Emergency departments (EDs) provide the essential service of evaluating patients with unscheduled, acute, undifferentiated, and decompensated conditions. ED crowding impairs this mission. Consequences of this are well documented and include delayed treatment, exposure to error, increased length of stay, and increased mortality.¹ Hospital boarding is the main driver of ED crowding, with patients nearly always awaiting transfer to inpatient beds and now more commonly, to other hospitals.

The Emergency Medical Treatment and Labor Act (EMTALA) mandates examination, treatment, and stabilization of anyone who comes to the ED. If the patient is found to have an emergency medical condition (EMC) requiring stabilization beyond the capability of the initial treating center, receiving hospitals must accept transfer, provided that they have the capacity and capability to treat the patient.² This article discusses the practical and ethical issues of interhospital transfer of these patients.

Case

An emergency physician working in the ED of a facility without the capability to perform dialysis diagnoses a dialysis-dependent patient with acute fluid overload, significant hyperkalemia, and uremia. The emergency physician calls the region’s tertiary center, which is at 110 percent capacity, including 25 boarders and 30 patients waiting to be seen in their 50-bed ED.

When considering inter-hospital transfer, the patient’s goals of care should be paramount in guiding the process. Said goals must be discussed with the patient and the receiving facility to ensure that the transfer is consistent with the patient’s or surrogate decision maker’s wishes, and so that the receiving facility can assess their capability to respect those expectations. Greater focus on this communication is needed, as data suggest poor agreement between sending facilities, patients, and receiving facilities as to why transfers were initiated.³

While it is ideal for patients to be transferred to a hospital where they are known, that is not always possible because of the accepting facility’s capacity or capability. There are limited data on the average number of hospitals that sending facilities typically call before an acceptance, but if a patient has an EMC that requires higher-level specialty care unavailable at the initial facility, sending clinicians should pursue multiple destinations in expanding radii until an appropriate disposition can be established.⁴ Transfers of patients who are unstable or have the potential to decompensate should be prioritized. The sending facility’s current ED and hospital census should only be an influencing factor if the receiving facility is not at capacity, has appropriate resources and has accepted the transfer.

The chief difficulty for the receiving center is determining whether it has the capacity to care for the potential transfer. Tertiary centers must continuously evaluate availability of space and resources to serve patients already under their direct care, as well as predicted needs for patients for scheduled and unscheduled care. Unfortunately, many tertiary hospitals routinely operate at censuses of greater than 100 percent capacity, due to factors including insufficient acute care bed capacity, a shortage of nursing care, and misaligned incentive structures for health care more generally.⁵ In such situations, tertiary centers must make the difficult decisions of when to accept transfer patients with critical needs. Important considerations in these decisions include granular detail about hospital resources and predicted scheduled care, the availability of nearby facilities with similar capability to provide care, and whether the patient already receives care at that center. Ultimately, receiving centers must accept transfers for critically needed care that is unavailable elsewhere within a reasonable radius from the transferring center, even when capacity is marginal. Accordingly, it is a moral imperative that tertiary centers focus efforts to preserve or create capacity, including working with regional peers to load-level such transfers to satisfy their shared mission to provide both high quality, scheduled care of complex medical conditions, and acute care to their region.

It is becoming clear that EMTALA is not sufficient to address the transfer crisis. In many transfer situations, both whether the patient has a time-sensitive EMC and whether the receiving facility has “capacity” are ill-defined or uncertain. Moreover, receiving centers are financially incentivized to prioritize elective admissions and surgeries at the expense of protecting capacity for transfers requiring stabilization.⁵ This perverse incentive structure, along with the vagueness of “capacity,” encourages facilities to evaluate transfers in a way that deviates from the intended purpose of EMTALA, which is to ensure that patients’ acute needs are not in competition with the financial interests of institutions or clinicians. Currently, clarification of how “capacity” is defined and what specific circumstances constitute an “EMC” exist only through violation investigations and penalties. There is a critical need for proactive system optimization to align incentives with patient needs and provide clarity around capacity thresholds (Table 1). Without legislative or regulatory guidance and funding intervention, the challenges of interhospital transfers will continue to cause acute patient care needs to be compromised by hospital operations incentives.

