Episode 6: Transfers

When you gotta go, you gotta go...to another hospital. Let's talk about transfers!

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Transcript

Actually wait, wait, cut the music.

Before we begin today, first I want to thank everyone for the support! It’s nice to hear that people are enjoying the show, even those already well versed in the ER, and I really appreciate the feedback. If you have any criticism, praise, grievances, well wishes, suggestions, whatever, then please don’t hesitate to email at insidetheer@gmail.com That’s all one word, no spaces, insidetheer@gmail.com

Next I’d like to explain that I see these early episodes of the podcast as logistical? Is that the right word? Focused on the ins and outs, nuts and bolts, of being an ER patient. I’m hoping this podcast grows into, as one listener put it, a “good resource” that people can use to navigate my workplace. Remember that even if an episode doesn’t seem to apply to you directly, you’re still going to get that insider perspective.

Like last episode was about leaving against medical advice or AMA. One might think, “Oh I wouldn’t do that, that’s not for me.” Maybe not, but learning about the thinking and process behind an AMA will still have value. And, AND! You’re going to hear later in this episode a situation where even the most prudent patient may AMA. Anyway, once the show gets more established, the episodes may become more focused on specific conditions or cases, with guests sprinkled in here and there. So stick with me, because we’re just getting started!

And if you can...please tell people you know. 

 All right, let’s go on with the episode proper.

Hello and welcome to Inside the ER. My name is Dr. Padraic Gerety and I’m a practicing, board certified emergency physician.

Today you’re joining us today for our sixth episode, entitled “Transfers.” This is not transferring money or college credits or something. This is about patients being sent from one hospital or ER to another. Since we’ve already covered being discharged, admitted, leaving without notice, and leaving against medical advice, I figured this made sense to cover now. If you don’t remember these other topics then maybe you should relisten to the previous 5 episodes…just a thought.

This episode should round out all the ways you can be dispositioned in the ER. Is that word self explanatory in this context, disposition? For an ER provider it just means what will be the destination of the patient: are they being discharged or admitted or transferred? When I work with students or residents, I always ask them “what’s the dispo?” As in, where do they think this patient is going end up when we’re done with them? Many, if not most, patients we see we know the disposition right off the bat. As in, this patient is definitely being sent home or staying…or…OR, they’re gonna be transferred. That’s the option that’s always lurking behind the corner, I tend to forget about it until it jumps out at me.

A hospital transfer is when a patient is transferred from one ER (or inpatient unit) to another hospital where their staff will take over their care. Why should you care about this? Because you may find yourself in this situation next time you’re Inside the ER.

So, why would we do this? There’s generally four reasons. 

First and the most common is because the sending hospital does not have the capabilities of the receiving hospital. Do you remember from the end of episode four, I said if you have an eye complaint consider going to an ER with ophthalmology in house? No? Me neither but apparently I did say that because I just checked the script. This is the main reason, in my experience, why we transfer patients. Many, many ERs are similar in that we don’t have a certain set of specialities in house. Besides ophthalmology, to name a few there’s ENT or ear nose and throat (the proper term is Otolaryngology but no one says that), cardiothoracic surgery, interventional cardiology or radiology, plastic surgery, oral and maxillofacial surgery, and the big one: neurosurgery.

You see a trend here? No? Ok i’ll just say it: they’re all surgical specialities! Why doesn’t every hospital have these in house? Well for starters, there’s a lot fewer of these type of doctors than myself, ER, and internal medicine, pediatrics, ya know, the generalists. Also, these surgical specialities require lots of support and a heavy volume of patients to operate, so you’ll often find them practicing out of large academic hospitals or tertiary care centers. Sometimes a phone consult with a specialist at another hospital is enough, but if my patient requires direct care from a speciality not in house, then transfer may be the only option.

I called Neurosurgery the big one because that’s a common source of transfers for those of us at hospitals where they aren’t in house. If I have a patient in my ER that needs a neurosurgeon because of an intracranial mass or bleed, then I’m on the phone, calling around. A lot of these patients may not even need a surgery, but they need to be formally assessed by a neurosurgeon and likely need a neuroICU.

A large subset of capability? transfers, let’s call them, yeah that sounds good, capability transfers, are psychiatric. This will be its own episode one day for sure. Some patients who present to the ER in psychiatric distress require an inpatient psychiatric admission. But, most ERs do not have psychiatric facilities on site, and hence the need for a transfer.

