The Emergency Medical Treatment and Labor Act EMTALA

1
The Emergency Medical Treatment and Labor Act
(EMTALA)

• Iowa Health System Community Network
• Presented by
• Nancy Ruzicka
• Director of Regulatory Compliance
• Iowa Health System Law Department

2
What is EMTALA?

• Emergency Medical Treatment and Labor Act-enacted
  in 1986
• Known as the anti-dumping statute
• Enacted in response to the practice of some
  hospitals of refusing to see or transferring the
  poor and uninsured
• Purpose of act to ensure all patients receive
  appropriate medical screening, stabilizing
  treatment and, if necessary, appropriate transfer
  to another facility.

3
The Cost of Dumping Violations

• Ultimate cost Termination of the hospital from
  the Medicare program
• Increased surveillance by CMS and IDIA
• Finesup to 50,000 per violation or example
  cited
• Up to 50,000 per knowing or negligent violations
  for physicians
• Direct costs of compliance dependent upon
  hospital size but range from 50,000 to over
  150,000

4
Survey Process

• Complaint driven process
• Focus is on initial allegation and discovery of
  any additional violations
• Even if original allegation is not confirmed,
  surveyors must ensure all requirements met
• Revisit protocol would include
• Verification original citation has been corrected
• Verification hospital remains in compliance with
  all other EMTALA requirements even if not cited
  in original investigation

5
EMTALA Overview
Patient comes to the dedicated emergency
department or is on hospital property requesting
treatment for a medical condition or an emergency
medical condition
Hospital provides triage
Hospital provides Medical Screening Examination
6
Once medical screening is done
If screening reveals no emergency medical
condition
Hospital discharges patient with or without
treatment
7
Once medical screening is done
If medical screening exam reveals emergency
medical condition
Hospital provides treatment to stabilize emergency
Patients emergency medical condition is resolved
and patient is stable for discharge if reasonable
to get continued care as outpatient or later as
inpatient. Patient receives plan for follow-up
care with discharge instructions.
Patients emergency medical condition is resolved
and patient is stable may be admitted to
hospital for continued care or transferred.
8
If hospital unable to stabilize patient
Hospital unable to stabilize emergency medical
condition
Hospital provides unstable patient with an
appropriate transfer.
9
Where at Your Hospital does EMTALA apply?

• If a patient presents
• At the hospitals dedicated emergency
  department and requests treatment or examination
  for a medical condition.
• Traditional emergency departments
• OB DepartmentIf the hospital still routinely
  delivers
• On hospital property and requests examination or
  treatment for what may be an emergency medical
  condition.

Individuals do not have to come through the
emergency department doors to have come to the
emergency department
10
What is a Dedicated Emergency Department (DED)?

• Licensed by the State as an emergency room (not
  applicable in Iowa)
• Held out to the public as a place that provides
  care for emergency medical conditions on an
  urgent basis without requiring a previously
  scheduled appointment including traditional ED,
  obstetrical unit or psych units.
• During the preceding calendar year, 1/3 of all
  outpatient visits were for the treatment of EMC
  without scheduled appointment (if treated as a
  provider based clinic).

11
Who is Protected?

• Center for Medicare and Medicaid Services (CMS)
  and courts define this broadly
• Individuals who present to the dedicated
  emergency department and request exam/treatment
• Individuals who present to the hospital in an
  emergency medical condition
• Individuals in hospital-owned ground or air
  ambulance
• Individuals in non-hospital owned ambulance on
  hospital property
• Need not be indigent to be protected

12
Use of Emergency Department for Nonemergency
Services

• If a person comes to the ED and a request is made
  for exam or treatment for a medical condition but
  the nature of the request makes it clear that the
  medical condition is NOT of an emergency nature,
  the hospital must only perform such screening as
  appropriate to determine no emergency medical
  condition exists.
• If no emergency medical condition, then the
  person may be referred to physician office.
• Example A hospital MAY have protocols that
  permit a qualified medical provider, such as a
  registered nurse, to conduct a MSE, such as a
  request for a blood pressure check. If the check
  reveals that the BP is within normal range and it
  is determined there is no emergency medical
  condition, EMTALA obligation ceases.

