OBSTETRICAL PATIENTS AND EMTALA COMPLIANCE

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OBSTETRICAL PATIENTSAND EMTALA COMPLIANCE

• Nancy Ruzicka
• Director of Regulatory Compliance
• Iowa Health System

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PRESENTATION TO HOSPITAL

• DEFINE IN POLICY WHERE THE MSE WILL OCCUR FOR
  WOMEN IN LABOR
• IF IN OTHER THAN TRADITIONAL ED, THEN A SEPARATE
  LOG MUST BE MAINTAINED FOR UNSCHEDULED PATIENTS
  REQUESTING TREATMENT OR SCREENING
• MUST MAINTAIN SAME INFORMATION AS ED LOG

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CMS DEFINITION OF LABOR

• Labor means the process of childbirth beginning
  with the latent or early phase of labor and
  continuing through the delivery of the placenta.
  A woman experiencing contractions is in true
  labor unless a physician, certified nurse-midwife
  or other qualified medical person as defined by
  the hospital certifies that after a reasonable
  time of observation, the woman is in false labor
• Reference 42 CFR 489.24(b)effective 10-1-06 and
  S/C 6-32

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DIAGNOSIS OF PRETERM LABOR

• STILL CONSIDERED PROBLEMATIC
• SUSPECTED PRETERM LABOR SHOULD BE OBSERVED FOR
  1-2 HOURS
• SUGGESTED CRITERIA INCLUDE
• Gestation of 20 weeks or greater but less than 37
  weeks
• Persistent uterine contractions (4 q 20 minutes
  or 8 q 60 minutes) AND
• Documented cervical change OR
• Cervical effacement of 80 or greater OR
• Cervical dilation of greater than 1 cm

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MEDICAL SCREENING EXAM

• MUST BE ADEQUATE TO DETERMINE WHETHER OR NOT IN
  LABOR
• CAN NOT SIMPLY TELL PATIENT WE DONT DELIVER
  BABIES AND SEND TO NEXT HOSPITAL
• MUST PERFORM SCREENING EXAM WITHIN CAPABILITY
• AT A MINIMUM SHOULD INCLUDE FETAL HEART TONES AND
  VAGINAL CHECK (PER RECENT IDIA INVESTIGATIONS)

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MSE CONDUCTED BY QUALIFIED STAFF

• DEFINE IN POLICY WHO IS QUALIFIED TO CONDUCT MSE
  OF OB PATIENTS
• DEFINE IN POLICY WHO CAN CERTIFY WHETHER WOMAN IS
  IN LABOR OR FALSE LABOR
• DEFINE IN POLICY WHAT A REASONABLE TIME OF
  OBSERVATION IS

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STABILIZATION OF WOMAN IN LABOR

• IF A WOMAN IS DETERMINED TO BE IN LABOR, ONLY WAY
  TO STABILIZE IS TO DELIVER CHILD AND PLACENTA
• THEREFORE IF IN LABOR, WOMAN IS ALWAYS UNSTABLE

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BORN ALIVE INFANTS PROTECTION ACT OF 2002

• SC 5-26
• MAY BE OCCASIONS THAT AN INFANT MAY BE BORN ALIVE
  AND THE HOSPITAL FAILS TO COMPLY WITH EMTALA
• BORN ALIVE IS DEFINED AS
• At any stage of development who after such
  expulsion or extraction breathes or has a beating
  heart, pulsation of the umbilical cord, or
  definite movement of voluntary muscles,
  regardless of whether the expulsion or extraction
  occurs as a result of natural or induced labor,
  cesarean section or induced abortion.

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How does BIPPA interact with EMTALA?

• If an infant was born alive in the DED
  (traditional ED or labor/delivery) AND a request
  made on infants behalf for screening of a
  medical condition OR based upon the infants
  appearance or behavior that the infant needed
  exam or treatment based upon a prudent layperson
  standard AND the hospital failed to provide such
  an exam, the hospital and physician could be
  liable under EMTALA

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Deficiencies Related to Women in Labor

• Patient presented to ED with contractions every
  2-3 minutes, dilated to 3-4 cm, ruptured
  membranes and positive Nitrazine paper. Called
  physician and on-call physician indicated that
  the patient needed to get to her own physician.
  On-call physician did not come to the ED there
  was no entry into the central log, and the
  patient was instructed to go to her own physician
  at another hospital and to call the hospital via
  cell phone when she was closer and went by
  private car.
• The hospital was cited for lack of on-call
  physician responding, lack of documentation in
  central log, lack of appropriate medical
  screening exam, and inappropriate transfer.

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• Patient presented to ED after spontaneous
  rupture of her bag of water. Staff informed
  patient that if an exam was performed, then you
  must stay here as patient. Patient stated she
  did not want to have baby at that hospital.
  Patient left in private car after receiving
  directions to desired hospital.
• Hospital was cited for lack of a screening
  examination, lack of medical record, and lack of
  appropriate transfer.