new to the ER with a question for you experts :)

Altra, BSN, RN · Jan 15, 2011

ER boarding of admitted patients who don't yet have a bed is one thing ... it's a disaster waiting to happen and has been previously discussed.

But to take a patient previously admitted to an inpatient unit, pack them up and transport them to a bed in the ER?? I confess that's a new one for me. There are so many things wrong with this it's hard to know where to start.

If they, on paper, remain under the care of the admitting physician, it *might* fly as far as EMTALA. But if this ER is in a state which, like several, has in recent years tightened its regulations regarding situations where hospital ERs can go on divert, that might be the way to get it addressed. One or two reports to the health department that your hospital had to go on divert because inpatients were being physically transferred to ER beds should definitely get someone's attention.

LilgirlRN, ADN, RN · Jan 19, 2011

Our administration will no longer let us go on diversion. Doesn't matter if there is not ONE bed left in the house. To me, this seems to violate EMTALA. If we knowingly accept a patient from the field or another hospital that will need an ICU setting and we don't have a bed???

I suppose it also depends on their view of nurses. Are ER nurses critical care nurses? IMHO, yes. I do many of the same things ICU nurses do everyday. We intubate patients everyday. Use ACLS in some form everyday. Pressors, yes. Hang blood, yes. Monitor vitals and rhythms, yes. Interpret labwork, yep. However, can I give my ICU patient all the attention he deserves? Probably not. I may have 3 others besides him to take care of.

Yesterday I was off, they called and said they were holding 10 admits in the ER. Can you come help? No, sorry. CYA is the name of the game. I don't want to be involved with a situation that could lead to a lawsuit.

Esme12, ASN, BSN, RN · Jan 20, 2011

esme- good info. would it still be considered emtala if they were under the care of the admitting inpatient physician and not the ed physician? they were just geographically in the ed area? this is where i was coming from in my initial response of it not being emtala.
such an informative thread!

technically,no...... because they are still under the care of another md; they are just taking up space in an area called the ed that has monitors. but the ed md can have no involvement in the patients care. that is how the system is circumvented. but if a violation occurs the hospital is not obligated to self report therefore, the problem of ed misuse continues and the patent is "transfered"(dumped) back to the ed. thus increasing risk and decreasing quality but the heavier liability is on the ed nurse because she/he is responsible for both inpatient and ed patients........someone will ultimately suffer. i have always argued it is a violation of emtala and is going to a "lower" level of care.....where i have managed/worked i have won the arguement inpatients do not belong in the ed........the liability and quality alone is cause not to follow this practice.

originally, emtala was dubbed the "anti-dumping law" as years ago ambulances would go hospital to hospital looking for an ed only to be "dumped" to the next. there were plenty of suprise "dumps" that would show up as a "transfer" from another facility as ambulances were sent to other facilities based on ability to pay.......and yes, this really happened. ambulances were owned by the hospitals or an involved third party and they would triage from the field based on insured and uninsured. they could be in front of the hospital and would send the patient to the "charity hospital". true story! or pack up someone delivering a baby to "transfer" them to a hospital with an ob unit. now those were nightmare transfers. they were not required at that time to even ensure that there would be a bed at the other hospital. this was thankfully was not the standard for most facilities but it was frequent enough to madate federal law.

this is why some states and individual facilities have eliminated diverson. it is being looked at as an emtala violation by the hospitals surrounding the facility on diversion. the facility on diversion is "dumping" on the surrounding hospitals thus making it miserable and dangerous for everyone. emtala ensures a "treat and secured transfer" when a hospital is on diversion patients that would "normally" go to a particular facility are sent to another now stressing the police and fire departments of critical coverage for their districts and the patient has a longer transport to stabilzation at an ed thus causing a "delay in treatment". no big deal in the city.....a huge deal for rural areas with limited and/or volunteer coverage. i worked at a hospital that had a hospital that was on diversion more than it was off diversion and they refused to play nice therefore constantly over whelming my ed.

