EMTALA fears come true with too few on-call docs

When EMTALA was finalized last year, risk managers worried that changes in the rule might mean they would find it impossible to schedule enough specialists on call to meet EMTALA needs. That nightmare is coming true. Two-thirds of emergency department (ED) directors are reporting shortages of on-call specialists, such as neurosurgeons, orthopaedists, and obstetricians, at their hospitals, according to a new study from the American College of Emergency Physicians (ACEP) in Irving, TX.

About one-third (33%) indicated they were spending more time placing calls to medical specialists since regulatory changes to a federal law took effect in November 2003, which eased their obligation to take calls from the ED.

The ACEP survey, conducted from April to August 2004 in conjunction with researchers from Johns Hopkins University in Baltimore and funded by the Robert Wood Johnson Foundation in Prince-ton, NJ, is the largest study ever designed to evaluate problems with on-call coverage. J. Brian Hancock, MD, president of ACEP, explains that medical directors from a total of 1,427 hospital emergency departments participated in the survey — a sample size equal to 32% of all U.S. acute care hospitals.

"The decrease in the number of medical specialists willing to be on-call in the nation's emergency departments is a looming national health care crisis," Hancock says. "Our biggest concern is for our patients. When a person has a traumatic head injury, they need access to a neurosurgeon right away, because delays can result in further brain damage and even death."

Liability risk increased

According to some of those surveyed, the lack of needed specialist backup is causing problems that risk managers know can lead to EMTALA violations and liability: delays in patient treatment, increases in patient transfers between EDs, and concerns that the lack of timely access to specialists may be placing patients at risk of harm.

Respondents reported other adverse effects of the shortages, including decreased ability of EDs to make optimum use of resources, patient frustration due to extended time in the ED as well as subsequent transfer, increased wait times for patients in waiting rooms, and more crowding at referral hospitals where patients were transferred.

According to the new survey, 16% of respondents indicated that some specialists were negotiating with their hospitals for fewer on-call coverage hours. Emergency physicians also said they were spending more time seeking specialists for consultation and admission of ED patients.

Emergency physician Ben Vanlandingham, MD, a Robert Wood Johnson Clinical Scholar at The Johns Hopkins University and principal investigator of the study team, says the EMTALA on-call crisis is found nationwide. "Nearly 1,000 hospitals across the country are telling us this is a problem," he says. "When we looked at the results across different geographic regions in the country, or with regard to hospital size, the responses were essentially the same."

In changing the federal EMTALA law, the government narrowed some definitions about what is and is not an ED and limited the regulation from being applied to patients once they are admitted to a hospital. The new regulations acknowledge the need to balance hospital and physician legal duties with the practical realities of overcrowded EDs and the concerns of on-call specialists and their own practice demands. While hospitals are required to maintain a list of on-call physician specialists, individual physicians may be on call at more than one hospital at the same time and may limit their amounts of call time.

In September 2003, ACEP expressed concerns that the new EMTALA regulation potentially could increase the shortage of on-call medical specialists and exacerbate an already difficult situation, says Barbara Marone, the study director and ACEP’s director of federal affairs. An EMTALA Technical Advisory Group (TAG) was established by the Medicare Modernization Act of 2003 and will meet in the next few months. S he says ACEP is urging the TAG to place timely access to medical specialists in the nation’s emergency departments at the top of its list of priorities to develop specific recommendations.

The survey is part of an ongoing investigation that will track changes over the next year. Vanlandingham said his team would be following up these new data with an examination of whether on-call coverage problems are greater in states with malpractice crises and the highest penetration of specialty hospitals and outpatient surgery centers.