Cases & Commentaries

To Transfer or Not to Transfer

Spotlight Case
Commentary By Jesse M. Pines, MD, MBA, MSCE

Case Objectives

  • Explore the benefits of the continuity
    of hospital care.
  • Understand the rules and regulations
    behind triage and hospital choice decisions by emergency medical
    services (EMS) providers, and the roles of ambulance diversion and
    federal Emergency Medical Treatment and Active Labor Act (EMTALA)
    statutes.
  • Identify ways to improve continuity of
    hospital care.

The Case

A 74-year-old man had a long history of coronary
artery disease requiring coronary artery bypass grafting as well as
placement of an automated internal cardioverter-defibrillator
(AICD) for ventricular arrhythmias. His AICD was almost 10 years
old, and his cardiologist had found minor lead displacement (one of
the wires to his heart had moved over time). Admitted to Hospital X
(less than 1 mile from his house), he underwent the placement of a
new AICD—a minor surgical procedure, which was uncomplicated.
The patient was discharged 2 days later.

Within hours after arriving home from the
hospital, the patient's newly placed AICD began
"firing"—shocking his heart with large amounts of energy and
causing considerable pain. As the AICD fired more than 15 times in
the course of minutes, his wife called 911.

Emergency medical services (EMS) arrived and
found him lying on the couch, awake and alert, but in discomfort.
His heart rate and blood pressure were normal. Because of repeated
AICD firings and concern for a heart attack, he was taken in the
ambulance.

The patient told paramedics that he had received
all of his care at Hospital X and had just been discharged from
there. However, they took him to Hospital Y, a few miles away.

In the emergency department (ED) of Hospital Y,
the patient's AICD continued to fire shocks. The defibrillation
stopped after the patient was treated with amiodarone and
supportive care. He was then admitted to cardiology at Hospital Y
for ongoing management. The next day, when the patient was
clinically stable, the cardiologist considered transferring him
back to Hospital X but decided to keep him at Hospital Y.

Unfortunately, the patient continued to have more
ventricular arrhythmias and firings of his AICD even with medical
treatment. Despite maximal efforts, the patient eventually died
from a cardiac arrest.

It was unclear whether the patient's death could
have been prevented had he been taken to Hospital X. However, one
could argue that he may have received better informed care had he
been admitted to his original hospital.

The Commentary

This case raises a key question: Did the
decisions by EMS to take the patient to Hospital Y and by the
cardiologist to keep him there contribute to the patient's death
because he might have received better care at Hospital X? The
answer brings up several issues in patient safety for prehospital,
ED, and hospital care:

Issue 1: After stabilization,
should the cardiologist at Hospital Y have transferred the patient
to Hospital X? More broadly, is continuity of hospital care
associated with better outcomes? To my knowledge, there are no
studies comparing outcomes for patients with continuity of care
(same doctor, same hospital) with those cared for by different
doctors. In the absence of data, we must rely on clinical
experience and common sense to explore this issue.

Continuity of Hospital
Care

It is certainly easier logistically for providers
when they know the patient. Any first encounter is a learning
process as providers become familiar with current and past medical
history and social issues. When problem lists are complex, this
process involves considerable time and can add inconvenience
because of the need to transfer and review medical records. There
is a learning curve not only for physician care, but for the entire
team (nursing/other services)—a curve that is avoided when
patients are known to a hospital unit. Complex patients also
typically come with a large volume of records, which may or may not
be organized to make salient information easily accessible, or may
be missing key information. Old records also may be unavailable at
certain times (e.g., nights/weekends). As a result of these
problems with records, important information to guide the safest
care may only be known by providers who are acquainted with the
patient.

On the other hand, transferring care between
physicians can sometimes change management for the better.
Transfers can result in a "fresh set of eyes," which will sometimes
result in a previously overlooked diagnosis being made or treatment
being chosen. A similar benefit is sometimes observed when
physicians hand off patients during an admissions process or
transfer patients between hospital services, or when hospital-based
physicians go off-service and the oncoming physician offers a
different perspective.

When it comes to this case, although it may have
been easier for the cardiologist at Hospital X to care for the
patient, there is no particular evidence to suggest that this would
have necessarily prevented the patient's death.

