EMTALA. Federal Law and the Medical Staff. Shaheed Koury, MD, MBA, FACEP SVP & Chief Medical Officer Quorum Health

Transcription

1 EMTALA Federal Law and the Medical Staff Shaheed Koury, MD, MBA, FACEP SVP & Chief Medical Officer Quorum Health

2 Objectives Review EMTALA Law Clarify Key Terms Define Hospital and Physician Responsibilities Address Special Circumstances and Challenges Discuss EMTALA Investigation and Violation Process Present Case Examples Questions 2

3 What is EMTALA? Emergency Medical Treatment and Labor Act: A Federal Law requiring Medicare participating hospitals to provide a Medical Screening Exam (MSE) and stabilizing treatment(s) for anyone that presents to the hospital s dedicated emergency department requesting medical examination or treatment, regardless of their ability to pay. 3

4 EMTALA History Enacted to prevent refusing the treatment of patients based on financial status (or other discriminatory reasons), sometimes referred to as patient dumping. EMTALA is not simply an anti-dumping law. EMTALA is a federally mandated standard of practice for hospitals and physicians. 4

5 What must the hospital provide? 1. An appropriate Medical Screening Exam (MSE) to anyone who comes to the emergency department and requests an exam or treatment. 2. Necessary stabilizing treatment to a person with an emergent medical condition (EMC), including an individual in labor, regardless of their ability to pay. 5

6 What must the hospital provide? 3. An appropriate transfer if: The individual requests the transfer, OR The hospital does not have the capability or capacity to provide the treatment necessary to stabilize the EMC, and/or have the capability or capacity to admit the individual for treatment, AND the benefits of the transfer outweigh the risk 6

7 Additional requirements 4. The treatment must be the same that would be provided to any patient arriving with those signs and symptoms. 5. Treatment decisions must be made in a nondiscriminatory manner regardless of diagnosis (e.g., labor, AIDS), financial status (e.g., uninsured, Medicaid), race, color, national origin (e.g. Hispanic or Native American surnames), and/or disability. 7

8 Hospital Property Main hospital campus Parking lot Sidewalk Driveway Hospital departments Definitions Any building owned by the hospital within 250 yards of the main building. 8

9 Definitions Comes to the Emergency Department An individual requests examination or treatment, OR A prudent layperson would believe that the individual needs emergency examination or treatment. 9

10 Definitions Medical Screening Exam A Medical Screening Exam (MSE) is an exam performed by a qualified medical practitioner, to determine the presence, or absence, of an emergent medical condition. This includes the presence, or absence, of labor. 10

11 Definitions Appropriate Screening An MSE is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an Emergency Medical Condition or not. 11

12 Definitions Proper Screening An MSE is an ongoing process, not an isolated event. May be a brief history and physical examination, or can include ancillary studies and procedures. 12

13 Definitions Emergency Medical Condition (EMC) A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part. 13

14 Definitions Emergency Medical Condition (EMC) With respect to a pregnant woman who is having contractions: There is inadequate time to effect a safe transfer to another hospital before delivery, or The transfer may pose a threat to the health or safety of the woman or her unborn child. 14

15 Medical Screening Examination Triage is not a Medical Screening Exam! Triage simply means to sort the patient based on acuity. Only a Registered Nurse can triage a patient. Only a Qualified Medical Provider can perform a MSE. 15

16 Medical Screening Examination Every patient is considered emergent until determined otherwise by a Medical Screening Exam performed by a QMP. 16

17 Medical Screening Examination You cannot delay the MSE to inquire about insurance or ability to pay for care. Even if it causes no delay, you cannot seek authorization from an insurer until the MSE is complete and stabilizing treatment is initiated. 17

18 The QMP has performed the Medical Screening Exam Does an EMC Exist? If No, the patient is determined to have a non-emergent condition. No further obligation under EMTALA. If Yes, or EMC is not ruled out, then must: STABILIZE, ADMIT, or TRANSFER* *Appropriate Transfer 18

19 Definitions Stabilized Emergency Medical Conditions: No material deterioration of the patient s condition is likely to result from discharge. Patients in Active Labor: The infant and the placenta have been delivered. Psychiatric Patients: Protected and prevented from injuring or harming him/herself or others. 19