in my state there was a leveled system adopted for levels of diversion green, open [color=yellow]yellow,caution....critical can still be accepted but consider strongly another facility red, no traffic accepted ed gridlock and black,internal disaster....no traffic, diversion system. no 2 facilities within districtrict can be on red diversion at the sametime or both return to green or yellow status. manditory updates were required every 4 hours. i would call the powers that be and place my facility on red divert just to dump them back to an open status for 4 hours because we were drowning. but resources were still streched and delays in treatment were increasing not decreasing and patient were suffering due to the delays because of transport.....the "treat and transfer" go to the closest facility have been returned and diversion status has been deleted. but the overcrowding continues.

this is not a simple issue. as hospitals try to do more with less.......beds will remain closed and flucuating census influencing staffing patterns emergency departments will continue to bear the brunt of this do the most with the least mentality and alternative solutions need to be explored like cdu's (clinical decision units) and float staff but alas............they all cost money and using money is a hard cell to the "higher up's" in an already high liability area of the hospital.......the stakes just got higher and things like that article on here...... 5 hour wait in ed caused amputaions of limbs will probaly continue to increase....... :crying2:

edrnbailey · Jan 24, 2011

EMTALA (Emergency Medical Transport and Active Labor Act) refers to transporting patients between facilities. I don't see how it applies to bringing someone downstairs. I agree that boarding patients sucks for everyone but I don't see how it is against the law. In the long term this should not be the default method that admin uses for overflow or changes in acuity, but in the short term it is the best thing to do. I think it is certainly safer than leaving a critical patient on a non critical unit.

It is not an EMTALA violation. However you may want to check CMS regulations. You are moving a patient from the inpatient service to the outpatient service. CMS includes ED as "outpatient". I remember being told we could not move patients for that reason just can't recall off the top of my head where it stemmed from. Sorry!!! Reimbursement is a BIG deal these days. Also there is the part where CMS states there doesnt have to be any INTENT to defraud to be found guilty of it. I don't mean to sound negative or scary, but there it is. Hope this helps or at least gives you another path to search, because we all agree this is not the best practice for patient safety.

Esme12, ASN, BSN, RN · Jan 25, 2011

it is not an emtala violation. however you may want to check cms regulations. you are moving a patient from the inpatient service to the outpatient service. cms includes ed as "outpatient". i remember being told we could not move patients for that reason just can't recall off the top of my head where it stemmed from. sorry!!! reimbursement is a big deal these days. also there is the part where cms states there doesnt have to be any intent (another good point)to defraud to be found guilty of it. i don't mean to sound negative or scary, but there it is. hope this helps or at least gives you another path to search, because we all agree this is not the best practice for patient safety.

oooooo.......good point.......cms regulations.....

https://www.cms.gov/home/regsguidance.asp

and another really cool and informative website.....

http://www.healthreformwatch.com/2010/05/10/cms-regulations-in-the-best-interest-of-patient-care-or-the-industry/

2009 cms final rule 1390-f

upon review of solicited comments, cms ultimately decided not to adopt the 2008 proposed rule clarifications in its 2009 final rule regarding transfer and inpatient care requirements under emtala. instead, in the [color=#2255aa]2009 final rule, cms stated that under emtala individuals can only be appropriately transferred to another hospital for specialized stabilizing care where two requirements are met: (1) the individual must have an emergency medical condition that requires specialized stabilizing treatment not available at the hospital where the individual is first screened, and (2) the individual has not already been admitted as an inpatient.

but when patients are just boarded, not admitted, in the ed.......they technically can get away with it. emtala is all about transfer to another facility.....but i believe the requirement of "has not already been admitted as an impatient" still applies.

amandagbrink · Apr 20, 2015

This has happened at my hospital. We've had to take post-op patients back in the ED because there weren't any rooms for them to go to. This article articulates the EMTALA side of this problem well. Probably something administrators will ignore until someone successfully sues.

https://sullivanlaw.wordpress.com/2011/02/06/bringing-inpatients-to-the-emergency-department/