CPE-110 EMTALA - Regional Health

CPE-110 EMTALA
Objectives
By the end of this course,
learners will be able to identify
the intricacies of EMTALA.
During the course learners will:
1.
2.
3.
4.
Analyze EMTALA’s
legislation
Interpret Physician’s
responsibilities
Review Hospital’s
obligations
Identify EMTALA’s
enforcement
Eugene Barnes was stabbed in the head. He was
transferred to a hospital where two neurosurgeons
refused to come in and assess him.
Two neighboring hospitals refused to accept him as a
transfer.
As a result he died 3 days later.
When you are ready click the Sharon Ford Story.
Sharon Ford was in active labor and she was
transferred from one hospital to another which was
a member of her Medicaid HMO.
Legislation
EMTALA was originally enacted in 1986, due to wide-spread concerns
that hospitals were turning away or transferring patients who were in
need of emergency medical care, but who were unable to pay for the
needed services.
EMTALA prohibits a
hospital from delaying
care, refusing treatment,
or transferring patients to
another hospital based on
the patient’s inability to
pay for services.
Time to take your pulse.
Before we go any further, we are going
to review a scenario.
Scenario:
A rural hospital had a transfer involving an intoxicated young adult
with a previous brain injury; therefore, requiring a neurosurgery
consult. The on-call physician at the receiving facility knew of the
patient, his non-compliance and difficult placement issues and
refused to accept the patient even though the facility had capacity.
Is it okay for the higher level of care
facility to deny acceptance?
A hospital with specialized capabilities
or facilities (e.g. burn units,
neurosurgery, neonatal intensive care
units) may not refuse an appropriate
transfer if the patient requires the
hospital’s specialized capabilities and
the hospital has the capacity to treat
the individual.
Would this be an EMTALA violation?
This would constitute an EMTALA
violation.
Definitions
“DED”
EMTALA requires that a hospital provide an appropriate medical
screening examination and stabilize all persons who present
themselves to the hospital’s “dedicated emergency department.”
Dedicated Emergency Department (DED) refers to a far greater
range of facilities than those formally designated as emergency
departments. Any patients presenting on campus (250 yard rule)
must be stabilized before transferring to the designated ED.
“Hospital Campus”
The hospital campus includes the physical area immediately
adjacent to the hospital’s main building and within 250 yards.
When a patient presents to an area of a hospital other than a
dedicated emergency department, EMTALA obligations are
triggered if the individual or someone on their behalf requests
examination for an emergency medical condition or a prudent
layperson believes, based on the patient’s appearance or behavior,
that the individual needs emergency examination or treatment.
For example, a patient presenting to a clinic located on the
hospital campus with a gun shot wound must be stabilized before
transfer to the emergency department.
“MSE”
Medical Screening Exam (MSE) is the process required to
determine whether the individual has an emergency medical
condition or not. MSE typically begins but does not end with
triage.
“MSE Continued”
An appropriate medical screening examination means screening to
determine the existence of an emergency medical condition which
is the same as or similar to the screening provided to all patients
presenting to the emergency room complaining of the same
condition or exhibiting the same symptoms or conditions. The key
take away is to evaluate each encounter in an objective manner
without prejudice of previous encounters with patient.
“MSE Continued”
The MSE must be:
• Provided to every presenting patient without undue delay;
of sufficient scope to rule in or rule out an emergency
medical condition.
• Conducted by a credentialed provider.
• Initiated before obtaining payment information.
The MSE can range from a quick evaluation lasting a few seconds
to a longer evaluation with extensive workup and tests
“MSE Continued”
The MSE should include:
• Triage record
• Vital signs
• History
• Physical examination
• All necessary available testing
• Use of on-call physicians as needed
• Discharge or transfer vital signs
Psych Significant MSE Components
• Once a patient is deemed “stable,” EMTALA no longer
applies and patients may be transferred even for
economic reasons. The operative word for stabilizing
psychiatric patients is “protected.” A psych patient is
considered stable for transfer when, by use of either
medication or physical restraints, the patient can be
protected from hurting him or herself or others.
• Practitioner should use great care when determining if
the medical condition is in fact stable after
administering medication or physical restraints.
“Labor and Delivery”
Labor is defined as: The process of childbirth beginning with the
latent or early phase of labor and continuing through the delivery
of the placenta.
A physician, a nurse midwife, or an OB nurse in consultation with
a physician, must certify that the patient is not in true labor before
discharge or transfer. (The consultation may be by telephone)
A woman in active labor is considered unstable under EMTALA,
preventing discharge or transfer, unless the transferring hospital
has absolutely no capability to deliver the baby safely. This is
acceptable only if the benefits of transfer outweigh the risks.
