Transfers

I’ve read some ED blogs commenting on transfers recently (well, when I started writing this post), and I’d like to add my two cents, as an EM doc working in a facility that accepts more than 2,000 transfers a year.

At my hospital the vast majority of transfer calls are fielded by the EM doc on duty, and it’s an interesting dance: listen to the physician who wants to send, determine if you have the resource the sending docs’ patient needs, and then make a decision if our receiving hospital can medically handle the patient being sent.  This includes a lot of facility-specific knowledge, not just the ‘on call’ list but our special capabilities that aren’t on the call list, etc.  Of course, this is just the “medical” part, then there’s the “Administrative” part, over which I have nor want any influence.

The rules about this are myriad and complex, and typically we err on the side of accepting a transfer.

A style point: if you’re trying to send a patient, start with “I have a patient who needs ENT, do you have that coverage” rather than the much more typical, “Mr. Smith is a 74 year old male with hypertension, diabetes and CHF…” because I will then cut you off and say ‘what do you need, and how can we help you’?.  This is a ‘Just the Facts Ma’am’ conversation, and should be short and sweet, respecting both our times.

And, the hard and ugly truth: transfers have allowed a lot of very dysfunctional hospitals to stay open, IMHO.  A hospital cannot get Ortho coverage (for example, not specific to bones), for the myriad reasons specific to that specialty?  Well, just transfer them to a hospital that does.  In this way, bad hospitals (administrators and medical staffs alike) aren’t confronted with their failures, their failures are transferred.  The inadequate hospital now doesn’t have to face angry patients and their families for their inability to manage their medical staffs, they just defer their responsibility to those who are just that: responsible.

I have told sending docs I would take their patient, but they had to go out and pry the word “Hospital” off their signs.  If it was you I was talking to……..I meant it.


Comments

  1. GD, Excuse my sticking my nose in and commenting on something that I know very little about and that isn’t very relevant to me.

    I think you’re being too harsh on hospitals that do not have all the facilities. Surely you don’t expect every hospital in every locality to be fully equipped and staffed to deal with all medical needs! You may be generalizing based on bad experiences of irritating referrals/transfers from habitual offenders in your area.

  2. A hospital cannot get Ortho coverage (for example, not specific to bones), for the myriad reasons specific to that specialty? Well, just transfer them to a hospital that does. In this way, bad hospitals (administrators and medical staffs alike) aren’t confronted with their failures, their failures are transferred.

  3. I have to disagree with you on this one.
    The rural hospital where I moonlight has been trying to recruit specialists for years. No one wants to work there. Not enough patient volume and the payer mix is horrible – 10% insured, 30% Medicare.
    No neurosurgeon or trauma surgeon for decades. Neurologist has an office in town where he sees patients twice a month. We had an ENT for about 6 months until we found out that he lied on his application and that he lost his license in the state where he previously worked. Ditto with a CV surgeon. One of the orthopedists there decided he doesn’t want to take any patients with back injuries and will not be involved with worker’s compensation cases.
    So what are rural hospitals like this supposed to do? Shutter their windows and board up their doors because they don’t have full specialist coverage?
    Then the tertiary care centers would have a bigger problem because all of the things that the rural hospitals CAN take care of would end up in the big hospital waiting rooms.
    I know the frustration from the other side of the coin while working at my university hospital. But I also know that most rural ED docs are doing their best.
    You’re killing the messenger when you get pissed at the ED doc trying to transfer a patient.

  4. You make a great point WhiteCoat. Health professionals have been in shortage for years and years, so it may very well be the reason for transfers. Inadequate funding for facilities, or lack of interest for working for a particular hospital could be the problem. You may have had some experiences with irresponsible, incompetent hospitals, but that might not always be the case.

  5. Grunt
    I think this makes the case for hospitals being able to directly employ physicians. One can hardly expect a physician of any specialty to try and establish a practice in a community of no-pay or poor pay patients.

  6. Agree with Whitecoat. You should try the sending side of a transfer in North Nowhere, Oregon, when you get the “have you called our neurosurgeon, because I can’t accept if he won’t accept” for a head bleed, and the neurosurgeon won’t call back to our area code. Nor will any other neurosurgeon, IN THE STATE! Try having that conversation with the patient’s family.

