You come to work Monday morning and hear this tale from your emergency department (ED): A patient presented in the ED over the weekend with compartment syndrome and needed a fasciotomy, but no specialist was available. None of the available physicians had done one since medical school, so the physician who drew the short straw studied the procedure on YouTube before proceeding.
The mind reels with the potential liability, but that incident actually happened at a respected hospital, a physician tells Healthcare Risk Management. Ensuring that your ED has adequate specialists on call is one of the oldest and most frustrating challenges for risk managers, and it seems no one has yet found the perfect solution. Some strategies have emerged, however, that can lessen the risk of liability from failing to have physicians on call.
In her years as risk manager and chief nursing officer at several facilities, Kim Adams, RN, MSN, LHRM, tried several strategies for improving on-call coverage in the ED but never found the perfect solution. Adams is now a risk management consultant and president of Adams & Associates of North Florida in Lynn Haven.
The first step in trying to ensure adequate ED call coverage is to make sure hospital bylaws specify that physicians on staff must take call coverage, she notes. That requirement can include physicians who maintain their own practices but still remain on active status with the hospital, which often is required by malpractice insurers.
“Requiring a certain number of days on call will make some physicians say they won’t be on staff, so it’s a push and shove,” Adams says.
In the Florida panhandle where she works, finding orthopedic specialists and ear, nose, and throat (ENT) specialists for ED coverage have been the biggest challenges, she notes. Many orthopedists would resist coming to the ED when called. They would insist that the patient didn’t need emergency care from a specialist and could be seen in the physician’s office later. Thus, ED physicians and staff members were in the habit of providing whatever treatment was immediately necessary, such as putting a boot on a fracture, and instructing the patient to make an appointment with the orthopedist.
Then patients complained that when they had a Medicaid referral, the physician wouldn’t see them without payment upfront because many Florida physicians won’t accept Medicaid. That situation led patients to come back to the ED and complain that the physicians wouldn’t see them. After some negotiation involving Adams’ sister-in-law, who worked at an orthopedic practice, a group of about 10 physicians agreed to take Medicaid patients. That change helped ED coverage with that specialty.
“But at another facility, we were launching a trauma center, and orthopedists didn’t want to be on call without payment because of the type of patients they would get. We weren’t willing because that’s a slippery slope, and then your ENT won’t be on call without pay. You become a hospital that subsidizes physician practices, and it’s no longer the collaboration and becomes more an employee model.”
Rather than paying for on-call coverage, Adams’ hospital went ahead and adopted the employee model. It hired its own specialists, gave them office space, and allowed them to run their practice from the hospital.
That situation didn’t work out in the end because the specialists found that, between their regular practice and the hours spent on call for the ED, they were overloaded. In the trauma center, the specialists were required to go to the ED and see patients within 30 minutes when on call, rather than simply referring them for an office visit.
The orthopedists are negotiating with the hospital to go back to the original offer and provide on-call trauma coverage for a fee, Adams says. The hospital is considering that option, because it was never successful in putting together a large, profitable orthopedic group.
“This is a problem that hospitals and risk managers struggle with every day, and we’re always looking for another idea that might work better,” Adams says.
Strategies for addressing on-call coverage will differ depending on why you have a shortage, says David Birdsall, MD, a practicing emergency physician and vice president for leadership development with CEP America, a national physician staffing company in Emeryville, CA. Are you having trouble with call coverage because there is a lack of those specialists in the area, or is it because they just don’t want to take call coverage because it is inconvenient and they can make more money in their offices? Also, do you need a wide range of specialists as you would for a trauma center, or are you in a small hospital that routinely refers patients to larger facilities, and so you can get by with specialists in a few key areas such as surgery and obstetrics?
Requiring call coverage for physicians on staff tends not to be popular and is especially ineffective when the physician can take his or her business down the street to another hospital, Birdsall notes. The advent of ambulatory surgery centers has given many surgeons the option of practicing without being on staff at a hospital, says Peter D. Steckl, MD, a practicing ED physician and the risk manager for EmergiNet, an emergency medical staffing and management company based in Atlanta.
“It used to just be assumed that you would have to do call coverage just to maintain your staff privileges and operate, but now you don’t have to have staff privileges to operate,” Steckl says. “That means the doctors that remain have more leverage to say you’re going to have to pay them for taking call.”
