Emergency Medical Treatment and Active Labor Act

1. Emergency Medical Treatment and Active Labor Act EMTALA SEMINAR [DATE] Presenter: [NAME & TITLE]

2. The Purpose of EMTALA • The purpose of the statute is to prevent hospitals from rejecting patients, refusing to treat them, or transferring them to "charity hospitals" or "county hospitals" because they are unable to pay or are covered under the Medicare or Medicaid programs. Note, however, that cases have not limited the application to the indigent. • Applies to any person, regardless of their nationality or citizenship.

3. Which providers must comply with EMTALA? • Hospitals who participate in the Medicare program that have a “Dedicated Emergency Department” (DED), • Physicians, and • Hospital-owned ambulances

4. When does EMTALA apply? • When any individual “comes to the ED” requesting treatment for any medical condition or when a request is made on his/her behalf; and • When any individual (including visitors, employees, etc.) presents on “hospital property” other than an ED and requests examination/treatment for an emergency condition or a request is made on his/her behalf or the need is obvious under the prudent lay person standard. • NOTE: “Hospital property” for EMTALA purposes excludes physician offices, rural health centers, skilled nursing facilities, restaurants, shops, and other non-medical activities.

5. When does EMTALA not apply? • EMTALA does not apply to an individual who has begun to receive outpatient services for a non-emergency condition and develops an emergency medical condition, even if the individual is moved to the ED for treatment. • EMTALA obligations cease upon admission as an inpatient (must be in good faith). • BUT Medicare Conditions of Participation do apply in these situations.

6. What are the basic EMTALA requirements? • Appropriate “medical screening exam” (MSE) by a “qualified medical provider” (QMP) to determine if an “emergency medical condition” (EMC) exists. • If an EMC exists: • stabilization of the EMC within the capabilities and capacity of the hospital, and • medically appropriate transfer if necessary.

7. What is a “Medical Screening Examination”? • A physical (and mental when necessary) health evaluation used to determine if a patient has an emergency medical condition. • Must be performed by persons designated by the hospital’s governing body in Board or Medical Staff bylaws (QMPs). • Triage is not an MSE. • You can not delay the MSE to inquire about insurance or ability to pay for care.

8. What is a “Medical Screening Examination”? • The MSE must use capabilities of the hospital (departments, personnel and equipment) as needed, meaning resources available for inpatients are also available for ED patients. • The MSE must be “adequate.” This means the same screening exam should be performed for all patients presenting with the same symptoms (same standard of care).

9. What is a “Medical Screening Examination”? For pregnant women having contractions, MSE includes at a minimum: • ongoing evaluation of FHTs, • observation and recordation of the regularity and duration of uterine contractions, • fetal position and station, and • cervical dilation, status of membranes (leaking, intact, ruptured). False labor must be certified by a physician.

10. How is “Emergency Medical Condition” defined? • "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in -- • placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, orserious dysfunction of any bodily organ or part, or • "With respect to a pregnant woman who is having contractions -- • that there is inadequate time to effect a safe transfer to another hospital before delivery, orthat the transfer may pose a threat to the health or safety of the woman or her unborn child."

11. How is “Emergency Medical Condition” defined? • The law does not give much guidance as to what specifically constitutes an EMC except that: • The regulations have stated that the need for a medication refill for a person on psychotropic medication who is experiencing suicidal or homicidal urges can constitute an EMC. • The regulations state that the removal of “simple sutures” is not an EMC.

12. What about Individuals Who Present to the ED for Non-Emergency Services? • EMTALA still applies, but the hospital is only required to perform a MSE as is appropriate to determine if an emergency medical condition exists. • The MSE may be limited to (1) the individual’s statement that he/she is not seeking emergency care and (2) brief questioning by a qualified medical provider.

13. Necessary Stabilization Treatment • When the determination is made that the patient has an emergency medical condition, further treatment must be provided to stabilize the condition. • Stabilization is defined as: • no material deterioration of the patient's condition is likely to result; and • (for patients in active labor) the infant and the placenta have been delivered.

14. For Transfer Patient is not “technically” medically stable, but physician has certified that the benefits of transfer outweigh the risks associated with the transfer EMTALA transfer forms must be used. For Discharge Patient’s medical condition has been stabilized to the extent that the patient is now ready to be discharged from the hospital’s care, though they may be referred to outpatient provider Patient should not be “discharged” to another hospital’s ED EMTALA transfer form SHOULD NOT be used. Stabilization

15. Transfers • A physician must certify in writing that the benefits of transfer outweigh the risks to the person or unborn child, and • The person should consent in writing to the transfer. • If a physician is not present in the ED at the time of transfer, a qualified medical person can sign the certificate after consultation. • This physician must later countersign the certificate.

