Transcript EMTALA Training - Office of Compliance Services

EMTALA Rules of the
Road
2008
The History of EMTALA
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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.
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What Conditions Does EMTALA
Cover?
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“Emergency Medical Conditions”
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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
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EMTALA Who Receives a Medical Screening
Examination?
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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!
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EMTALA What is Providing Stabilizing
Treatment?
Emergency Medical Condition Exists
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When MSE reveals the existence of an emergency medical condition,
our obligations are as follows:
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We must provide 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
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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:
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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
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EMTALA What if Stabilizing Treatment is Needed
Beyond the Resources of the Hospital?
An Emergency Medical Condition Exists – what is the next step?
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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.
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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).
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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
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EMTALA Regulations –
What is an Appropriate Transfer?
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An Appropriate Transfer is defined in the EMTALA regulations as when:
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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.
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EMTALA –
What if the Patient Refuses the Transfer or
Requests a Transfer before Completing
Stabilizing Treatment?
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A patient under EMTALA has the right to:
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Request a Transfer to Another Facility, or,
Refuse Transfer to Another Facility
The right exists for patients with emergency medical conditions
that have not been stabilized
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:
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Transferring without receiving stabilizing treatment, or,
Refusing to transfer to obtain stabilizing treatment.
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EMTALA –
What does it Require of the Receiving
Hospitals?
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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.
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“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.
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EMTALA … What does it Require for
UCLA?
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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:
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The patient presented to the Transferring Hospital seeking emergency care and
treatment;
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The patient has an emergency medical condition which is not stabilized;
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The Transferring Physician determines that the patient requires further
examination and treatment to stabilize the emergency medical condition;
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The Transferring Hospital does not have the capability or capacity to stabilize the
patient’s emergency condition; and,
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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.
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EMTALA…the Potential Punishment
for Failure to Follow the Regulations
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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
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The Top EMTALA Rules to Remember
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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.
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The Top EMTALA Rules to Remember
(cont.)
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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).
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The Top EMTALA Rules to Remember
(cont.)
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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 oncall 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.
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The Top EMTALA Rules to Remember
(cont.)
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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.
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The Top EMTALA Rules to Remember
(cont.)
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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.
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The Top EMTALA Rules to Remember
(cont.)
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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.
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The Top EMTALA Rules to Remember
(cont.)
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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.
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The Top EMTALA Rules to Remember
(cont.)
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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.
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The EMTALA Policies and Forms
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EMTALA –Compliance with the Emergency Medical Treatment
and Active Labor Act (EMTALA)
EMTALA Reporting Policy
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EMTALA On Call Policy
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Maintain On Call Physician Awareness Prospectively
Keep Rosters for 5 years
EMTALA Signage Policy
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Reporting Form
Prominently Post CMS Required Signage in ED, Admitting, Hospital
Entrances, Labor & Delivery, Clinics
Visible from 20 feet away
EMTALA Central Log Policy
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Logs maintained by ED, L&D and Clinics
When complete, forward logs to HIMS for maintenance
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Questions and Answers
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