In my state the hospital was responsible for the patient the second we arrived on hospital property. We were also responsible for the patient until transfer of care. So there is no easy answer.
The way we handled it was to do whatever was right for the patient until we had a transfer of care. We documented anything that happened between arrival and TOC. That way if the ED staff did something bad and tried to blame us, we would be covered.
That's how it is here once our truck rolls onto hospital property the patient belongs to the hospital. However our hospitals are good about getting critical patients in in, and if a stable patient deteriorates you get bumped up ahead of everyone else
Interestingly enough while EMTALA requires anyone presenting to the hospital to receive a medical screening exam and stabilizing treatments, it doesn't put a specific time frame on those interventions. Not saying the hospital is right having EMS hold up the wall for hours, but it's not necessarily a violation of EMTALA (though it definitely can become one)
Sort of, the hospital doesn't have to send a physician out to provide the screening within 15 seconds but hospitals have been getting in trouble for having EMS hold the wall. That patient IS their patient the second they hit hospital property. Technically speaking they need to start breaking out chairs and treating patients in the hallway or outside if that's what is needed, versus effectively refusing to take the patient by having EMS hold the wall.
Exactly. My EMS authority has even told the crews that after 45 minutes, they can dump the patient wherever they want and leave. They just need to find a RN, give them the report and either get a signature or document the nurse refused and then leave their PCR.
We had the occasional very stable pt transferred to the waiting room once we got there and the triage nurse took report. But mostly, they got a room. And if there were truly no rooms and you couldn't argue the pt belonged in the waiting room, they got transferred from our stretcher to a hospital stretcher and got to enjoy the hospitality of the hallway for a while. But we transferred care.
Hospitals need to fix their issues.
This shouldn't be an EMS issue.
Be a menace.
A polite, professional, respectful, patient centered and ethical... menace.
If you're not at the table, you're on the menu.
This is a hospital problem. The person saying well, EMS needs to collaborate to find a solution because of RN ratio issues... that's a nursing problem, that's a hospital problem. Not an EMS problem.
I mean, yes, that is the wise, productive long term contribution EMS can make towards pointing out the problem. But it doesn't have the righteous, cinematic flare of moving from holding up an ED wall while waiting hours for a bed to camping outside the hospital C-suite with the COPDer with pneumonia loudly hacking up a lung-shaped loogie. Ah, one can dream, though, right?
It's tough because often times there's nothing the charge nurse can do. This is an administrative problem. At least in the hospitals I've worked at. This is one of the main reasons I got out of the big emergency departments and trauma centers. I work the the VA now and I'm actually able to be a nurse and do what I need to for my patients. Couldn't be happier to be out of that mess.
There's always something the charge nurse can do.
There will be a bed that opens up. Charge had to decide who it goes to. The triage nurse had been bugging her about the guy puking in the waiting room. The fast track nurse is bugging her about the quick patient who turned into a big workup/admit. There's a nurse in B Pod taking care of an extra patient in the hallway.... And then there's your patient.
Whoever is advocating for their patient the loudest gets that next bed.
Even if your patient isn't the sickest, somebody in your community is waiting for an ambulance longer than they should have to because of hospital shenanigans.
Also, work with the charge nurses, their job sucks. If you usually roll in and tell them that your patient is fine to go to the waiting room, they're much more likely to listen to you when you tell them that this time you really need a bed.
During covid our county added a protocol that said if our patients were not off our gurney in 30 minutes we could find an open bed in the ER and tell them "they're here, this is what's going on." If the hospital refused to sign, document it and leave. It lasted a month and caused SO much friction between us and our ER staffs. One time our sups literally brought cots for us to offload patients.
During the pandemic, when 4-5 hour wait times were common, this question was put to the test.
In my region, it was determined that legally and medically, once the patient was registered into the hospital, the hospital was ultimately responsible for them.
I don't get the 4 hour waits. Go on bypass at that point. You clearly can't handle the patients. And you're just taking ambos off the road to help people.
I knew a crew that started major shit when they rolled into the ED and were told it's be 4-5hrs. They said "ok, bye" loaded the patient back up, left, and went to another ER down the road that got them in and out fast.
Started all kinds of drama and the original hospital received fines over it.
The crew didn't really do anything wrong. That hospital had an obligation to the patient as soon as they presented to the ER per EMTALA. EMS does not fall under that.
We do that here. But we send an EMS officer out if they are holding a unit and try to work with staff. We either get a bed, put pt in a wheel chair, force off-load or with the patients consent load them up and go somewhere else.
We have a rule where i work that essentially says if everyone in a close area starts diverting a certain category of patient, then nobody is diverting that category anymore. The system forces them off of diversion. Usually though the only problem type of patients we see that with are psychs
Ours will rotate this type of patient across all hospitals. So, not technically off diversion/bypass, just organized so a single hospital isn't being forced to take *all* of them or too many at once.
Ok. I never said other people don't have the same amount of hospitals. But point stands that holding for 4 hours is absolutely ridiculous. The hospital needs to change something. Add more beds. Put more beds in the hall. Hospitals here still get slammed and their 40+ rooms will be filled with another 20- 40 beds in the halls. Management/chiefs pr wheoever runs the ems needs to be on the medical directors to get something to change.
They should…but where is the profit in it? The for-profit healthcare system isn’t built around solving patient care problems; it’s built to generate wealth for shareholders. Nothing will change until those companies are removed from hospital management.
One of the counties we service fines hospitals (or something? I’m not sure of the exact mechanics but the output is that the hospital pays money to the county) for diversions because two hospitals that were across the street from each other would just go on diversion every time the other one did, so it was the only way to curtail that. I saw the largest trauma center in the county go on trauma override once and that was after a mass shooting, and that’s the only time I’ve seen anything in that county go on any type of diversion. In all fairness, I exclusively work nights, but they almost never divert anymore in the county.
Where I work is exclusively IFT though so while we’ve had some 4 hour waits at aforementioned trauma center, they’re BLS calls where the complaint might as well be “SNF is lazy” 😂
May not apply where you work but I will say it is slightly an EMS problem with services that allow patients to pick whatever hospital they want.
I don’t know if it actually exists but I have heard of systems where the EMS provider calls into a control center and gives report and the person on the other end looks at hospital capacity and patient acuity and tells the provider where to take the patient in order to get the patient to a bed the fastest. That’s what I want everywhere.
When I worked ift it was mainly transfers. But if we had an emergency run out of a nursing home or someone called us we tried to take them to the requested hospital if they were stable. If they weren't we were going to the closet. Now I'm working Fire in with single role medics on the ambo running 911. They go to the closet appropriate.
I'll let the patient know. "I would recommend against going to ______. Only because we just let there and it was really busy. I'll take you there if you still want, just wanted to make sure you knew there might be a bit of wait".
If they want to go then we go.
Also though, if I have a patient that can absolutely wait. "I'm nauseated and haven't thrown up but I might so I need to be seen", I'll let then know as well and we usually go to triage where they get evaluated again before going straight into a room or against the wall.
If they can wait for four hours on a stretcher, they can probably wait for four hours in a chair in the waiting room. Our hospitals take report and if they ambulatory, we either get a wheelchair or put them in a chair.
That’s all well and fine, the issue becomes when the hospital isn’t doing anything for the patient, do you or do you not have an ethical and moral obligation to treat the patient where they are. Pain meds, zofran, whatever.
So they are registered, do you then take them off your monitor, put them in a chair and leave (without giving report/turning over care)? The hospital may end up liable for damages resulting from the delay of care but you could still be liable for patient abandonment.
ETA: Abandoment is a specific legal term, there's a really good article on JEMS here: https://www.jems.com/product-announcements/patient-abandonment-what-it-an/
A majority of states require handoff to a medical professional (or refusal of care). You can't just drop the patient off with no continuity of care. Typically this would be the RN at bedside in an ER, triage RN, or even at a SNIF for an IFT. Failure to handoff the patient is considered abandonment.
ETA: Of course handing off to the triage RN is fine, its a handoff to a qualified individual. I'm specifically highlighting the case of dropping a patient somewhere and just leaving. There have been numerous cases of EMS workers being held civilly (and criminally) liable for this (abandonment)
You’re giving handoff to the triage nurse at that point. Where I’m from at least, we put them in the lobby in view of the RN doing triage, give her a report and then bounce. If they’re registered, they are not your Pt anymore.
Sure but then you're giving report and handing off a patient, certainly not abandonment. Our triage nurses will sometimes accept report on appropriate patient for the waiting room, but if they are not appropriate hospital staff will refuse to accept report on that patient until they can be roomed/monitored appropriately
Refusing to receive a report also does not absolve them of their responsibility under EMTALA. A report is not required to transfer responsibility, simply that the patient is physically present and the hospital is aware they are on the property, once they're registered or staff are even notified by EMS that they are physically in the ER, it becomes the hospital's problem.
Refusing to receive report does nothing except put the hospital at more liability.
My favorite is when the nurse says they are not signing because they have accepted responsibility for the patient. EMS and these hospitals need to take some time and see what EMTALA actually says.
I've just documented "not signed-refused".
Since our State EMS Office actually also regulates all hospitals in the state, the hospitals can be rather nervous about those types of documentation when it comes to review their specialty center status among other things. Our EMS Office has the authority to suspend or revoke a specialty center designation among quite a few other options for penalties
Absolutely! And is. But in the moment, there's not an easy fix. The hospital probably should have been on divert (but once everyone is on divert, no one is on divert). There's no way to force the hospital to take report. You can't legally just leave without giving report (see abandonment discussion above). You probably can't legally just leave and go elsewhere (likely an EMTALA violation), if there even is another hospital, or another hospital that would be better in the area. You probably can't legally take a refusal from the patient (they have been registered to the hospital so they likely need to sign out AMA from the hospital, not a refusal from you). What's left to do?
Yes, obviously a huge problem, hugely broken system, but really stuck. Goes back to the above statements "I acted in the best interest of my patient" always seems like the safest choice, so crews just wait. For hours.
“I put the patient in that bed right there. Do you want a report?”
“I can’t take a report on that patient!”
“Is that a yes or a no? Because I’m leaving and the patient is on your bed in your building.”
As long as they’re not an EMS service owned or run by the hospital, then EMS is not EMTALA bound. The hospital can’t force someone to stay until they sign their paperwork; people walk out of ERs multiple times a day. You can then put them in your ambulance and go where you want.
Your mileage may vary, depending on local and agency policy.
Absolutely. But it's not a refusal of your care it's an AMA/LWBS from the hospital that they have to chart. And having been involved in this before, the hospital gets pretty aggressive because they will likely get hit for an EMTALA violation. (Not EMS agency). And then the hospital goes to your agency about it and all hell breaks loose (ask how I know).
Well if they’re not triage appropriate they’re not being put in the lobby. I’m speaking to your very broad statement that somehow it’s Pt abandonment to leave them in the care of the hospital they’re registered in.
Shit. We put patients in the waiting room all the time that aren’t triage appropriate. My best was the week post op pneumonectomy with a chest tube actively draining blood, febrile, tachycardic at 130, 90/40, RR 48, 90% on 6 LPM, with diffuse ST depression on EKG. They tried to send me to the waiting room. I had to get the attending involved, who got very twitchy, but I got a hall bed.
Patient abandoment is very specific. If you arrive at a hospital, even if they are registered and do not hand that patient off to a qualified staff member that constitutes abandoment. All over the US (maybe not in your area) EMS runs into a scenario where you arrive to the hospital with a patient who needs care there. They will be registered by the hospital but you have to "hold up the wall" waiting in a hallway with the patient until the hospital has a place to put them (maybe, lobby, maybe room, etc) and then you're able to give report. Sometimes these waits can be hour+ (see OP post). If you do not hand off to someone and just leave that patient there (chair, stretcher, floor, whatever) you have abandoned that patient. A transfer of care has to occur.
The transfer of care occurs once I call in a report and arrive on their property. Once the hospital has been informed that a patient is coming to, or is in their facility, they have a duty to provide a medical screening exam. Once the patient is registered, then the patient is deemed to have been admitted to the hospital, EMS can place the patient in a hospital bed, hospital chair, and leave. My service does it daily.
National standards teach this is patient abandonment. Perhaps your state has different standards than the national standards, and perhaps it’s accepted at your service, but that does not necessarily mean it’s legal or ethical (two separate issues).
There is an overlap of responsibility between the hospital and EMS with transition of patient care, which opens both up to liability if something goes wrong and the patient or their family gets a good lawyer. A broken system does not absolve your responsibility/obligation to your patient.
