EMTALA Presented by The Office of Corporate Compliance and The Office of Risk Management

1. EMTALA Presented by The Office of Corporate Compliance and The Office of Risk Management For those working on the frontline.

2. What is EMTALA? • The Emergency Medical Treatment and Active Labor Act is a FEDERAL statute which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he/she is in an unstable medical condition. • EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as "the COBRA law". In fact, a number of different laws come under that general name. Another very familiar provision, also referred to under the COBRA name, is the statute governing continuation of medical insurance benefits after termination of employment. • EMTALA applies only to hospitals that participate in the Medicare Program.

3. So What Does All of That Mean to You? • Simply put, it means that any and all patients who present to the Emergency Department (or on hospital grounds) and that request assistance for a possible emergency medical condition, must at a minimum, receive a medical screening by a qualified medical professional and, if needed, receive medical stabilization and an appropriate transfer if necessary.

4. Who is a Qualified Medical Professional? • EMTALA allows for individual hospitals to identify, in their hospital bylaws, who the qualified medical professionals are. • The University Hospital bylaws state that medical screenings may be done by a physician, advanced practice professional or by a registered nurse acting under medically approved protocols.

5. What is an Emergency Medical Condition? • The definition provided under the statute is: "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."

6. Caution!! According to CMS Interpretive Guidelines Some intoxicated individuals may meet the definition of “emergency medical condition”because the absence of medical treatment may place their health in serious jeopardy or result in serious dysfunction of a bodily organ. Further, it is not unusual for intoxicated individuals to have unrecognized trauma.

7. Caution!! According to CMS Interpretive Guidelines Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would be considered an “emergency medical condition.”

8. What is an Acceptable Medical Screening? CMS Interpretive Guidelines state the following; • Individuals coming to the emergency room must be provided a medical screening beyond initial triage. • The medical screening must be the same medical screening that the hospital would perform on any individual coming to the hospital’s emergency room with those signs and symptoms, regardless …………..to pay.

9. What is an Acceptable Medical Screening? • A medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. • Depending upon the patient, this process will vary from only a brief H&P to a complex process involving ancillary studies and specialty consultations.

10. What is an Acceptable Medical Screening? • A medical screening is not an isolated event. It is an ongoing process. • Hospital and Department medical staff should address, through policy and medical standards, how best to provide the screening. • Medical Screenings are required to be documented. • If it isn’t written down, it never happened!!

11. Medical Screening Documentation • Need to document why the patient is now stable enough to be transferred. • Is patient hemodynamically stable to the best of our capabilities? • Has psychiatric condition been evaluated and treated to the best of our capabilities? • Have any abnormal test (EKGs) been repeated if the first one was abnormal and the patient has been in our care for a lengthy period of time?

12. Caution!! Regardless of a positive or negative patient outcome, a hospital will be in violation of the anti-dumping statute if it fails to meet any of the medical screening requirements. • If a misdiagnosis occurs, but the hospital utilized all of its resources, a violation of the screening requirement does not occur.

13. TransfersDocumentation • Must show that the transfer was initiated by either a written request by the patient (or his/her representative) or a physician’s certification. • Must state the reason for the transfer. • The receiving facility and the accepting physician. Recommendation: Include a brief statement that the patient’s full condition was discussed with the accepting physician. • The risk and benefits of the transfer.

14. TransfersDocumentation Risk & Benefits!! • Need to be realistic and pertinent to the case. • MVA is not usually a true risk of the transfer that needs to be documented in most cases. • Worsening of condition, lack of medical equipment, increase of pain, increase exposure to infection and no physician for intervention are some examples of true risk.

15. Sounds Simple But……. • EMTALA sounds simple but incidences happen everyday that could potentially cost a hospital thousands of dollars.

16. CAUTION!!!!!! • Case history has not been kind to hospitals who utilized non-physician medical screeners even though by law, it is allowed. • TRAIGE IS NOT CONSIDERED TO BE A MEDICAL SCREENING!!!!!

17. Don’t Our Bylaws Make us a Target? • Answer: • NO. • Not as long as we understand our responsibilities and our liabilities. • There is less liability for those patients without an emergency condition.

18. The Simple Rules • Never turn a patient who is requesting treatment away from the facility once they are on hospital property. • Always perform a medical screening if the patient is requesting services. • Document Everything!! • Make Sure You Document Everything!!

19. Items of Interest • Diversions, (Arrington vs Wong) Case study says that you cannot redirect an ambulance unless a compelling reason exists. (ex: lack of staff or resources.) Do not pick and choose patients when on diversion.