Issue 2: Armed with the
knowledge that the patient was just discharged from Hospital X,
what policies in EMS and ED systems may have necessitated transfer
to Hospital Y, which was farther away? In considering this
question, the first issue is determining whether the patient would
have been classified as "unstable." Policies are different when
dealing with these patients than when dealing with stable patients
with normal vital signs.

It is impossible to know precisely why EMS took
this patient to the farther hospital, but two possibilities come to
mind:

1. Hospital X and Hospital Y were both
appropriate facilities, and Hospital X was "on diversion" (not
accepting patients).

2. Hospital Y was considered the closest
appropriate facility because EMS was concerned about acute
myocardial infarction, and Hospital X may not have had cardiac
catheterization facilities.

Ambulance
Diversion

Some hospitals have "ambulance diversion"
policies that are activated when the ED reaches a certain level of
crowding.(1) The
purpose of diversion is to signal to EMS that hospital services
cannot accommodate additional patients. A central cause for ED
crowding and ambulance diversion is hospital crowding.(2)
Over recent decades, there has been a reduction in the number of
hospital beds across the United States.(3) In competitive environments, one strategy employed by
many hospitals to maximize profitability is to operate at high
occupancy and prioritize elective admissions.(4) Subsequently, during daily surges of ED patients
requiring admission, demand for inpatient bed capacity commonly
exceeds supply, and ED admissions board in the ED for long periods.
When the ED is boarding admitted patients, the remaining beds
saturate. And as effective capacity to care for new patients is
diminished, new patients experience long waits. During these
periods, many hospitals will use diversion to direct ambulance
traffic elsewhere. In the case of an "unstable" patient like this
one with an AICD firing, it was possible that ED crowding in
Hospital X and ensuing diversion may have resulted in the decision
to drive farther to Hospital Y.

EMS Destination
Decisions

EMS considered acute myocardial infarction as a
potential cause for the AICD firing. EMS may have considered
Hospital Y the closest appropriate facility because it had better
capabilities (such as cardiac catheterization services) than
Hospital X. For "unstable" patients, EMS policies are designed to
match hospital capabilities with patient complaints. For example,
EMS ambulances may bypass local hospitals to bring patients to
Level I trauma centers, stroke centers, or centers with cardiac
facilities. Recently, EMS has also considered the ability to
provide therapeutic hypothermia after return of spontaneous
circulation in cardiac arrest in making destination
decisions.(5)
However, in most cases, critically ill patients (such as those in
respiratory distress) are taken to the closest hospital, where
decisions to transfer to a higher level of care can be made after
stabilization.

When it comes to both stable and unstable
patients, there are no federal destination policies or regulations.
Policies are made locally (state, county) by EMS medical directors.
Accordingly, policies may be very different depending upon the
local geography and EMS and health system resources. In general,
EMS medical directors are authorized to determine specific zones of
transfer hospitals for the 911 system. Stable patients may request
transfer to a particular in-zone hospital (consideration is given
to where they receive regular care). But when there is a request or
indication to transfer outside the zone, EMS providers must contact
a supervisor or online medical command to determine the most
appropriate facility.

In some cases, this system may seem
counterintuitive to hospital-based providers, who may ask: "Why
didn't they just bring the patient back?" But EMS providers prefer
to stay in-zone to ensure that ambulances are available when a
patient truly has a life-threatening emergency. Taking an ambulance
out of service for even a short period can have devastating
consequences if that out-of-zone ambulance is needed but unable to
respond.

Federal regulations do come into play when there
is an EMTALA issue. EMTALA is a statute that regulates treatment
refusals and transfers between hospitals for unstable
patients.(6)
Since EMTALA was passed (1986),
several court decisions (i.e., case law) have updated its
interpretation. The most applicable case was in 2001 (Arrington v.
Wong).(7) In
Arrington, EMS contacted online medical command for a patient with
shortness of breath/respiratory distress. The physician directed
the patient to a facility that was farther away (where the
patient's doctor was), and the patient died shortly after ED
arrival. In the appeal ruling, the court determined that if an
ambulance contacts a hospital, that hospital must provide
emergency care for that patient under EMTALA rules, unless that
hospital is on diversion. In this case, if the ambulance had made
contact with an online physician at Hospital Y, then Hospital Y
would have violated EMTALA if it failed to provide emergency
stabilization services.

