1. Chapter 2
Medical-Legal Issues

2. Elements That Contribute to the Quality of Care
Skills maintenance
Continuing education
Protocol familiarity and compliance
Interpersonal communications

3. Laws and Regulations that Govern Practice
Federal laws that apply across all American jurisdictions
State and local requirements that differ considerably from one area to another

4. Interfacility Transport
Comprises main responsibility of critical care transport service
Continues to see increased demand across the United States
Creates additional areas of legal liability for services

5. Emergency Medical Treatment and Active Labor Act
Affects hospitals that participate in Medicare reimbursement programs
Originally part of COBRA 1996
Called “antidumping act”
Requires medical facilities to choose “qualified personnel and transportation equipment” for each patient transferred in unstable condition

6. EMTALA Obligations to the Patient
Provide appropriate medical screening examination within hospital’s capabilities to any individual
Provide necessary treatment to stabilize emergency condition or transfer patient to another appropriate medical facility
Obtain patient or legal representative consent
Adhere to EMTALA whenever patients come onto hospital premises

7. Medical Screening Examination (1 of 2)
Required to determine if emergency condition exists and includes:
Triage record
Initial vital signs
Oral history
Physical examination

8. Medical Screening Examination (2 of 2)
Includes: (continued)
Use of appropriate diagnostic resources
Use of on-call physicians, if necessary
Discharge vital signs

9. EMTALA and Transport by Helicopter
May not apply if hospital-owned helipad is used by local EMS as pickup point for transport of patient to another hospital.
May apply if flight or EMS crew requests intervention of hospital’s physician.

10. Penalties for Violating EMTALA
Fines between $25,000 and $50,000 per violation
Physician fines up to $50,000
Hospital or physician termination from Medicare and Medicaid programs

11. Examples of Judgments (1 of 2)
EMTALA is not a substitute for malpractice action.
Emergency stabilization is not long-term.
Plaintiff bears the burden of proof.
An unstable patient can be transferred if benefits outweigh risks.
Stabilization relates to available capabilities.
Patient must present to emergency department to trigger EMTALA.

12. Examples of Judgments (2 of 2)
Patient must have an emergency condition.
Transfer by ambulance is not required.
Radio medical control does not invoke EMTALA.
Physician has an obligation to “certify” transfer.
Active labor requires treatment.

13. Law Types

14. Law Sources

15. Laws vs Regulations (1 of 2)
Usually general
Include scope of practice, definitions of EMS provider classes

16. Laws vs Regulations (2 of 2)
More specific than laws
Govern types of procedures that can be performed in certain circumstances
Govern training required for initial licensure or certification
Govern requirements for relicensure or recertification

17. CCTP’s Responsibilities (1 of 3)
Understand you can be sued by anyone, but plaintiff bears the burden of proof.
Review employer’s malpractice insurance policy to ensure coverage extends to interfacility transports.
Understand having own insurance has some benefits, but may also lead to conflicts with employer’s insurance

18. CCTP’s Responsibilities (2 of 3)
Educate yourself on state’s malpractice insurance requirements, employer’s policies, personal risks.
Understand your significant legal responsibility to patients, medical director, and the public.
Understand that you need medical direction to practice.

19. CCTP’s Responsibilities (3 of 3)
Understand your significant legal and ethical responsibility to the public to function competently.

20. Right to Advance Directives or Do Not Resuscitate Orders
Requires written order from a physician
Provide resuscitation whenever questions regarding valid orders arise.
Varies from state to state, so be familiar with your own state laws.

21. Right to Self-Determination (1 of 3)
Considered basic patient right
Places CCTP who provides care without consent at risk for assault or battery liability
Requires CCTP to explain possible consequences of refusing care to patient
Includes patient’s right to terminate treatment at any time

22. Right to Self-Determination (2 of 3)
Places CCTP who transports patients against their will at risk for tort actions for false imprisonment, assault, and/or battery
Places authority to consent to/refuse treatment for minor with custodial parent or legal guardian

23. Right to Self-Determination (3 of 3)

24. Requirements of Informed Consent
Patient must be of legal age and sound mind.
Patient must be aware of procedure, its risks, alternatives, likely outcomes, and risks if not performed.

25. Right to Consent (1 of 3) Informed (express) consent
Required for any medical treatment, including transport
Generally considered physician’s legal responsibility

26. Right to Consent (2 of 3) Implied consent Emancipation
Exception for patients who are unconscious or otherwise unable to express consent
May also apply to other populations, such as children, mentally ill patients
Emancipation
Minor legally severs bonds with parents

27. Right to Consent (3 of 3)
© Mark C. Ide

28. Right to Receive Care Without Interruption (1 of 2)
Patient has the right to receive uninterrupted care.
Examples of abandonment include:
Initiating care and then leaving or releasing patient to someone without sufficient training
Leaving patient unattended for brief period

29. Right to Receive Care Without Interruption (2 of 2)
Failing to transfer patient information to receiving facility
Failing to respond to or complete ambulance call
Failing to immediately report one’s inability to complete emergency response because of equipment failure or own health status

30. Right to Appropriate Care
CCTP expected to have same training, skills, ability as other CCTPs
CCTP expected to exercise reasonable care and diligence in applying skills and knowledge in patient care

31. Four Elements Required for Negligence
Failure of duty to act
Breach of duty to act
Damage as a result from breach of duty to act
Proximate (direct) cause of injury resulted from CCTP’s actions or failure to act

32. HIPAA Overview (1 of 2) Includes primary goals of
Creating consistent standards for protection of patient privacy
Increasing patient rights and informing them of their rights while allowing state laws to be more protective
Applies to all covered entities

33. HIPAA Overview (2 of 2) Requires
Enhanced security and privacy protection for PHI
Establishment of patient rights, use of privacy notice, implementation of policies and procedures
Discipline for breaches, violations
Training for all personnel of covered entity

34. HIPAA and EMS Providers
Most important aspects of HIPAA related to disclosures of PHI
HIPAA violations incur penalties.
Understand that
State laws are usually more stringent than federal law.
Federal law allows state law to control when requirements are the same or more stringent.