13
Presentation in DED

• Coming through the DED for non-emergency services
• EMTALA only applies if request is made in DED for
  exam/tx of a medical condition
• Does not apply to contact resulting from
• DED serving as hospital point of entry for
  registration during nonbusiness hours
• Outpatient passing through to access scheduled
  lab or radiology services

14
Lets Review

• Sara Due is a 26 year old who comes to the front
  lobby of the hospital. She states she is having a
  terrible headache and needs to see a doctor. Does
  EMTALA apply?
• Yes
• No

15
Non-emergency services

• A non-emergency can be established if
• The request for medical care is clearly unlikely
  to involve an emergency medical condition (EMC)
• The person states that he/she is not seeking
  emergency care
• The brief medical screening by the qualified
  medical provider (QMP) as defined in the hospital
  EMTALA policies, establishes there is no EMC

16
Non-emergency services

• Some examples may include
• Preventative care requests
• Law Enforcement clearances prior to incarceration
• Blood Alcohol
• Medicationsrequest for
• Determination is on a case-by-case basis.

17
Use of Dedicated ED for Scheduled Outpatient
Appointments

• Scheduled appointments in the DED
• Patients must be logged in a separate outpatient
  log book (from the central log) as presenting to
  the DED with a scheduled appointment and EMTALA
  requirements do not apply.
• In order for this part of the regulations to
  apply, there must be an appointment and not
  simply a statement by the patient The dr sent me
  here to have my catheter unclogged.

18
Provider Based Departments and EMTALA

• EMTALA does not apply to provider based
  departments such as skilled nursing facilities,
  hospices or home health agencies since each of
  these entities have their own Medicare provider
  number.
• EMTALA does not apply to the off-site departments
  such as outpatient surgical sites or outpatient
  clinics since these sites do not meet the DED
  definition.
• HOWEVER, the governing body of your hospital
  must assure the medical staff has written
  policies and procedures in effect with respect to
  these departments for the appraisal of
  emergencies and referrals, when appropriate. A
  911 policy may suffice.

19
Presenting on campus outside Emergency Dept

• CMS presumes individuals needing emergency care
  will present to the ED
• Generally EMTALA will NOT apply to individuals
  presenting outside ED
• EXCEPTION EMTALA will be triggered outside ED
  if a prudent layperson would believe that the
  individual needs treatment for an EMC.
• What is a prudent layperson?
• It is the opinion of the ordinary person with no
  health care background.

20
Medical Screening Exam (MSE)

• The process required to reach, with reasonable
  clinical confidence, the point at which it can be
  determined whether a medical emergency does or
  does not exist. This screening process shall be
  applied to all persons in a non-discriminatory
  manner.

21
What is included in a MSE?

• More than triage
• Triage only determines the order in which
  patients are seen
• Examination by a physician or an authorized
  health care provider (QMP) to determine if
  underlying EMC exists
• Provides all necessary testing and on-call
  services available within the capability of the
  hospital
• Screening must be non-discriminatory and
  consistent with what the hospital would provide
  to any patient presenting with same signs and
  symptoms

22
Who Can Conduct the MSE?

• Left to the hospitals discretion
• The qualifications of the Qualified Medical
  Person (QMP) must be described in a written
  document approved by the governing body. At IMMC,
  this is described in the medical rules and
  regulations.
• May include
• Physicians
• Nurses in consultation with ED physician
• or OB physician
• Physician Assistants
• Advanced Registered Nurse Practitioners
• Certified Nurse Midwives

23
May MSE be Delayed to Check Insurance Status???
NO

• The MSE may not be delayed to check insurance
  status or ability to pay. This includes
  obtaining prior authorization from managed care
  insurers or directing the patient to call.
• Authorization may be sought while treatment is
  being provided.

24
Registration process

• Follow REASONABLE registration process including
  asking whether an individual is insured and if so
  what that insurance is so long as the inquiry
  does not delay screening or treatment.
• REASONABLE registration process may not
  discourage individuals from remaining for further
  evaluation.

25
Emergency Medical Condition (EMC)

• A medical condition that manifests itself by
  acute symptoms of sufficient severity including
  severe pain, psychiatric disturbances, or
  symptoms of substance abuse, such that the
  absence of immediate attention could reasonably
  be expected to result in
• Serious jeopardy to health of individual or
  unborn child
• Serious impairment to bodily functions
• Serious dysfunction of any bodily organ or part

26
Emergency Medical Condition

• For a pregnant woman who is having contractions
• Inadequate time for safe transfer to another
  hospital before delivery
• Transfer may pose a threat to health/safety of
  woman or unborn child

27
What if an EMC Exists?

• If the medical screening examination reveals an
  EMC, the hospital must either provide
• Further medical treatment, within the staff and
  facilities available to the hospital, as may be
  required to stabilize the medical condition
• OR
• Transfer of the individual in accord with the
  requirements of an appropriate transfer

28
Lets Review

• John Keepmehere comes to the ER and states he
  wants his blood pressure checked. The triage
  nurse takes the blood pressure and gets a reading
  of 200/130. Since John came only requesting his
  blood pressure to be checked, he is not
  considered to have an emergency medical
  condition.
• True
• False

29
What defines stabilized?

• With respect to an emergency medical condition,
  to provide such medical treatment of the
  condition necessary to assure, within reasonable
  clinical confidence that the EMC has been
  resolved (even though the underlying medical
  condition may persist)
• Stabilized does not imply cured
• With respect to a woman in labor, the woman has
  delivered, including the placenta.
• A woman experiencing contractions is in true
  labor unless a physician certifies that after a
  reasonable time of observation the woman is in
  false labor.

