1. 1 The Rules become “Reality EMTALA ” Carole A. Klove, RN, JD Chief Compliance Officer and Privacy Officer (310) 825-7166 cklove@mednet.ucla.edu

2. 2 History EMTALA – “Anti-Dumping Act” EMTALA – “Anti-Dumping Act” Amended 1988 & 89 Amended 1988 & 89 Final rule 1994 Final rule 1994 Amended 2002 Amended 2002 Interpretation published November 2003 Interpretation published November 2003

3. 3 What Changed? CMS changed how the regulations are interpreted and enforced

4. 4 What did not Change? EMC EMC Documentation Documentation Stabilization Stabilization Signage Signage Transfer elements Transfer elements Medical records Medical records Central log Central log Sanctions Sanctions Reporting Reporting Private lawsuits Private lawsuits

5. 5 Basic Rules of the Road EMTALA applies to EMTALA applies to Individuals presenting to a “dedicated emergency department”Individuals presenting to a “dedicated emergency department” Off campus facilities and departments defined as “dedicated emergency departments”Off campus facilities and departments defined as “dedicated emergency departments” Hospital owned ambulances – ground and airHospital owned ambulances – ground and air

6. 6 Basic Rules of the Road EMTALA does not apply to EMTALA does not apply to Outpatient settingsOutpatient settings Individuals who are inpatientsIndividuals who are inpatients

7. 7 “Individual” Comes to the DED With respect to an individual who is not a patient, the individual presents to the DED requesting evaluation or treatment of a medical conditionWith respect to an individual who is not a patient, the individual presents to the DED requesting evaluation or treatment of a medical condition Prudent layperson observer Individual on hospital campus requesting treatment for an EMC; or A prudent layperson observer believes the individual needs evaluation for EMC

8. 8 Dedicated Emergency Department Meets at least one of the following: Licensed under applicable state law as an EDLicensed under applicable state law as an ED Held out to the public as a place that provides care on an urgent basis without requiring an appointment, orHeld out to the public as a place that provides care on an urgent basis without requiring an appointment, or During the previous calendar year at least 1/3 of all the outpatient visits were for the treatment of emergency medical conditionsDuring the previous calendar year at least 1/3 of all the outpatient visits were for the treatment of emergency medical conditions

9. 9 Hospital Owned & Operated Ambulance The examination or treatment of an individual in a ground/air ambulance owned & operated by a hospital is not subject to EMTALA, if it operates: under community wide EMS protocolsunder community wide EMS protocols at the direction of an MD who is not employed or affiliated with the hospitalat the direction of an MD who is not employed or affiliated with the hospital

10. 10 Diversion The hospital directs the ambulance to another facility because it does not have the capacity or capability to accept any additional emergency patients The hospital directs the ambulance to another facility because it does not have the capacity or capability to accept any additional emergency patients Is this appropriate?

11. 11 Requirements Stabilization Transfer Screening

12. 12 Screening Anyone presenting to the DED or hospital campus requesting treatment for a medical condition is entitled to a medical screening examination (MSE) Anyone presenting to the DED or hospital campus requesting treatment for a medical condition is entitled to a medical screening examination (MSE) The MSE involves a process of sufficient scope to conclude, with reasonable clinical confidence, whether an emergency medical condition does or does not exist The MSE involves a process of sufficient scope to conclude, with reasonable clinical confidence, whether an emergency medical condition does or does not exist

13. 13 Change in Interpretation If an individual comes to the dedicated emergency department and the nature of the request is clear that the condition is not an emergency, the requirement is to perform a screening appropriate for any individual presenting in the same manner.

14. 14 Stabilization Provision of treatment for the EMC to ensure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the patient. Provision of treatment for the EMC to ensure, within reasonable medical probability, that no material deterioration of the condition is likely to result from, or occur during, the transfer of the patient. In the case of a woman in labor, the woman’s medical condition shall be considered stabilized if the woman has delivered the child and the placenta. In the case of a woman in labor, the woman’s medical condition shall be considered stabilized if the woman has delivered the child and the placenta.

