Risk Management for Patient Transfers

Educational Objectives

The goal of this program is to improve outcomes of patient transfers. After hearing about and assimilating this program, the clinician will be better able to:

1. Comply with Emergency Medicine Treatment and Labor Act (EMTALA) regulations for interhospital transfers of patients.

Summary

Transferring patients from nontertiary care center emergency departments (EDs): transferring patients from rural or remote areas can be difficult because, for various reasons, larger hospitals are often not open to accepting transfers; as a result, patients whose needs are beyond the capacity of a rural ED may experience adverse outcomes, including death, while waiting for transfer; recommendations — establish protocols for “auto accept” with some large-capacity receiving institutions; document every attempt made to transfer the patient to a facility with a higher level of care; ensuring patient safety during transfer — it is the responsibility of the sender to ensure that the team transporting the patient has appropriate training and equipment to care for the patient; failure to do so is a violation of the Emergency Medicine Treatment and Labor Act (EMTALA)

Measures: establish processes ahead of time to avoid the need to call multiple hospitals in emergencies; facility administration should establish appropriate policies and form relationships with receiving facilities; establish relationships with ambulance crews and expand networks; ensure that patients are not placed in an ambulance unless an accepting physician has been identified; to comply with EMTALA, ensure that the level of training of the ambulance crew is appropriate

Emergency Medicine Treatment and Labor Act: enacted in 1986 as an “antidumping” regulation (to prevent hospitals from accepting or refusing patients based on insurance coverage or ability to pay); obligations under EMTALA — 1) the patient must have an emergency medical condition; 2) maximal medical screening and stabilization must have been provided, based on the sending facility’s resources; 3) an accepting physician and appropriate transport crew must be identified; arranging transportation is the responsibility of the sending physician; the sending physician remains responsible until the patient enters the receiving institution

Stabilization prior to transfer: document the level of stability achieved, discussions with family, and the risks of staying in a facility without appropriate resources vs transferring

Pregnancy: under EMTALA, even if a facility does not have an obstetrics department, pregnant patients must receive a medical screening examination to identify emergency medical conditions before arranging a transfer; it is best to establish policies about transfer of obstetric patients in advance

Conditions of transfer: cannot be imposed by the accepting facility

Managing patients at high risk: involve facility administrators when needed, regardless of time of day; document extensively; document the list of contacted institutions

Readings

Armagan E, Al MG, Engindeniz Z, et al. Compliance with protocols in transferring emergency patients to a tertiary care centre. Injury. 2004 Sep 1;35(9):857-63; Rosenbaum S, Somodevilla A, Casoni M. Will EMTALA be there for people with pregnancy-related emergencies? N Engl J Med. 2022;387(10):863-865. doi:10.1056/NEJMp2209893; Understanding EMTALA ACEP // Home Page. Accessed: December 6, 2022). Available at: https://www.acep.org/life-as-a-physician/ethics--legal/emtala/emtala-fact-sheet/.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Vieth was recorded at Managing Medical Emergencies 2022, held on May 18, 2022, in Lebanon, NH, and presented by the Dartmouth-Hitchcock Medical Center. For information about upcoming CME activities from this presenter, please visit dartmouth-hitchcock.org/ce. Audio Digest thanks the speakers and the Dartmouth-Hitchcock Medical Center for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

EM400403

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.