20. Items of Interest • New regulations do not pertain to inpatients. (Caution: Carey’s Opinion; be cautious about refusing an inpatient transfer from another hospital that has recently developed an emergency condition that is beyond the resources of the referring hospital.

21. EMTALA Facts • Since 10/1/99, there have been 154 EMTALA investigations done by CMS involving Missouri hospitals. • Since November 1998, the University hospital has been investigated four times. • The University Hospital has been cited 2 out of the 4 times it has been investigated.

22. Practical Case Study Let’s Discuss

23. Practical LessonsCase #1 • The ER attending physician receives a call from a small rural hospital wanting to transport a 50 y/o male with chest pain to your facility. The rural hospital has done an EKG and performed blood work. Your ER attending denies the transport suggesting that the patient be admitted to the rural hospital for observation. The rural hospital does not have a cardiologist on staff.

24. Is this an EMTALA violation? • YES!! • Why?? • Under EMTALA, if a hospital does not have the staff or the resources to treat and stabilize a patient with an emergency medical condition, a tertiary care center (or any hospital) who does have the resources, has to accept the patient if requested.

25. Case #2 • A local law enforcement agency presents to the ER with a subject whom they have arrested. They request a psychiatric evaluation on the subject. The hospital is on psychiatric diversion due to no beds. The triage nurse advises the law officers of this and they voluntarily take the subject to another hospital.

26. EMTALA Violation? • Answer • YES • Why: The patient was present on hospital grounds and a request for services was made. At a minimum, the patient should have had a medical screening completed and documented. If the law officers voluntarily decide to leave without a medical screening, it should be documented with the appropriate details that the patient left without being seen.

27. Use Caution when Dealing With Psych Patients • ED physicians and staff should appropriately document any symptoms on which the determination that an emergency medical condition exists is based. Items to screen for: Does the patient have a history of violence to himself or others? Has the patient made a suicide attempt or voiced suicidal ideations? Is the patient a potential danger to others through violent actions or threats? Is substance abuse present that could impair their judgment or are they showing signs of confusion for which a reason cannot be determined?

28. Case #3 • A 23 y/o female presents to the ER requesting a suture removal. The wound appears to be healing appropriately and appears to be free from infection. The patient is evaluated and appears not to be suffering from any emergency medical condition. Due to the high volume of patients in the ER, the patient is referred to her primary care physician for suture removal.

29. EMTALA Violation? • Answer • NO!! • Once the patient received a medical screening from a qualified medical professional and it was found that an emergency medical condition did not exist, EMTALA is no longer applicable. The medical screening should, however be documented.

30. Case #4 • A middle aged male approaches the registration area and states that he would like to go to Mid-Mo. You give him directions to Mid-MO and he leaves without any further conversation.

31. EMTALA Violation? • Answer: • NO!! • Why: Because the subject did not ask for any medical services, only directions. • NOTE: If this person had displayed behavior that would lead even a prudent layperson to believe that a emergency medical condition did exist, you would have to offer a medical screening.

32. CASE #5 • The helicopter has just landed with a patient who is supposed to be a direct admit to the V.A. Hospital. The patient was stabilized at the referring hospital and has remained stable throughout the flight. The patient is brought through the ER enroute to the tunnel. Should the ER perform a medical screening?

33. Case # 5 Review • Answer • NO!! • Why? Unless the patient requests (or a representative requests) a medical service, or the patient’s condition is such that immediate care is needed, EMTALA does not kick in. • Discussion:

34. Case # 6 • Your UHC ambulance responds to a minor MVA. The patient is from out of town and requests to be taken to the closest hospital for evaluation. Your partner examines the patient and tells the patient that he doesn’t need to be transported by ambulance. You and your partner return to service.

35. Case #6, EMTALA Violation? • YOU BET!! • If this patient is later found to have an emergency medical condition, EMTALA has been violated. A hospital based ambulance is an extension of the hospital. In addition, EMT-B and EMT-Paramedics are not recognized in the hospital bylaws as QMPs.

36. Case #7 • A 21 y/o female is brought by an outside ambulance to the ER. The patient is complaining of intermittent back pain. The patient is 38 weeks gestation with her first child. No radio report had been given and the patient arrived unexpectedly. The EMTs say the patient is to be admitted to OB. You direct the ambulance crew to CRH.

37. Case #7EMTALA Violation? • Answer: Yes • Why?: The patient may be in active labor. Without knowing any prior history, there is a potential danger of redirecting this patient without performing a medical screen. • Rule of thumb for active labor: It is active labor until observation for an acceptable period of time can prove otherwise.

38. Questions and Answers What scenarios would you like to talk about?