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.