Transferring patients to larger hospitals...

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    I don't know if it is just our particular facility or what, but we have had major problems getting the larger facilities to accept pts for transfer. We are a small hospital, and there are certain conditions we are not equipped to handle. But lately when our family docs have tried to get a patient to a larger facility, no physician wants to accept them. I am talking about cases like a 13 y/o with a grand mal seizure (with no history of seizures) who is post-ictal for hours. We do not have a neurologist or a pediatrician on staff at our facility.... took about 14 hours to convince a peds guy to accept this kid....(kid ended up having viral encephalitis)...complicated pneumonia in a young adult failing to respond to antibiotics...the docs at the larger facilities don't want to accept these cases....gets real frustrating at times....anyone else running into this problem?
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    I work at a very small rural hospital. And occasionally we do have a problem getting a doctor to accept a patient (especially a patient without insurance with an orthopedic problem). However, there are two teaching hospitals within a couple of hours and these hospitals will usually accept anyone.
    I think this is something your administration needs to addess. I don't know what kind of liability your hospital would have if a patient is harmed by a delay in their care because you can't get an accepting doctor.
    There are a lot of unique challenges working out in the boonies.
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    Don`t have a problem getting an accepting doc, but DO have problems getting a bed...Have had some patients waiting for 2-3 days at times....ARRGH....................Some times the big boys really are full, but other times, just not enough nurses........One of our cardiologist,who comes up here once a week,is very good about accepting almose any patient we want to get to big city, he figures that even if NOT cardaic patient, once patient is down there, he can consult with appropriate specialists...works..most of the time...
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    Cardiology is usually the one area we don't have trouble getting accept. We have cardiology coverage M-F and one of the docs is a homegrown doc, and most of the townsfolk really like him. Neuro and peds have been are biggest problems lately. And I am not talking about little bitty things either. One was a C2 fracture for crying out loud. Our facility has absolutely no business messing with this type of patient except for stabilizing them and moving them on.....the other case was a 13 y/o kid who had a witnessed grand mal seizure (with absolutely no prior seizure history). Spent about 8 hours trying to convince peds that he needed further evaluation and work-up. Finally got him transferred....kid had viral encephalitis....I mean come on. My other favorite thing is when a patient has surgery at one of the "big" hospitals and then complications set in and they pt comes to our facility. The family docs will contact the surgeon (who doesn't come to our facility) about the patient. Sometimes it is just a case of dehydration from post-op N/V, but sometimes it is more serious. The surgeon doesn't want to take them!! My feeling is they created the Frankenstein, let them fix the monster....
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    At our hospital, when we have trouble transferring directly to the appropriate service we call the ER and transfer them to the ER of the chosen hospital. It is a little sneaky, but sometimes if the pt doesn't get the higher level care they will not survive, and some docs hate getting out of bed.
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    No trouble getting the bigger hospitals to accept transfers from here. We usually go with the hospitals our outreach docs come from, so we already have a relationship with them. Some of our younger docs like to use the hospitals they have done their residencies at, and this also seems to grease the wheels.

    The transfers we have a harder time arranging are the psych. patients, the OD's, the drunks needing detox, the acute exaserbation of confusion/dementia. These can be very aggrevating to try to accomplish!
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    Two words (acronyms):


    EMTALA/COBRA
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    Canoehead
    Babs is right on it!! There is nothing sneaky about ER to ER transfers!! That is the EMTALA. Most specialists do not want to accept a patient and most hospitals shudder over direct admits in the middle of the night, what a lovely world it would be if a general ist or hospitalist just happily accepted every pt from a rural ER.

    One thing we do where I work is hold the patient in ER til am (not my favorite) then the MD may have an easier time getting a specialist to accept, if not good old EMTALA still allows-mandates actually that we transfer to higher level of care, so ER to ER they go. Of course the ER does have to accept, but they can get cited for refusal unless on bypass, and most don't want to go that route-something about federal money-----
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    Not all hospitals have rural transfer coordinators, but thats what i do. I work at a 600 bed hospital in Arizona. We have a 1 -800 line - one call does it all. I find patients admitting doctors, specialists and a bed. We are here 24/7 waiting to get those calls from those rural facilities. Some specialties we don't have very good luck with such as ortho and ENT, but others such as neurosurgery, toxicolgy and cardiology we have an excellent rate of getting those patients to our facility for great care. Those hospitals that are refusing your patients are missing out on a great opportunity to establish a relationship with your rural facility. Hard to believe they don't need the business!
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    I'm glad someone mentioned the EMTALA violations, i.e. patient dumping. I have generally worked in one of the larger hospitals that are on the receiving end. Before EMTALA, it was not unusual for a rural ambulance service to show up at our door with a train wreck patient and say something about the radio not working, or they tried to call and we didn't answer. That is not a good thing for the patient and facility to facility cooperation! We even had a patient show up by helicopter once without notice. Not fun.

    There are several reasons the larger hospitals may not take the patient. Generally it does involve bed placement. I worked in a 500 bed hospital that only had staff for 300, so if there is no staff, there are no beds. It doesn't matter how many empty beds there are if there is no one to take care of the patient. I have also worked in teaching hospitals/transplant centers where we may have been on divert for surgical patients because a liver/heart/lung transplant was going on, tying up a large amount of staff. Sometimes the hospital may be able to accept the patient but the surgeon/medical doc on call is not available, or just doesn't want to accept it. I am not sure what the laws are and if they "require" that a private physician accept a transfer. I know they have to see what ever comes in for the hospital where they are on call, but not sure about transfers, especially if it is not a designated trauma facility.

    Sometimes we are holding patients in the ER who should have been transfered to floor/ICU hours or days ago, and we certainly can't take anyone from outside safely. We have discharged patients from ER after holding for 48 hours who should have been floor patients.

    Staffing situations may be bad in rural areas but they are just as bad in the cities, only proportional. I currently work in a 52 bed ER and generally we are full with patients waiting. At one point on New Years Eve, we had every room full and 30+ in the waiting room. No one was happy!

    So, please think twice about sneeking around and sending a patient to another ER. Not only is it against the law, it is unethical, not fair to the receiving hospital and potentially more dangerous for the patient. You don't know what is happening on the other end of the ambulance ride.


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