    “Well, put my husband in an ambulance and send him GruntDoc’s hospital… they have a neurosurgeon, right?”
    “Yes, but there is a federal law that says I need a doctor to accept him”.
    “And the only place that would take my husband is in the next state, 300 miles away. But GruntDoc’s hospital is only 50 miles away”.
    “Yes. tried everywhere in state. Either no beds or the specialist won’t answer back to our area code. The ER Doctor won’t take your husband without his neurosurgeon’s permission. The ER Doc says that without a neurosurgeon, they are no longer a higher level of care.”
    “He might die in the back an Evac plane!”
    “He might. But I don’t have a choice. It’s the law called EMTALA.”

    So, I guess I better take the “hospital” sign off my ER here in North Nowhere, Oregon, So should most of the rural hospitals in the US, as well as many city hospitals.
    Please, Gruntdoc, don’t blame me for trying to take care of people in a medical system that has died and just hasn’t had the good graces to fall over yet.

  7. Goatwhacker says:

    GD, you’re making two points in this post.

    The first I agree with – that the first sentence you say to the accepting doc should tell him why you want to transfer the patient. The medical student presentation really has no place here.

    The second – that lack of specialist coverage somehow correlates to a dysfunctional hospital – I have to disagree with. I work in a small-medium community and would love to have more specialists around. It would make my life a heck of a lot easier. But not only is there not big money here for specialists, there are no Marshall Fields or Macy’s, no pro sports, minimal theatre, very few decent restaurants, etc, etc. I like it here but most doctors don’t. For that matter it’s very unlikely we will see an EM residency trained doctor here, either. As a member of the credentials committee it is depressing to often see the only specialists that want to come here are the ones that have had problems elsewhere.

    This isn’t the sign of a dysfunctional hospital though, it’s economic and social reality. If you’re interested in coming here and working let me know.

  8. Suburban ER Doc says:

    Grunt doc,

    I also agree with Whitecoat. Do you think the ER doc across town is personally responsible for recruiting a full medical staff? Besides, I know for a fact that your hospital can’t always handle every everything either. Should you take the “Hospital” sign down if you don’t have a hand surgeon?

  9. I wondered if anyone still read this blog. Now I know how to rouse people to comment.

    First, let’s separate out the difference between the EM doc I’m talking to and the hospital they work at. I know the EM doc (usually) is just the middleman. (Usually). I have worked away from meccas, realize there are true limits to capabilities, and never say a word to those docs at those hospitals.

    Second, my hospital isn’t perfect, and we still have coverage gaps, requiring occasional transfers out. Our hospital admin is actively, aggressively recruiting to fill the gaps, and we still take a lot more than we send away. The difference is we’re trying, and we take a ton of transfers.

    Talk to any docs who take a lot of transfer calls from a lot of places, and you can smell the dumps. They do happen, and they seem to come from the Usual Suspects of sending joints.

  10. Having been on both ends of the transfer many times, I have noticed that sometimes when I try to transfer a patient, I get a difficult ED physician who is not happy to hear about a transfer, and sometimes they will grill me or press me for minutiae about the patient and their presentation. Doesn’t happen often, but this is one reason you may get such a detailed history.
    But I can’t say I blame them too much because when I accept transfers, I like to have a good knowledge of why the patient is being sent and what to expect when they hit the door.

    If they say a patient has a peritonsillar abscess and they don’t have ENT coverage, how do they know it’s an abscess? Have they done a CT? Attempted needle aspiration? Is the patient having any breathing difficulties? What meds have been given? Just one example but it’s nice to know some details as far as I’m concerned. Other reason I bring this up is that not all ED physicians are created equal. Not to offend people who work in smaller places; often times they do a great job. But the more I hear about the management the more I know about their skill level and why they are sending them. If they have a head bleed, did they get cerebryx? Is the head of the bed elevated? I like to know these kinds of things, and if you don’t ask you may have your head bleed show up seizing because someone didn’t think of something before sending them, or wind up having to do more work on your end than you should have….

  11. Suburban ER Doc says:

    You may never say a word but some of your colleagues and the specialists give us the third degree. I’ve been told by people at your hospital that they know better than I what my hospital can do!

    It’s nice to hear that you are trying to fill out your medical staff. What makes you think that others aren’t?

    I’m just suggesting that you should be careful with that broad brush of yours.

  12. Gruntdoc,

    You really stirred up the pot on this one.
    I have worked at the smaller hospitals and had to transfer lots of patients that could have been taken care of at any hospital. Sometimes it was that there was no specialist available or they just didn’t want to get involved. I have a problem with someone trying to transfer a pt that hasn’t been assessed by their specialist when they have one. However, most of time there is no specialist and the ED doc has no choice. I suggest you go work a weekend in some small town TX ED and see how difficult it is to get a pt to a specialist in the middle of the night.

