EMTALA : It’s the law ….

Today’s goal: To review the basic requirements of the federal law known as “EMTALA” and how the policies and forms at Bedrock Hospital support compliance with its requirements.

First, a quiz: EMTALA stands for: a) Every Medical Treatment and All Labor & Deliveries for free Act b) Emergency Medical Training of All Lawyers Act c) Emergency Medical Treatment and Active Labor Act

EMTALA Passed 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; and Transfer appropriately when necessary

The hospital must be able to prove PLUS…….. The hospital must be able to prove that it did all these things without regard to whether it expected the patient to be able to pay for them.

Under EMTALA the “big three” duties are: So : Under EMTALA the “big three” duties are: SCREEN TREAT if possible TRANSFER appropriately

A 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

“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 basis The regulations specifically include “psychiatric disturbances and/or symptoms of substance abuse.” May include: History, vitals, physical exam, lab / imaging studies On-call specialists

Psychiatric “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.

Particular risks - Insufficient workup of “not serious” suicidal gestures Overdoses – insufficient assessment after medical clearance Transfers without appropriate personnel or equipment

Rule of thumb: “Screening” is complete when the patient has been assessed by an NP, PA or physician AND an emergency condition is ruled out or “treatment” (including placement attempts) has begun.

Sometimes this happens faster than other times …

Q: So when can we ask for money, insurance information, employer, etc.??????

A: When “screening” is complete.

Does everybody do it this way? No, but Lots 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.

So at BEDROCK we screen first, ask financially related questions later.

This 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.

What 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 otherwise The EMTALA “emergency” ends when the baby and placenta are delivered or labor is ruled out.

“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.

Plus EMTALA established that the services of specialty physicians on call to the ED are part of what each patient is entitled to without regard to whether the patient is able to pay those on-call specialists.

The first EMTALA “fink” rule IF… a patient requires specialty care; the physician on call for that specialty fails or refuses to come in and the patient must be transferred. WE MUST include the physician’s name and address in the transfer documentation sent to the next hospital.

When they need or want something we don’t have ….

EMTALA 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) and The receiving facility’s agreement to take the patient and The patient’s consent or request to go

No transfer until each (assessment, acceptance, consent) is documented Missing one of these? No transfer until each (assessment, acceptance, consent) is documented

Amazingly, All these requirements support good care!! Thoughtful consideration of the patient’s needs (documented) Doctor --- >>>>>> Doctor communication Doctor --- >>>>>>Patient communication

Also required: Continued stabilizing care until the transfer takes place Appropriate personnel and equipment during the transfer for 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

One form handles all: The “Transfer Certification, Consent and Checklist” form is designed to capture the required documentation AND the identity of who accepted the patient at the other hospital what’s being sent with the patient

EMTALA Fink Rule # 2 To enforce these requirements, EMTALA requires hospitals that receive transferred patients to call CMS if they receive an unstable patient that is improperly transferred 1-800-CMS

Receiving hospitals Must accept patients who require specialized care available there. Even when the patient does not have $$$$$ to pay for the specialized care

Other requirements: Signage to reassure patients A “log” of everyone who comes and what happens to them CES 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, …..

So what if we don’t do this well? ……..Investigations ……….Fines ……..Civil law suits Each costs time and $$$ we could spend on more important stuff

Does 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 Medicare During 2011 9 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

Even 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.

It won’t happen at Bedrock Hospital …right?

Hope you enjoyed the show. If you want to incorporate part or all of this into your training efforts, please give credit where due. Martha Ann Knutson