30
Example of Stabilized Patient

• An individual presents to the hospital
  complaining of chest tightness, wheezing, and
  shortness of breath and has a medical history of
  asthma.
• A physician (or QMP) completes a MSE and
  diagnoses the individual as having an asthma
  attack, which is an EMC.
• Stabilizing treatment is provided (medication
  and oxygen) to alleviate the acute respiratory
  symptoms.
• In this scenario, the EMC was resolved, but the
  underlying medical condition of asthma still
  exists.
• After stabilizing the patient, the hospital no
  longer has an EMTALA obligation. The physician
  or QMP may discharge the patient home, admit to
  the hospital or transfer.

31
Stable for transfer

• A patient with an EMC is considered stable for
  transfer if
• the patient is transferred from one hospital to a
  second hospital and
• the treating physician attending to the patient
  has determined, within reasonable clinical
  confidence, that the patient is expected to leave
  the first hospital and be received at the second
  hospital with no material deterioration in
  his/her medical condition and
• the treating physician reasonably believes the
  receiving facility has the capability and
  capacity to manage the patients medical
  condition and any reasonably foreseeable
  complication of that condition
• Stable for transfer does not require final
  resolution of the EMC but does require an
  appropriate transfer.

32
Stable for discharge

• A patient is considered stable for discharge when
  within reasonable clinical confidence, it is
  determined that the patient has reached the point
  where his/her continued care, including
  diagnostic work-up and/or treatment, could be
  reasonably performed as an outpatient or later as
  an inpatient, PROVIDED the patient is given a
  plan for appropriate follow-up care with
  discharge instructions.
• Stable for discharge does not require final
  resolution of the EMC.

33
Psychiatric Stabilization

• A psychiatric patient is stable for transfer when
  he/she is protected and prevented from injuring
  self or others. This may be done with
  appropriate restraints.
• A psychiatric patient is stable for discharge
  when he/she is no longer considered to be a
  threat to self or others.

34
When is EMTALA not applicable?

• Scheduled outpatients
• Outpatients who develop EMC after outpatient
  services initiated
• Persons clearly requesting non-emergency services
  (i.e., physician office sent patient over to have
  lab work drawn)
• Inpatients
• Hospitals can not circumvent EMTALA stabilization
  and treatment requirements by simply admitting
  individuals with EMC and then discharging short
  time later from hospital

35
When a patient leaves against medical advice

• If the patient chooses to withdraw the request
  for examination or treatment the hospital must
• Offer the individual further medical examination
  and treatment as required to identify and
  stabilize an EMC
• Explain risks of leaving and benefits of
  receiving screening/treatment
• Take all reasonable steps to secure the written
  informed consent to leave AMA.
• Document in the medical record a description of
  the examination, treatment, or both that was
  refused.
• If patient leaves without staff notification,
  document such in the record.

36
On-Call Physician Requirements

• We must keep a list of physicians on-call to
  provide additional screening exam and/or
  treatment after the screening examination.
  Individual physicians may direct a non-physician
  (PA or ARNP) to respond to the call on a case by
  case basis.
• The preamble does recognize that on-call
  physician availability may impose constraints on
  the scope of the list.
• Physicians, including specialists, are not
  required to take call nor be on-call at all
  times. Medical staff rules may set forth
  expectations on call.
• There is no predetermined ratio to determine how
  many days a hospital must provide on-call
  coverage for a specialty.
• The on-call list must be maintained in a manner
  that meets the needs of the hospital patients.

37
General On-Call Requirements

• Individual physician must be named vs group
• Call list should be conspicuously posted and
  retained 5 years
• Physician must respond to hospital if requested
• You cannot transfer the patient for physician
  convenience
• If an EMC has not been ruled out, you cannot
  Send them to office

38
On-Call Requirements

• Must have written policy in place to respond to
  situations in which a particular specialty is not
  available or the on-call physician cannot respond
  because of circumstances beyond the physicians
  control.
• Must also have written policy in place if a
  physician is allowed to conduct elective surgery
  while on call or serve call at more than one
  hospital simultaneously.

