EMTALA Rules of the Road 2008

1. EMTALA Rules of the Road2008

2. The History of EMTALA • The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA). • It was designed to prevent hospitals from refusing to treat patients or transferring them to charity hospitals or county hospitals because they are unable to pay or are covered by Medicaid. • The Act was amended in 1988 and 1989. • Final rules were issued in 1994 and subsequently amended with additional changes to interpretive guidelines issued in March 2008.

3. What Conditions Does EMTALA Cover? • “Emergency Medical Conditions” • Danger to patient health, function, organ or body part • Acute undiagnosed pain • Pregnancy with contractions present • Psychiatric Disturbances • Symptoms of substance abuse • The judgment of the Transferring Physician will generally take precedence over the UCLA physician in determining the emergency medical condition and the need for the transfer to a higher level of care • The availability of closer hospitals to the Transferring Hospital is not relevant in a hospital’s obligation to accept a patient under EMTALA

4. EMTALA -Who Receives a Medical Screening Examination? • Every patient presenting to the hospital requesting emergency services is entitled to a medical screening examination (MSE) performed by a qualified medical personnel and must be of sufficient scope to determine existence of an emergency medical condition . • At Santa Monica UCLA Medical Center, patients who present requesting emergency care and treatment will receive an MSE by a physician with the exception of the OB unit • An RN who has been credentialed by the Inter-disciplinary Practice Committee to perform a labor MSE, can perform the MSE without the presence of a physician; however, only a physician can certify false labor and order discharge before delivery. Questions relating to financial status cannot be asked before the MSE!

5. EMTALA -What is Providing Stabilizing Treatment? Emergency Medical Condition Exists • When MSE reveals the existence of an emergency medical condition, our obligations are as follows: • We mustprovide stabilizing treatment within the capabilities and resources of the hospital • For woman in labor, the emergency medical condition is defined as existing until the delivery of the baby and placenta, or the certification by a physician or mid-wife of false labor No Emergency Medical Condition Exists • When the MSE, using the resources of the hospital in a manner consistent with all similar patients and regardless of payer, reveals no emergency medical condition: • UCLA’s "Obligations” under EMTALA cease and the patient may be transferred to another hospital or level of care in consultation with health plan or payer

6. EMTALA -What if Stabilizing Treatment is Needed Beyond the Resources of the Hospital? An Emergency Medical Condition Exists – what is the next step? • If the hospital does not have the capacity, capability or resources to provide stabilizing treatment for an EMC, an appropriate transfer must be arranged for the patient to a facility with the capacity, capability and resources to provide stabilizing treatment. • As an academic medical center, UCLA generally have the capability and resources for most situations; however, we may need to transfer the patient because we do not have an operating room available in the time required or we do not provide the specialized service (e.g., a burn unit). • As a Level 1 Trauma Center and Academic Medical Center, UCLA has many services which local community hospitals do not have and imposes EMTALA obligations as a receiving hospital

7. EMTALA Regulations – What is an Appropriate Transfer? • An Appropriate Transfer is defined in the EMTALA regulations as when: • The Transferring Hospital has provided treatment to the individual with an emergency medical condition within capacity of hospital • The Transferring Hospital has obtained agreement to accept the patient from Receiving Hospital, including identifying a Physician to accept the patient • The Transferring Hospital has provided sufficient data, including medical records, X-rays, lab reports as available, to the Receiving Hospital to facilitate continuing evaluation and treatment • The Transferring Physician has certified the transfer and arranged for the use of appropriate mode of transportation, personnel and equipment The judgment of the Transferring Physician will take precedence when determining the existence of an EMC and the appropriateness of the Transfer.

8. EMTALA –What if the Patient Refuses the Transfer or Requests a Transfer before Completing Stabilizing Treatment? • A patient under EMTALA has the right to: • Request a Transfer to Another Facility, or, • Refuse Transfer to Another Facility • The right exists for patients with emergency medical conditions that have not beenstabilized • If the request or refusal is made by the patient, the request or refusal should be documented in the patient’s medical record; the patient or his/her personal representative should sign a form documenting that he/she understands the risks associated with either: • Transferring without receiving stabilizing treatment, or, • Refusing to transfer to obtain stabilizing treatment.

9. EMTALA –What does it Require of the Receiving Hospitals? • EMTALA requires hospitals with the specialized capabilities, capacity and resources needed by a patient with an unstabilized emergency medical condition that are not available at the Transferring Hospital to accept that patient in transfer. • “Capability” relates to services provided at the specific hospital • “Capacity” relates to staffing and bed availability • EMTALA does not require hospitals to accept a patient who does not require the specialized capabilities of the hospital whether or not the patient has an emergency medical condition. • Under current law, a hospital’s obligation to accept a patient under EMTALA, only relates to transfers from an Emergency Department of the Transferring Hospital and not inpatient Transfers.

10. EMTALA … What does it Require for UCLA? • UCLA has an obligation to accept an appropriate transfer of a patient with an unstabilized emergency medical condition who requires specialized capabilities or facilities if UCLA has the capacity to treat the individual. • UCLA is required to accept a transfer from a Transferring Hospital if the following exist: • The patient presented to the Transferring Hospital seeking emergency care and treatment; • The patient has an emergency medical condition which is not stabilized; • The Transferring Physician determines that the patient requires further examination and treatment to stabilize the emergency medical condition; • The Transferring Hospital does not have the capability or capacity to stabilize the patient’s emergency condition; and, • UCLA has the capability and capacity to treat the patient – including not holding a “Bed” unless a patient is in surgery and expected to be admitted to that bed.