20 Stabilizing Treatment Asthma Management Bronchospasm resolved Psychiatric Patient No longer a danger to self or others Broken Bone Pain managed, fracture splinted Woman in Labor Delivery of child and placenta 20

21 Stabilized If a patient comes to the Hospital and is determined to have an EMC following a MSE, the Hospital must provide further medical examination and treatment, including hospitalization if necessary, as required to stabilize the EMC within the capabilities of the staff and facilities available at the Hospital, including on-call physicians. 21

22 Within The Capabilities The hospital resources and staff available to inpatients All resources available in the emergency department. the capability of its emergency department includes the services of its on-call physicians. The capability of the hospital includes that of the hospital as a whole 22

23 When a Transfer Occurs: The hospital does not have the capacity or capability to provide the treatment needed to stabilize the patient for a discharge disposition, and the benefits of the transfer outweigh the risk, Patient request OR 23

24 Stabilized Discharge versus Transfer Confusing Terminology! Stabilized for Discharge: No material deterioration of the patient s condition is likely to result. Stabilized for Transfer: Benefits of transfer outweigh risks of transfer. SO. Unstable then means: Unstable for Discharge: Material deterioration of the patient s condition is likely to result. Unstable for Transfer: Risks of transfer outweigh the benefits of transfer. 24

25 Steps to ensuring an Appropriate Transfer 1. Provide stabilizing treatment to the extent possible given the hospital s current capacity and capability. 2. Obtain an accepting hospital with the capability and capacity to treat the patient. 3. Completion of the EMTALA Transfer Form. 4. Send copies of the medical records/chart. 5. If the on call physician refused to respond need to list their name and address on the form. 25

26 Related to Private Vehicles: REMEMBER, when transferring a patient, the sending hospital is ultimately responsible for ensuring that the transfer is effected appropriately. There is no way to ensure that a patient will arrive at the intended destination when transported by private vehicle. Ask yourself: What is the best way to ensure that the patient arrives at the receiving hospital? 26

27 A Note about Private Vehicles: When transferring a patient, the sending hospital is ultimately responsible for ensuring that the transfer is effected appropriately. There is no way to ensure that a patient will arrive at the intended destination when transported by private vehicle. CMS does not consider private vehicle an appropriate mode of transportation for an EMTALA transfer. Patients can make their own decision including deciding to self-transport (unless special circumstance such as involuntary psychiatric admission). The appropriate box is checked under section B and the patient disposition is transfer.

28 Example: Standard Transfer Form NOTE: PRIVATE VEHICLE not considered Appropriate Mode of Transfer and therefore not an option to select. 28

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31 Note about Non-EMTALA Transfers Applies to areas other than the ED, such as the inpatient unit (EMTALA obligation ceases on good faith inpatient admission). ED Transfers are treated as EMTALA Transfers. 31

32 On-Call Coverage Obligations The hospital is responsible for maintaining an on-call list in a manner that best meets the needs of its patients in accordance with the resources available to the hospital. The hospital must have written policies and procedures to respond to situations where a particular specialty is not available; where a hospital permits on-call physicians to provide simultaneous call; where a hospital permits physicians to schedule elective surgery during call. 32

33 On-Call Coverage Obligations Each Hospital must establish a process for identifying those physicians on-call for a given specialty. On-call physicians, after being called, must respond to the Dedicated Emergency Department as specified in the Hospital s Medical Staff Bylaws. 33

34 On-Call Coverage Obligations The Hospital must document on the transfer form the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment, and must report such information to Hospital administration as soon as possible. 34

35 Does a hospital violate EMTALA if a patient refuses treatment? No, an individual may refuse to consent to examination and treatment, but only after the hospital offers to provide further medical examination and treatment and informs the individual of the risks and benefits of refusing examination and treatment. The hospital MUST take all reasonable steps to secure the individual s written consent to refusal of further medical examination and treatment. 35

36 Notice and Record Keeping Hospitals are required to maintain all records related to persons transferred for a minimum of 5 years. Maintain the list of on-call physicians. Maintain a central log on each patient who comes to the DED to track the care provided. 36

37 Recipient hospital responsibilities: A hospital is required to report to CMS or the State survey agency within 72 hours of the occurrence when it suspects it may have received an improperly transferred individual. Failure to report improper transfers may subject the receiving hospital to termination of its provider agreement. 37

