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.

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.

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.

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.

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….

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.

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?