An emergency physician client recently asked a question regarding providing inpatient care in a rural critical access hospital. The hospital had a 4 bed emergency department and had 12 inpatient beds. He was recruited as an emergency physician, but since it was a small facility, during his 24 hour shift, the hospital also wanted him to provide inpatient care and round on inpatients during his emergency department shifts. He commented that “I can’t remember the last time I worked up hyponatremia or adjusted a patient’s home medications based on an echocardiogram report.”
Should he take the job?
Under these circumstances, the physician and the hospital could be assuming quite a bit of liability if a patient suffers a bad outcome – either on the inpatient unit or in the emergency room.
Outpatient Care versus Inpatient Care
Emergency medicine training doesn’t involve much inpatient medicine. Once residency training is completed, an emergency physician’s practice is almost always limited to outpatient care in the emergency department or in an acute care clinic. Occasionally, physicians with emergency medicine training may work in a primary care office or may work in a specialty clinic. Few emergency physicians have a lot of experience working in an inpatient setting.
For a physician to perform inpatient care in a hospital, the physician has to be credentialed to perform inpatient care in a hospital. Each hospital has its own criteria for providing physician credentialing. If a hospital credentials a health care provider to perform hospital medicine when that provider has little or no formal training in hospital medicine, it creates an argument for “negligent credentialing” against the hospital.
Consider the duties of a hospitalist. Emergency physicians are comfortable admitting patients for evaluation of chest pain. How many emergency physicians are comfortable ordering appropriate tests for an inpatient workup or with determining patient discharge criteria for patients admitted for chest pain? Similarly, CMS has criteria for admitting a patient to the hospital under observation versus inpatient status. For patients admitted as an inpatient, CMS requires physicians to attest that patient meets inpatient criteria. If a hospital is later the subject of a RAC audit or CMS determines that admitted patients did not meet inpatient criteria, CMS can demand that the hospital reimburse them for any overpayments. The hospital may then seek reimbursement from the physician – especially if the physician agrees to an indemnification clause in an employment contract. How would the emergency physician address simultaneous emergencies on the floor and in the ED? How would the emergency physician address a floor patient that requires extensive time for stabilization and transfer if the emergency department is busy?
Are emergency physicians insured when providing routine inpatient care?
If a hospital’s malpractice insurance policy doesn’t provide coverage for both inpatient and outpatient activities (ED is considered outpatient) then the healthcare provider may be left without insurance in the event of a malpractice claim.
Is it safe for emergency physicians to provide inpatient care during a shift?
The American College of Emergency Physicians has a policy regarding an emergency physician’s responsibilities outside of the emergency department. https://www.acep.org/patient-care/policy-statements/emergency-physicians-patient-care-responsibilities-outside-of-the-emergency-department/
This policy recommends that hospitals provide response plans for emergencies that occur outside of the emergency department and that those plans should not rely on the presence of an emergency physician. In addition, the policy specifically recommends that emergency physicians are provided with adequate legal protections when responding to inpatient emergencies. This ACEP policy mentions nothing about providing routine inpatient care.
This issue of patient safety when emergency physicians were required to leave the emergency department was addressed in a whistleblower lawsuit filed against two Healthcare Corporation of America (HCA) hospitals and against two subsidiaries of EmCare (now Envision Physician services). In this case, the emergency physician alleged that hospital policies forced the physicians to respond to “code blue” calls in the hospital and also required the physicians to cover emergencies in a separate pediatric emergency department. In one year, emergency physicians were required to leave the emergency department with no available physician 209 times. When the physician wrote a letter to hospital administrators and to EMCARE voicing these concerns, he was fired a few months later. The physician sued both Overland Park Regional Medical Center and EmCare. During the trial his attorney described how publicly traded companies such as Envision and Team Health focused primarily on profits to the detriment of patient safety. After a 10 day trial, the jury awarded the emergency physician a $28.8 million verdict.
Is it safe for the emergency physician to leave an emergency department to care for inpatients during a shift? Occasional trips to the inpatient units to provide critical care in an emergency probably don’t present much of an issue. However, the more time an emergency physician is required to be outside an emergency department during a shift, the more likely that the practice will be viewed as “unsafe.”
Should an emergency physician accept a position that requires both emergency medicine and hospitalist medicine duties? The answer depends upon the physician’s training, practice comfort, and risk tolerance. Being aware of some of the issues involved and talking with other physicians who have worked in the emergency department at the facility may help guide the decision.
Photo by Paolo Nicolello on Unsplash