16. What is an “appropriate transfer”? 1. The transferring hospital must provide medical care within its capability to minimize the risk to the patient or unborn child, 2. The receiving facility has space and qualified personnel to care for the patient, 3. The receiving facility has accepted the transfer,

17. What is an “appropriate transfer”? 4. The transferring hospital must send all medical records (including ones that are developed after the patient leaves the ED), 5. Under law, the records must include the name and address of any on-call MD who refused or failed to show up within a reasonable amount of time (if applicable), and 6. The transfer must be performed with qualified personnel and transportation equipment.

18. What if the patient refuses the MSE, stabilization and/or transfer? • EMTALA is met if: • the patient or his/ her legal representative (LR) has been informed of the risks and benefits of the offered examination, treatment and/or transfer; and • after the information is given, the patient or his/her LR refuses to consent to the examination, treatment and/or transfer. • and the following documentation standards are met: • the medical record contains a description of the examination, treatment and/or transfer that was refused and the risks and benefits that were explained to the patient or LR; • the hospital has taken all reasonable steps to secure the refusal in writing (and documented those steps if written consent is not obtained); • the document to be signed by the patient or his/her LR should include a statement of the fact that the patient or LR has been informed of the risks and benefits of the refused examination, treatment and/or transfer.

19. What if the patient requests transfer? • A patient may request a transfer to another institution, and this request takes the place of the physician's certification mentioned above. However, the transfer must still meet the requirements of an "appropriate transfer." • The regulations require that the reason for the patient's request must be charted.

20. Potential penalties for failure to comply with EMTALA Sanctions include: • Termination of hospital’s provider agreement, • Civil money penalties ($50,000 if over 100 beds, $25,000 if less than 100 beds) against both hospital and physician, • Exclusion of physician if violation is gross and flagrant. • Malpractice suit.

21. What provisions apply specifically to physicians? • A penalty may be imposed on a physician who fails to respond to an emergency situation when he/she is assigned as the on-call physician. • A physician who signs a certification in support of an appropriate transfer may be liable if he/ she knew or should have known that the certification was false.

22. Problem Areas • Trying to arrange a transfer by going directly through the on-call physician at the receiving hospital without first speaking with the hospital itself (doing this does not trigger the other hospital’s EMTALA obligation). • Failure to document physician certification. • Failure to document on-call refusals. • Failure to report “dumps” and transfer refusals. • Discharge of unstable patients.

23. HYPOTHETICAL#1 • A patient presents at Hospital A’s DED complaining of sniffling, coughing, and diarrhea. The patient is given a medical screening exam by an ED physician and determined not to have an emergency medical condition. The patient requests continued treatment at Hospital A and Hospital A requests payment before providing the additional treatment. • Has Hospital A violated EMTALA?

24. HYPOTHETICAL#2 • An intoxicated man comes in a non-emergency side entrance of Hospital A. The man stumbles to the administrative offices of the hospital while yelling, “I need emergency care!” • Does the hospital have any EMTALA duties to the intoxicated man?

25. HYPOTHETICAL #3 • A patient presents to the ER of Hospital A and receives a medical screening exam. The exam shows that the patient has a condition that will require admission and Hospital A has the capability and capacity to treat the condition. When the patient’s primary physician is contacted, he instructs the ER to transfer the patient to Hospital B (for his convenience). • Is this an appropriate transfer?

26. HYPOTHETICAL#4 • Patient with severe burns is brought to Hospital A. Hospital A performs a medical screening exam, stabilizes within its capability and capacity, and seeks to transfer the patient because Hospital A does not have a specialized burn unit. Hospital A requests that Hospital B, which has a specialized burn unit, accept a transfer of the patient. Hospital B refuses the transfer. • Has Hospital B violated EMTALA?

27. HYPOTHETICAL#5 • A patient comes to the DED with a broken foot and an appropriate screening is performed. The on-call orthopedist is called. The ED physician requests the orthopedist to come to the DED to stabilize the patient. The orthopedist refuses to come in. • Is there a potential EMTALA violation?

28. HYPOTHETICAL#6 • Same facts as previous question except the orthopedist tells the ED physician to send the patient to the orthopedist’s office across the street from the DED. • Is there a potential EMTALA violation?

29. Questions ?????