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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