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.