ED-to-ED Transfers: Optimizing Patient Safety

Case Commentary

Obstetrical emergencies are challenging even in a fully supported ED, and these challenges are heightened significantly in EDs that lack obstetric and pediatric support. In retrospect, it is truly difficult to determine if any action could or would have altered the outcome of this case.

In some circumstances, determining that a patient is “stable for transfer” or that the benefits of a transfer outweigh the risks is complicated and difficult. In this case, the patient was never “stable,” as she was in active labor. The EMTALA statute and its provisions govern when and how a patient may be transferred from one hospital to another when an unstable medical condition exists, but does not prohibit transferring an unstable patient. The OB’s understanding of the law was mistaken by the assumption that the patient was unstable and therefore could not be transferred at all.² The essential provisions of the statute state that any patient who comes to the ED requesting examination or treatment for a medical condition must be provided with an appropriate medical screening examination to determine if (s)he is suffering from an emergency medical condition.³ If (s)he is, then the hospital is obligated to either provide him/her with treatment until (s)he is stable or transfer him/her to another hospital that has the capability to provide definitive care for the patient, and the benefit of transfer for this stabilizing care outweighs the risk of the transfer.³

Under the circumstances of this case scenario, it seems reasonable to transfer a pregnant patient in labor if the transferring physician felt that the safety of both mother and baby would be best served at the receiving hospital with specialized services and that the timing of the transfer was appropriate, considering the clinical findings and distance to the receiving hospital—with anticipation that delivery is most likely to occur after arrival at the receiving hospital.⁴ Again, this is a very complex situation, and the possibility exists that if the transfer proceeds, delivery could occur in the ambulance, which may introduce an additional potentially adverse event.

There is no time to delay in this decision-making process, and the risks and benefits of transfer are not clearly defined. The additional circumstance of an extremely preterm infant who will require specialized NICU care augments the need for expeditious transport to the sister hospital, as contrasted with active labor in a full-term gestation.  

Part of EMTALA states “hospitals with specialized capabilities are obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions.” In this case, the risk of delivering such a preterm infant at a hospital not equipped with even basic obstetrical and pediatric services may outweigh any potential risks of transport to a sister hospital 13 minutes away by ground transport. To mitigate the risk of an in-transit delivery, supporting the transport team with a physician or registered nurse to ride along may have been an option.

Finally, delivery of the premature newborn created a second unstable patient in even greater danger than the mother. Interhospital transfers of critically ill and injured pediatric patients to pediatric hospitals often involve specialized transfer units staffed by expertly trained paramedic and/or nurse teams under the medical control of the pediatric hospital. The unfortunate outcome of this premature infant may have been the ultimate outcome at 24 weeks, despite the extubation and inability of the team to re-intubate. However, communication with the EP in the department in the decision to change the ET tube may have been helpful to the team in the face of a difficult re-intubation.  

Opportunities for Patient Safety Improvement. A solid understanding of the EMTALA statute and its provisions is essential not only for providers in the ED, but also for consultants who must understand their responsibilities under the law. Timely transfer arrangements cannot be underestimated, and hospital policy should support expeditious positive responses in emergent situations. Active communication between the sending EP and transport team while still in the ED is prudent.  

Conclusion

Interhospital ED-to-ED transfers are frequent occurrences in many EDs. An ED-to-ED transfer of a patient is a process that often involves complex decision-making and a rapid but thorough assessment of the potential risks and benefits. At each stage of the transfer process, each party involved must anticipate, to best degree possible, patient risks and communicate these risks clearly from the pretransfer phase to the transfer team and to the receiving facility. Assurance of the six aims of the Institute of Medicine⁵ are central to good decision-making that leads to an appropriate disposition of patient transfer to another ED. These aims demand that care delivered is safe, timely, effective, patient-centered, efficient, and equitable.⁵ When interhospital ED-to-ED transfer is deemed necessary, the sending provider generally is responsible for making certain the right care at the right time is safeguarded from the time the patient enters the ED until he arrives at the receiving ED. The receiving ED then completely assumes the responsibility to evaluate and manage the patient until the definitive caregiver takes over.