15. 15 Transfer An appropriate transfer includes determining capacity & capability An appropriate transfer includes determining capacity & capability Receiving hospital has the capacity, e.g., beds to provide medical treatmentReceiving hospital has the capacity, e.g., beds to provide medical treatment Receiving hospital has the capability to provide specialized services by qualified personnelReceiving hospital has the capability to provide specialized services by qualified personnel

16. 16 Record Requirements Hospitals shall maintain the following records & retain them for at least 5 years Hospitals shall maintain the following records & retain them for at least 5 years Physician on call listPhysician on call list Central logCentral log Transfer recordsTransfer records

17. 17 On Call “Best meets the need” “Best meets the need” Roster requirements Roster requirements Elective surgery & back up call Elective surgery & back up call Frequency of call Frequency of call Emergency physician & on call disagreements Emergency physician & on call disagreements Disparate response to requests Disparate response to requests

18. 18 Now that you know the Rules…. Reality EMTALA Scenario No. 1 A patient is brought to a community hospital by a family member via private car. The family member found the individual “down”. X-rays depict a sub-arachnoid hematoma. There is no neurosurgeon on call. A patient is brought to a community hospital by a family member via private car. The family member found the individual “down”. X-rays depict a sub-arachnoid hematoma. There is no neurosurgeon on call. What are your options? What are your options?

19. 19 Now that you know the Rules…. Reality EMTALA Scenario No. 2 A 13 year old female is brought into the ED by the police under legal hold (detainment). It is determined by the ED attending that the child needs a psych consult. The psych consult determines that the child is a danger to herself. Parents cannot be located and you do not have an adolescent psych unit. A 13 year old female is brought into the ED by the police under legal hold (detainment). It is determined by the ED attending that the child needs a psych consult. The psych consult determines that the child is a danger to herself. Parents cannot be located and you do not have an adolescent psych unit. What do you do? What do you do?

20. 20 Now that you know the Rules…. Reality EMTALA Scenario No. 3 A 42 year old mill worker presents with a significant crushing trauma injury to the hand and partially amputated digits. The emergency physician examines the patient and determines a hand and vascular consult is needed as part of the MSE. The vascular surgeon refuses to come to the ED. A 42 year old mill worker presents with a significant crushing trauma injury to the hand and partially amputated digits. The emergency physician examines the patient and determines a hand and vascular consult is needed as part of the MSE. The vascular surgeon refuses to come to the ED. What do you do? What do you do?

21. 21 Now that you know the Rules…. Reality EMTALA Scenario No. 4 During a recent evening shift, an employee of your hospital is exposed to a needle stick and presents to the Emergency Department. During a recent evening shift, an employee of your hospital is exposed to a needle stick and presents to the Emergency Department. What obligations are now triggered? What obligations are now triggered?

22. 22 Key Points Maintain a central log & on call list Maintain a central log & on call list Determine chief complaint & level of urgency (triage) Determine chief complaint & level of urgency (triage) Define who can perform the MSE Define who can perform the MSE Do not delay the MSE to verify method of payment, obtain insurance approval, etc. Do not delay the MSE to verify method of payment, obtain insurance approval, etc. Perform medically indicated tests to rule out or confirm EMC Perform medically indicated tests to rule out or confirm EMC

23. 23 Key Points Stabilize the patient Stabilize the patient Confirm capability & capacity when considering transfer Confirm capability & capacity when considering transfer Document risks & benefits to support need for transfer Document risks & benefits to support need for transfer Provide appropriate transport Provide appropriate transport Maintain records for at least 5 years Maintain records for at least 5 years

24. 24 EMTALA…the Potential Punishment for Failure to Follow the Regulations Potential fine of up to $50,000 per patient incident Termination from Medicare and Medicaid 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

25. 25 Questions & Answers Carole A. Klove, RN, JD Chief Compliance Officer and Privacy Officer (310) 825-7166 cklove@mednet.ucla.edu