What Does ACEP Say on Boarded Inpatients?

Two of the American College of Emergency Physicians (ACEP)'s policies address the issue of who is responsible for inpatients being held in EDs. The October 2007 policy, "Responsibility for Admitted Patients" recognizes that the patient benefits when there is a clear delineation of who is responsible for the patient's care.

The policy states: "Regardless of the location of an admitted patient within the hospital, the ultimate responsibility for an admitted patient's medical care rests with the admitting physician."

The policy also recommends that hospital policies clearly state that once an admitting physician has accepted a patient, that the admitting physician has assumed responsibility for the patient.

"The reasoning behind this policy is important," says William Sullivan, DO, JD, FACEP, director of emergency services at St. Margaret's Hospital in Spring Valley, IL, and a practicing attorney. Some admitting physicians argue that because an admitted patient is still in the ED, that the emergency physician is responsible for the patient's care.

"The idea that a patient's location determines what doctor is responsible for the patient's care really doesn't make much sense," says Sullivan. If a patient is in radiology having a chest X-ray, it isn't the radiologist's responsibility to write routine orders for intravenous lines. "Admitted patients in the emergency department are not, and should not be, any different," says Sullivan. "Of course, any physician is available to help in an emergency, but routine care should be handled by the admitting physician."

Outside Scope of Training

Another reason admission should be the point at which care transfers to the admitting physician is that ED physicians generally aren't credentialed to provide routine inpatient care.

"The emergency department is considered an outpatient setting," says Sullivan. If an ED physician provides routine care for admitted patients, the physician could be liable for exceeding his scope of training or credentialing.

The hospital also could be liable for allowing the physician to practice outside the scope of his or her training and credentialing. "We wouldn't allow an orthopedic surgeon to perform an appendectomy without demonstrating competence in performing that surgical procedure," says Sullivan. "Nor should hospitals allow emergency physicians to perform routine inpatient care without demonstrating competence in performing such care."

Finally, medical malpractice insurance may not cover ED physicians for providing routine inpatient care. "It would be important to review one's policy language to determine the exact scope of coverage in this regard," says Sullivan.

ACEP's policy, "Writing Admission and Transition Orders" states that even if an ED physician writes temporary admission orders, the admitting physician should retain responsibility for the patient's care.

"Admission orders signed by an emergency physician may appear to extend responsibility for a patient's care past the admission point, or even onto the medical floor," says Sullivan. "This may cause confusion with the nurses, especially in the middle of the night if an admitting physician is unavailable."

ACEP recommends that hospital policies clearly state that the responsibility for a patient's care changes when the patient is admitted. "Such a policy would prevent any misunderstandings and lapses in patient care," says Sullivan.

Policies not Legally Binding

Ultimately, the legal responsibility for an admitted patient is determined by the jury in a medical malpractice case or by a government agency during an investigation. "While ACEP's policies may be persuasive, they are not binding on a jury or on a government agency," says Sullivan.

Sullivan notes that a search of legal databases shows no appellate case involving transition of care issues in the ED. "But most medical malpractice cases do not advance to an appellate level. The legal databases may not reflect the true incidence of such cases," he adds.

Sullivan advises using ACEP policies to lobby hospital administrators or hospital board members to create a hospital policy regarding responsibility for admitted patients.