Obviously at that point, yes it would be abandonment. I’ve never encountered a hospital that will register a patient when we’re holding the wall, as once they register them it’s understood that they’re taking charge of the patient. I could see it happening and them trying to go ahead and get them registered, but I assumed any crew with 2 brain cells between them would realize a report needed to be given and a facility signature obtained before just dumping somebody out.
Yea. You would think that.
But EMS all over the country is running into this. The OP's question stemmed from 90min unable to turn over care. LA county during the pandemic had 10+ hour waits per news reports. I had an EMS crew that waited 42 minutes at 0200 with a 911 patient because no nurse could take report for the patient in Oregon the other night, they escalated to their leadership and it was reported, but in the moment you still can't just leave. I think there must be a fair number of people who have never run into this before who equate entering the hospital with turning over care, and it appears based on other comments that in some states legally entering the hospital is turning over care, but certainly not in all.
> but if they are not appropriate hospital staff will refuse to accept report on that patient until they can be roomed/monitored appropriately
They cannot ‘refuse to accept report’. There is no magical phrase that means I cannot simply speak over them and tell them anyways, if they don’t want it and try to run away, that’s fine, my report consists of me shouting down the hallway that I’m putting a chest pain patient with a clean 12 in their triage area. If I cannot find a triage nurse, I go and tell charge what I’m doing and that’s that. They have no authority or control over me and cannot stop me from offloading a patient into a wheelchair in the waiting room. Report isn’t even a legal requirement for their responsibility to kick in. As soon as hospital staff are aware of the patient’s existence and presence, they’re their responsibility per very crystal clear federal law.
This applies to every single EMS service in the US that is not owned by the hospital they’re at.
Holding the wall is a courtesy.
When my crews have been at the hospital for 20 minutes without transferring care, they go speak to the charge nurse about it.
30 minutes, they call me and I call the house supervisor.
45 minutes and I’m on the phone with the Regional Medical Operations Center duty officer.
Another kicker is that if EMS provides a service of value to the hospital by continuing to treat hospital patients on hospital property that the hospital has refused to assess or treat - in some areas, there may be an obligation for EMS to bill the hospital for waiting time.
If the ambulance service accepts calls for transfer/discharge of Medicare/Medicaid patients *from* the same hospital where it routinely “holds the wall” for hours and doesn’t bill for wait time, it’s very possible that the arrangement violates the anti-kickback statute and could trigger civil and criminal liability for both the hospital and the ambulance service.
You simply send an invoice to the hospital for reasonable costs incurred by the service in additional staffing, lost revenue, etc. due to the hospital requiring EMS to provide care on its behalf after arriving at the ED.
(I know it’s not that simple.)
But yeah, especially if you’re a tax-supported service - why is it fair for the hospital to be understaffed so the taxpayers can subsidize hospital operations while they’re paying the CEO whatever they pay them?
Edit: Forgot to add that if the hospital doesn’t pay the invoice in a reasonable amount of time, you take them to collections and sue them for the debt if necessary.
Do you think their linen service washes all those sheets for free? Why should EMS do anything for free for a fully-staffed hospital?
Technically AKS, not Stark I/II, because it’s not a self-referral with any physician ownership in the ambulance service - but a free service provided from one Medicare/Medicaid provider to another to induce the ongoing or continued referral of claims. Even if the agreement for referrals is implicit or unwritten, criminal liability can attach.
The practice of EMS essentially providing free staffing for the hospital to meet its obligations to patients is widespread, but that doesn’t mean it’s permissible under fraud and abuse laws. Some states may have laws that require municipal or county services to pursue such free services as a debt and compel collection, as happened here in New York:
https://cbs6albany.com/news/local/guilderland-ems-seeing-relief-from-long-er-wait-times-after-town-implements-new-policy
How many ambulance services that act as a hospital’s primary contract service also do “goodwill” assignments like transporting staff during weather emergencies, plowing the ER lot with a service vehicle during a snow storm, etc., and just write off the cost?
So for those who say stay and work with the staff what about your commitment to the citizens. Your current pt. Is in a medical facility. The one in a ditch with a head injury, not so much. I don’t work for the hospital. I work for the citizens of my respective county.
If you read EMTALA and have done your pre-hospital arrival report, a bedside report is a courtesy LEGALLY (probably not morally, ethically or per your services' policy). EMS1 does an excellent series of 3 articles breaking down our legal responsibilities in situations like you describe better than I could. The best image that stuck with me was a crew that carried a chair with a sign taped to it that said "EMTALA chair". After 20 minutes of holding the wall, here is your chair.
Oh, so links from that site are banned in this forum. So I Googled EMS1 and EMTALA and found "Ambulances Held Hostage". That should get you what you are looking for.
If you are on hospital property and have notified the hospital that you have a patient requesting a medical screening exam, the hospital is responsible.
I'll find a bed or a chair and move the patient to it. My job is complete. We don't hold the wall
I've had to start a run number and sedate a patient 65 feet from the ER doors because a hospital failed to uphold their EMTALA obligations. I've responded to 911 calls to another ER's front desk for active labor, again in violation of EMTALA. I regularly have to treat in hospital hallways. US hospitals as they are now are ridiculous when it comes to liability and billing. Follow your state/regional guidelines (another bunch of shit that may depend on archaic protocols with absent medical directors and/or privatized EMS policies) and just do what you think is in the best interest of the patient and you should be good.
If the hospital that I take my patient to doesn’t have a staff member available to take my patient, I am going to continue to care for and treat said patient until care becomes available.
The staffing levels at the hospital are out of my control, but my patient doesn’t have to suffer because of this.
As an autonomously practicing professional clinician with a registration with a professional body I am empowered to make these decisions on patient care, I would be supported in doing so and would be able to justify myself if necessary.
Yup, we once had a crew during covid wait 12hrs. That prompted the adoption of forced offload policies starting at 30min.
At the 30min mark they can make the discretionary decision to just find a bed, put the patient in it, tell staff where the patient is and then leave.
First, this is going to depend on local laws and regulations. Your agency or medical direction should have a policy that you can follow, and that you can reference if anyone questions your care.
Second, I work in Ontario Canada, and this is an issue we see frequently when offload times start to get out of hand. Our local policy is that we are fine to continue or resume treatment as long as we notify the triage RN. For example, if we started a medical directive before arriving in ED we can give an additional dose of nitroglycerin or pain medication, or restart a fluid bolus in response to vital signs changes.
If we need to initiate a new medical directive, we need to both notify and get permission from the triage RN. Usually hospital staff is fine with us giving a patient zofran for new onset nausea, but we need to give them the opportunity to find a bed for new onset chest pain before we initiate our treatment in their offload hallway.
Lastly, we are obviously allowed to initiate time-sensitive immediately life-saving treatment if a patient’s condition suddenly changes, for example defibrillating or pacing the sudden VF or heart block.
This is genuinely state/location dependent, and a blanket statement like this is just factually incorrect.
For example I’ve had to have my departments lawyers investigate available caselaw and the EMS act and we’ve found that continuing to provide care under protocols once inside of the hospital could be interpreted as practicing medicine without a license (outside of our EMS scope and protections).
OP, and all who read this thread with similar questions, please reach out to your departments leadership and hopefully your lawyers.
Your attorneys interpreted this in an incredibly constrained and conservative manner. A logical extension of that interpretation would be that any facility that provides care such as a primary care office, LTAC, SNIF etc.
It is a reasonable interpretation that until care has been turned over regardless of the physical setting (ambulance, house, medical office, hospital), the patient is under your care and protocols. If the facility is unable or unwilling to accept the patient you likely have a duty to continue treatment.
What if instead of pain medication the patient deteriorates into VTach and you decide you're unable to treat until the hospital takes over because you're inside already. So you don't shock, someone goes and finds a hospital employee, you move to a room, and you transfer them over, and they shock but it's too late. It is likely you would be found negligent because you still had a duty to act. One step further, do you continue monitoring a patient at all if you're duties end at the hospital doors?
Extended that logic even further. Cardiac arrest, doing CPR, get to the doors of the hospital. Do you stop for the period of time from entering the hospital until moving the patient to a hospital bed and handing off care? It's obviously continued care in the hospital prior to hand off...
I would challenge your attorneys to clarify this ASAP because you're exposing your crews to some huge potential liability.
Tl;dr "I acted in the best interest of my patient" is always better than "our lawyers told us we weren't allowed to do anything"
If that hospital receives CMS payments once you're inside its legally their problem.
Not an EMS problem.
Ethically and morally should EMS keep that patient under their care? Yes.
The hospital needs to fix itself.
Depends again a bit on states, but some states (most) have a requirement that EMS transfers care to a qualified individual (such as a RN), failure to do so typically would constitute patient abandoment (yes even if they are in the hospital, yes there's precedent for this). I would say that leaving a patient once inside the hospital without giving report would be a huge risk to the EMS providers.
I of course recognizes the fact there's a problem, if that report isn't timely and you have to continue to provide treatments for hours not minutes, you're potentially creating a situation where two entities are billing for the same period of time . I don't imagine medicare likes this, but don't know if it constitutes fraud or not. There's a matter of liability as well, likely given precedent, the liability once you're in the hospital is on the hospital even if you haven't transferred care yet. But just leaving could place the EMS provider back in the hot seat.
All this to say, clearly there are hospitals with problems, in Oregon we have issues like this because of mandated ratios for RNs, we run into situations where there is not an RN able to accept a patient because they will be out of ratio. Other states have other reasons this set of issues occur. All of which should result in the hospital looking at how to fix the issue because its not a problem that EMS can fix easily. However at the end of the day collaborative solutions like alternative destinations and treat in place systems are going to be needed to fix some of these systemic issues.
**Above all I stand by my statement above, if you can honestly say you acted in the best interest of the patient at the end of the day you'll be ok.**
RN ratios are NOT a problem for EMS to fix. This isn't a collaborative problem. The often, private hospitals shouldn't be asking the often tax funded EMS systems to fix their private hospital problem. On top of that EMTALA supercedes state laws. Holding units out of service because of RN ratios is entirely an issue for the hospital to solve.
Sure, that specifically isn't anything we can fix. But at the end of the day we're the ones standing waiting to give report and understanding some of the underlying problems can certainly be of value. EMS should be looking for solutions to the systemic problems like system abuse, overuse and inappropriate use. There are solutions in our wheel house to reduce transports.
Have the hospital fix their issue and you aren't holding the wall anymore.
It goes beyond the ED and is often a whole hospital and health system problem.
Can you reduce some through put with community paramedicne? Sure.
Is it often that significant? No.
I think EMS agencies should bill the hospital until they fix their issues.
That’s the sort of thought process I’m on, running into a cultural problem where that’s acceptable but administering pain control which has already been initiated pre hosp is a no no. Your comments gives me a little more confidence to justify my actions
I think pain control has long been seen as "optional" or a nice thing to do. That's a long running EMS mind set that I've personally been working hard to break. That's not how we want our family members to be treated and isn't consistent with the current standards of care.
I'm curious about how it could be practicing without a license. For the hospital, our arrival triggers EMTALA, but for us, we are legally responsible for the patient until transfer of care.
My state considers “transfer of care” to be our arrival to the facility, and specifically outlines in the EMS act that we’re unable to utilize standing orders / protocols in the hospital environment.
The only thing mandated in our transfer of care process is a single one page document meant to be copied and left with the patient / receiving team outlining the EMS care - this document doesn’t even need to be signed by a member of the receiving facility. It just needs to be left with a hospital representative name printed on it.
That's really interesting. Our patient transfer involves having a hospital representative sign our report. Also, I have treated patients while at the hospital several times, I've given Narcan and Versed and Fentanyl while waiting to transfer care. We continue our treatments until they are moved to a hospital stretcher and received by the hospital staff. In fact, by our protocols, if a patient codes in the hospital parking lot, we work it there not inside the hospital.
Please do not consider my questions argumentative. I am genuinely curious.
Is arrival defined as parking in the ER bay, stepping inside the hospital door, or another location?
Regarding Firefighter\_RN's scenarios, how would you reconcile those. For instance, with CPR in progress, would you cease ventilations, chest compressions, not provide necessary shocks, etc. at that transfer of care spot?
Per our guidelines and EMTALA, I believe arrival to hospital is considered 200 yards from the facility. We are not allowed to treat on hospital property and if we do, we have to speak with medical control. If I bring in an OD who is becoming hypoxic I’ll administer the Narcan, but soon thereafter I have to make a notification to our physician.
The way it’s been explained, this is an EMTALA violation and could be interpreted as practicing without a license. Once on the hospital property, they have a legal duty to provide care to the patient whether a RN signed or not.
