2Today’s goal:To review the basic requirements of the federal law known as “EMTALA”and how the policies and forms atBedrock Hospital support compliancewith its requirements.
3First, a quiz: EMTALA stands for: a) Every Medical Treatment and All Labor & Deliveries for free Actb) Emergency Medical Training of All Lawyers Actc) Emergency Medical Treatment and Active Labor Act
4EMTALAPassed by Congress in 1986 to require that hospitals with Emergency Departments:“Screen” all patients for “emergency conditions”Treat those who have them, if the hospital has the capacity to do so; andTransfer appropriately when necessary
5The hospital must be able to prove PLUS……..The hospital must be able to provethat it did all these things without regard to whether it expected the patient to beable to pay for them.
6Under EMTALA the “big three” duties are: So :Under EMTALA the “big three” duties are:SCREENTREAT if possibleTRANSFER appropriately
7A little more detail: What’s “screening”? More than triage – although it starts there.Each patient must see a “qualified medical person”, which at Bedrock Hospital = a physician, PA or nurse practitioner
8“Screening” means:Sufficient assessment to “rule in or rule out” the presence of a condition that could not safely be followed up on an outpatient basisThe regulations specifically include “psychiatric disturbances and/or symptoms of substance abuse.”May include:History, vitals, physical exam, lab / imaging studiesOn-call specialists
9Psychiatric “screening” exam May be a component of “medical screening” in certain cases – intoxication, overdose, suicide attempt, self-mutilation, violence, reported depression.Required even when there are no medical symptoms.Often overlooked or not well documented.
10Particular risks -Insufficient workup of “not serious” suicidal gesturesOverdoses – insufficient assessment after medical clearanceTransfers without appropriate personnel or equipment
11Rule of thumb:“Screening” is complete when the patient has been assessed by an NP, PA or physicianANDan emergency condition is ruled out or “treatment” (including placement attempts) has begun.
12Sometimes this happens faster than other times …
13Q: So when can we ask for money, insurance information, employer, etc.??????
15Does everybody do it this way? No, butLots of EDs do, because the greatest source of EMTALA investigations is patients’ perceptions that they were treated “differently” because of how their care will be paid for.Plus, when you or a family member is injured or sick, you will be very sensitive to any delay.
16So at BEDROCK we screen first, ask financially related questions later.
17This takes teamwork between clinical and registration folk: When a patient has been screened, the primary nurse must notify the registrar.For patients treated in triage it requires “steering” them to registration before telling them they are free to go.
18What about laboring moms? EMTALA applies no matter where the screening and treatment is provided in the hospital.Women with contractions are presumed to be in “labor” until proved otherwiseThe EMTALA “emergency” ends when the baby and placenta are delivered or labor is ruled out.
19“Stabilizing Treatment” under EMTALA Means pretty much what it did before the law was passed.A patient with a psychiatric emergency condition is considered “stable” when the patient is no longer a threat to self or others.
20PlusEMTALA established that the services of specialty physicians on call to the ED are part of what each patient is entitled towithout regard to whether the patient is able to pay those on-call specialists.
21The first EMTALA “fink” rule IF…a patient requires specialty care;the physician on call for that specialty fails or refuses to come in andthe patient must be transferred.WE MUST include the physician’s name and address in the transfer documentation sent to the next hospital.
22When they need or wantsomething we don’t have ….
23EMTALA requires three things before a patient can be transferred: An assessment of the patient’s condition as well as risks AND benefits of the transfer, signed by the transferring physician (with benefits outweighing risks) andThe receiving facility’s agreement to take the patient andThe patient’s consent or request to go
24No transfer until each (assessment, acceptance, consent) is documented Missing one of these?No transfer until each (assessment, acceptance, consent) is documented
25Amazingly, All these requirements support good care!! Thoughtful consideration of the patient’s needs (documented)Doctor --- >>>>>> Doctor communicationDoctor --- >>>>>>Patient communication
26Also required:Continued stabilizing care until the transfer takes placeAppropriate personnel and equipment during the transferfor a psychiatric patient this means s/he is protected from harming self or others.Copies of the patient’s medical records for the next facility
27One form handles all:The “Transfer Certification, Consent and Checklist” form is designed to capture the required documentationANDthe identity of who accepted the patient at the other hospitalwhat’s being sent with the patient
28EMTALA Fink Rule # 2To enforce these requirements, EMTALA requires hospitals that receive transferred patients to call CMS if they receive an unstable patient that is improperly transferred1-800-CMS
29Receiving hospitalsMust accept patients who require specialized care available there.Even when the patient does not have $$$$$ to pay for the specialized care
30Other requirements: Signage to reassure patients A “log” of everyone who comes and what happens to themCES LA LEY! Si usted tiene una emergencia médica o está en trabajo, incluso si usted no puede pagar ni tiene seguro médico o le no dan derecho a Seguro de enfermedad o a Medicaid, usted tiene la derecha de recibir.....IT’S THE LAW!If you have a medical emergency or are in labor, even if you cannot pay or do not have medical insurance or you are not entitled to Medicare or Medicaid, you have the right to receive, …..
31So what if we don’t do this well? ……..Investigations……….Fines……..Civil law suitsEach costs time and $$$ we could spend on more important stuff
32Does it really happen?As of 2003 more than 1,700 hospitals had been subject to enforcement for EMTALA violations (medlaw.com)At least 4 hospitals have lost their right to bill MedicareDuring hospitals and 1 physician paid more than $430,000 total to settle civil monetary penalty allegations (oig.hhs.gov) and keep operating.Civil suit awards have been as high as $3.9 Million
33Even after the law was enacted: A patient with end-stage renal disease was discharged from an ED without being stabilized and died six hours later.A possible sexual assault victim arrived in an ambulance was sent to another hospital without screening, and there was no evidence in the record that the receiving hospital was notified or had agreed to accept the patient.An uninsured patient with suicidal symptoms was put into a taxi for transfer to another hospital without being examined.A patient who was bleeding at a dialysis shunt site was not screened or stabilized before transfer to a receiving hospital that had not been notified the patient was coming.A hospital refused to accept transfer of an unstable patient with multiple traumas from a motor vehicle accident.