I may also need to transfer a patient because we’re lacking specific equipment. One example that comes to mind is a large capacity CT or MRI. The scanners at my ER can not support patients over a certain weight or circumference, so we’ve had to ship patients out somewhere where they have a specialized scanner.

All right, are you still following me? Moving on from capability transfers, we have the second reason for transfer: capacity. The sending hospital does not have space to care for the patient and will transfer them to a receiving hospital with the appropriate resources but also staffed beds. I’ve had to do this before for patients in critical but stable condition. If an admitted patient is boarding in the ER, ya know waiting for a bed upstairs, we’re less worried about them decompensating if they’re not critically ill. But when it is a critically ill patient, and we have no ICU beds available, then it may be better to transfer the patient to a free ICU bed somewhere else. In these cases, I’ll work closely with my ICU colleagues to stabilize the patient before transferring. This only works for a specific type of critically ill patient, sometimes they are just too unstable to transfer.

A provider at a freestanding, or stand-alone, ER has to transfer out all admitted patients for both of these two previous reasons. Like it sounds, these are ERs that are not housed within a hospital. So the building has neither the capability nor capacity to care for any admitted patient. There’s no inpatient unit…it’s just the ER. Every admitted patient has got to go out. Often freestanding ERs have agreements with larger hospital systems to streamline the admit/transfer process. The ER provider knows where they’re transferring the patient. They’re not calling hospital after hospital like I am when I try to transfer someone.

Ok don’t worry, the reasons for transfer get simpler from here!

The third reason is for continuity of care. I’ve dealt with this a fair amount, often patients with cancer or organ transplants. The patient gets all of their highly specialized care at another hospital, and the physicians there want them back, so I ship them out. Or, the patient just had surgery somewhere else and now has a serious complication. Any surgeon worth their salt will demand their patient gets transferred back to them. Remember what I said. Pay attention to what ER you’re going to, especially if you just had surgery. 

And the final reason, phew, simple enough, is patient preference. The patient prefers a different hospital and wants a transfer.  This is a tricky one because if there’s no medical reason for the transfer, it is usually up to the patient and their family to make all the arrangements themselves. Navigating the transfer system is tough but some people do figure it out, but almost always when the patient is already admitted. 

It’s time for a break, we’ll be right back after a word from our sponsor.

Today’s sponsor of Inside the ER is knowing where EMS will take you. Are you considering calling 911? Do you assume the ambulance will drop you off at your favorite ER? Well, not so fast my friend, cause that is no guarantee. EMS have to follow protocol when transporting patients, which may mean using the closest ER or avoiding certain ERs due to overcrowding. It’s not a taxi and you may not end up where you wanted to go. “I didn’t want to come here,” they say, but that’s what happens when you call an ambulance. So unless you’re gravely ill and can’t wait, keep this in mind the next time you call 911!

Now, back to the show:

So, how does this work, anyway? Well, first, according to the Emergency Medical Treatment and Active Labor Act, or EMTALA, remember that? As the ER provider, I’ve gotta take some steps before transferring a patient. First, is, of course, what I would normally do, diagnose and then treat the emergent medical condition. Next, I’ll decide, hey, a transfer is warranted in this case, and get consent from the patient. 

Part of the consent process is explaining the benefits and risks of the transfer. The benefit is obvious: I’m sending the patient to where they can get definitive care. In terms of risks, there’s the obvious one of a traffic accident, and the more nebulous one of decompensating during the transport. As I’ve said, I can’t wave a wand to treat, nor can I look into a crystal ball to tell me if the patient’s condition will worsen despite our best efforts. My goal is of course to stabilize prior to transport to reduce the risk of decompensation, and let the patient know my best assessment as to the risks of transfer.

I remember a patient few months ago who came in with sudden onset of severe headache and  nausea. He was found to have an intracranial hemorrhage, a brain bleed, and extreme hypertension. In this case, I knew that no matter how unstable he was, he had to get transferred out. So, in consultation with a neurosurgeon at the receiving hospital, we put him on an antihypertensive drip, that’s blood pressure medication in the IV, and gave him a large dose of an IV antiepileptic, medicine to prevent a seizure. His vitals and symptoms improved and that was as stable as I was ever going to get him for transfer. Don’t worry, he did well.

There are patients who are, despite my best intervention, unstable. But, but! transferring them is necessity, it is the only option to save their life, so it has to be done.