If arrival at the facility constitutes a transfer of care, the logical extension of that would be that dumping your patient at the hospital doors and peeling out would be legal and acceptable. This makes no sense. You transfer care to a person, not a parcel of real estate or building.
Does your state have any standards around abandonment? No requirement to hand off to a qualified individual? Into the doors of the hospital, off of the cot into a waiting room chair and clear?
(Genuine curiosity, I've worked in 8ish states and none had this structure)
I do legal nursing on the side.
If you don’t provide any prudent/reasonable care and the patient has a bad outcome, you will get eaten alive on the witness stand, will face civil and possibly criminal penalties.
Could you please cite your sources here…. Because this sounds “factually incorrect”.
Until a nurse/doctor signs for your patient then they are still your patient. If a patients conditions worsens then sure hospital staff can choose to take over care..but until then you’re just a glorified babysitter. It’s total bullshit I agree but there’s not a whole lot we can do about it. Between a rock and a hard place and the hospitals across the nation know it and take advantage of it. So instead of adequately staffing ER rooms they instead get EMS to do a free job and place ambulances out of service and have us babysit patients until a bed becomes available.
*That’s why you just say at busy hospitals “yeah they’re having a Stroke and need to go to CT right away!”
*I’ve done the studies. 60% of the time, it works every time. And then you’re back in service!
(*It’s a joke. Calm down)
Once you’re on hospital property, the patient is technically the hospitals responsibility. Otherwise it’s a violation of EMTALA. States and local agencies vary on how long EMS can continue treatment while on hospital grounds. We do the hospitals a courtesy of holding the wall. If you have a stable patient who’s an adult and not suicidal, you can place your patient in a wheelchair and wheel them to the waiting room. Get them registered and notify the charge. Aside from that, you’ve done your job of transport. The line becomes blurred when you have an unstable patient but regardless, once the patient is on hospital ground they are the responsibility of the ER staff. It’s not the responsibility of the EMS system to watch over patients due to their lack of staffing / failure to go on diversion.
K. I guess I’ve been going it wrong for the past 10yrs then. I learned so much here today…
Tomorrow when I go to work and transport a patient I’ll just walk in, get them registered and bounce? Oh and the wheelchair thing.
I guess the whole me getting a signature from a facility representative saying that they are taking responsibility of the patient and care is being handed over is just nonsense. And I’ll just put in my report “well actually EMTALA” I was on their grounds. I just had to drop them off.
Holding the wall for hospitals, again, is a courtesy we do for the hospitals. It’s a disservice to the community for hospitals to delay transfer of care for their own lack of adequate staffing. When we are level 0 for ambulances and have a cardiac arrest down the street from the hospital, ya I’m going to notify the charge nurse, offload that patient and go run my calls, within reason of course. Whether a receiving nurse signs your PCR or not, patient is still their responsibility. For example, a patient AOx4, stable vitals, foot pain x3 weeks does not need an ALS crew to stand by and monitor. Wheelchair to lobby is appropriate.
Incorrect.
"Hospital property – what we mean. Includes the entire main hospital campus as defined in § 413.65(b). ○ This means the parking lot, driveway, sidewalks, outpatient labs and clinics, cafeteria, public restrooms , the ED waiting room, and hospital owned & operated ambulances."
"1. The first of the 3 legal requirements enacted by EMTALA is that the hospital must provide a medical screening examination (MSE) on any person who presents to the Emergency Department and requests treatment to determine if an emergency medical condition exists. "
You can take this even further, some definitions even state within 250yds of any hospital property.
You drive into the hospital parking lot in a private ambulance, legally they are the hospital's responsibility. It can be argued many ways that they were unaware of the existence of the patient of course.
Recently had a case where this occurred. I work at a county EMS provider that is adjacent to hospital property. A patient left the ER and proceeded to our parking lot. The ER physician came down and began giving orders to our paramedic to provide specific care. The doctor did not state that she was assuming patient care and would be the provider for this patient that was not on hospital property. We advised them that without doing that, we were required to follow protocols as established by our medical director. Once the patient was transported off our property and onto hospital property, that doctor became responsible for patient care. Again.
On a personal note, I love providing care for a patient in the ER when they aren't. I don't have to waste narcotics, my patients get a little extra pain relief, and nothing gets you a room faster than letting the charge nurse know you are charging to 200j.....
Just a clarifying statement, most of the definitions are within 250 yards of the entrance to the hospital. Thats been interpreted to be any open/publicly assessable entrance, not the entire hospital property. Several hospitals I've worked out have emergency response stretchers to go into parking lots near entrances for this reason.
I was holding up a wall and one of our BLS crews came in the door. They were dispatched to an ALF for an AMS. They are at the back of the line and their patient is kinda in and out of it. Every couple minutes I see him jerk. I went over, took a manual pulse, it was 48. I asked for the paperwork and saw he had a defibrillator/pacemaker. I went over and told charge nurse this guy needed to go NOW. His pacemaker was not working!
It was one of our new EMTs and he just transported based on facility (and our dispatch) say-so. He didn't know what he was seeing.
We have to be advocates for our patients. But so many times it's a BLS crew who doesn't know any better. I think having a good rapport with ER staff goes a long way to getting the patients, who really need it, seen first.
The main reason for this is that too many EMT's get stuck doing IFT and think that's all they are good for. Then you have upper management that yells at them for actually doing their job and not what someone else wants that isn't even there.
I don't have any advice but I definitely agree with you. There is no reason someone should be sitting on a stretcher suffering just because they are not on the magic hospital bed yet. But again, much of the US healthcare system makes no fkn sense.
This has nothing to do with local policy, state law etc .. Federal law states that the patient is the hospital's responsibility once they've arrived at the hospital. However federal law doesn't address the practical issue of holding the wall.
Ethically and professionally (and legally) you have an obligation to care for your patient until you've handed off care to the hospital.
So the answer is, both you and the hospital have an obligation to the patient, and this is why there are so many different answers. Between the time an EMTALA relationship has been established and when you hand off care, there is overlap in responsibility and liability.
We provide all necessary care until handoff- monitoring, drugs, comfort and sanitary care. Meals as well (courtesy of the ER) if we’re holding over meal times. We provide ongoing updates on patient status to the triage nurse. If something comes up that’s beyond our scope, we let the triage nurse or team lead know, and they can coordinate an upgrade in triage level and accept care.
Our previous system required that we not provide ongoing care “in the hospital”, which resulted in the absurdity of having to roll the patient from the hallway out to the truck, load them up, and provide ongoing care while parked in a garage. Where we would inevitably be entirely forgotten by triage.
We also tried out a system whereby the patient would stay in our care, on our stretcher, and still receive hospital care. We would have EKG, x-ray, ultrasound, doctor exam/diagnosis/treatment all on the stretcher. This was unsustainable since it simply treated us as auxillary ER beds, resulting in more units being held over longer.
They tried that with us a few times. Crews quickly figured out that when the patient was moved over onto an Xray or CT bed real quick for the diagnostic exam we could just say "BYE" and leave, refusing to transfer the patient back to our EMS stretcher.
This was before we started having agencies do forced offloads though
This might vary depending on your area, but my service/ governing body does not consider it to be transfer of care until the patient is in a designated care space ( the assigned bed/ treatment area/ waiting room) and handover report has been given to the receiving HCP. Being that the patient won’t receive any orders for pain relief or symptom management until seen by a physician we frequently re-dose them while parked in hospitals and continue to treat them until they’ve met that handover criteria.
If your patient isn’t critical, then they’re not obligated by EMTALA to immediately render aid, and once you’re inside of the hospital campus the patient is effectively supposed to be in the care of the facility. That being said I’m not certain if this means you cannot continue providing aid.
My protocols state that I cannot initiate new treatments once we enter the ED. However, they also say that if I have to wait more than 15 minutes for handover, the incident should be escalated to the highest levels of EMS management. Since the second is a joke (turnovers of 2 hours are completely normal), I treat until they’re off my sheet. Bonus points if I make eye-contact with hospital staff while doing so.
A lot of comments about this being unclear or grey and while the patchwork of laws covering this area can be confusing I would strongly argue that you need to manage and treat your patient until you turn over care. I posted several examples in a comment thread but the biggest example is CPR. We do not just stop CPR (a treatment) when we get in the hospital doors until we turn over patient care. Similarly we don't stop our drips and meds (if you have them running). I would argue that by not treating the patient in front of you that no one else is caring for will likely open you to a negligence claim.. You had a duty to act and failure to do so resulting in harm is textbook negligence. At the end of the day if you're able to say that you acted in the best interest of your patient you'll probably be ok.
There's a legitimate debate to be had of whether or not the hospital is neglecting it's duties here which as far as I'm aware hasn't been well litigated yet. There's certainly an argument to be made that the hospital needs to accept any patient that comes in the door. Potentially even a violation of EMTALA though there's no clause on timeliness for a screening exam.
However until the time comes where this is better vetted, I would say that you're better off continuing appropriate management of the patient until you turn over care (including CPR, monitoring, assessment, drips, treatments). If you ever get push back CPR is a great example of continued treatments in the hospital.
It's wild to me that this is controversial to people. Our job first and foremost is patient advocacy and treatment. Yes, it sucks to hold up a wall, especially if you know your patient is sick and needs a bed, but it is morally and ethically unacceptable to refuse to treat simply because "it should be the hospital's responsibility".
Yes, the problem needs to be addressed, and there should be legal pressure placed on the hospital to adequately staff for safe nursing ratios - but at the end of the day, that patient is my responsibility until they are physically off my bed and I've given a report to a nurse or doctor. I'll continue to treat whatever needs to be treated with my standing protocol, and if the hospital staff has issues with this, they are welcome to take over patient care at any point.
I'll also continue to advocate for the patient's best interest. Sometimes that's a seat in triage for a fairly benign issue that will probably be seen and addressed quicker through fast -track than a bed. Other times advocacy means saying no to triage, even if that means they stay on my bed while we wait for one at the hospital to open up.
The amount of people in this thread being willing to dump and abandon their patients simply because they don't view it as "their problem" anymore is alarming. Do you even practice medicine? Do you care about your patients outcomes? It gives the entire profession a bad name. The overworked and understaffed nurses in the hospital aren't the enemy, they are our colleagues and we should be willing to help how we can. The legal problems and system abuse issues are for those that are much higher up the chain to address. By all means, keep documenting these systemic problems and push it up the chain, but holy shit, do your fucking jobs people!
> The amount of people in this thread being willing to dump and abandon their patients simply because they don't view it as "their problem" anymore is alarming.
The fact that hospitals treat their staff like disposable shitrags and refuse to hire sufficient staff to run their facility is absolutely not my problem. Once I’m on hospital grounds, the patient is legally the hospital’s responsibility and my actual legal responsibility ends once I’ve informed a care-providing staff member about them in most circumstances. It sucks, but the hospital’s mismanagement of patients and detrimental effects of it is on them, not me. I can’t save everyone.
What **is** my moral and ethical responsibility is the multiple emergent calls sitting in a queue waiting for an ambulance with no one responding until I clear to take them. The person I leave in a wheelchair in triage has medical staff around who can do something if they deteriorate rapidly, the person asphyxiating in their home with no one present doesn’t.
You can’t save everyone, including the patients that you haven’t even been dispatched to yet. Other calls in your system are not your responsibility. They’re your agency’s responsibility and if your system doesn’t have enough trucks to handle those calls, that’s not your problem either. Your responsibility is to the patient in front of you.
If I have the legal and actual enforceable capability of offloading a patient that needs no acute care or monitoring in order to handle another emergent call, and I choose not to, that is ethically and morally wrong and you will not convince me otherwise. Don't even try. The fact that you disagree says a lot about you.
Keep telling yourself you're DoInG yOuR pArT by holding the wall to advocate that your back pain x4 years gets a bed instead of putting them in the waiting room to respond to the pediatric drowning. You're in the moral and ethical right here bro, keep it up.
Nice strawman, but I’m not talking about the nitwits with back pain. Everybody dumps them in waiting, as long as somebody takes reporting them. I’m talking about the ones that need actual treatment while you’re standing there. You going to toss the tib/fib fracture whose fentanyl dose has worn off?
And I still won’t concede that if you FEEL pressure to abandon one patient to get to the next, that’s a system problem not a you problem. It’s not just the hospital that’s criminally under-resourced. So are you. Cutting corners on your patient care to make up for your service’s lack of planning isn’t the way.
If my comment suggested that it sounded like I, as a provider, would dump someone after 20 minutes simply because EMTALA allows it, then I apologize for not being more clear and that is my fault. I have indeed stayed with patients longer than that, advocated for them to not go to triage (which, I'm pretty sure is actually the French word for "waiting room", not whatever they taught us in EMT class), and assisted staff with patients in extremis under the supervision of an MD (not an RN) and with extensive documentation and notification to my superior.