35. PHI
Individually identifiable information, health information, demographic information
Information in any form: written, verbal, electronic
Disclosure for purposes not permitted under HIPAA incur penalties

36. Examples of Permissible PHI Disclosures (1 of 2)
Purposes of treatment
Sharing PHI in process of providing health care, coordinating care among providers, referring patient
Purposes of payment issues
Billing, processing claims, reviewing health care services

37. Examples of Permissible PHI Disclosures (2 of 2)
Purposes of performing other health care operations
Performing quality assessment and improvement, evaluating performance of health care providers, performing general administrative functions

38. Additional Examples
Patient or patient’s legal representative provides authorization.
Appropriately executed court document compels its release
As required by state law
Other
Organ donation, to avert threats to public health or safety

39. Patient’s Fundamental Rights
Right to inspect and copy their medical records
Right to request restrictions to what is disclosed when the covered entity releases PHI
Right to request that amendments be made to their medical records
Right to request confidential communications
Right to request an accounting of disclosures

40. Covered Entity’s Responsibilities (1 of 2)
Ensure that the patient is offered a copy of the organization’s Notice of Privacy Practices.
Train staff in the Privacy Rule.
Develop and implement policies and procedures to ensure compliance.
Monitor compliance.
Respond to concerns or complaints.

41. Covered Entity’s Responsibilities (2 of 2)
Provide appropriate discipline for violations.
Retain HPAA-related records for at least 6 years.

42. Practical Aspects to Ensure Compliance
Ensure telephone communications are not overheard.
Confirm fax communications have appropriate fax number.
Ensure patient signs written authorization.
Relay communications about patient’s condition only to appropriate personnel.

43. Before Initiating Transport
Patient has patent and secured airway.
Patient has patent and secured IV access.
Appropriate measures are instituted to treat hemodynamic instability.
Chemical or physical restraint used for confused or agitated patients who pose a threat.
Appropriate monitoring is used as indicated.

44. Work to Resolve Conflicts
State concerns clearly and professionally.
Contact receiving facility’s physician.
Contact critical care transport agency’s medical director.
Refuse to transport as a last resort.
Begin transport and then consult with online medical direction.

45. Communicate with Health Care Team
Communicate effectively, professionally, and succinctly with other members of team.
Work to resolve conflicts
Communicate capabilities and limitations to sending physicians who are unfamiliar with local protocols.
Communicate transport service’s payment policy up front.

46. Steps for Transport Preparation (1 of 2)
Obtain pertinent patient information
Reason for transfer
Name of the receiving hospital/physician
Whether a BLS or ALS provider must accompany the patient
Treatment provided at sending facility
Medical treatment and drug orders
Complications to anticipate

47. Steps for Transport Preparation (2 of 2)
Obtain name of receiving physician before transport.
Ensure availability of physician-to-physician contact.
Review transport orders for treatment; ensure they do not exceed scope of practice.

48. Patient Documentation (1 of 2)
Required from sending physician
Records of patient’s emergency condition
Patient’s signs or symptoms
Current diagnosis and any treatment provided
Results of any tests that were conducted
Written patient consent agreeing to the transfer

49. Patient Documentation (2 of 2)
Verification from sending physician that benefits of transferring patient outweigh its risks
Samples of pertinent laboratory specimens
Patient report at time of transfer with pertinent information

50. Patient Assessment (1 of 2)
Perform rapid baseline physical exam before initiating transport.
Determine any changes in patient’s condition.
Determine whether transfer warrants additional personnel or resources.
Assessment consists of brief review of:
ABCs
Cardiovascular, neurologic, gastrointestinal, and genitourinary systems

51. Patient Assessment (2 of 2)
© Mark C. Ide

52. Medical Direction
Performed off-line during transport using established written protocols
Performed online if treatment beyond protocol indicated or consultation needed
Determined by communication capabilities

53. Other Duties of Sending Physician
Realize that prehospital protocols for EMS systems do not automatically apply in interfacility transport.
Designate qualifications of personnel accompanying patient during transport.
Consider possible skill ranges of personnel aboard transport vehicles.

54. Actions to Minimize Liability During Transport (1 of 3)
Assess the patient.
Discuss potential complications with sending physician.
Ensure sending physician understands capabilities, limitations of transport team
Provide appropriate care within scope of practice.
Inform medical control of changes in patient’s condition.

55. Actions to Minimize Liability During Transport (2 of 3)
Provide continued support of respiratory and circulatory systems and continued fluid volume replacement.
Use appropriate medications as ordered.
Monitor vital signs.
Maintain communications.
Maintain accurate records of the transport and hand off during completion.

56. Actions to Minimize Liability During Transport (3 of 3)
© Mark C. Ide

57. Transport Completion
Ensure continuity of care by giving a report to the designated receiving provider.
Transfer specimens, records, and laboratory and radiography results.
Make yourself available to answer questions.

58. Run Report Contents (1 of 2)
Times of each set of vital signs and each assessment finding
Details and times of each intervention
Patient responses to all interventions
Untoward or adverse reactions

59. Run Report Contents (2 of 2)
Communications with medical control
Deviation from transfer orders or standing orders
Diversion to another hospital
Refusal of treatment by the patient