Issue 3: Assuming continuity of
hospital care is important, can we improve the current system to
better balance EMS resource use and continuity for complex
patients? This question applies primarily to stable patients
because EMS systems are designed to direct unstable patients to the
closest hospitals with appropriate facilities. I see two
possibilities:

1. Ensure that patients are transferred to the
right hospital after stabilization.

2. Reconsider EMS policies so that stable
patients are directed to the right hospital the first time
around.

Transfer after
Stabilization

Should there be an explicit policy to repatriate
all complex patients to home hospitals after stabilization? In my
judgment, probably not, for the following reasons: (i) it would be
difficult to interpret and enforce the policy because many patients
are cared for by several hospitals, and (ii) hospitals may not want
to transfer patients for economic reasons and may resist the
policy, particularly in the absence of literature demonstrating
that such a policy would improve outcomes. The better possibility
is to reduce administrative barriers to transfer. Providers can see
transfer as more work than an admission and often encounter
labyrinthine processes: paperwork, finding accepting physicians,
many phone calls. Streamlining processes for easier transfer
between facilities may allow for better continuity of care.

Changing EMS
Policy

This is a tougher issue. Because EMS policies are
local (appropriately so because of variability in local resources
and system constraints), making sensible, national policy to
repatriate complex stable patients would be very difficult. One of
the solutions proposed is "systems status management" where
ambulances are on standby when a local ambulance goes
out-of-zone.(8)
However, these systems can require considerable coordination and
expense. In addition, they may not work in areas with long
distances between hospitals or with few ambulances. The other
possibility is to expand zones, but that would be a local decision
by the EMS medical director.

Take-Home Points

  • Continuity of hospital care may be
    better for patients, but there is little evidence to demonstrate
    this.
  • EMS policies are determined locally, and
    these policies must differentiate between "stable" and "unstable"
    patients.
  • Ambulance diversion may cause EMS to
    bring patients to hospitals where they have not previously received
    care.
  • Federal EMTALA laws can play into EMS
    decisions when contact is made between EMS and online medical
    command.
  • Solutions may exist to repatriate
    stable, complex medical patients to home hospitals, but changing
    EMS policy may not be the solution.

Jesse
M. Pines, MD, MBA, MSCE
Associate Director, Division of Emergency Care Policy and
Research
Assistant Professor of Emergency Medicine and Epidemiology

Hospital of the University of
Pennsylvania

Faculty Disclosure: Dr. Pines has
declared that neither he, nor any immediate member of his family,
has a financial arrangement or other relationship with the
manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, his commentary
does not include information regarding investigational or off-label
use of pharmaceutical products or medical devices.

Acknowledgement:
Dr. Pines would like to thank Ray Fowler, MD, Crawford Mechem,
MD, and Edward Dickinson, MD, for their help in preparing this
commentary.

References

1. Pham JC, Patel R, Millin MG, Kirsch TD,
Chanmugam A. The effects of ambulance diversion: a comprehensive
review. Acad Emerg Med. 2006;13:1220-1227. [go to
PubMed]

2. Moskop JC, Sklar DP, Geiderman JM, Schears RM, Bookman KJ. Emergency department crowding, part 1-concept, causes, and moral consequences. Ann Emerg Med. 2009;53:605-611. [go to
PubMed]

3. Sun BC, Mohanty SA, Weiss R, et al. Effects of
hospital closures and hospital characteristics on emergency
department ambulance diversion, Los Angeles County, 1998 to 2004.
Ann Emerg Med. 2006;47:309-316. [go to
PubMed]

4. Pines JM, Heckman JD. Emergency department boarding and profit maximization for high-capacity hospitals: challenging conventional wisdom. Ann Emerg Med. 2009;53:256-258. [go to
PubMed]

5. Hartocollis A. City pushes cooling therapy for
cardiac arrest. The New York Times. December 3, 2008. [Available at]

6. Emergency Medical Treatment and Active Labor
Act (EMTALA). [Available at]

7. Hayes CM. New EMTALA ruling makes ambulance
diversion rules more confusing. EMSVillage.com. [Available at]

8. Dean S. The origins of system status
management. Emerg Med Serv. 2004;33:116-118. [go to
PubMed]