• Explore the benefits of the continuity of hospital care.
• Understand the rules and regulations behind triage and hospital choice decisions by emergency medical services (EMS) providers, and the roles of ambulance diversion and federal Emergency Medical Treatment and Active Labor Act (EMTALA) statutes.
• Identify ways to improve continuity of hospital care.

A 74-year-old man had a long history of coronary artery disease requiring coronary artery bypass grafting as well as placement of an automated internal cardioverter-defibrillator (AICD) for ventricular arrhythmias. His AICD was almost 10 years old, and his cardiologist had found minor lead displacement (one of the wires to his heart had moved over time). Admitted to Hospital X (less than 1 mile from his house), he underwent the placement of a new AICD—a minor surgical procedure, which was uncomplicated. The patient was discharged 2 days later.

Within hours after arriving home from the hospital, the patient's newly placed AICD began "firing"—shocking his heart with large amounts of energy and causing considerable pain. As the AICD fired more than 15 times in the course of minutes, his wife called 911.

Emergency medical services (EMS) arrived and found him lying on the couch, awake and alert, but in discomfort. His heart rate and blood pressure were normal. Because of repeated AICD firings and concern for a heart attack, he was taken in the ambulance.

The patient told paramedics that he had received all of his care at Hospital X and had just been discharged from there. However, they took him to Hospital Y, a few miles away.

In the emergency department (ED) of Hospital Y, the patient's AICD continued to fire shocks. The defibrillation stopped after the patient was treated with amiodarone and supportive care. He was then admitted to cardiology at Hospital Y for ongoing management. The next day, when the patient was clinically stable, the cardiologist considered transferring him back to Hospital X but decided to keep him at Hospital Y.

Unfortunately, the patient continued to have more ventricular arrhythmias and firings of his AICD even with medical treatment. Despite maximal efforts, the patient eventually died from a cardiac arrest.

It was unclear whether the patient's death could have been prevented had he been taken to Hospital X. However, one could argue that he may have received better informed care had he been admitted to his original hospital.

This case raises a key question: Did the decisions by EMS to take the patient to Hospital Y and by the cardiologist to keep him there contribute to the patient's death because he might have received better care at Hospital X? The answer brings up several issues in patient safety for prehospital, ED, and hospital care:

Issue 1: After stabilization, should the cardiologist at Hospital Y have transferred the patient to Hospital X? More broadly, is continuity of hospital care associated with better outcomes? To my knowledge, there are no studies comparing outcomes for patients with continuity of care (same doctor, same hospital) with those cared for by different doctors. In the absence of data, we must rely on clinical experience and common sense to explore this issue.

Continuity of Hospital Care

It is certainly easier logistically for providers when they know the patient. Any first encounter is a learning process as providers become familiar with current and past medical history and social issues. When problem lists are complex, this process involves considerable time and can add inconvenience because of the need to transfer and review medical records. There is a learning curve not only for physician care, but for the entire team (nursing/other services)—a curve that is avoided when patients are known to a hospital unit. Complex patients also typically come with a large volume of records, which may or may not be organized to make salient information easily accessible, or may be missing key information. Old records also may be unavailable at certain times (e.g., nights/weekends). As a result of these problems with records, important information to guide the safest care may only be known by providers who are acquainted with the patient.

On the other hand, transferring care between physicians can sometimes change management for the better. Transfers can result in a "fresh set of eyes," which will sometimes result in a previously overlooked diagnosis being made or treatment being chosen. A similar benefit is sometimes observed when physicians hand off patients during an admissions process or transfer patients between hospital services, or when hospital-based physicians go off-service and the oncoming physician offers a different perspective.

When it comes to this case, although it may have been easier for the cardiologist at Hospital X to care for the patient, there is no particular evidence to suggest that this would have necessarily prevented the patient's death.

Issue 2: Armed with the knowledge that the patient was just discharged from Hospital X, what policies in EMS and ED systems may have necessitated transfer to Hospital Y, which was farther away? In considering this question, the first issue is determining whether the patient would have been classified as "unstable." Policies are different when dealing with these patients than when dealing with stable patients with normal vital signs.

It is impossible to know precisely why EMS took this patient to the farther hospital, but two possibilities come to mind:

1. Hospital X and Hospital Y were both appropriate facilities, and Hospital X was "on diversion" (not accepting patients).

2. Hospital Y was considered the closest appropriate facility because EMS was concerned about acute myocardial infarction, and Hospital X may not have had cardiac catheterization facilities.

Ambulance Diversion

Some hospitals have "ambulance diversion" policies that are activated when the ED reaches a certain level of crowding.(1) The purpose of diversion is to signal to EMS that hospital services cannot accommodate additional patients. A central cause for ED crowding and ambulance diversion is hospital crowding.(2) Over recent decades, there has been a reduction in the number of hospital beds across the United States.(3) In competitive environments, one strategy employed by many hospitals to maximize profitability is to operate at high occupancy and prioritize elective admissions.(4) Subsequently, during daily surges of ED patients requiring admission, demand for inpatient bed capacity commonly exceeds supply, and ED admissions board in the ED for long periods. When the ED is boarding admitted patients, the remaining beds saturate. And as effective capacity to care for new patients is diminished, new patients experience long waits. During these periods, many hospitals will use diversion to direct ambulance traffic elsewhere. In the case of an "unstable" patient like this one with an AICD firing, it was possible that ED crowding in Hospital X and ensuing diversion may have resulted in the decision to drive farther to Hospital Y.