“Against Medical Advice” (AMA)
CMS clarified that EMTALA obligations exist for hospitals even
when a patient leaves without notifying the hospital. For any
patient who refuses further care or “leaves without being seen”,
the emergency department staff must log and document who
refused care, what time the hospital discovered that the patient
left, retain all triage notes and additional records, and document
attempts to obtain written refusal. If investigated by CMS, the
hospital must show that the refusal of care was not due to delay of
care caused by discriminatory reasons such as economic/insurance
status, race, color, nationality, gender etc.
DOCUMENT, DOCUMENT, DOCUMENT
Log Requirements
• EMTALA requires that hospitals maintain a central log for each
individual who comes to the ED. It must indicate whether these
individuals refused treatment or were treated, stabilized, and/or
transferred or discharged. State surveyors will want to review the
central log at the beginning of an investigation and they will expect
that the log be sequential, complete and organized.
• If a patient leaves without being identified, a description of the
patient should be included in the log (i.e. male, adult, date/time).
• The log needs to be maintained for seven years.
ED Signage Requirements
Signs should be posted “in a place or places likely
to be notice by all individuals entering the
emergency department, as well as those individual
waiting for examination or treatment (e.g. waiting
or admissions area). Signage should also be
readable from a distance of 20 feet and translated
in applicable languages.
When does EMTALA end?
EMTALA ends when the patient is considered
stable!
The term “Stabilized” means, in respect to an
emergency medical condition, that no material
deterioration of the condition is likely, within
reasonable medical probability, to result from or
occur during the transfer of the individual from a
facility or that the woman has delivered the child
and the placenta.
EMTALA ends when the patient is considered
stable!
A patient is deemed stabilized if the attending
physician has determined, with reasonable clinical
confidence, that the emergency condition has
resolved. A patient is considered stable for
discharge when a physician determines, with
reasonable clinical confidence, that the patient has
reached the point where his or her continued care,
including diagnostic workup and/or treatment,
could reasonably be performed on an outpatient
basis.
On-call Responsibility/Accountability
As a requirement for participation in the
Medicare program, hospitals must maintain a
list of physicians who are on-call for duty.
This list is technically an EMTALA-related
requirement rather than a specific requirement
of the EMTALA portion of the act.
The list clearly ensures that the hospital’s
personnel are aware of which physicians, including
specialists and subspecialists are available to provide
stabilizing treatment.
On-call Responsibility/Accountability:
The emergency department physician has the
ultimate authority in deciding whether the
specialist needs to come to the hospital to help
stabilize the patient. If the on-call physician
refuses to come to the hospital and the
emergency physician is forced to transfer the
patient for emergency care, EMTALA mandates
that the name and phone number of the refusing
on-call physician be documented on the chart so
that the receiving hospital can report the on-call
physician.
On-call Responsibility/Accountability:
On-call physicians need to fully understand their
EMTALA responsibilities. On-call physicians must
respond to the hospital when requested to
attend to patients in a timely manner and
complete a Medical Screening Exam or provide
stabilizing care unless circumstances beyond the
physician’s control prevent a response.
On-call Responsibility/Accountability:
On-call physicians cannot change, or engage in
delay tactics such as debating with emergency
department physician on the necessity of
coming to the hospital, ordering that the
patient be transferred to another hospital
because of severity or scope of condition,
asking about payment status, offering only
office follow-up, or insisting on another
specialist before coming to the hospital.
On-call Responsibility/Accountability
CMS has continued its policy of not
defining what it means by “reasonable
response time.” However, the new
guidelines state that expected response
time should be stated in actual minutes in
the hospitals’ policies.
EMTALA Requirements with Transfers
Prior to transfer, a patient must be stabilized
to the best of the hospital’s ability given their
resources. Once the transfer is determined to
be necessary the transferring physician must
speak directly to the receiving physician and
obtain acceptance. This is documented on the
certificate of transfer. In addition, there must
be documentation that the medical benefits
associated with the transfer should outweigh
the risks and be documented on the certificate.
EMTALA Requirements with Transfers
Patient must be transferred using
appropriate means of transportation,
equipment and personnel. If the patient
refuses ambulance transfer, and chooses to
go private vehicle, an “AMA form” must be
signed. This form releases the physician
and facility from responsibility once the
patient leaves the hospital via private
vehicle.