38 Recipient hospital responsibilities: A hospital that has specialized capabilities or facilities (including, but not limited to, facilities such as burn units, shock trauma units, neonatal intensive case units, or, with respect to rural areas, regional referral centers) may not refuse to accept from a referring hospital an appropriate transfer if the receiving hospital has the capacity to treat the individual. 38

39 The patient s visit to the ED should contain the following to meet CMS expectations: 1. Central log entry with disposition 2. Triage record 3. On-going vitals recorded 4. Oral history 5. Physical exam of affected systems 6. Physical exam of potentially affected systems and known chronic conditions 7. Any testing necessary to rule out the presence of a legally defined Emergency Medical Condition 8. Use of on-call personnel PRN to complete above 9. Use of on-call physician PRN to diagnose and stabilize patient 10. Resolution of abnormal findings or test results by normalization (serial values) or explanation of why they are not significant to the presentation 11. Discharge/transfer vitals 12. Adequate documentation of all above 39

40 Who is the Enforcer? CMS Sanctions include: Termination of hospital s provider agreement. Civil money penalties ($50,000 if over 100 beds, $25,000 if less than 100 beds) against both hospital and physician. Exclusion of physician. Malpractice suit. Physicians are not covered under their Malpractice insurance for a violation of EMTALA. 40

41 Suspected Violation? What to do? Contact your direct supervisor, and follow normal event reporting protocol. Administration, in conjunction with corporate, will development a corrective action plan and complete a root cause analysis. 41

42 Example: A Texas hospital paid a $20,000 fine after a patient left the ED without getting a medical screening exam ( MSE ) because a desk clerk recommended he go to his family physician. Takeaway: no matter how small an injury appears, all patients seeking emergency care must get an appropriate MSE. 42

43 Example: In Texas, a suicidal patient presented with underlying hypotension. The hospital treated the psychiatric condition and transferred the patient to a specialty hospital, but they failed to fully treat the hypotension. The hospital paid $20,000. Takeaway: when a patient has multiple conditions, the hospital must stabilize each one within its capability. 43

44 OIG Example: An on-call surgeon at a large academic medical center in Tennessee (AMC) refused to accept a patient. The patient was transferred to another facility and died. The AMC agreed to pay $45,000, and the physician was personally fined $35,000. Takeaway: make sure physicians know they must accept patients if the facility has the capacity and capability to treat them. 44

45 On-Call Scenario On-call physician asked to come in to see an ED patient, responds with instructions to admit or to run various testing and that the on-call physician will see the patient at a later time. EMTALA requires prompt response within a "reasonable" time to be specified by the bylaws. These times are not extended by necessary or prudent testing or by admission. Delays will lead to violations for failure to promptly evaluate or stabilize the patient. 45

46 On-Call Scenario On-call physician asked to come in to see an ED patient, debates with ED physician over the necessity of coming in. Once the request is made to come in, the duty attaches. In addition, EMTALA places the decision power with the physician with eyes on the patient. Response is not negotiable or debatable. 46

47 EMTALA Q/A When covering more than one hospital on-call, asking a patient be sent to the hospital where the on-call physician is currently seeing patients instead of going to the patient s location. EMTALA requires all care to be rendered in the hospital where the patient presents. The only circumstances where the request to transfer would be valid would be if the needs of the patient could not be met in timely fashion where the patient presented, and the requested transfer would allow more timely intervention for patient safety and response of the on-call physician was not possible (i.e. currently involved in surgery). Thorough documentation would be important. 47

48 Interpretive Guidelines Who Must Take Call? CMS will consider all relevant factors, including the number of physicians on staff, other demands on these physicians, the frequency with which the hospital s patients typically require services of on-call physicians, and the provisions made for situations in which a physician specialty is not available. 48

49 Simultaneously On-Call On-call docs can be oncall at more than one institution. Must be a plan for when the on-call physician is not available. 49

50 Interpretive Guidelines The best practice for hospitals, which offer particular services to the public, should be available through on-call coverage of the ED. CMS Phone Contact: Any specialty with a significant presence on a medical staff, offering services to the community, available for inpatient care, will be represented on the on-call schedule. 50

