By Stacey Kusterbeck
An EP wants to admit a patient, but another provider raises objections. Is the level of care right? Should the patient transfer to another facility? Should this patient be admitted at all? “Working together to come to an agreement with the patient’s best interest in mind is ideal but not always easy,” says Melanie Heniff, MD, JD, FACEP, FAAP, associate professor of clinical emergency medicine at Indiana University School of Medicine in Indianapolis.
If a hospitalist, admitting physician, or consultant disputes the need for admission, EPs should consider using the available escalation process. “Plaintiff experts in particular often criticize EPs for failing to properly escalate issues,” warns Timothy C. Gutwald, JD, an attorney at Miller Johnson in Grand Rapids, MI.
EPs also can request a formal consult if a specialist says admission is not indicated. This obligates an on-call physician to visit the patient in the ED. “Refusal to respond to a request to consult likely violates hospital bylaws, and could be an EMTALA violation,” Heniff explains.
When faced with this tricky situation, EPs should carefully document discussions and remember they are responsible for clearly communicating about the patient’s condition, test results, and indication for admission. “Often, when a consultant who refused to admit a patient over the phone personally evaluates the patient, the indication for admission becomes more clear,” Heniff says.
If a patient requires hospitalization, but the admitting clinician refuses, EPs can consider other offers, according to Andrew P. Garlisi, MD, MPH, MBA, VAQSF, EMS medical director at Cleveland-based University Hospitals EMS Training & Disaster Preparedness Institute:
• The EP can notify the ED director and continue up the hospital administrative chain of command until the problem is resolved.
• The EP can require the physician who refuses the hospitalization to personally assess the patient in the ED and discharge the patient.
• The EP can keep the patient for continued observation. The EP should simultaneously go through the chain of command and find an appropriate specialist on staff to admit the patient. “If this is the only option, it is better to retain the patient than to risk a discharge with potential hazardous outcome,” Garlisi says.
• If the patient resides at a nursing facility, the EP can discuss patient care with the nursing home physician before discharge, and the possibility of the nursing home providing intravenous therapies, nebulizer treatments, or oxygen therapy.
• The EP can arrange for next-day follow-up with the patient’s physician or specialist.
Rural EDs face additional obstacles in admitting patients that increase risks for both patients and providers. Garlisi has worked in several rural EDs where the hospital staff consisted of one full-time primary care physician and a handful of part-time staffers rarely available for emergency consultation.
“Depending on the mood or work schedule of the lone admitting physician, patients could be refused admission for any number of reasons,” Garlisi explains.
This would require the EP to call other hospitals to find a physician who would accept the patient for admission. These are some reasons why EPs may be unable to admit a patient at a rural ED:
• Specialists often are unavailable. Generally, for rural hospitals, access to specialists is limited, if any are available at all. Other than the EP, a family practice physician often is the only physician in the entire hospital. “This lone family physician assumes responsibility for the admitted patient but, unlike a hospitalist, is not always physically present in the hospital,” Garlisi notes.
There probably is no on-site neurologist, gastroenterologist, nephrologist, pulmonologist, anesthesiologist, cardiologist, or even general surgeon present regularly. Virtual consults always are an option. “But, obviously, the virtual consult would be limited by lack of a hands-on physical examination of the patient,” Garlisi adds.
• Family physicians often suggest the patient be treated as an outpatient. Since the family physician is disputing the need for admission, it would make sense for the EP to ask that physician to personally examine the patient in the ED.
• Lack of available bed space is a common problem. There often is nowhere to place ED patients who require hospitalization. That means patients are stuck in the rural ED for hours or days, waiting for an available bed at a higher-level facility. “This situation forces the ED to assume the extra roles of a critical care unit and a hospital ward, but without the resources or staffing of those units,” Garlisi says.
ED nurses typically handle multiple patient assignments in a busy rural or community hospital ED. “They cannot devote the time or attention to a boarded critical patient who might require one-on-one care,” Garlisi says.
Garlisi has seen patients wait in rural EDs for several days, including patients with sepsis, gastrointestinal bleeds, and COPD exacerbations. “These boarded patients are prone to patient safety miscues for a number of reasons,” Garlisi says.
The main concern is that potentially unstable patients might have no chance of receiving intervention if their condition deteriorates. Thus, Garlisi argues that for critical patients (or those requiring specialty care or consultation), transfer to a tertiary care center is preferable. If the receiving facility is overloaded, the patient will end up boarded there instead. “But at least in this scenario, the patient has direct access to specialty service consultants who can provide timely interventions expeditiously,” Garlisi offers.
Garlisi sees serious legal risks for ED providers if a boarded patient decompensates in a rural or limited-capacity ED. “I contend that a jury would find sufficient cause for a negligence verdict in cases of boarded patients waiting for transfer who experience sentinel events,” Garlisi warns.
Such litigation, adds Garlisi, would mean potential liability for “any and every healthcare provider who interacted, or failed to interact, with the boarded patient during the duration of the patient’s stay in the ED.”
When faced with this tricky situation, emergency physicians should carefully document discussions and remember they are responsible for clearly communicating about the patient’s condition, test results, and indication for admission.
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