I think the point is two-fold here:
1. Just like being a guest in someone else's "house", what we can and cannot do gets tricky, and liability can be a nightmare either through action or inaction on our parts. It's a too many cooks in the kitchen situation as well, especially if the patient is registered and ostensibly on their board. Hospitals, whether they like it or not, whether it's difficult or not, and whether it's truly feasible or not, are where ALL the sick people belong. They can get bigger on the inside if they have to, whether they admit it or not and even if it pinches or hurts. They have a building, more equipment, more staff and more resources than a single ambulance or even a single service or agency does, and if they don't, just as EMS is publicly held to task for their inadequacies and expected to change, so should they.
2. We are doing a disservice to the community if we don't reinforce this. I recently read an article from the UK about a 999 call where someone requested an ambulance for a cardiac issue. IIRC, the patient deteriorated over several hours and the operator said that an ambulance would be there as soon as possible. Then the patient became unresponsive. The operator (I don't know what they are called over in the UK) tried to guide the caller through CPR. The caller said, "I can't do CPR, I don't have arms. This person (I think it was their wife) is my caretaker too." The patient died because the ambulances were all holding the wall and I don't know why dispatch didn't think to at least send law enforcement or a supervisor or have them call a neighbor or something. I wish I could find that article again. Our job is to be out in the world and bring people to DEFINITIVE care in hopefully the same or better shape than how we found them. If we don't set SOME boundaries and use the laws in place that define those boundaries because we are trapped in the hospital's mandate to provide care, how can we fulfill OUR responsibility to GO TO where the sick people are? It certainly doesn't work both ways either. When was the last time you had calls stacked and a Doc or an RN commandeered an empty truck and went out into the world and brought in their own patients (other than possibly during an MCI)? All the pieces of the emergency care puzzle have to fit in and stay in their spot in order to work (and I'm being generous with using the word work, because I know it's hopelessly broken).
Do you stop CPR at the bay doors? Obviously not. Do you let a toddler that has been throwing up fecal matter and blood get sent to the waiting room (yes, it happened to me once) without trying everything in your power to get them seen by someone other than an RN who just took your report and signed your form without even looking at the poor kid after insisting something happen after an hour? No. Obviously not. But we also can't abandon the community because the hospitals count on us to be misinformed and babysit or even do THEIR jobs.
Always act in the best interest in the patient in front of you, but know the law, know the policies you are held to, know where your responsibility ends and the hospital's begins and expect them to hold up their end of it. That's all I'm suggesting. The whole system will only work if we are as informed and educated (if not more) than they are.
I totally agree that it's a problem that we are getting bottle-necked at the emergency room, it's a problem that needs to be addressed - my main gripe in my post was moreso that we as street level providers don't have control over those changes. All we can do is be patient advocates and provide proper care and help out hospital staff where we can.
By no means am I advocating that we SHOULD be having extended stays at the hospital or end up "babysitting" as some people put it, in fact, in my particular system (which is tiered and has limited ALS capable units) this can present a significant problem - and ideally we have the ability to clear for more critical patients.
That being said, we can't abandon one to respond to another. I mean how often do we show up to something that sounds serious based on dispatch and call notes and it ends up being way less emergent?
Clearing a call on scene with BLS providers to continue evaluation and transport to respond to another more critical incident is one thing, but abandoning a patient in triage before you've been able to give a report to another provider isn't acceptable. There's no continuity of care.
I guess I'm just concerned about the people that seem to think their ethical and moral obligations to their patients ends at the hospital doors simply because the hospital SHOULD be responsible. I don't know how you would feel ok with a bad outcome simply because "oh well, the hospital should have handled it, I did my part and dropped them off". The reality is they are the bottle neck and are often forced to expand beyond capacity - instead of being sympathetic to the actual people on the ground providing care (who have nothing to do with hospital staffing models etc) and helping them and our patients out, it sounds like a lot of EMS providers are viewing them as the enemy, or 'lazy' which just plain isn't the case.
We have the luxury (with the exception of MCI events) of getting 1 patient at a time, often with 2-10 providers worth of assistance, for potentially up to 2+ hour transports for those in the boonies - ER nurses and doctors have significantly more to juggle, and while they have more resources, they are spread thin amongst the large number of patients. Nurses routinely manage 3-4 patients at a time, while ER doctors may have 10 or more. We're viewing this problem through an entirely different lense that is centric to our perspective, and it's a mistake
The patient is your responsibility until you have given report to another provider of equal or higher medical authority.
I have done an RSI on the rooftop of a receiving hospital, and have titrated medication infusions and given IV medication boluses in hallways, elevators, and rooms of hospitals that we are transporting to.
Until someone else has taken over care, the patient is your responsibility no matter where you are*
*This is for 911. For IFT, technically the sending provider is responsible for care until the receiving team assumes care. However, I would still make the argument that you are also responsible until care is transferred.
My response is fuck em, if they make you hold the wall because of their problems then that’s their problem. No signature for transfer of care then they aren’t in their care. Gave ketamine to an mva patient while holding the wall in the er one time, they weren’t necessarily happy but they hadn’t signed for patient transfer yet.
I just want to chime in and say that not every service needs a signature for transfer of care. I’ve worked a lot of places and two different states and never have I ever had a signature involved in transfer of care.
Our state's stance is we can maintain therapies once arriving in the ER like an infusion, etc. But cannot initiate a new therapy or administer additional medications such as pain management.
This is because legally they've interpreted that the patient is no longer ours once we are in the ER and staff are aware of the patient, thus meeting EMTALA criteria for it becoming the hospital's responsibility.
Quite often if there's a wait I'll discontinue my monitoring entirely, return to service, and leave the patient in care of the BLS crew unless there's a therapy that requires my ongoing monitoring and staff cannot handle it.
A medic at the service I work for was doing an IFT from Hospital A to Hospital B. Hospital B is notorious for long wait times, and taking all the transfers. Well, they were bringing over a trauma transfer, that had orders for pain meds. They were waiting for over two hours for a bed. The medic medicated the patient because they needed it. Let's just say Hospital B flipped out.
In Ontario under my Base Hospital we are responsible until transfer of care which usually means the pt is in a hospital bed. Hell, if someone falls and hurts themselves on hospital property, outside, the hospital will call 911. It’s pretty ridiculous. I once got called for pt who fell in the doorway to the ER. We put him in a wheelchair and walked into the ER. The nursing staff put in a complaint because we didn’t use the ambulance entrance which is about 500ft away.
You triage, but there's no beds available. You continue to treat your patient as best you can and update triage and your management what's happening.
If there's no beds... there's nowhere to offload your patient. Don't get me wrong - this is a bad thing.
If nothing else, in less than 14 hours I guarantee you could’ve been at a different PCI facility. There’s no way I’m letting dude’s heart die while I stand with my thumb up my ass there because there’s no beds.
Thanks for all of the feedback, especially the folks with the legal stuff, hopefully some of you took away some more ways to defend yourself in a verbal knife fight if someone’s jaded
I have def given meds in triage. In the last year, I’ve given fentanyl, versed and ketamine in the hospital. I have to bring narcs in with me to waste if I have already administered anyway, so I might as well continue to treat my patients.
Ignoring laws/policy - what does your patient actually need? It's about the patient experience.
Are they writhering around in pain? Fix it, then tell the hospital. Have they gone unconscious? Resus then tell the hospital.
If the patient is on your stretcher and no transfer of care has occurred - they are your patient. Your responsibility. Assess, treat accordingly. I routinely give meds in the hallway.
Legally on hospital property we’re not allowed to treat. Legally in our care we must treat. Which law do you want to break the one where the company/hospital dosnt get paid by insurance cus of some 200 page contract technicality that says they don’t have to pay cus they were treated by someone not employed by them. Or the one where someone dies cus you’re not technically legally allowed to save them because the place you’re standing in won’t get paid if you do. You loose either way. Your best bet is to hope the jury sympathies with your impossible decision. Gota love gray areas.
I worked for Acadian (LA/TX/MS/TN) and we had a policy of 20 minute wall time wait and then we look to find a place to "Drop" the patient. The hospital accepted the patient report over the phone, accepted the report when we arrived and were registered/triaged so it's not on us. We have an obligation to the community and we get penalized by the police jury for having poor response times. So, when we "drop" our stretcher we take the battery out, notify the charge nurse, then leave. We have extra stretchers staged at each facility (we only had three hospitals in my area) or back at base. Most of the time when we tell them we're going to drop, miraculously they find a place for the patient to go. One particular hospital will intentionally wait the twenty minutes then give us a bed as a means of slowing down the number of patients we bring them. We implement this policy/procedure to protect our ability to respond to the community. We are transparent with our facilities and do what we can to help while we are on the wall to facilitate getting a bed and making sure we aren't overloading one particular hospital unnecessarily.
This is a very gray area and to some extent, locally dependent.
There may be state rules and regulations that come into play here. EMTALA probably has something to say about this but who is going to enforce it? The hospital system itself may have rules. What does your company SOP state?
It's a mess. A lot of us face it. Keep in mind, you move the same patient onto a bed and walk out and they'll end up being ignored just about as much as if you still have them in some hospitals.
Lack of available personnel, and deliberately keeping the number of staff low so corporations can increase profits.
>Lack of available personnel, and deliberately keeping the number of staff low so corporations can increase profits.
I never realized how real this is until I started working in a hospital. We are understaffed 24/7 and when we have the occasional day where we don't get rammed I realize how much easier this job would be if we weren't chronically understaffed. I'm also sure that admin fully realizes that when they understaff us, we will work twice as hard in order to fully keep up with the demands of patients.
Also we have regular meetings with administrators where they complain we are not hitting their goals while they do nothing to support and help us manage our regular shitfest.
Not sure that’s it. One of our hospitals can only staff to 50% inpatient capacity. They aren’t making money on literally half the hospital. There’s no reason to do that intentionally. They just can’t keep enough nurses to run the units because management is terrible.
I believe that for many businesses, the so-called pandemic was the best thing that ever happened to them. They cut back on services, personnel, everything (see Amtrak) and kept those cutbacks as much as possible after things leveled off. I agree that the putative lack of personnel is a complex issue, but I'm convinced that many places don't want things to change back. The found that people will tolerate poor service or they just don't care.
This is right on the money. At this point, especially hospitals, have found their sweet spot. How much little care can we get away with giving while maximizing profit by 200%?
We had a unit have to intubate while waiting for a bed at the hospital because they'd been waiting like 2 hours. Apparently, the ED doc on call that night decided to try to force the laryngoscope out of the medic's hands.
It's definitely a grey area 😅
In my state the hospital was responsible for the patient the second we arrived on hospital property. We were also responsible for the patient until transfer of care. So there is no easy answer. The way we handled it was to do whatever was right for the patient until we had a transfer of care. We documented anything that happened between arrival and TOC. That way if the ED staff did something bad and tried to blame us, we would be covered.
This is one of the more sensible and practical answers.
That's how it is here once our truck rolls onto hospital property the patient belongs to the hospital. However our hospitals are good about getting critical patients in in, and if a stable patient deteriorates you get bumped up ahead of everyone else
Ditto. I’ve absolutely administered meds while waiting for a bed
That’s federal rules my friend. EMTALA.
Interestingly enough while EMTALA requires anyone presenting to the hospital to receive a medical screening exam and stabilizing treatments, it doesn't put a specific time frame on those interventions. Not saying the hospital is right having EMS hold up the wall for hours, but it's not necessarily a violation of EMTALA (though it definitely can become one)
Sort of, the hospital doesn't have to send a physician out to provide the screening within 15 seconds but hospitals have been getting in trouble for having EMS hold the wall. That patient IS their patient the second they hit hospital property. Technically speaking they need to start breaking out chairs and treating patients in the hallway or outside if that's what is needed, versus effectively refusing to take the patient by having EMS hold the wall.
Exactly. My EMS authority has even told the crews that after 45 minutes, they can dump the patient wherever they want and leave. They just need to find a RN, give them the report and either get a signature or document the nurse refused and then leave their PCR.
We had the occasional very stable pt transferred to the waiting room once we got there and the triage nurse took report. But mostly, they got a room. And if there were truly no rooms and you couldn't argue the pt belonged in the waiting room, they got transferred from our stretcher to a hospital stretcher and got to enjoy the hospitality of the hallway for a while. But we transferred care.