51 EMTALA Q/A When asked to come in to see an E.D. patient, declining on the basis that the patient was previously discharged from the physician s practice for non-compliance, prior litigation, or non-payment. While the patient has the right to decline the on-call physician, the on-call physician does not have the right under EMTALA to decline the patient. He/she may arrange for someone else to present in his/her stead. 51

52 Transfer Acceptance Scenario #1 ER attending physician receives a call from a small rural hospital wanting to transport a 50 yo male with chest pain to your facility. The rural hospital has done an EKG and performed blood work. ER attending denies the transport suggesting that the patient be admitted to the rural hospital for observation. Rural hospital does not have a cardiologist on staff. Is this an EMTALA violation? 52

53 Transfer Acceptance Scenario #1 EMTALA Violation : YES The transferring hospital determines that the patient requires further examination and treatment in order to stabilize the emergency medical condition A hospital with specialized capabilities may not refuse to accept an appropriate transfer if patient requires specialized capabilities and there is capacity and capability. 53

54 Transfer Acceptance Scenario #2 45 yo male with a subdural hematoma from a fall. ED physician calls the regional trauma center to transfer. Resident from trauma facility refuses the transfer even though hospital has NS coverage. Is this an EMTALA violation? 54

55 Transfer Acceptance Scenario #2 EMTALA Violation : YES The transferring physician determines that the patient requires further examination and treatment in order to stabilize the emergency medical condition. A hospital with specialized capabilities may not refuse to accept an appropriate transfer if patient requires specialized capabilities and there is capacity and capability. 55

56 Transfer Acceptance Scenario #3 35 yo female with ovarian torsion. Local facility does not have GYN services. ED physician called the referral hospital which refused to accept the patient since they did not participate in her insurance. Advised to call other facilities which delayed ultimate care. Is this an EMTALA violation? 56

57 Transfer Acceptance Scenario #3 EMTALA Violation : YES A hospital with specialized capabilities may not refuse to accept an appropriate transfer if patient requires specialized capabilities and there is capacity and capability. Cannot inquire about financial status. 57

58 Transfer Acceptance Scenario #4 85 yo male presents with a ruptured AAA. Local hospital has no general or vascular surgery backup. Patient is unstable with hypotension and tachycardia. ED physician speaks to CV surgeon at referral hospital. Surgeon states patient is too ill and unstable for transfer and refuses transfer. Patient expires 8 hours later after multiple attempts to transfer fail. Is this an EMTALA violation? 58

59 Transfer Acceptance Scenario #4 EMTALA Violation : YES When a hospital has exhausted all of its capabilities in attempting to resolve the EMC, it must effect an appropriate transfer of the individual (see Tag A-2409/C-2409). If an individual s EMC has not been stabilized, prior to transferring the individual to another hospital, the sending hospital is required under EMTALA to pursue a transfer because either: the individual requests the transfer; or the expected benefits of the transfer outweigh the increased risks of the transfer. 59

60 Frequent ED patient example A frequent Flyer patient was seen, treated and discharged from the ED. Patient returned to the same ED within minutes of discharge with different complaints and threats of self-harm, asking to be seen. The same ED doctor who was still on duty refused to see the patient and went to lobby and told the patient to leave. Patient went to the parking lot and called 911 and reported intent to kill himself, had a knife in his hand when police arrived. Police returned patient to ED registration and asked for a psychiatric/medical evaluation and treatment on patient s behalf. Doctor again came to lobby and told police she had seen this patient earlier, and refused to see the patient again. Police took patient to another ED in the same city and filed EMTALA complaint with the state department of health. 60

61 EMTALA Example (Medical Screening) Patient #1 stated she presented at the hospital ED on 11/07/16 and asked if there was a doctor who specialized in kidney failure. Patient #1 stated she was told to go next door to see a doctor as a walk-in as the ED is only for emergencies. 61

62 References 1. Centers for Medicare and Medicaid (2005), Social Security Act Section 1867 (42 USC 1395dd), Regulations: 42 CFR State Operations Manual,(Rev. 60, ) : Appendix V Interpretive Guidelines Responsibilities of Medicare Participating Hospitals in Emergency Cases Guidance/Guidance/Manuals/Downloads/som107ap_v_ emerg.pdf 62

63 Contact Us Shaheed Koury, MD, MBA, FACEP Senior Vice President & Chief Medical Officer (615) (615)