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In the interim, the principles of triage in both usual and crisis standards of care should apply equally to the sending and receiving hospitals and their patients. These include assessing the acuity of each patient’s needs equitably, with safeguards against discrimination or bias. To categorically prioritize those patients already at a receiving hospital over a sending hospital has inherent bias, may run afoul of appropriate medical acuity triage, and thus is inappropriate on the grounds of both medical and ethical triage principles. Patients at both the transferring and receiving facilities have the same moral standing as persons. The triage of multiple patients across facilities requires cooperation and trust between sending and accepting facilities that must reach a mutual understanding of where the patient requesting transfer falls in prioritization for treatment. It may, therefore, be appropriate for a patient to hold and wait, as happens in every ED waiting room, but it also may be appropriate for patients in the receiving hospital to wait longer or to be relocated for the inbound patient.

A subtle practice has been described on social media outlets in which a patient awaiting transfer “signs out AMA”—perhaps with an undocumented recommendation from the sending ED physician—and then immediately presents to the destination facility’s ED. Practically, this circumvents the EMTALA and transfer obstacle, overcomes the receiving facility’s triage prioritization, and facilitates the patient’s arrival at their destination sooner. But, this is not an ethically or medically appropriate practice for one of two reasons: either (1) the patient is of sufficiently high acuity that they should have been prioritized over the receiving hospital’s patients and their transfer expedited (confirming inappropriate prioritization on the receiving hospital’s part), or (2) the patient is of appropriately lower acuity compared to the queue of patients at the receiving hospital, and the attempt to circumvent this triage harms the receiving facility’s patients.

Case Resolution

The emergency physician arranges for the patient to receive temporizing care in the ED at the sending facility by the on-call hospitalist for four hours, while a regional transfer center (unaffiliated with any specific hospital system) locates a facility to take the patient in an inpatient stepdown/ICU-level bed where dialysis can be performed.

Conclusion/Recommendation

ED crowding is a national patient safety issue driven by hospitals routinely operating over capacity. Hospitals have no financial incentive to reduce elective admissions to increase inpatient or ED capacity. Yet their crowded EDs must fulfill ethical and legal obligations to provide acute, episodic, unscheduled care to all who enter their doors. Emergency physicians and related advocacy organizations must call for legislation to better define capacity, stability, and what constitutes an EMC. This advocacy should include efforts to establish processes for centralized transfer centers not beholden to any specific organization but to our communities and the care they need. These transfer centers could be authorized to make standardized decisions about when and where patients should go, based on knowledge of regional capacity and where resources are housed.

Dr. Baker is a community emergency physician in the greater Toledo, Ohio, area.

Dr. Marshall is an associate professor and vice chair of clinical operations at the department of emergency medicine at the University of Kansas Medical Center.

Dr. Vearrier is an associate professor of emergency medicine at the University of Mississippi Medical Center.

Dr. Bookman is professor and vice chair of operations for the department of emergency medicine at the University of Colorado School of Medicine and senior director of informatics for UCHeatlh.

Dr. Kluesner is an emergency physician in Iowa City, Iowa, at UnityPoint Health-Iowa Methodist Medical Center.

References

1. Morley, Claire, et al. Emergency department crowding: a systematic review of causes, consequences and solutions. PloS one 13.8 (2018):e0203316.
2. Smith JM. EMTALA basics: what medical professionals need to know. Emergency Medical Treatment and Active Labor Act. J Natl Med Assoc. 2002 Jun;94(6):426-9.
3. Iwashyna, Theodore J. The incomplete infrastructure for interhospital patient transfer. Critical care medicine 40.8 (2012): 2470-2478.
4. Kindermann, Dana R., et al. Emergency department transfers and transfer relationships in United States hospitals. Academic Emergency Medicine 22.2 (2015):157-165.
5. Kelen GD, Wolfe R, D’Onofrio G, et al. Emergency Department Crowding: The Canary in the Health Care System. Published online 2021:26.