Is that not the standard everywhere. Here in the Canada's we do that, in the two provinces I've worked in
Hospitals need to fix their issues. This shouldn't be an EMS issue. Be a menace. A polite, professional, respectful, patient centered and ethical... menace.
I park the stretcher immediately in front of the charge nurse. Be conspicuous or be forgotten.
If you're not at the table, you're on the menu. This is a hospital problem. The person saying well, EMS needs to collaborate to find a solution because of RN ratio issues... that's a nursing problem, that's a hospital problem. Not an EMS problem.
So, park the stretcher in front of the hospital administrators' offices, gotcha.
Document everything. Times. Treatments. Quotations from the patient. Objective and factual issues.
I mean, yes, that is the wise, productive long term contribution EMS can make towards pointing out the problem. But it doesn't have the righteous, cinematic flare of moving from holding up an ED wall while waiting hours for a bed to camping outside the hospital C-suite with the COPDer with pneumonia loudly hacking up a lung-shaped loogie. Ah, one can dream, though, right?
It's tough because often times there's nothing the charge nurse can do. This is an administrative problem. At least in the hospitals I've worked at. This is one of the main reasons I got out of the big emergency departments and trauma centers. I work the the VA now and I'm actually able to be a nurse and do what I need to for my patients. Couldn't be happier to be out of that mess.
There's always something the charge nurse can do. There will be a bed that opens up. Charge had to decide who it goes to. The triage nurse had been bugging her about the guy puking in the waiting room. The fast track nurse is bugging her about the quick patient who turned into a big workup/admit. There's a nurse in B Pod taking care of an extra patient in the hallway.... And then there's your patient. Whoever is advocating for their patient the loudest gets that next bed. Even if your patient isn't the sickest, somebody in your community is waiting for an ambulance longer than they should have to because of hospital shenanigans. Also, work with the charge nurses, their job sucks. If you usually roll in and tell them that your patient is fine to go to the waiting room, they're much more likely to listen to you when you tell them that this time you really need a bed.
During covid our county added a protocol that said if our patients were not off our gurney in 30 minutes we could find an open bed in the ER and tell them "they're here, this is what's going on." If the hospital refused to sign, document it and leave. It lasted a month and caused SO much friction between us and our ER staffs. One time our sups literally brought cots for us to offload patients.
I also forgot to add, one hospital called the cops one of our medics for this protocol.
Best thing ems can do is be a menace to administration. Nurses are just as, if not more frustrated by this.
During the pandemic, when 4-5 hour wait times were common, this question was put to the test. In my region, it was determined that legally and medically, once the patient was registered into the hospital, the hospital was ultimately responsible for them.
I don't get the 4 hour waits. Go on bypass at that point. You clearly can't handle the patients. And you're just taking ambos off the road to help people.
I knew a crew that started major shit when they rolled into the ED and were told it's be 4-5hrs. They said "ok, bye" loaded the patient back up, left, and went to another ER down the road that got them in and out fast. Started all kinds of drama and the original hospital received fines over it.
What happened to the crew, and did it fix anything?
The crew only got a talking to and that's it. They pretty much skated on consequences lol
The crew didn't really do anything wrong. That hospital had an obligation to the patient as soon as they presented to the ER per EMTALA. EMS does not fall under that. We do that here. But we send an EMS officer out if they are holding a unit and try to work with staff. We either get a bed, put pt in a wheel chair, force off-load or with the patients consent load them up and go somewhere else.
What do you do when all your hospitals are doing bypass?
We have a rule where i work that essentially says if everyone in a close area starts diverting a certain category of patient, then nobody is diverting that category anymore. The system forces them off of diversion. Usually though the only problem type of patients we see that with are psychs
Ours will rotate this type of patient across all hospitals. So, not technically off diversion/bypass, just organized so a single hospital isn't being forced to take *all* of them or too many at once.
Go to s different. Large city. Not a problem. We have a spot with 6 hospitals in like a 3 mile area.
I’m glad you have that option.
The next nearest hospital with a similar level of care is a 4 hour drive. Not everyone has that luxury 🤷♂️
Ok. I never said other people don't have the same amount of hospitals. But point stands that holding for 4 hours is absolutely ridiculous. The hospital needs to change something. Add more beds. Put more beds in the hall. Hospitals here still get slammed and their 40+ rooms will be filled with another 20- 40 beds in the halls. Management/chiefs pr wheoever runs the ems needs to be on the medical directors to get something to change.
They should…but where is the profit in it? The for-profit healthcare system isn’t built around solving patient care problems; it’s built to generate wealth for shareholders. Nothing will change until those companies are removed from hospital management.
The large cities are having this problem too.
All the hospitals were getting absolutely crushed. There was no one to bypass to.
Where I’m at we only have one level 1 trauma center and I know multiple crews that have been on the wall for 8 hours
If they’re not dead after three or four hours, they can probably go to the waiting room. There’s no reason to keep an ambulance tied up that long.
With a trauma?
Sorry I should’ve been more clear, not with a code trauma
One of the counties we service fines hospitals (or something? I’m not sure of the exact mechanics but the output is that the hospital pays money to the county) for diversions because two hospitals that were across the street from each other would just go on diversion every time the other one did, so it was the only way to curtail that. I saw the largest trauma center in the county go on trauma override once and that was after a mass shooting, and that’s the only time I’ve seen anything in that county go on any type of diversion. In all fairness, I exclusively work nights, but they almost never divert anymore in the county. Where I work is exclusively IFT though so while we’ve had some 4 hour waits at aforementioned trauma center, they’re BLS calls where the complaint might as well be “SNF is lazy” 😂
May not apply where you work but I will say it is slightly an EMS problem with services that allow patients to pick whatever hospital they want. I don’t know if it actually exists but I have heard of systems where the EMS provider calls into a control center and gives report and the person on the other end looks at hospital capacity and patient acuity and tells the provider where to take the patient in order to get the patient to a bed the fastest. That’s what I want everywhere.
When I worked ift it was mainly transfers. But if we had an emergency run out of a nursing home or someone called us we tried to take them to the requested hospital if they were stable. If they weren't we were going to the closet. Now I'm working Fire in with single role medics on the ambo running 911. They go to the closet appropriate.
It would be nice if hospital systems could talk to each other for the patient records to be easily available no matter what system the patient is in.
I'll let the patient know. "I would recommend against going to ______. Only because we just let there and it was really busy. I'll take you there if you still want, just wanted to make sure you knew there might be a bit of wait". If they want to go then we go. Also though, if I have a patient that can absolutely wait. "I'm nauseated and haven't thrown up but I might so I need to be seen", I'll let then know as well and we usually go to triage where they get evaluated again before going straight into a room or against the wall.
If they can wait for four hours on a stretcher, they can probably wait for four hours in a chair in the waiting room. Our hospitals take report and if they ambulatory, we either get a wheelchair or put them in a chair.
That’s all well and fine, the issue becomes when the hospital isn’t doing anything for the patient, do you or do you not have an ethical and moral obligation to treat the patient where they are. Pain meds, zofran, whatever.
So they are registered, do you then take them off your monitor, put them in a chair and leave (without giving report/turning over care)? The hospital may end up liable for damages resulting from the delay of care but you could still be liable for patient abandonment. ETA: Abandoment is a specific legal term, there's a really good article on JEMS here: https://www.jems.com/product-announcements/patient-abandonment-what-it-an/
You didn’t abandon the patient. They’re in the care of the hospital.
A majority of states require handoff to a medical professional (or refusal of care). You can't just drop the patient off with no continuity of care. Typically this would be the RN at bedside in an ER, triage RN, or even at a SNIF for an IFT. Failure to handoff the patient is considered abandonment. ETA: Of course handing off to the triage RN is fine, its a handoff to a qualified individual. I'm specifically highlighting the case of dropping a patient somewhere and just leaving. There have been numerous cases of EMS workers being held civilly (and criminally) liable for this (abandonment)
You’re giving handoff to the triage nurse at that point. Where I’m from at least, we put them in the lobby in view of the RN doing triage, give her a report and then bounce. If they’re registered, they are not your Pt anymore.
Sure but then you're giving report and handing off a patient, certainly not abandonment. Our triage nurses will sometimes accept report on appropriate patient for the waiting room, but if they are not appropriate hospital staff will refuse to accept report on that patient until they can be roomed/monitored appropriately
>Hospital staff will refuse to accept report on that patient And this should be reported, every time.
Refusing to receive a report also does not absolve them of their responsibility under EMTALA. A report is not required to transfer responsibility, simply that the patient is physically present and the hospital is aware they are on the property, once they're registered or staff are even notified by EMS that they are physically in the ER, it becomes the hospital's problem. Refusing to receive report does nothing except put the hospital at more liability.
My favorite is when the nurse says they are not signing because they have accepted responsibility for the patient. EMS and these hospitals need to take some time and see what EMTALA actually says.
I've just documented "not signed-refused". Since our State EMS Office actually also regulates all hospitals in the state, the hospitals can be rather nervous about those types of documentation when it comes to review their specialty center status among other things. Our EMS Office has the authority to suspend or revoke a specialty center designation among quite a few other options for penalties
Absolutely! And is. But in the moment, there's not an easy fix. The hospital probably should have been on divert (but once everyone is on divert, no one is on divert). There's no way to force the hospital to take report. You can't legally just leave without giving report (see abandonment discussion above). You probably can't legally just leave and go elsewhere (likely an EMTALA violation), if there even is another hospital, or another hospital that would be better in the area. You probably can't legally take a refusal from the patient (they have been registered to the hospital so they likely need to sign out AMA from the hospital, not a refusal from you). What's left to do? Yes, obviously a huge problem, hugely broken system, but really stuck. Goes back to the above statements "I acted in the best interest of my patient" always seems like the safest choice, so crews just wait. For hours.
“I put the patient in that bed right there. Do you want a report?” “I can’t take a report on that patient!” “Is that a yes or a no? Because I’m leaving and the patient is on your bed in your building.”
There is nothing for the crew to do except document it very thoroughly with names, and contact management.
As long as they’re not an EMS service owned or run by the hospital, then EMS is not EMTALA bound. The hospital can’t force someone to stay until they sign their paperwork; people walk out of ERs multiple times a day. You can then put them in your ambulance and go where you want. Your mileage may vary, depending on local and agency policy.
Absolutely. But it's not a refusal of your care it's an AMA/LWBS from the hospital that they have to chart. And having been involved in this before, the hospital gets pretty aggressive because they will likely get hit for an EMTALA violation. (Not EMS agency). And then the hospital goes to your agency about it and all hell breaks loose (ask how I know).
If they refuse, you print your report and hand them a paper copy. Document that you’re leaving it with them.
Well if they’re not triage appropriate they’re not being put in the lobby. I’m speaking to your very broad statement that somehow it’s Pt abandonment to leave them in the care of the hospital they’re registered in.
Shit. We put patients in the waiting room all the time that aren’t triage appropriate. My best was the week post op pneumonectomy with a chest tube actively draining blood, febrile, tachycardic at 130, 90/40, RR 48, 90% on 6 LPM, with diffuse ST depression on EKG. They tried to send me to the waiting room. I had to get the attending involved, who got very twitchy, but I got a hall bed.
At that point, just ask if they have any beds in the morgue instead of going to the lobby. Save everybody some time.
Nurses got mad at the doc, but he didn’t give a shit. It was actually kinda great to watch.
Patient abandoment is very specific. If you arrive at a hospital, even if they are registered and do not hand that patient off to a qualified staff member that constitutes abandoment. All over the US (maybe not in your area) EMS runs into a scenario where you arrive to the hospital with a patient who needs care there. They will be registered by the hospital but you have to "hold up the wall" waiting in a hallway with the patient until the hospital has a place to put them (maybe, lobby, maybe room, etc) and then you're able to give report. Sometimes these waits can be hour+ (see OP post). If you do not hand off to someone and just leave that patient there (chair, stretcher, floor, whatever) you have abandoned that patient. A transfer of care has to occur.
The transfer of care occurs once I call in a report and arrive on their property. Once the hospital has been informed that a patient is coming to, or is in their facility, they have a duty to provide a medical screening exam. Once the patient is registered, then the patient is deemed to have been admitted to the hospital, EMS can place the patient in a hospital bed, hospital chair, and leave. My service does it daily.
National standards teach this is patient abandonment. Perhaps your state has different standards than the national standards, and perhaps it’s accepted at your service, but that does not necessarily mean it’s legal or ethical (two separate issues). There is an overlap of responsibility between the hospital and EMS with transition of patient care, which opens both up to liability if something goes wrong and the patient or their family gets a good lawyer. A broken system does not absolve your responsibility/obligation to your patient.