39
On Call Requirements

• On-call physicians must respond to all calls and
  not selectively respond (especially based upon
  payment source).
• ED physician or the QMP has the responsibility to
  determine if on-call physician must appear in the
  hospital or respond by phone.
• If ED physician or QMP asks the on-call physician
  to come to the hospital, he/she must.

40
On -Call Requirements

• Failure to respond to call must be reported to
  the receiving hospital if the patient is
  transferred.
• Failure to respond to call is an EMTALA violation
  for both the hospital and the physician.

41
Appropriate Transfer Requirements

• The transferring hospital provides medical
  treatment within capacity to minimize risk of
  transfer
• Receiving hospital has agreed to transfer and has
  space and personnel
• Qualified personnel and equipment are provided
  during patient transfer
• All medical records are sent with patient
  including
• Written consent or certification
• Other records as soon as practical
• Name and address of on-call physician, if that
  physician failed to appear and this caused the
  transfer to occur

42
Unstable Transfer Components

• If a patient is unstable with an EMC, the patient
  may still be transferred, without risk of an
  EMTALA violation, if
• The physician certifies that benefits outweigh
  the risks of transfer
• Qualified medical person certifies benefits
  outweigh the risks of transfer, with physician
  countersignature
• Patient asks for and signs written request for
  transfer, without suggestion or pressure of
  hospital or physician to induce request
• The transfer must still be considered an
  appropriate transfer and meet the other
  components of a transfer

43
Notice of Hospital Responsibilities

• Brief statement of hospitals obligations under
  statute
• Include benefits/risks certification
• Any transfer must be initiated by physician
  certification or patient request
• Written request must be part of medical record

44
Physician/QMP certification

• Expected benefits outweigh risks of transfer
• Specific (not presumed) benefits LISTED
• Specific risks LISTED
• Reason for transfer clearly stated in record
• Must clearly document lack of capability or
  capacity of hospital to take care of patient
• QMP must consult with the physician prior to
  transfer. The risk/benefits certification MUST
  be countersigned by physician

45
Patient Transfer Record

• The following must be included in the patient
  transfer record
• Patient Name
• Transferring hospital and transferring physician
• Receiving hospital including town hospital is
  located in and complete name and title of
  individual who accepted
• Documentation of physician/physician
  contact--sending hospital needs to be involved
• Mode of transfer-including personnel and
  equipment
• Which medical records sent

46
Receiving Hospital Responsibility

• All transfer patients must be accepted under
  these conditions
• The receiving hospital has capabilities and
  capacity to treat
• AND
• Patient has an EMC
• AND
• The receiving hospital has specialty services not
  available at the sending hospital
• If a receiving hospital refuses to accept the
  patient, despite having the capabilities, this
  needs to be reported as a potential EMTALA
  violation.

47
Lets Review

• Chris Codeman is a 37 year old involved in a
  motor vehicle collision. He has received a
  thorough examination for injuries and a CT scan,
  as well as blood work and other xrays. He has a
  large amount of intracerebral bleeding and is
  unconscious. There is no available neurosurgeon
  in the area. The general surgeon decides to
  transfer Chris to another facility for
  neurological care. Which of the following is
  true?
• The general surgeon cannot transfer this
  patient once he has taken care of him.
• The surgeon has to wait for all the vital signs
  to be stable before he can transfer the patient.
• The surgeon must make sure the receiving
  facility is contacted and has the resources to
  care for the patient (i.e., neurosurgeon).

48
Central Log Documentation

• The Central Log should include
• All non-scheduled individuals who come to the DED
  requesting treatment or screening.
• All individuals who present to the hospital
  requesting treatment or screening for an
  emergency medical condition.
• DO NOT include those individuals with scheduled
  appointments for outpatient services in the ED.

49
Most Common Violations of EMTALA

• Failure to screen a person presenting to the ED
  for an emergency medical condition
• Inappropriate transfer of an unstable patient
• Lack of signs specifying the rights of
  individuals under EMTALA
• Failure to maintain a central log
• Policies and procedures that do not meet EMTALA
  requirements
• Problems with on-call physicians

50
Iowa Investigations

• In 2006-14 Iowa hospitals were investigated by
  Iowa Department of Inspection and Appeals (IDIA)
  for potential EMTALA violations.
• 2 hospitals had no deficiencies
• As of late October, 2007, 17 hospitals have been
  investigated for potential violations.
• 2 of the hospitals investigated had no
  deficiencies.

51
Iowa Fines

• Fines assessed in 2003--10,000 for a violation
  /investigation conducted in 2000
• Fines assessed in 2004--15,000 for a
  violation/investigation conducted in 2001
• Fines in Iowa have ranged from 4000--44,000