Transferring Patients

[ILoveHorses]

I have a question that I need answered. Everyone knows that you don't take a stable medical surgical inpatient and move them to the emergency room. What I need is the documentation to support that. I have been looking everywhere and can't find it in writing. Any help would be greatly appreciated.

[MunoRN, RN]

It would be helpful to know why you want to send a hospital inpatient to the ER, since that would then clarify any legal or regulatory issues related to this.

One of the issues would be an EMTALA violation, particularly if you are sending an inpatient to another hospital via the ER just to basically get rid of the patient. There are valid reasons to send an inpatient to the ER, I once had a patient whom the covering physician refused to give any orders on because the primary physician had neglected to give them report on the patient, we declared the patient abandoned by the primary physician and the patient was sent to the ER, but those exceptions are extremely rare.

[ILoveHorses]

The CRNA wanted to give Ketamine to a stable pediatric patient to start a peripheral IV without first attempting without meds.

[MunoRN, RN]

The CRNA wanted to give Ketamine to a stable pediatric patient to start a peripheral IV without first attempting without meds.

I don't understand why that would necessitate a transfer to the ER?

[ILoveHorses]

The trip to the ER was made due to the ketamine. Not enough staffing to do sedation on the floor. Also lacking in proper equipment for sedation on the med/surg floor.

[MunoRN, RN]

While ketamine can be used in place of sedatives for procedural sedation, it is actually a dissociative and not a sedative, it is more than safe enough to be used to help kids tolerate uncomfortable procedures on regular medical, surgical, or peds units and does not require intra- or post-procedure 1:1 monitoring.

[bugya90, ASN, BSN, LVN, RN]

We wouldn't transfer them to the ER. They would have to have critical care staffing for this patient so the 1:2 for ICU or 1:3 for ER. If we couldn't send them to ICU then a float nurse would be pulled to our floor to assume care. Most of our float nurses can do everything from lower acuity ICU patients to Med-Surg.

[JKL33]

The CRNA wanted to give Ketamine to a stable pediatric patient to start a peripheral IV without first attempting without meds.

This is not the same situation as administering, say, ketamine/versed/atropine.

I can't see much of a legal problem if this was basically the idea of "using a room" or borrowing a staff member as opposed to inappropriately discharging an inpatient so that they can be seen in the ED, and it also doesn't trigger a new ED EMTALA obligation - but it's certainly an abuse of ED resources, since the ED is obligated to all the patients who have not yet been screened and/or don't already have the benefit of an admitting service assigned to their care. The situation you describe is unnecessary and isn't the best way to care for inpatients who need something that freaks out someone on the floor - - especially as a one-off where there isn't a legally-vetted process/policy in place. It comes with a lot of unnecessary but understandable angst.

There's another problem if they send the inpatient to ED wanting the ED provider to initiate and be responsible for specific orders for an inpatient. This could run afoul of credentialing....depending.

[hawaiicarl, BSN, RN]

I think the usual concern is that you can't send a patient from an inpatient unit to an outpatient unit. Your situation sounds totally different though. If ER nurses are the only nurses in your facility who can monitor conscious sedation, I would have one of them come up to the unit for the procedure. I think a lot of small hospitals have this problem where only certain types of nurses get trained in conscious sedation, I forget when JHACO started requiring that.

Cheers

[ILoveHorses]

Thank you everyone for relieving all doubts that I had.