    I now work at a hospital that accepts pts for the entire state. It is painful to deal with all the dumps when your ED is already at capacity. One thing we did was to take the ED docs out of the loop and have the transferrring MD talk directly to the accepting specialist. If a specialist is not readily available then it goes to IM, Surgery or Trauma, accordingly.
    One question. Since we are the only state in the country without a state wide trauma system, and we are assuming a trauma system will allow us to send pts to other level II or III centers and help ease the burden on the two hospitals in the state that take most of the transfers. Do you think having a trauma system will help to sread out the transfers to level II or III centers or do they all still come to you?

    Good topic, good comments.

  13. Gunner,
    I have moonlit in small places, and transferred. It’s not easy but it can be done. I have also been put in the bind of moving the dump, because the specialist we had on staff didn’t want to do their job that day. Unpleasant.

    As for your state getting a trauma system and that spreading the load: maybe. We have a regional trauma RAHC (not sure what the acronym stands for) but it’s a safety valve for a hospital with a trauma problem they can’t handle to call one place, the they put them in touch with the next trauma hospital on the list. It works fairly well (it helps people make the right decisions when they know they’re being recorded); I don’t know that it would solve a ‘send all trauma to the mecca’ problem, but it would help to spread those cases around the meccas.

    The unintended consequence of having a ‘trauma system’ is that it relieves a lot of docs who do trauma now, in smaller hospitals, from having to keep doing it. “It’s a trauma, transfer them to the trauma center” is then a perfectly viable option, and it gets exercised.

  14. NCT TRAC – North Central Texas Trauma Regional Advisory Council

    Scribes are required to know all the abbreviations :)

    I’m still on board with your previous suggestion — Stop the ER-ER transfers, take the ED doc out of it, go to a transfer center model, let the sending doc talk to the specialist, and if they won’t accept then sic the EMTALA dogs on them. I’ve seen few transfers that really even needed to be seen in the ER for stabilization. Direct admit them to the specialist. The pt will just be more pissed after they’ve sat in an ED hall bed anyway.

  15. What I can’t stand are the small hospitals that have 2 or 3 doctors in a specialty but never make them take call. They call and demand a transfer but we know who works there.
    They bludgeon us with EMTALA but there is no mechanism to make these skimmers do their part.

  16. Having managed a hospital transfer center accepting nearly 3000 patients a year and working in a “model”, yet dysfunctional, trauma system I agree with the originating author. Hospitals have a responsibility to determine the average needs of the community they serve and then to make a good faith effort to meet those needs. Have 2 orthopedic surgeons on staff scoping knees and performing other profitable procedures Monday through Friday? Then make a plan to provide coverage for the colles’ fracture that walks into your ER at least 3-4 nights a week and an occasional weekend. Smaller hospitals should not allow themselves to become hide- outs for physicians who have no intent to meet the obligations that title implies. How about larger facilities that ‘have no call requirement’ in certain subspecialties? The community hospital that makes a significant profit in their outpatient surgery center as the only facility in town with affiliated oral surgeons. Why do the oral surgeons practice only there? Because the hospital’s rules allow them to take every night and weekend off. Why does the hospital allow that? $$$$$ And that state operated trauma transfer center? Someone is going to die. Real life: the neurosurgeon is in the OR and has a second crani holding in the ER and a post op patient in the neuro ICU that needs emergent attention, the trauma surgeon and his backup are up to their elbows in the evening’s carnage, the OR is running all 4 call teams, the ER is holding something-teen patients for monitor and ICU beds and is backed up several hours. The trauma transfer center calls and, by state regulation, forces the acceptance of 2 more transferring trauma patients. How, I ask, is the receiving facility going to be able to provide any conceivable level of care, much less avoid allowing someone to fall through the cracks. By the way- the concept of referring minor or moderately injured patients to facilites, other than the trauma center, that have claimed to have the ability to care for them “hasn’t matured yet”. And before anyone becomes defensive about rural facilities with legitimately limited capabilities I understand where you are coming from. I actually worked in a 28 bed hospital with 2 FPs and one general surgeon. No one, especially at the facility to which patients were referred, expected more of that hospital than could reasonably be provided- limited medical and general surgical care. The expectation of that hospital’s administration and medical staff was that their capabilities and capacities would be employed first and then, if necessary, others would be called upon for assistance. That is the way it should be, every where. To expect anything else is to propagate dysfunction.

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