Spotlight Case January 2009 To Transfer or Not to Transfer

2 Source and Credits This presentation is based on the January 2009 AHRQ WebM&M Spotlight Case –See the full article at –CME credit is available Commentary by: Jesse M. Pines, MD, MBA, MSCE University of Pennsylvania –Editor, AHRQ WebM&M: Robert Wachter, MD –Spotlight Editor: Bradley A. Sharpe, MD –Managing Editor: Erin Hartman, MS

3 Objectives At the conclusion of this educational activity, participants should be able to: Explore the benefits of continuity of hospital care Understand rules and regulations behind triage and hospital choice decision by Emergency Medical Services (EMS) providers, and the roles of ambulance diversion and federal EMTALA statutes Identify ways to improve continuity of hospital care

4 Case: To Transfer or Not A 74-year-old man had a long history of coronary artery disease (CAD), requiring coronary artery bypass grafting (CABG) and an automated internal cardioverter-defibrillator (AICD) for ventricular arrhythmias. The AICD was almost 10 years old, and his cardiologist found minor lead displacement. Admitted to Hospital X (less than one mile from his house), the patient underwent placement of a new AICD—a minor surgical procedure, which was uncomplicated. He was discharged 2 days later.

5 Case: To Transfer or Not (2) Within hours of arriving home from the hospital, the patient’s newly placed AICD began “firing”—shocking his heart with large amounts of energy and causing considerable pain. As the AICD fired more than 15 times in the course of minutes, his wife called 911. Emergency Medical Services (EMS) arrived and found him lying on the couch, awake and alert, but in discomfort. His heart rate and blood pressure were normal. Because of repeated AICD firings and concern for a heart attack, he was taken in the ambulance.

6 Case: To Transfer or Not (3) The patient told paramedics that he had just been discharged and received all of his care at Hospital X. However, they took him to Hospital Y, a few miles away. In the emergency department (ED), the patient’s AICD continued to fire shocks. The defibrillation stopped after treatment with amiodarone and supportive care. The patient was then admitted to cardiology at Hospital Y for ongoing management. The next day, when the patient was clinically stable, the cardiologist considered transferring him back to Hospital X, but decided to keep him at Hospital Y.

7 Case: To Transfer or Not (4) Unfortunately, the patient continued to have more ventricular arrhythmias and firings of his AICD even with medical treatment. Despite maximal efforts, the patient eventually died from a cardiac arrest. It was unclear whether the patient’s death could have been prevented had he been taken to Hospital X. However, one could argue that he may have received better informed care had he been admitted to his original hospital.

8 Issues from Case Safety for prehospital, emergency department (ED), and hospital care Did decision by EMS to take patient to Hospital Y contribute to patient’s death? Should cardiologist at Hospital Y have transferred patient back to Hospital X? Is continuity of hospital care associated with better patient outcomes?

9 Continuity of Hospital Care There are no studies comparing outcomes for patients with continuity of care (same hospital, same doctor) versus those cared for by different doctors at other hospitals To explore this issue, must rely on clinical experience and common sense

10 Weighing Continuity of Care In general, continuity of hospital and physician care may be better for patients: –Providers are familiar with current and past medical history and social history –Time is not spent obtaining and reviewing medical records Transferring care between physicians could potentially improve care if a ‘fresh set of eyes’ identifies previously overlooked diagnosis

11 Continuity in Present Case In this case, it may have been easier for the cardiologist at Hospital X to care for the patient However, there is no evidence to suggest this would have prevented his death

12 EMS Triage Question Given the patient’s recent discharge from Hospital X, why did EMS take him to Hospital Y, which was further away?

13 EMS Triage Decision Impossible to know precisely why EMS took patient to further hospital Two possibilities: –Both hospitals were appropriate, but the ED at Hospital X was “on diversion” (not accepting patients) –Hospital Y was chosen specifically because it could better care for the patient

14 ED Crowding and Ambulance Diversion Some hospitals have ambulance diversion policies when the ED becomes too crowded Hospitals more crowded due to reduction in hospital beds; EDs frequently full of patients waiting for beds This backup can lead to ED overcrowding, leading new patients to be diverted to other hospitals In this case, Hospital X may have been “on diversion” so the patient was taken to Hospital Y See Notes for references.

15 EMS Destination Decisions There are no federal regulations or policies that dictate EMS decisions about where ambulances take patients Policies are made locally (state or county) by EMS directors Most cities or areas are divided into zones; patients in a particular area are taken to EDs in that zone Ambulances try to stay in-zone so they can easily respond to life-threatening emergencies

16 Ambulance Destinations Ambulance destination also depends on the stability of the patient For ‘unstable’ patients, EMS policies are designed to match hospital capabilities with patient complaints –For example, ambulances may bypass local hospitals to bring patients to Level I trauma centers, stroke centers, or centers with cardiac facilities Critically ill patients (e.g., in respiratory distress) most often taken to nearest hospital, after which transfer decisions can be made

17 EMTALA Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal statute that regulates treatment refusals and transfers between hospitals for unstable patients See Notes for reference.

18 EMTALA and EMS EMTALA can dictate ambulance destination in specific situations: –If an ambulance contacts a hospital about a patient en route, that hospital must provide emergency care for that patient under EMTALA rules, unless that hospital is on diversion In this case, if Hospital Y was contacted about the patient, they were required to provide emergency services See Notes for references.

19 Improving EMS Systems EMS systems are designed to direct unstable patients to closest hospital with appropriate facilities If continuity of hospital care may improve patient outcomes, how can we improve the system to ensure maximal continuity for stable patients? Two possible areas of focus: –Transfer patients to the right hospital after stabilization –Reconsider EMS policies—direct stable patients to the right hospital in the first place

20 Transferring Patients to Right Hospital Difficult to interpret or enforce a policy mandating this transfer Patients often cared for at many hospitals May adversely impact hospitals financially May be possible to lower administrative barriers and make transfer of patients easier (reduce paperwork, phone calls, etc.)

21 Changing EMS Triage Policy? Difficult to implement national policy given variability in local resources and system constraints One possible solution is “systems status management” where ambulances are on stand-by when local ambulance goes out-of-zone Regional areas could consider expanding zones of coverage; would be a local decision See Notes for reference.

22 Take-Home Points Continuity of hospital care may be better for patients, but there is little evidence to demonstrate this EMS policies are determined locally, and these policies must differentiate between ‘stable’ and ‘unstable’ patients Ambulance diversion may cause EMS to bring patients to hospitals where they have not previously received care

23 Take-Home Points (2) Federal EMTALA laws can play into EMS decisions when contact is made between EMS and online medical command Solutions may exist to repatriate stable, complex medical patients to home hospitals, but changing EMS policy may not be the solution