EMS Destination Decisions

EMS considered acute myocardial infarction as a potential cause for the AICD firing. EMS may have considered Hospital Y the closest appropriate facility because it had better capabilities (such as cardiac catheterization services) than Hospital X. For "unstable" patients, EMS policies are designed to match hospital capabilities with patient complaints. For example, EMS ambulances may bypass local hospitals to bring patients to Level I trauma centers, stroke centers, or centers with cardiac facilities. Recently, EMS has also considered the ability to provide therapeutic hypothermia after return of spontaneous circulation in cardiac arrest in making destination decisions.(5) However, in most cases, critically ill patients (such as those in respiratory distress) are taken to the closest hospital, where decisions to transfer to a higher level of care can be made after stabilization.

When it comes to both stable and unstable patients, there are no federal destination policies or regulations. Policies are made locally (state, county) by EMS medical directors. Accordingly, policies may be very different depending upon the local geography and EMS and health system resources. In general, EMS medical directors are authorized to determine specific zones of transfer hospitals for the 911 system. Stable patients may request transfer to a particular in-zone hospital (consideration is given to where they receive regular care). But when there is a request or indication to transfer outside the zone, EMS providers must contact a supervisor or online medical command to determine the most appropriate facility.

In some cases, this system may seem counterintuitive to hospital-based providers, who may ask: "Why didn't they just bring the patient back?" But EMS providers prefer to stay in-zone to ensure that ambulances are available when a patient truly has a life-threatening emergency. Taking an ambulance out of service for even a short period can have devastating consequences if that out-of-zone ambulance is needed but unable to respond.

Federal regulations do come into play when there is an EMTALA issue. EMTALA is a statute that regulates treatment refusals and transfers between hospitals for unstable patients.(6) Since EMTALA was passed (1986), several court decisions (i.e., case law) have updated its interpretation. The most applicable case was in 2001 (Arrington v. Wong).(7) In Arrington, EMS contacted online medical command for a patient with shortness of breath/respiratory distress. The physician directed the patient to a facility that was farther away (where the patient's doctor was), and the patient died shortly after ED arrival. In the appeal ruling, the court determined that if an ambulance contacts a hospital, that hospital must provide emergency care for that patient under EMTALA rules, unless that hospital is on diversion. In this case, if the ambulance had made contact with an online physician at Hospital Y, then Hospital Y would have violated EMTALA if it failed to provide emergency stabilization services.

Issue 3: Assuming continuity of hospital care is important, can we improve the current system to better balance EMS resource use and continuity for complex patients? This question applies primarily to stable patients because EMS systems are designed to direct unstable patients to the closest hospitals with appropriate facilities. I see two possibilities:

1. Ensure that patients are transferred to the right hospital after stabilization.

2. Reconsider EMS policies so that stable patients are directed to the right hospital the first time around.

Transfer after Stabilization

Should there be an explicit policy to repatriate all complex patients to home hospitals after stabilization? In my judgment, probably not, for the following reasons: (i) it would be difficult to interpret and enforce the policy because many patients are cared for by several hospitals, and (ii) hospitals may not want to transfer patients for economic reasons and may resist the policy, particularly in the absence of literature demonstrating that such a policy would improve outcomes. The better possibility is to reduce administrative barriers to transfer. Providers can see transfer as more work than an admission and often encounter labyrinthine processes: paperwork, finding accepting physicians, many phone calls. Streamlining processes for easier transfer between facilities may allow for better continuity of care.

Changing EMS Policy

This is a tougher issue. Because EMS policies are local (appropriately so because of variability in local resources and system constraints), making sensible, national policy to repatriate complex stable patients would be very difficult. One of the solutions proposed is "systems status management" where ambulances are on standby when a local ambulance goes out-of-zone.(8) However, these systems can require considerable coordination and expense. In addition, they may not work in areas with long distances between hospitals or with few ambulances. The other possibility is to expand zones, but that would be a local decision by the EMS medical director.

Take-Home Points

• Continuity of hospital care may be better for patients, but there is little evidence to demonstrate this.
• EMS policies are determined locally, and these policies must differentiate between "stable" and "unstable" patients.
• Ambulance diversion may cause EMS to bring patients to hospitals where they have not previously received care.
• Federal EMTALA laws can play into EMS decisions when contact is made between EMS and online medical command.
• Solutions may exist to repatriate stable, complex medical patients to home hospitals, but changing EMS policy may not be the solution.

Jesse M. Pines, MD, MBA, MSCE
Associate Director, Division of Emergency Care Policy and Research
Assistant Professor of Emergency Medicine and Epidemiology

Hospital of the University of Pennsylvania

Faculty Disclosure: Dr. Pines has declared that neither he, nor any immediate member of his family, has a financial arrangement or other relationship with the manufacturers of any commercial products discussed in this continuing medical education activity. In addition, his commentary does not include information regarding investigational or off-label use of pharmaceutical products or medical devices.

Acknowledgement: Dr. Pines would like to thank Ray Fowler, MD, Crawford Mechem, MD, and Edward Dickinson, MD, for their help in preparing this commentary.

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