On-call specialists and higher level of care transfers in California emergency departments

Objectives: To survey California emergency department (ED) medical directors' impressions of on-call specialist availability and higher level of care (HLOC) transfer needs and difficulties and changes since the passage of the Emergency Medicine Treatment and Active Labor Act (EMTALA) final rule in 2003. Methods: The authors conducted a survey of all California ED medical directors from February to June 2006 with regard to the composition of the ED on-call panel and need for HLOC transfer. ED demographic data were obtained from the California Office of Statewide Health Planning and Development. Results: Overall response rate was 243 of 347 (70%). More than 80% of respondent EDs reported having internal medicine, obstetrics/gynecology (OB/GYN), and pediatrics on call. However, fewer than 60% of EDs reported cardiac surgery, otolaryngology, neurosurgery, plastic surgery, or vascular surgery on call. Specialists were less likely to be on call in rural EDs. On-call coverage was rated worse than 3 years ago for 10 of 16 specialties. Rural EDs were more likely, and trauma centers and teaching hospitals were less likely to transfer at least one patient daily for HLOC. ED medical directors reported that the ability to transfer for HLOC has worsened over the past 3 years for all specialties. Respondents indicated that more than 40% of ear, nose, and throat (ENT), orthopedics, plastic surgery, and mental health HLOC transfers take more than 3 hours. Conclusions: This survey of California ED medical directors suggests ED on-call specialist availability and the ability to transfer for HLOC have worsened since the passage of the EMTALA final rule in 2003.