EMTALA Rules and Regulations Our Responsibilities Under the Law Bonnie Simmons D.O. FACEP Chair Emergency Medicine Lutheran Medical Center

Today You Will Learn: What is EMTALA? History. What is an EMTALA VIOLATION ? To be an “Independent EMTALA thinker” Learn what to do at LMC if faced with a patient care decision

Where It’s an Issue: ED/Admitted patients Transfers In/Out Special Issues: OB patients Psych/Detox patients

What Can Happen if We Don’t Comply? Title 18 Survey DOH Fines $3 million dollars Medicare Funding – CMS and OIG Physicians License

Mandatory Reporting Mandatory Reporting Reporting must be within 72 hours

EMTALA Key Focus Triage Before Registration Insurance questions can never delay treatment Stabilization first, then transfer to a higher level of care List of on-call physicians posted in ED and roster retained for 5 years A Subspecialist must always be on-call and come to ER regardless of insurance Sending a patient to a doctors office does not comply Can NP and PA’s respond ? Yes and No

REQUESTS FOR TRANFERS-IN: CAN transfer in if the patient is not stable under certain circumstances E.G. higher level of care: Trauma Strokes/Interventional STEMI

Transfers-IN “Duty to Accept” NON DISCRIMINATION: “…shall not refuse to accept an appropriate transfer if the patient requires specialized treatment if the receiving hospital has the capacity to treat”

Diversion Even if we are on Diversion our ED accepts transfers Diversion is not an EMTALA violation – but once ambulance is here – must treat and stabilize (‘keep the patient’)

Reasons to Refuse a transfer: NONE Needs specialty service (ie: Burn Center) DOCUMENT and CALL Nursing Supervisor on Duty & Don’t Say NO!!!!!

Accept Even If: Equipment out of order or unavailable MD unavailable Diversion

When in Doubt Just Say Yes We can always reflect back Consequences too great Call Nursing Administration (7550) Call Administrator on Call (0) “I’ll need to make the arrangments and call you right back”

Transfer Out Unstable Patients Only IF: Patient Requests It Hospital does not have necessary capacity or capability to handle condition In Labor, Woman or her representative MUST request it

Documentation for Transfers-Out Patient Must Consent Patient Must be Apprised of Risks and Benefits Condition, vital signs at time of departure Accepting MD Name at Transfer-To Institution Send supporting test results In All Cases Use the Transfer Forms

Scenario #1 A Patient presents with a sudden onset of scrotal pain and a swollen testicle. The ultrasound examination is equivocal and does not provide the Emergency Physician (EP) with a definite diagnosis. The EP believes that an onsite examination by the on-call urologist is necessary. The examination by the urologist would be considered: 1. Stabilizing treatment 2. Part of the medical screening examination 3. Neither of these answers 4. Both of these answers

Scenario #2 A 36-week pregnant woman presents to the ED with labor pains. She is not registered or triaged in the ED, but is sent directly to labor and delivery. Which of the following is true? 1. This is a violation of EMTALA. 2. The Emergency Department must at least triage the patient. 3. The Emergency Department must at least put the patient in EMTALA log. 4. This is acceptable as long as: it is consistent with hospital policy; the governing body is aware the labor and delivery LIP’s are doing screening exams; and the labor and delivery LIP’s have orientation to the hospital medical screening examination policy.

Scenario #3 A patient presents to the ED with a laceration on the back of the hand and an obvious tendon injury. The EP calls the Hand Surgeon on call who correctly points out that tendons do not need to be repaired immediately. The Hand Surgeon tells the EP to close the wound loosely, apply a splint, and send the patient to the Hand Surgeons office the next day. Under EMTALA, once the wound is cleansed, loosely sutured and splinted, and the patient is stable for discharge, the patient can be discharged and referred to the Hand Surgeon. 1. True 2. False

Scenario #4 A 3-year old child presents to the EP with a fever and an earache. The EP performs a complete examination and finds an otitis media, a supple neck, and minimal temperature. The child is awake, happy and playful. The EP diagnoses otitis media and discharges the child on appropriate antibiotics. The next day the patient presents to the same ED with Meningitis, and is severely brain injured as a result. Which of the following is true? 1. This child could not have been stable for discharge. This is an EMTALA violation. 2. This was an adequate screening exam. There was no emergency medical condition. EMTALA did not apply. 3. This must be a per se violation of EMTALA. 4. This is both medical negligence and a violation of EMTALA.

Scenario #5 A 34-year-old male patient presents to a small rural hospital by ambulance with head trauma following a tractor accident. CT reveals an epidural bleed. The hospital has no neurosurgical services. The ED physician contacts the local regional referral center that has a specialty neurosurgical unit. Although there are beds available, the resident on call refuses the transfer. Which of the following is true? 1. EMTALA does not apply to residents. 2. Under the EMTALA Nondiscrimination Provision the local regional referral center is obligated to take this patient. 3. The resident must allow an attending physician to make this decision. 4. EMTALA has no relevance in this situation.

Scenario #6 1. 14 month old female EMS notification for finger amputation. 2. Patient arrived then sent by ambulance to outside hospital because “our plastic surgeon wasn’t available last time we called him” 3. No chart was generated and the child was sent to neighboring hospital EMTALA Issue?

True or False The EMTALA statute and regulations contain a requirement whereby hospitals with special capabilities have a duty to accept patients in transfer if the hospital has the beds and staff (i.e. the capacity) to treat the individual. 1. True 2. False

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Scenario Answer Key Scenario 1: Answer # 4: Both of these answers Scenario 2: Answer # 4: This is acceptable as long as: it is consistent with hospital policy; the governing body is aware the labor and delivery LIP’s are doing screening exams; and the labor and delivery LIP’s have orientation to the hospital medical screening examination policy. Scenario 3: Answer # 1: True Scenario 4: Answer # 2: This was an adequate screening exam. There was no emergency medical condition. EMTALA did not apply. Scenario 5: Answer #: 2 Under the EMTALA Nondiscrimination Provision the local regional referral center is obligated to take this patient. Scenario 6: Answer: Yes Question 7: Answer: True