. Complete an incident report.incident report.
  48. 48. If the patient needs immediate attention, then theIf the patient needs immediate attention, then the hospital must do everything it can within itshospital must do everything it can within its capabilities and capacity (resources) to stabilizecapabilities and capacity (resources) to stabilize the patient. If there is disagreement between thethe patient. If there is disagreement between the emergency physician and an on-call physicianemergency physician and an on-call physician regarding whether the patient is stable for transfer,regarding whether the patient is stable for transfer, then hospital policy should require the on-callthen hospital policy should require the on-call physician to come into the ED, personally examinephysician to come into the ED, personally examine the patient, and assume care of the patient. Thisthe patient, and assume care of the patient. This includes arranging the transfer if the on-callincludes arranging the transfer if the on-call physician still insists on transferring the patient,physician still insists on transferring the patient, and obtaining the patient’s consent to the transfer.and obtaining the patient’s consent to the transfer.
  49. 49. Under these circumstancesUnder these circumstances does the hospital being called todoes the hospital being called to arrange transfer (receivingarrange transfer (receiving hospital B) have an obligation tohospital B) have an obligation to accept the patient in transfer?accept the patient in transfer?   
  50. 50. Under the general rule, if the EDUnder the general rule, if the ED truly can’t obtain the services oftruly can’t obtain the services of the on-call physician, forthe on-call physician, for whatever the reason, then yes,whatever the reason, then yes, Hospital B must accept theHospital B must accept the patient in transfer. However,patient in transfer. However, Hospital B does not have toHospital B does not have to accept any patient in transfer ifaccept any patient in transfer if Hospital A has the necessary on-Hospital A has the necessary on- call services and resourcescall services and resources available to manage the patient’savailable to manage the patient’s EMC.EMC.
  51. 51. If a patient is legally stable, butIf a patient is legally stable, but has a medical condition thathas a medical condition that requires the care of a tertiaryrequires the care of a tertiary facility, does EMTALA requirefacility, does EMTALA require the tertiary facility to accept thethe tertiary facility to accept the patient in transfer?patient in transfer?
  52. 52. ...requires the tertiary facility to accept...requires the tertiary facility to accept an “appropriate” transfer. The meaningan “appropriate” transfer. The meaning of appropriate here could refer back toof appropriate here could refer back to the definition of an “appropriatethe definition of an “appropriate transfer,” for purposes of transferringtransfer,” for purposes of transferring an unstable patient, or it could be justan unstable patient, or it could be just the common language meaning thatthe common language meaning that the patient needs the service, thethe patient needs the service, the tertiary facility has that service, andtertiary facility has that service, and therefore the facility must accept thetherefore the facility must accept the patient in transfer.patient in transfer.
  53. 53. Presently, both HCFA andPresently, both HCFA and the OIG take the positionthe OIG take the position that anything the patientthat anything the patient needs that you got, andneeds that you got, and the transferring facilitythe transferring facility does not, you must acceptdoes not, you must accept in transferin transfer
  54. 54. Try your best to reach anTry your best to reach an acceptable solution holding theacceptable solution holding the patient’s best interest at apatient’s best interest at a premium. If your reasonablepremium. If your reasonable efforts fail, document them, andefforts fail, document them, and call other hospitals until you findcall other hospitals until you find one that will accept the patient.one that will accept the patient.
  55. 55. Under EMTALA there is noUnder EMTALA there is no requirement for physicians torequirement for physicians to take hospital ED call,take hospital ED call, unlessunless thethe medical staff bylaws or hospitalmedical staff bylaws or hospital rules & regulations state thatrules & regulations state that duty.duty. http://www.azcep.org/emtala/on_call.htmlhttp://www.azcep.org/emtala/on_call.html
  56. 56. The medical staff by-laws orThe medical staff by-laws or policies and procedures mustpolicies and procedures must define the responsibility of on-define the responsibility of on- call physicians to respond,call physicians to respond, examine and treat patients withexamine and treat patients with emergency medical conditions.emergency medical conditions.
  57. 57. If hospitals and physiciansIf hospitals and physicians don't solve the problem,don't solve the problem, government and politiciansgovernment and politicians certainly will.certainly will.
  58. 58. Emergency Department on-callEmergency Department on-call coverage issues will be the finalcoverage issues will be the final EMTALA hurdle for hospitals.EMTALA hurdle for hospitals.
  59. 59. “Money is the root of all evil” but unfortunately is not the entire solution for the on-call issue. Fully funding on-call coverage would bankrupt most hospitals and divert funding sorely needed in other areas of healthcare. It also sets up a perverse system that rewards physicians for doing as little as possible and builds resentment from those on-site doing the bulk of the work.
  60. 60. The ED: A “Besieged”The ED: A “Besieged” Work EnvironmentWork Environment
  61. 61. Causes of Increase in ProviderCauses of Increase in Provider Dissatisfaction coming to ED?Dissatisfaction coming to ED?  Critical Shortage of Qualified Nursing StaffCritical Shortage of Qualified Nursing Staff  30-60 minute waits for Nurses to help30-60 minute waits for Nurses to help  Needed Equipment to evaluate patientsNeeded Equipment to evaluate patients either not available or inadequate or in illeither not available or inadequate or in ill repairrepair
  62. 62. Solutions to this?Solutions to this?  ““Hand holding” practices to meet on callHand holding” practices to meet on call physicians needs when in to evaluate EDphysicians needs when in to evaluate ED patientspatients  Increase Training and Retention programsIncrease Training and Retention programs for seasoned ED nurses in order to reducefor seasoned ED nurses in order to reduce turnover and improve staff satisfactionturnover and improve staff satisfaction

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