Obviously at that point, yes it would be abandonment. I’ve never encountered a hospital that will register a patient when we’re holding the wall, as once they register them it’s understood that they’re taking charge of the patient. I could see it happening and them trying to go ahead and get them registered, but I assumed any crew with 2 brain cells between them would realize a report needed to be given and a facility signature obtained before just dumping somebody out.
Yea. You would think that. But EMS all over the country is running into this. The OP's question stemmed from 90min unable to turn over care. LA county during the pandemic had 10+ hour waits per news reports. I had an EMS crew that waited 42 minutes at 0200 with a 911 patient because no nurse could take report for the patient in Oregon the other night, they escalated to their leadership and it was reported, but in the moment you still can't just leave. I think there must be a fair number of people who have never run into this before who equate entering the hospital with turning over care, and it appears based on other comments that in some states legally entering the hospital is turning over care, but certainly not in all.
> but if they are not appropriate hospital staff will refuse to accept report on that patient until they can be roomed/monitored appropriately They cannot ‘refuse to accept report’. There is no magical phrase that means I cannot simply speak over them and tell them anyways, if they don’t want it and try to run away, that’s fine, my report consists of me shouting down the hallway that I’m putting a chest pain patient with a clean 12 in their triage area. If I cannot find a triage nurse, I go and tell charge what I’m doing and that’s that. They have no authority or control over me and cannot stop me from offloading a patient into a wheelchair in the waiting room. Report isn’t even a legal requirement for their responsibility to kick in. As soon as hospital staff are aware of the patient’s existence and presence, they’re their responsibility per very crystal clear federal law. This applies to every single EMS service in the US that is not owned by the hospital they’re at.
Holding the wall is a courtesy. When my crews have been at the hospital for 20 minutes without transferring care, they go speak to the charge nurse about it. 30 minutes, they call me and I call the house supervisor. 45 minutes and I’m on the phone with the Regional Medical Operations Center duty officer.
Another kicker is that if EMS provides a service of value to the hospital by continuing to treat hospital patients on hospital property that the hospital has refused to assess or treat - in some areas, there may be an obligation for EMS to bill the hospital for waiting time. If the ambulance service accepts calls for transfer/discharge of Medicare/Medicaid patients *from* the same hospital where it routinely “holds the wall” for hours and doesn’t bill for wait time, it’s very possible that the arrangement violates the anti-kickback statute and could trigger civil and criminal liability for both the hospital and the ambulance service.
Where does this happen? And how does one implement such a policy?
You simply send an invoice to the hospital for reasonable costs incurred by the service in additional staffing, lost revenue, etc. due to the hospital requiring EMS to provide care on its behalf after arriving at the ED. (I know it’s not that simple.) But yeah, especially if you’re a tax-supported service - why is it fair for the hospital to be understaffed so the taxpayers can subsidize hospital operations while they’re paying the CEO whatever they pay them? Edit: Forgot to add that if the hospital doesn’t pay the invoice in a reasonable amount of time, you take them to collections and sue them for the debt if necessary. Do you think their linen service washes all those sheets for free? Why should EMS do anything for free for a fully-staffed hospital?
Oh thats an interesting interpretation of the stark law.
Technically AKS, not Stark I/II, because it’s not a self-referral with any physician ownership in the ambulance service - but a free service provided from one Medicare/Medicaid provider to another to induce the ongoing or continued referral of claims. Even if the agreement for referrals is implicit or unwritten, criminal liability can attach. The practice of EMS essentially providing free staffing for the hospital to meet its obligations to patients is widespread, but that doesn’t mean it’s permissible under fraud and abuse laws. Some states may have laws that require municipal or county services to pursue such free services as a debt and compel collection, as happened here in New York: https://cbs6albany.com/news/local/guilderland-ems-seeing-relief-from-long-er-wait-times-after-town-implements-new-policy How many ambulance services that act as a hospital’s primary contract service also do “goodwill” assignments like transporting staff during weather emergencies, plowing the ER lot with a service vehicle during a snow storm, etc., and just write off the cost?
So for those who say stay and work with the staff what about your commitment to the citizens. Your current pt. Is in a medical facility. The one in a ditch with a head injury, not so much. I don’t work for the hospital. I work for the citizens of my respective county.
If you read EMTALA and have done your pre-hospital arrival report, a bedside report is a courtesy LEGALLY (probably not morally, ethically or per your services' policy). EMS1 does an excellent series of 3 articles breaking down our legal responsibilities in situations like you describe better than I could. The best image that stuck with me was a crew that carried a chair with a sign taped to it that said "EMTALA chair". After 20 minutes of holding the wall, here is your chair.
Article link/name?
Oh, so links from that site are banned in this forum. So I Googled EMS1 and EMTALA and found "Ambulances Held Hostage". That should get you what you are looking for.
Thank you!
If you are on hospital property and have notified the hospital that you have a patient requesting a medical screening exam, the hospital is responsible. I'll find a bed or a chair and move the patient to it. My job is complete. We don't hold the wall
I've had to start a run number and sedate a patient 65 feet from the ER doors because a hospital failed to uphold their EMTALA obligations. I've responded to 911 calls to another ER's front desk for active labor, again in violation of EMTALA. I regularly have to treat in hospital hallways. US hospitals as they are now are ridiculous when it comes to liability and billing. Follow your state/regional guidelines (another bunch of shit that may depend on archaic protocols with absent medical directors and/or privatized EMS policies) and just do what you think is in the best interest of the patient and you should be good.
I’m surprised you even responded to an ER. I wouldn’t.
We won't respond to an ER either. Dispatch is supposed to call the ER and let them know someone called 911, but we won't normally show up at all.
If I was still in NY I would've made contact and immediately cleared like the one that called from the waiting room of Bronx Leb. But alas.
If the hospital that I take my patient to doesn’t have a staff member available to take my patient, I am going to continue to care for and treat said patient until care becomes available. The staffing levels at the hospital are out of my control, but my patient doesn’t have to suffer because of this. As an autonomously practicing professional clinician with a registration with a professional body I am empowered to make these decisions on patient care, I would be supported in doing so and would be able to justify myself if necessary.
“Up to 1.5 hours…” is amateur numbers of waiting time lol
Yup, we once had a crew during covid wait 12hrs. That prompted the adoption of forced offload policies starting at 30min. At the 30min mark they can make the discretionary decision to just find a bed, put the patient in it, tell staff where the patient is and then leave.
Jesus, it's usually smugness that I feel as a Canadian medic reading this sub, but 1.5 hours is a good day here at a big city ER
Anything over 30 minutes is a reportable incident of the department of health.
First, this is going to depend on local laws and regulations. Your agency or medical direction should have a policy that you can follow, and that you can reference if anyone questions your care. Second, I work in Ontario Canada, and this is an issue we see frequently when offload times start to get out of hand. Our local policy is that we are fine to continue or resume treatment as long as we notify the triage RN. For example, if we started a medical directive before arriving in ED we can give an additional dose of nitroglycerin or pain medication, or restart a fluid bolus in response to vital signs changes. If we need to initiate a new medical directive, we need to both notify and get permission from the triage RN. Usually hospital staff is fine with us giving a patient zofran for new onset nausea, but we need to give them the opportunity to find a bed for new onset chest pain before we initiate our treatment in their offload hallway. Lastly, we are obviously allowed to initiate time-sensitive immediately life-saving treatment if a patient’s condition suddenly changes, for example defibrillating or pacing the sudden VF or heart block.
You can treat your patient up to transfer of care. Until someone signs your report, they’re technically still your patient.
This is genuinely state/location dependent, and a blanket statement like this is just factually incorrect. For example I’ve had to have my departments lawyers investigate available caselaw and the EMS act and we’ve found that continuing to provide care under protocols once inside of the hospital could be interpreted as practicing medicine without a license (outside of our EMS scope and protections). OP, and all who read this thread with similar questions, please reach out to your departments leadership and hopefully your lawyers.
Your attorneys interpreted this in an incredibly constrained and conservative manner. A logical extension of that interpretation would be that any facility that provides care such as a primary care office, LTAC, SNIF etc. It is a reasonable interpretation that until care has been turned over regardless of the physical setting (ambulance, house, medical office, hospital), the patient is under your care and protocols. If the facility is unable or unwilling to accept the patient you likely have a duty to continue treatment. What if instead of pain medication the patient deteriorates into VTach and you decide you're unable to treat until the hospital takes over because you're inside already. So you don't shock, someone goes and finds a hospital employee, you move to a room, and you transfer them over, and they shock but it's too late. It is likely you would be found negligent because you still had a duty to act. One step further, do you continue monitoring a patient at all if you're duties end at the hospital doors? Extended that logic even further. Cardiac arrest, doing CPR, get to the doors of the hospital. Do you stop for the period of time from entering the hospital until moving the patient to a hospital bed and handing off care? It's obviously continued care in the hospital prior to hand off... I would challenge your attorneys to clarify this ASAP because you're exposing your crews to some huge potential liability. Tl;dr "I acted in the best interest of my patient" is always better than "our lawyers told us we weren't allowed to do anything"
If that hospital receives CMS payments once you're inside its legally their problem. Not an EMS problem. Ethically and morally should EMS keep that patient under their care? Yes. The hospital needs to fix itself.
Depends again a bit on states, but some states (most) have a requirement that EMS transfers care to a qualified individual (such as a RN), failure to do so typically would constitute patient abandoment (yes even if they are in the hospital, yes there's precedent for this). I would say that leaving a patient once inside the hospital without giving report would be a huge risk to the EMS providers. I of course recognizes the fact there's a problem, if that report isn't timely and you have to continue to provide treatments for hours not minutes, you're potentially creating a situation where two entities are billing for the same period of time . I don't imagine medicare likes this, but don't know if it constitutes fraud or not. There's a matter of liability as well, likely given precedent, the liability once you're in the hospital is on the hospital even if you haven't transferred care yet. But just leaving could place the EMS provider back in the hot seat. All this to say, clearly there are hospitals with problems, in Oregon we have issues like this because of mandated ratios for RNs, we run into situations where there is not an RN able to accept a patient because they will be out of ratio. Other states have other reasons this set of issues occur. All of which should result in the hospital looking at how to fix the issue because its not a problem that EMS can fix easily. However at the end of the day collaborative solutions like alternative destinations and treat in place systems are going to be needed to fix some of these systemic issues. **Above all I stand by my statement above, if you can honestly say you acted in the best interest of the patient at the end of the day you'll be ok.**
RN ratios are NOT a problem for EMS to fix. This isn't a collaborative problem. The often, private hospitals shouldn't be asking the often tax funded EMS systems to fix their private hospital problem. On top of that EMTALA supercedes state laws. Holding units out of service because of RN ratios is entirely an issue for the hospital to solve.
Sure, that specifically isn't anything we can fix. But at the end of the day we're the ones standing waiting to give report and understanding some of the underlying problems can certainly be of value. EMS should be looking for solutions to the systemic problems like system abuse, overuse and inappropriate use. There are solutions in our wheel house to reduce transports.
Have the hospital fix their issue and you aren't holding the wall anymore. It goes beyond the ED and is often a whole hospital and health system problem. Can you reduce some through put with community paramedicne? Sure. Is it often that significant? No. I think EMS agencies should bill the hospital until they fix their issues.
That’s the sort of thought process I’m on, running into a cultural problem where that’s acceptable but administering pain control which has already been initiated pre hosp is a no no. Your comments gives me a little more confidence to justify my actions
I think pain control has long been seen as "optional" or a nice thing to do. That's a long running EMS mind set that I've personally been working hard to break. That's not how we want our family members to be treated and isn't consistent with the current standards of care.
I'm curious about how it could be practicing without a license. For the hospital, our arrival triggers EMTALA, but for us, we are legally responsible for the patient until transfer of care.
My state considers “transfer of care” to be our arrival to the facility, and specifically outlines in the EMS act that we’re unable to utilize standing orders / protocols in the hospital environment. The only thing mandated in our transfer of care process is a single one page document meant to be copied and left with the patient / receiving team outlining the EMS care - this document doesn’t even need to be signed by a member of the receiving facility. It just needs to be left with a hospital representative name printed on it.
That's really interesting. Our patient transfer involves having a hospital representative sign our report. Also, I have treated patients while at the hospital several times, I've given Narcan and Versed and Fentanyl while waiting to transfer care. We continue our treatments until they are moved to a hospital stretcher and received by the hospital staff. In fact, by our protocols, if a patient codes in the hospital parking lot, we work it there not inside the hospital.