Wait, wait, I’m getting ahead of myself. Once the ER provider diagnoses the problem, renders whatever stabilizing treatment they can, and then realizes a transfer is needed, then comes the tricky part. Finding the receiving hospital and accepting physician. For some ERs, this is a very simple process: they have an established relationship with a large hospital system, so they call a centralized transfer center. The center connects the ER provider with an appropriate physician, say a neurosurgeon who can admit to a neuroICU. The specialist will give recommendations and assuming there’s an available bed, agree to accept the transfer.

For many ER providers, however, it is much more laborious process to transfer a patient. I’m talking about contacting multiple hospital systems, waiting sometimes hours for a callback, telling the same story over and over again to specialists at different hospitals, all for there to be no beds in the area. I’ve spent countless hours just on the phone trying to get patients transferred for appropriate care, all while I’m managing the other patients inside the ER. Sometimes this means sending a patient far away, when all close options are exhausted. 

Now IF you get an accepting physician, and they actually have a bed available, there’s the matter of transport. How is the patient getting there, as in an ambulance or helicopter? What’s even available? Are we going to wait hours for ambulance? It’s happened. And what kind of crew needs to be on it? This will all vary depending on the condition of the patient, the geography of the region, the weather, and how far away the receiving hospital is. Some patients are stable and go with two EMTs in an ambulance. Other patients are critically ill, going far distances, and so will require a helicopter staffed by paramedics, nurses, maybe even a physician.

Speaking of modes of transport, another option is transfer via private vehicle. These are very specific cases where the patient is perfectly stable and deterioration is not expected: they have normal vital signs, baseline mental status, not on any IV medication infusions, can get around, and have an access to a ride. 

This actually happened recently with patient who had burns to his feet. He had a history of peripheral vascular disease, which caused a narrowing of the arteries in his legs, and diabetes. This combination meant that not only was he prone to poor wound healing, but also a resulting neuropathy, or nerve damage. So, he had reduced sensation and bothersome nerve pain in his feet. He told me that he often soaked his feet in warm water to ease the pain.

A day before I saw him, his feet were hurting and he sought the comfort of a foot bath. But because his feet are numb, he didn’t feel that the water was actually scalding. Before he realized, he had already burned his feet. He came in with large, painful, and sloughing blisters. I consulted with our local burn center who wanted to evaluate him in their ER, and accepted him for transfer. But, he was otherwise fine, and didn't want to wait hours or pay an ambulance bill, and so he had his family drive him there. 

Why not just discharge him and tell him to go to the other ER? Because of EMTALA! Of course, it all goes back to EMTALA. Once a patient checks in, ya know, the ER has taken them on as a patient, so we can’t boot them and we can’t tell them to leave and go somewhere else. That’s a violation. We can not discharge a patient with the plan to go to another ER, it has to be a transfer, but a transfer does not always mean ambulance, in a few cases, like this one, private vehicle is fine. 

In the beginning of the episode, I mentioned there is a situation in which a reasonable patient may AMA. Well, here it is. But first, first! I want to make something very clear, mainly to cover my butt: I completely understand why patients do this but I am NOT encouraging anyone to do it. I’ve had patients say, “Hey, I realize I should have went to where I had my surgery or where my doctor works,” and they decide to AMA and get a ride somewhere else. Or, the patient is initially agreeable to a transfer, but then I find out there’s going to be a huge delay in securing an ambulance or a bed assignment at the other hospital. The patient decides, “Hey, I don’t feel too sick, it’ll be much faster if I have someone drive me.” 

I’ve also had this happen when I can’t even get a consultant on the phone. I hope you never know the pain of futilely hounding a transfer center, desperately searching for a specialist who in all likelihood wishes I would give up, all while the patient gets more and more upset. Ya know, it’s like I know this patient needs emergent consultation with, but no one will call me back. What does the patient do? AMA and go to a different hospital when they’re in house and can’t ignore when the ER doc pages them. I’m not exaggerating, this happens.

Again, I encourage patients not to do this, and they’re signing out against medical advice with all of the risk inherent in that. But, I completely understand why they do. 

Before I go, I’ll reiterate an important point. All my talk of choosing the right ER is all dependent on the patient being stable. If you as the patient are in distress, very ill, then there’s no time to futz around. You gotta call 911 and go to the nearest ER. If you’re not gravely ill and there’s time to think, then you can contemplate where to go. But if there’s no time, then don’t sweat it!

And that is where I’ll leave you, we’ll be back in two weeks!

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Thanks for listening and all the best.