Can a patient be moved to the Emergency Department (ED) and remain under the care of the hospitalist service?

Can a Patient Be Physically Moved to the ED and Remain Under the Care of the Hospitalist Service?

No, moving an already-admitted inpatient patient back to the ED while keeping them under hospitalist care is inappropriate and violates EMTALA regulations, which prohibit transfers lacking medical justification. 1

Regulatory and Legal Framework

Moving admitted inpatients backward to the ED constitutes an improper "transfer" under federal law. The Centers for Medicare and Medicaid Services explicitly prohibits financially motivated transfers and requires that any transfer must demonstrate medical benefits outweighing risks. 1 This practice could result in:

• Civil monetary penalties up to $50,000 per violation 1
• Potential termination of Medicare provider agreements 1
• EMTALA non-compliance citations 1

The American College of Emergency Physicians and other medical societies specifically recommend against moving admitted inpatient floor patients backward to the ED as a capacity solution, citing both EMTALA violations and patient safety concerns. 1

Patient Safety Concerns

The ED environment is fundamentally designed for acute evaluation and stabilization, not for ongoing inpatient care. 1 ED crowding is already associated with:

• Medication errors 1
• Delays in care 1
• Patient safety deficits 1

Adding admitted inpatients to an already crowded ED compounds these risks and creates an inappropriate care environment for patients requiring ongoing hospitalist management.

Evidence-Based Alternatives for Capacity Management

When facing bed capacity constraints, the appropriate solution is moving admitted patients forward to inpatient hallways, not backward to the ED. 1, 2, 3

Inpatient Hallway Boarding Strategy

Research demonstrates that transferring ED-boarded patients to inpatient hallways is both safe and preferred:

• No increase in mortality: Patients admitted to inpatient hallways had lower mortality rates (1.1%) compared to standard bed admissions (2.6%). 2
• No increase in ICU transfers: Hallway-boarded patients required fewer ICU transfers (2.5%) versus standard admissions (6.7%). 2
• Overwhelming patient preference: 85% of patients preferred inpatient hallway boarding over ED hallway boarding. 3
• Improved patient experience across all domains: Patients rated inpatient hallways superior for rest (85%), safety (83%), confidentiality (82%), treatment (78%), comfort (79%), quiet (84%), staff availability (84%), and privacy (84%). 3

Additional Capacity Management Solutions

Implement these evidence-based strategies instead of moving patients to the ED: 1

• Maximize discharge efficiency by moving floor patients ready for discharge to designated holding areas while awaiting final orders and transportation 1
• Implement "surge discharge" protocols that prioritize early discharge of stable patients 1
• Transfer appropriate ICU patients to step-down units to free critical care beds 1
• Expand into post-anesthesia care units, procedure rooms, and step-down units for patients requiring monitoring 1
• Defer elective procedures to preserve bed capacity 1

Current Practice Patterns

Despite evidence supporting inpatient hallway boarding, adoption remains limited. Only 42.5% of surveyed hospitals reported using inpatient hallway boarding in the last 12 months, and among those that did, the median number of patients moved was less than 1 per day. 4 This suggests significant underutilization of a safe, evidence-based strategy, while the inappropriate practice of moving patients backward to the ED should never be considered as an alternative.

Common Pitfalls to Avoid

• Never move admitted inpatients to the ED for capacity reasons - this violates EMTALA and creates patient safety risks 1
• Do not confuse ED boarding with inpatient hallway boarding - these are distinct practices with different regulatory implications 2, 3
• Avoid state-specific restrictions - some state health departments restrict inpatient hallway boarding usage, so verify local regulations 4
• Do not implement inpatient hallway boarding without proper protocols - ensure multidisciplinary team development of institutional protocols before implementation 2