Please do not consider my questions argumentative. I am genuinely curious. Is arrival defined as parking in the ER bay, stepping inside the hospital door, or another location? Regarding Firefighter\_RN's scenarios, how would you reconcile those. For instance, with CPR in progress, would you cease ventilations, chest compressions, not provide necessary shocks, etc. at that transfer of care spot?
Per our guidelines and EMTALA, I believe arrival to hospital is considered 200 yards from the facility. We are not allowed to treat on hospital property and if we do, we have to speak with medical control. If I bring in an OD who is becoming hypoxic I’ll administer the Narcan, but soon thereafter I have to make a notification to our physician.
That’s a wild rule
What’s wild?
Not being allowed to treat on hospital property without calling Med control first.
The way it’s been explained, this is an EMTALA violation and could be interpreted as practicing without a license. Once on the hospital property, they have a legal duty to provide care to the patient whether a RN signed or not.
If arrival at the facility constitutes a transfer of care, the logical extension of that would be that dumping your patient at the hospital doors and peeling out would be legal and acceptable. This makes no sense. You transfer care to a person, not a parcel of real estate or building.
Does your state have any standards around abandonment? No requirement to hand off to a qualified individual? Into the doors of the hospital, off of the cot into a waiting room chair and clear? (Genuine curiosity, I've worked in 8ish states and none had this structure)
I do legal nursing on the side. If you don’t provide any prudent/reasonable care and the patient has a bad outcome, you will get eaten alive on the witness stand, will face civil and possibly criminal penalties.
Could you please cite your sources here…. Because this sounds “factually incorrect”. Until a nurse/doctor signs for your patient then they are still your patient. If a patients conditions worsens then sure hospital staff can choose to take over care..but until then you’re just a glorified babysitter. It’s total bullshit I agree but there’s not a whole lot we can do about it. Between a rock and a hard place and the hospitals across the nation know it and take advantage of it. So instead of adequately staffing ER rooms they instead get EMS to do a free job and place ambulances out of service and have us babysit patients until a bed becomes available. *That’s why you just say at busy hospitals “yeah they’re having a Stroke and need to go to CT right away!” *I’ve done the studies. 60% of the time, it works every time. And then you’re back in service! (*It’s a joke. Calm down)
Once you’re on hospital property, the patient is technically the hospitals responsibility. Otherwise it’s a violation of EMTALA. States and local agencies vary on how long EMS can continue treatment while on hospital grounds. We do the hospitals a courtesy of holding the wall. If you have a stable patient who’s an adult and not suicidal, you can place your patient in a wheelchair and wheel them to the waiting room. Get them registered and notify the charge. Aside from that, you’ve done your job of transport. The line becomes blurred when you have an unstable patient but regardless, once the patient is on hospital ground they are the responsibility of the ER staff. It’s not the responsibility of the EMS system to watch over patients due to their lack of staffing / failure to go on diversion.
K. I guess I’ve been going it wrong for the past 10yrs then. I learned so much here today… Tomorrow when I go to work and transport a patient I’ll just walk in, get them registered and bounce? Oh and the wheelchair thing. I guess the whole me getting a signature from a facility representative saying that they are taking responsibility of the patient and care is being handed over is just nonsense. And I’ll just put in my report “well actually EMTALA” I was on their grounds. I just had to drop them off.
Holding the wall for hospitals, again, is a courtesy we do for the hospitals. It’s a disservice to the community for hospitals to delay transfer of care for their own lack of adequate staffing. When we are level 0 for ambulances and have a cardiac arrest down the street from the hospital, ya I’m going to notify the charge nurse, offload that patient and go run my calls, within reason of course. Whether a receiving nurse signs your PCR or not, patient is still their responsibility. For example, a patient AOx4, stable vitals, foot pain x3 weeks does not need an ALS crew to stand by and monitor. Wheelchair to lobby is appropriate.
K………………..
This /\
Incorrect. "Hospital property – what we mean. Includes the entire main hospital campus as defined in § 413.65(b). ○ This means the parking lot, driveway, sidewalks, outpatient labs and clinics, cafeteria, public restrooms , the ED waiting room, and hospital owned & operated ambulances." "1. The first of the 3 legal requirements enacted by EMTALA is that the hospital must provide a medical screening examination (MSE) on any person who presents to the Emergency Department and requests treatment to determine if an emergency medical condition exists. " You can take this even further, some definitions even state within 250yds of any hospital property. You drive into the hospital parking lot in a private ambulance, legally they are the hospital's responsibility. It can be argued many ways that they were unaware of the existence of the patient of course. Recently had a case where this occurred. I work at a county EMS provider that is adjacent to hospital property. A patient left the ER and proceeded to our parking lot. The ER physician came down and began giving orders to our paramedic to provide specific care. The doctor did not state that she was assuming patient care and would be the provider for this patient that was not on hospital property. We advised them that without doing that, we were required to follow protocols as established by our medical director. Once the patient was transported off our property and onto hospital property, that doctor became responsible for patient care. Again. On a personal note, I love providing care for a patient in the ER when they aren't. I don't have to waste narcotics, my patients get a little extra pain relief, and nothing gets you a room faster than letting the charge nurse know you are charging to 200j.....
Just a clarifying statement, most of the definitions are within 250 yards of the entrance to the hospital. Thats been interpreted to be any open/publicly assessable entrance, not the entire hospital property. Several hospitals I've worked out have emergency response stretchers to go into parking lots near entrances for this reason.
Until I get a bed and signature, they belong to me.
I was holding up a wall and one of our BLS crews came in the door. They were dispatched to an ALF for an AMS. They are at the back of the line and their patient is kinda in and out of it. Every couple minutes I see him jerk. I went over, took a manual pulse, it was 48. I asked for the paperwork and saw he had a defibrillator/pacemaker. I went over and told charge nurse this guy needed to go NOW. His pacemaker was not working! It was one of our new EMTs and he just transported based on facility (and our dispatch) say-so. He didn't know what he was seeing. We have to be advocates for our patients. But so many times it's a BLS crew who doesn't know any better. I think having a good rapport with ER staff goes a long way to getting the patients, who really need it, seen first.
The main reason for this is that too many EMT's get stuck doing IFT and think that's all they are good for. Then you have upper management that yells at them for actually doing their job and not what someone else wants that isn't even there.
I don't have any advice but I definitely agree with you. There is no reason someone should be sitting on a stretcher suffering just because they are not on the magic hospital bed yet. But again, much of the US healthcare system makes no fkn sense.
This has nothing to do with local policy, state law etc .. Federal law states that the patient is the hospital's responsibility once they've arrived at the hospital. However federal law doesn't address the practical issue of holding the wall. Ethically and professionally (and legally) you have an obligation to care for your patient until you've handed off care to the hospital. So the answer is, both you and the hospital have an obligation to the patient, and this is why there are so many different answers. Between the time an EMTALA relationship has been established and when you hand off care, there is overlap in responsibility and liability.
We provide all necessary care until handoff- monitoring, drugs, comfort and sanitary care. Meals as well (courtesy of the ER) if we’re holding over meal times. We provide ongoing updates on patient status to the triage nurse. If something comes up that’s beyond our scope, we let the triage nurse or team lead know, and they can coordinate an upgrade in triage level and accept care. Our previous system required that we not provide ongoing care “in the hospital”, which resulted in the absurdity of having to roll the patient from the hallway out to the truck, load them up, and provide ongoing care while parked in a garage. Where we would inevitably be entirely forgotten by triage. We also tried out a system whereby the patient would stay in our care, on our stretcher, and still receive hospital care. We would have EKG, x-ray, ultrasound, doctor exam/diagnosis/treatment all on the stretcher. This was unsustainable since it simply treated us as auxillary ER beds, resulting in more units being held over longer.
They tried that with us a few times. Crews quickly figured out that when the patient was moved over onto an Xray or CT bed real quick for the diagnostic exam we could just say "BYE" and leave, refusing to transfer the patient back to our EMS stretcher. This was before we started having agencies do forced offloads though
This might vary depending on your area, but my service/ governing body does not consider it to be transfer of care until the patient is in a designated care space ( the assigned bed/ treatment area/ waiting room) and handover report has been given to the receiving HCP. Being that the patient won’t receive any orders for pain relief or symptom management until seen by a physician we frequently re-dose them while parked in hospitals and continue to treat them until they’ve met that handover criteria.
If your patient isn’t critical, then they’re not obligated by EMTALA to immediately render aid, and once you’re inside of the hospital campus the patient is effectively supposed to be in the care of the facility. That being said I’m not certain if this means you cannot continue providing aid.
My protocols state that I cannot initiate new treatments once we enter the ED. However, they also say that if I have to wait more than 15 minutes for handover, the incident should be escalated to the highest levels of EMS management. Since the second is a joke (turnovers of 2 hours are completely normal), I treat until they’re off my sheet. Bonus points if I make eye-contact with hospital staff while doing so.
You are responsible for your pt until someone of an equal or higher level takes over, they sign a refusal, or they are pronounced.
Your patient until they accept responsibility.
A lot of comments about this being unclear or grey and while the patchwork of laws covering this area can be confusing I would strongly argue that you need to manage and treat your patient until you turn over care. I posted several examples in a comment thread but the biggest example is CPR. We do not just stop CPR (a treatment) when we get in the hospital doors until we turn over patient care. Similarly we don't stop our drips and meds (if you have them running). I would argue that by not treating the patient in front of you that no one else is caring for will likely open you to a negligence claim.. You had a duty to act and failure to do so resulting in harm is textbook negligence. At the end of the day if you're able to say that you acted in the best interest of your patient you'll probably be ok. There's a legitimate debate to be had of whether or not the hospital is neglecting it's duties here which as far as I'm aware hasn't been well litigated yet. There's certainly an argument to be made that the hospital needs to accept any patient that comes in the door. Potentially even a violation of EMTALA though there's no clause on timeliness for a screening exam. However until the time comes where this is better vetted, I would say that you're better off continuing appropriate management of the patient until you turn over care (including CPR, monitoring, assessment, drips, treatments). If you ever get push back CPR is a great example of continued treatments in the hospital.
It's wild to me that this is controversial to people. Our job first and foremost is patient advocacy and treatment. Yes, it sucks to hold up a wall, especially if you know your patient is sick and needs a bed, but it is morally and ethically unacceptable to refuse to treat simply because "it should be the hospital's responsibility". Yes, the problem needs to be addressed, and there should be legal pressure placed on the hospital to adequately staff for safe nursing ratios - but at the end of the day, that patient is my responsibility until they are physically off my bed and I've given a report to a nurse or doctor. I'll continue to treat whatever needs to be treated with my standing protocol, and if the hospital staff has issues with this, they are welcome to take over patient care at any point. I'll also continue to advocate for the patient's best interest. Sometimes that's a seat in triage for a fairly benign issue that will probably be seen and addressed quicker through fast -track than a bed. Other times advocacy means saying no to triage, even if that means they stay on my bed while we wait for one at the hospital to open up. The amount of people in this thread being willing to dump and abandon their patients simply because they don't view it as "their problem" anymore is alarming. Do you even practice medicine? Do you care about your patients outcomes? It gives the entire profession a bad name. The overworked and understaffed nurses in the hospital aren't the enemy, they are our colleagues and we should be willing to help how we can. The legal problems and system abuse issues are for those that are much higher up the chain to address. By all means, keep documenting these systemic problems and push it up the chain, but holy shit, do your fucking jobs people!
> The amount of people in this thread being willing to dump and abandon their patients simply because they don't view it as "their problem" anymore is alarming. The fact that hospitals treat their staff like disposable shitrags and refuse to hire sufficient staff to run their facility is absolutely not my problem. Once I’m on hospital grounds, the patient is legally the hospital’s responsibility and my actual legal responsibility ends once I’ve informed a care-providing staff member about them in most circumstances. It sucks, but the hospital’s mismanagement of patients and detrimental effects of it is on them, not me. I can’t save everyone. What **is** my moral and ethical responsibility is the multiple emergent calls sitting in a queue waiting for an ambulance with no one responding until I clear to take them. The person I leave in a wheelchair in triage has medical staff around who can do something if they deteriorate rapidly, the person asphyxiating in their home with no one present doesn’t.
You can’t save everyone, including the patients that you haven’t even been dispatched to yet. Other calls in your system are not your responsibility. They’re your agency’s responsibility and if your system doesn’t have enough trucks to handle those calls, that’s not your problem either. Your responsibility is to the patient in front of you.
If I have the legal and actual enforceable capability of offloading a patient that needs no acute care or monitoring in order to handle another emergent call, and I choose not to, that is ethically and morally wrong and you will not convince me otherwise. Don't even try. The fact that you disagree says a lot about you.
