American Academy of Emergency Medicine

Board of Directors to Consider Policy Regarding In-House Coverage

by Howard Blumstein, MD FAAEM and Raymond Roberge MD MPH FAAEM

Based on a suggestion from an AAEM member, we have begun to develop a policy statement regarding coverage of emergencies involving patients who are already in the hospital. The reality is that in many small hospitals there is little high quality care available for unstable patients. This is especially true during nights, weekends and holidays. The emergency physician working in the ED is often the only physician in the hospital, and is best prepared for such emergencies.

An emergency physician’s first duty is to the patients in the ED. If there is an unstable patient in the hospital in need of urgent attention, and you are the patient’s best hope for survival, a number of conflicts are created.

Our draft policy is intended to help define the emergency physician’s responsibilities to patients in the ED and provide some guidance for both the emergency physician and the hospital. The hospital’s obligations regarding providing alternative means of coverage and rapid relief of EPs responding to in-house emergencies are addressed, as well as liability issues.

Much of the policy is based on discussions we have had with AAEM members who work in small hospitals and are asked to respond to in-house emergencies. Before the Board of Directors formally considers the policy, we would like to get more member feedback. If you have worked in hospitals where EPs are asked to respond to in-house emergencies, please review the policy below and provide us with feedback. You can e-mail us at hblumste@wfubmc.edu or randmroberge@yahoo.com.

AAEM Draft Position Statement
Statement: The primary responsibility of the EP is the care of patients within the ED.

In some medical institutions (generally, smaller community hospitals), due to limited physician coverage, the EP is required to respond to various in-hospital (out-of-ED) situations demanding rapid response (e.g.; cardiac arrest, respiratory arrest, etc.). This is particularly true during evenings, nights, weekends, and holidays.

In those institutions with single EP coverage, responding to such situations leaves the ED without direct physician coverage. This then deprives ED patients of physician-supervised medical care, places undue stress and liability on ED nursing staff, and prevents the continuity of other physician-related ancillary tasks (e.g.; prehospital medical command, etc.). In addition, responding to situations that, by definition, will involve gravely ill patients about whom the EP has no prior knowledge increases the risk of poor outcomes that in and of itself imposes a potentially enormous burden of liability on the EP.

Nonetheless, the reality of life threatening situations, where no other physician is available, is such that EP response is an ethical and professional consideration.

It is the position of The American Academy of Emergency Medicine that:

  1. It is in the best interest of ED patients that a board-certified EP be continuously present within the confines of the ED to ensure optimal care;

  2. The EP’s first responsibility is to ED patients;

  3. Unstable or critically ill in-patients are best cared for by their attending physician(s) who has an ongoing knowledge of the patient's condition and hospital course;

  4. When asked to attend to a patient in a non-ED setting, the EP must determine whether he (she) can respond without compromising the safety and care of the ED patient(s). The EP may respond, at his (her) discretion.

  5. EPs should only respond to life threatening emergencies;

  6. EPs must not be required to perform prolonged resuscitations or stabilizations. Hospitals and medical staffs must ensure that other qualified medical personnel (preferably the patient’s attending physician) respond quickly to relieve the EP and continue patient care;

  7. Hospitals should provide liability coverage for EP services provided to in-patients;

  8. Hospitals are encouraged to find alternatives to requiring EPs to leave the ED, including:

    • procedures to be carried out by qualified non-physicians (e.g.; nurse anesthetists, respiratory therapists, etc.)

    • off-site medical direction via bedside television monitors/transmitters;

    • rapid transport to the ED, when feasible, of seriously ill in-house patients requiring EP assistance;

    • back up, on-call arrangements for ED coverage when the EP on duty must respond to in-hospital emergencies.