11. EMTALA…the Potential Punishment for Failure to Follow the Regulations • Termination from Medicare - • Potential fine of up to $50,000 per patient incident • Potential lawsuit for civil damages • Potential civil rights violations • Individual MDs can also be fined up to $50,000 per incident • Publication of the violation and penalty

12. The Top EMTALA Rules to Remember • Log in every patient who presents, together with complaint/diagnosis and disposition. A patient has “presented” when he/she is on the campus (i.e., 250 yard zone around the hospital), “provider based” remote sites and ambulances owned by the hospital without regard to means or ability to pay. • Triage patients per protocol to establish the order in which patients receive MSE. • Provide a medical screening examination, following triage, to all patients regardless of acuity who present in the hospital and/or “provider-based” locations (including moving the patient to the main hospital ED as necessary to complete the MSE). The MSE must be the same for all patients presenting with like signs and symptoms.

13. The Top EMTALA Rules to Remember (cont.) • Do NOT delay the Medical Screening Examination or attempt to secure verification or authorization from third party payor, nor attempt to influence the patient by drawing payor status issues to the patient’s attention prior to completion of Medical Screening Exam and initiation of stabilizing care. • Provide necessary testing, including on-call services, as needed to exclude the presence of a legally defined emergency medical condition (does NOT equate to emergent patient).

14. The Top EMTALA Rules to Remember (cont.) • To the extent of the capabilities of the hospital and/or “provider based” location, provide stabilization, such that the patient is not likely to deteriorate from or during transport or discharge (in the case of OB patients with contractions present, until stabilized by delivery of baby and placenta) and make a medically appropriate transfer if the patient exceeds hospital or “provider-based” location capabilities. • Have an on-call coverage schedule listing on-call physicians by individual name for all medical specialties represented on the medical staff, provide policies and procedures for occasions when the on-call physician is not available, and maintain the list of the individuals on-call. On-call physicians are not at liberty to decline patients unless he/she has consulted the Medical Director of the Transfer Center or his/her designee.

15. The Top EMTALA Rules to Remember (cont.) • Require on-call specialists to respond to the hospital to attend the patient (including transfer patients and in-house emergencies), in timely manner and provide legally defined stabilizing care and/or definitive treatment in the hospital without regard to means or ability to pay. • A physician can arrange transfer of EMTALA patients only if services or care are not available at the Hospital or upon patient request (documented to EMTALA requirements) and accept transfers for all ED patients where the Hospital is better able to care for the patient who requires a higher level of care than the hospital requesting transfer.

16. The Top EMTALA Rules to Remember (cont.) • Provide an medical screening exam, by either a physician or an RN who has been credentialed through the Inter-Disciplinary Practice Committee to provide MSEs, to OB patients and treat patients with contractions as unstable emergency patients as set forth in the EMTALA regulations. • When transferring a patient under EMTALA, obtain and document on the Transfer Form the advance acceptance from the receiving hospital, indicating the name of the physician and time. • When transferring a patient, the Transferring Hospital must provide medically appropriate vehicles, personnel, and life support equipment for all EMTALA transfers. Private vehicles are not appropriate transfer vehicles and may not be used without written refusal of ambulance.

17. The Top EMTALA Rules to Remember (cont.) • The physician who is initiating a transfer under EMTALA must document on the Transfer Form a physician certification with clearly stated risks and benefits of transfer for all EMTALA transfers. • The Transferring Hospital must provide medical records, labs, reports and consultation records to accompany the patient on all EMTALA transfers and this should be documented on the Transfer Form. • The Transferring Hospital/Physician must document on the Transfer Form the name of any on-call physician who refused to respond or failed to make a timely response of any EMTALA patient transferred as a result of that refusal or lack of timely response.

18. The Top EMTALA Rules to Remember (cont.) • The Transferring Hospital must obtain written refusal of services by a patient or responsible party that refuses exam, treatment, or transfer that documents the specific risks of refusal associated with the individual case, or document the reasonable efforts by the hospital to obtain written refusal. • The Transferring Hospital must obtain and document on the Transfer Form written consent to transfer from the patient or responsible party, or document reasonable justification for not obtaining the written consent. • Report any possible violations of EMTALA by another facility within 72 hours of receipt of the patient to Risk Management using the EMTALA Reporting Form.

19. The Top EMTALA Rules to Remember (cont.) • For each EMTALA patient, obtain and document full vitals including pain assessment on all presenting patients and maintain documented vitals at appropriate frequency during the stay, and in ALL CASES obtain discharge vitals or vitals at the time of discharge or transfer, and document such in the record. • Post EMTALA signs in all public entrances, waiting areas, registration and care areas. Signs that conflict with the intent and purpose of EMTALA may not be posted. Signs must be easily visible and readable from a distance of 20 feet or the position of the patient and must appear in non-English languages common to the patient population which is currently Spanish.

20. The EMTALA Policies and Forms • EMTALA –Compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA) • EMTALA Reporting Policy • Reporting Form • EMTALA On Call Policy • Maintain On Call Physician Awareness Prospectively • Keep Rosters for 5 years • EMTALA Signage Policy • Prominently Post CMS Required Signage in ED, Admitting, Hospital Entrances, Labor & Delivery, Clinics • Visible from 20 feet away • EMTALA Central Log Policy • Logs maintained by ED, L&D and Clinics • When complete, forward logs to HIMS for maintenance

21. Questions and Answers