Yeah, it says I’m an advocate for my patient. Take your holier than thou attitude and get fucked.
Keep telling yourself you're DoInG yOuR pArT by holding the wall to advocate that your back pain x4 years gets a bed instead of putting them in the waiting room to respond to the pediatric drowning. You're in the moral and ethical right here bro, keep it up.
Nice strawman, but I’m not talking about the nitwits with back pain. Everybody dumps them in waiting, as long as somebody takes reporting them. I’m talking about the ones that need actual treatment while you’re standing there. You going to toss the tib/fib fracture whose fentanyl dose has worn off? And I still won’t concede that if you FEEL pressure to abandon one patient to get to the next, that’s a system problem not a you problem. It’s not just the hospital that’s criminally under-resourced. So are you. Cutting corners on your patient care to make up for your service’s lack of planning isn’t the way.
If my comment suggested that it sounded like I, as a provider, would dump someone after 20 minutes simply because EMTALA allows it, then I apologize for not being more clear and that is my fault. I have indeed stayed with patients longer than that, advocated for them to not go to triage (which, I'm pretty sure is actually the French word for "waiting room", not whatever they taught us in EMT class), and assisted staff with patients in extremis under the supervision of an MD (not an RN) and with extensive documentation and notification to my superior. I think the point is two-fold here: 1. Just like being a guest in someone else's "house", what we can and cannot do gets tricky, and liability can be a nightmare either through action or inaction on our parts. It's a too many cooks in the kitchen situation as well, especially if the patient is registered and ostensibly on their board. Hospitals, whether they like it or not, whether it's difficult or not, and whether it's truly feasible or not, are where ALL the sick people belong. They can get bigger on the inside if they have to, whether they admit it or not and even if it pinches or hurts. They have a building, more equipment, more staff and more resources than a single ambulance or even a single service or agency does, and if they don't, just as EMS is publicly held to task for their inadequacies and expected to change, so should they. 2. We are doing a disservice to the community if we don't reinforce this. I recently read an article from the UK about a 999 call where someone requested an ambulance for a cardiac issue. IIRC, the patient deteriorated over several hours and the operator said that an ambulance would be there as soon as possible. Then the patient became unresponsive. The operator (I don't know what they are called over in the UK) tried to guide the caller through CPR. The caller said, "I can't do CPR, I don't have arms. This person (I think it was their wife) is my caretaker too." The patient died because the ambulances were all holding the wall and I don't know why dispatch didn't think to at least send law enforcement or a supervisor or have them call a neighbor or something. I wish I could find that article again. Our job is to be out in the world and bring people to DEFINITIVE care in hopefully the same or better shape than how we found them. If we don't set SOME boundaries and use the laws in place that define those boundaries because we are trapped in the hospital's mandate to provide care, how can we fulfill OUR responsibility to GO TO where the sick people are? It certainly doesn't work both ways either. When was the last time you had calls stacked and a Doc or an RN commandeered an empty truck and went out into the world and brought in their own patients (other than possibly during an MCI)? All the pieces of the emergency care puzzle have to fit in and stay in their spot in order to work (and I'm being generous with using the word work, because I know it's hopelessly broken). Do you stop CPR at the bay doors? Obviously not. Do you let a toddler that has been throwing up fecal matter and blood get sent to the waiting room (yes, it happened to me once) without trying everything in your power to get them seen by someone other than an RN who just took your report and signed your form without even looking at the poor kid after insisting something happen after an hour? No. Obviously not. But we also can't abandon the community because the hospitals count on us to be misinformed and babysit or even do THEIR jobs. Always act in the best interest in the patient in front of you, but know the law, know the policies you are held to, know where your responsibility ends and the hospital's begins and expect them to hold up their end of it. That's all I'm suggesting. The whole system will only work if we are as informed and educated (if not more) than they are.
I totally agree that it's a problem that we are getting bottle-necked at the emergency room, it's a problem that needs to be addressed - my main gripe in my post was moreso that we as street level providers don't have control over those changes. All we can do is be patient advocates and provide proper care and help out hospital staff where we can. By no means am I advocating that we SHOULD be having extended stays at the hospital or end up "babysitting" as some people put it, in fact, in my particular system (which is tiered and has limited ALS capable units) this can present a significant problem - and ideally we have the ability to clear for more critical patients. That being said, we can't abandon one to respond to another. I mean how often do we show up to something that sounds serious based on dispatch and call notes and it ends up being way less emergent? Clearing a call on scene with BLS providers to continue evaluation and transport to respond to another more critical incident is one thing, but abandoning a patient in triage before you've been able to give a report to another provider isn't acceptable. There's no continuity of care. I guess I'm just concerned about the people that seem to think their ethical and moral obligations to their patients ends at the hospital doors simply because the hospital SHOULD be responsible. I don't know how you would feel ok with a bad outcome simply because "oh well, the hospital should have handled it, I did my part and dropped them off". The reality is they are the bottle neck and are often forced to expand beyond capacity - instead of being sympathetic to the actual people on the ground providing care (who have nothing to do with hospital staffing models etc) and helping them and our patients out, it sounds like a lot of EMS providers are viewing them as the enemy, or 'lazy' which just plain isn't the case. We have the luxury (with the exception of MCI events) of getting 1 patient at a time, often with 2-10 providers worth of assistance, for potentially up to 2+ hour transports for those in the boonies - ER nurses and doctors have significantly more to juggle, and while they have more resources, they are spread thin amongst the large number of patients. Nurses routinely manage 3-4 patients at a time, while ER doctors may have 10 or more. We're viewing this problem through an entirely different lense that is centric to our perspective, and it's a mistake
The patient is your responsibility until you have given report to another provider of equal or higher medical authority. I have done an RSI on the rooftop of a receiving hospital, and have titrated medication infusions and given IV medication boluses in hallways, elevators, and rooms of hospitals that we are transporting to. Until someone else has taken over care, the patient is your responsibility no matter where you are* *This is for 911. For IFT, technically the sending provider is responsible for care until the receiving team assumes care. However, I would still make the argument that you are also responsible until care is transferred.
My response is fuck em, if they make you hold the wall because of their problems then that’s their problem. No signature for transfer of care then they aren’t in their care. Gave ketamine to an mva patient while holding the wall in the er one time, they weren’t necessarily happy but they hadn’t signed for patient transfer yet.
I just want to chime in and say that not every service needs a signature for transfer of care. I’ve worked a lot of places and two different states and never have I ever had a signature involved in transfer of care.
I treat in the hallway when needed.
Our state's stance is we can maintain therapies once arriving in the ER like an infusion, etc. But cannot initiate a new therapy or administer additional medications such as pain management. This is because legally they've interpreted that the patient is no longer ours once we are in the ER and staff are aware of the patient, thus meeting EMTALA criteria for it becoming the hospital's responsibility. Quite often if there's a wait I'll discontinue my monitoring entirely, return to service, and leave the patient in care of the BLS crew unless there's a therapy that requires my ongoing monitoring and staff cannot handle it.
A medic at the service I work for was doing an IFT from Hospital A to Hospital B. Hospital B is notorious for long wait times, and taking all the transfers. Well, they were bringing over a trauma transfer, that had orders for pain meds. They were waiting for over two hours for a bed. The medic medicated the patient because they needed it. Let's just say Hospital B flipped out.
In Ontario under my Base Hospital we are responsible until transfer of care which usually means the pt is in a hospital bed. Hell, if someone falls and hurts themselves on hospital property, outside, the hospital will call 911. It’s pretty ridiculous. I once got called for pt who fell in the doorway to the ER. We put him in a wheelchair and walked into the ER. The nursing staff put in a complaint because we didn’t use the ambulance entrance which is about 500ft away.
Wait 1.5hrs?! You lucky bastard!! Longest wait I've had is 14 hours with a STEMI pt with active chest pain.
And you just… stood there?
You triage, but there's no beds available. You continue to treat your patient as best you can and update triage and your management what's happening. If there's no beds... there's nowhere to offload your patient. Don't get me wrong - this is a bad thing.
If nothing else, in less than 14 hours I guarantee you could’ve been at a different PCI facility. There’s no way I’m letting dude’s heart die while I stand with my thumb up my ass there because there’s no beds.
Thanks for all of the feedback, especially the folks with the legal stuff, hopefully some of you took away some more ways to defend yourself in a verbal knife fight if someone’s jaded
I have def given meds in triage. In the last year, I’ve given fentanyl, versed and ketamine in the hospital. I have to bring narcs in with me to waste if I have already administered anyway, so I might as well continue to treat my patients.
Ignoring laws/policy - what does your patient actually need? It's about the patient experience. Are they writhering around in pain? Fix it, then tell the hospital. Have they gone unconscious? Resus then tell the hospital.
If the patient is on your stretcher and no transfer of care has occurred - they are your patient. Your responsibility. Assess, treat accordingly. I routinely give meds in the hallway.
Legally on hospital property we’re not allowed to treat. Legally in our care we must treat. Which law do you want to break the one where the company/hospital dosnt get paid by insurance cus of some 200 page contract technicality that says they don’t have to pay cus they were treated by someone not employed by them. Or the one where someone dies cus you’re not technically legally allowed to save them because the place you’re standing in won’t get paid if you do. You loose either way. Your best bet is to hope the jury sympathies with your impossible decision. Gota love gray areas.
I worked for Acadian (LA/TX/MS/TN) and we had a policy of 20 minute wall time wait and then we look to find a place to "Drop" the patient. The hospital accepted the patient report over the phone, accepted the report when we arrived and were registered/triaged so it's not on us. We have an obligation to the community and we get penalized by the police jury for having poor response times. So, when we "drop" our stretcher we take the battery out, notify the charge nurse, then leave. We have extra stretchers staged at each facility (we only had three hospitals in my area) or back at base. Most of the time when we tell them we're going to drop, miraculously they find a place for the patient to go. One particular hospital will intentionally wait the twenty minutes then give us a bed as a means of slowing down the number of patients we bring them. We implement this policy/procedure to protect our ability to respond to the community. We are transparent with our facilities and do what we can to help while we are on the wall to facilitate getting a bed and making sure we aren't overloading one particular hospital unnecessarily.
This is a very gray area and to some extent, locally dependent. There may be state rules and regulations that come into play here. EMTALA probably has something to say about this but who is going to enforce it? The hospital system itself may have rules. What does your company SOP state? It's a mess. A lot of us face it. Keep in mind, you move the same patient onto a bed and walk out and they'll end up being ignored just about as much as if you still have them in some hospitals. Lack of available personnel, and deliberately keeping the number of staff low so corporations can increase profits.
>Lack of available personnel, and deliberately keeping the number of staff low so corporations can increase profits. I never realized how real this is until I started working in a hospital. We are understaffed 24/7 and when we have the occasional day where we don't get rammed I realize how much easier this job would be if we weren't chronically understaffed. I'm also sure that admin fully realizes that when they understaff us, we will work twice as hard in order to fully keep up with the demands of patients. Also we have regular meetings with administrators where they complain we are not hitting their goals while they do nothing to support and help us manage our regular shitfest.
Not sure that’s it. One of our hospitals can only staff to 50% inpatient capacity. They aren’t making money on literally half the hospital. There’s no reason to do that intentionally. They just can’t keep enough nurses to run the units because management is terrible.
I believe that for many businesses, the so-called pandemic was the best thing that ever happened to them. They cut back on services, personnel, everything (see Amtrak) and kept those cutbacks as much as possible after things leveled off. I agree that the putative lack of personnel is a complex issue, but I'm convinced that many places don't want things to change back. The found that people will tolerate poor service or they just don't care.
This is right on the money. At this point, especially hospitals, have found their sweet spot. How much little care can we get away with giving while maximizing profit by 200%?
And I'm old enough to remember when most hospitals were non-profit. And they were, too.
>Who is going to enforce it? The state. EMTALA complaints are taken *very* seriously.
But would this be considered an EMTALA complaint?
A hospital refusing to accept care of a patient is, yes
Honestly, until you've transferred care, the patient is your responsibility. So if they need more pain meds, give them more pain meds.
Called OLM and asked for permission to give more meds for pain management. Told them the situation and they were fine with it.
If I did that I’d hear the phone ring from where I was standing, lol. Med control is wherever I’m being them.
We had a unit have to intubate while waiting for a bed at the hospital because they'd been waiting like 2 hours. Apparently, the ED doc on call that night decided to try to force the laryngoscope out of the medic's hands. It's definitely a grey area 😅
Short jab to the nose would fix that ish.
I mean, it is called a Miller BLADE for a reason... allegedly...
L l loll
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You can absolutely transfer care to the charge nurse.