Steckl notes that having insufficient specialists on call can be a serious threat to patient safety. Transferring a patient to another hospital with specialist care carries its own patient safety risks, he notes, and ED physicians often are forced to do specialty procedures that they would rather not do.
“We’re being called upon to deal with high-risk patients, high-risk procedures that are better handled by a specialist. We’re all trained in those procedures, but I can tell you I’ve done a total of three cricothyrotomies in my 25 years,” he says. “When we’re doing them, it’s stressful and we get them done, but likely not as well as a specialist. And then we have a patient with a cricothyrotomy, and we’re going to put them in an ambulance and ship them 45 minutes down the road.”
PAY STRUCTURE OPTIONS
Birdsall agrees with Adams that paying for on-call coverage is a slippery slope, but he notes that there are different ways to structure a pay agreement.
Specialists can be paid a stipend for simply agreeing to be on call a certain number of days, but you also can pay a response stipend that they receive if they come to the ED. You could add on a bonus rate for patients who are underinsured, he says. In that case, the hospital will pay the physician a certain percentage of Medicare rates, usually over the Medicare rate, to see that patient, he explains.
“That makes it financially viable, or at least not as burdensome, for the doctor to come in,” Birdsall says. “The other common strategy is begging and pleading, talking the specialists up about how important they are to the community, and that’s been known to work. I know a couple of hospitals where the medical staff lounge is probably the most opulent place I’ve ever seen. They get people to be on call and work at those sites because they get treated very well.”
Having a hospitalist on staff can significantly reduce the need for on-call specialists, Birdsall notes. In many cases, the ED physician does not need the specialist to come in, but only needs advice, and a hospitalist often can fulfill that need. A hospitalist also can admit the patient for the specialist, which can help reduce the burden on being on call, he says.
When the problem is a lack of specialists in the community, the hospital can recruit them for its own benefit. Recruiting also can be an effective strategy when you have enough available but they refuse to be on call. Birdsall worked with one hospital that recruited a specialist to the community specifically to take call coverage, and that caused the local specialists to worry so much about losing business that they agreed to start taking call coverage too.
Telemedicine also can ease the burden on specialists being on call, Birdsall notes. Anything that helps the specialist avoid coming into the ED will encourage them to take call coverage, he says.
MORNING ROUNDS INSTEAD
Another strategy is to have physicians agree that, as necessary, they will round on patients the next morning who were admitted through the ED during their on-call period.
In many cases, such as a gastrointestinal bleed, the ED physician is reluctant to admit the patient without the specialist coming in because there is a chance that the patient could get worse and need the specialist in the morning. If the specialist didn’t come in during the on-call period, he or she is not obligated to see the patient in the morning, and so the hospital is left to look for a specialist who will come see the patient. By agreeing to see such patients the following morning, specialists can avoid getting calls from ED physicians in the middle of the night just to ensure they’re not left stranded after the call period.
“That can be a good compromise that gets more specialists to say yes to being on call,” Birdsall says. “They worry less about being awoken in the middle of the night and then have to do a full day at work the next day. That appeals especially as you get older.”
Similarly, hospitals without adequate specialist coverage can make agreements with larger hospitals to accept transfers after patients are admitted. If that patient with a gastrointestinal bleed was not emergent during the night but does need a specialist in the morning, the larger hospital agrees to accept the transfer even though the Emergency Medical Treatment and Labor Act (EMTALA) no longer requires them to do so. That agreement can reduce the number of patients who are transferred before admission, while EMTALA still applies, just as a precaution.
“They agree that they will take the patient in the morning, if necessary, because they don’t want you sending over every patient just in case,” Birdsall explains. “The agreement also can specify that once the specialist care is provided at the larger hospital, the first hospital will take the patient back with no muss, no fuss.”
Kim Adams, RN, MSN, LHRM, Adams & Associates of North Florida, Lynn Haven. Email: [email protected].
David Birdsall, MD, Vice President, Leadership Development, CEP America, Emeryville, CA. Email: [email protected].
Peter D. Steckl, MD, Risk Manager, EmergiNet, Atlanta. Telephone: (770) 994-9326.