EMTALA Requirements with Transfers
If a patient requires diagnostic services not
available at the facility, the transferring
hospital still needs to have an EMTALAcompliant transfer with documentation,
certification, and acceptance by the receiving
hospital. The benefits still need to outweigh
the risks of transfer.
EMTALA Requirements with Transfers
When a hospital’s resources are at capacity and
it converts to diversionary status, it is not
required to accept further transfers to the
hospital. This activity must be documented in
the diversion log or “transfer request log.”
EMTALA Enforcement
Duty to Report
Hospitals/Providers who receive an improperly
transferred patient are required to report their
concerns to CMS or to their State survey agency
within 72 hours.
In South Dakota the Dept. of Health
investigates all EMTALA allegations.
Once the investigation is complete, the Denver
Regional CMS Office makes the final
determination.
EMTALA Enforcement continued
Fines/Penalties
• A hospital can be fined between $25,000 - $50,000 per violation
$25,000 limit for hospitals fewer than 100 beds
• Hospital can be excluded from the Medicare Provider Agreement
• Physician(s) can be fined $50,000 per violation
• Physician(s) can be excluded from Medicare and Medicaid
Read each scenario and see if you can
tell if this would be an EMTALA
violation.
Scenario:
The receiving facility is contacted by a rural hospital requesting
transfer of a patient. There is another facility closer to the
transferring rural hospital.
Is it acceptable for receiving facility to
deny the transfer stating that there is a
closer facility?
The receiving facility may only deny
transfer if it does not have adequate
space, equipment, and qualified
personnel to treat the individual.
Otherwise it must accept the transfer.
Scenario:
A patient presented to the hospital’s ED with stomach pain for one
week. The physician informs the patient that since they’ve had the
pain for that long, they can be seen in the attached clinic because
it’s cheaper. The physician then escorts the patient to the clinic.
Is this acceptable?
This is not acceptable because the
patient did not receive a medical
screening exam and was not stabilized
before being escorted to the clinic.
Scenario:
A patient presents to the ED with a complex ankle fracture following
a fall. The ED physician calls the on-call physician with a request to
see the patient. The on-call physician states he is seeing patients in
the clinic and can not come at this time and asks the ED physician to
splint the patient and send him over to the clinic.
Is this acceptable?
This is not acceptable because the ED
physician has determined that the
patient needs to be evaluated and
requested the on-call physician to come
to the ED. As part of their on-call
responsibility, they are required by
EMTALA to evaluate the patient in the
ED as requested by the ED physician.
Scenario:
The ED physician calls the on-call surgeon for a “hot appy”. The oncall surgeon is in surgery with another emergency case and requests
the ED physician call one of his partners.
Is this acceptable?
EMTALA requires the hospital have
processes in place when the on-call
physician cannot respond due to
circumstances beyond his control. In
this circumstance, the Medical Staff
would address this issue.
Scenario:
The SPRH ED receives a call from the Sundance , WY ambulance that
they have patient experiencing unstable chest pain. The original
plan was to transfer the patient to RCRH for a cardiac workup but
due to the deterioration of the patient’s condition, they want to stop
at SPRH. SPRH states they do not have a cardiologist on staff and to
continue on to RCRH.
Is this acceptable?
If the patient’s condition is
deteriorating, and they are unstable
then they need to be seen at the closest
facility for evaluation and stabilization.
Scenario:
The patient sat in the waiting room with abdominal pain and was
told it would be some time because they were busy. The patient
became frustrated and left the waiting room before being triaged.
No information was obtained other than the chief complaint and
the information was not entered into the log book.
Is this acceptable?
At a minimum, all patients that present
to the ED should be logged, triaged to
determine risk level and periodically reevaluated until a medical screening
exam can be performed.
Scenario:
A 32 week pregnant patient presents to ED with cervical pain and
inability to urinate. Medical screening exam completed by ED
physician without OB consult. The patient was observed in ED for an
hour, then discharged home without determining if the patient was
in active labor. Patient returns 4 hours later with vaginal bleeding
and was ultimately diagnosed with placental abruption.
Is this an EMTALA violation?
The patient should have a medical
screening exam done by a qualified OB
professional prior to discharge to
determine whether the patient was in
active labor.
You must now complete a short quiz and
get 80% correct to receive credit for this course.
You have reached the end of this course for
additional information please refer to the resources
listed below.
Regional Health Policies and Medical Staff Bylaws
Office of Inspector General (OIG) Website http://oig.hhs.gov/
Centers for Medicare and Medicaid Services http://www.cms.gov/Regulations-andGuidance/Legislation/EMTALA/index.html