SUBJECT: Emergency Treatment for Individuals at Off- Campus Dedicated Emergency Departments (DED) of the hospital Policy NUMBER: EFFECTIVE DATE: SUPERCEDES SPP: DATED: APPROVED BY: (Signature) DISTRIBUTION: Adapted from Department of Health & Human Services, Centers for Medicare and Medicaid Services (CMS), State Operations Manual, Appendix V Interpretive Guidelines Responsibilities of Medicare Participating Hospitals in Emergency Cases, Rev. 60, 07/16/2010. I. STATEMENT OF PURPOSE To establish the procedures by which individuals seeking or requiring emergency care are appropriately screened, examined, stabilized, treated and/or transferred from or to [insert facility name], including with respect to emergency, obstetrics, pediatrics, medical/ surgical and psychiatric services II. STATEMENT OF POLICY It is the policy of [insert facility name] to conduct medical screening examinations, provide stabilizing treatment, and transfer all individuals appropriately and without delay in compliance with federal guidelines. III. DEFINITIONS Comes to the Emergency Department: An individual, who is not a patient (as defined below), presents in one of the following manners: An individual has presented at a hospital s dedicated emergency department and requests examination or treatment for a medical condition or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual s appearance or behavior, that the individual needs examination or treatment for a medical condition.
The individual has presented on hospital property, other than the dedicated emergency department, and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf. In the absence of such a request by or on behalf of the individual, a request on behalf of the individual will be considered to exist if a prudent layperson observer would believe, based on the individual s appearance or behavior, that the individual needs emergency examination or treatment. The individual is in a ground or air ambulance owned and operated by the hospital for purposes of transporting the individual for an examination and treatment for a medical condition at a hospital s dedicated emergency department, even if the ambulance is not on hospital grounds. However, an individual in an ambulance owned and operated by the hospital is not considered to have come to the hospital s emergency department if the ambulance is operated under community-wide emergency medical services (EMS) protocols that direct it to transport the individual to a hospital other than the hospital that owns the ambulance; for example, to the closest appropriate facility. Note: An individual who requests emergency services while in an ambulance that is not on hospital property should not be diverted unless the hospital is in diversionary status. Dedicated Emergency Department (ED): Any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus that meets at least one of the following requirements: It is licensed by the state in which it is located as an emergency room or emergency department; It is held out to the public (by name, posted signs, advertising or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or During the calendar year immediately preceding the calendar year in which a determination under EMTALA is being made, based on a representative sample of patient visits that occurred during that calendar year, it provides at least one-third of all of its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. The organization may list the departments/facilities that meet the definition of a dedicated ED. Hospital property: The entire main hospital campus, including the parking lots, sidewalks, and driveways, and any buildings owned by the hospital that are within 250 yards of the hospital, but excluding other areas or structures of the hospital s main building that are not part of the hospital (such as physician offices, rural health centers, skilled nursing facilities or other entities that participate separately under Medicare, restaurants, shops or other non-medical facilities) Inpatient: An individual who is admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services, with the expectation that he or she will remain at least overnight and occupy a bed, even though the situation later develops that the individual is discharged or transferred to another hospital and does not actually use a hospital bed overnight Patient: An individual who has begun to receive outpatient services as part of an encounter, as defined in 410.2, other than an encounter that the hospital is obligated by this section [EMTALA] to provide, or an individual who has been admitted as an inpatient, as defined above
Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: Placing the health of the individual (or pregnant woman and/or her unborn child) in serious jeopardy, Serious impairment to bodily functions, or Serious dysfunction of any bodily organ or part, or with respect to a pregnant woman who is having contractions: o There is inadequate time to effect a safe transfer to another hospital before delivery, or o The transfer may pose a threat to the health or safety of the woman or the unborn child. Legal Representative: An individual who has legal authority to make healthcare decisions on behalf of an individual (e.g., durable power of attorney, legal guardian, parent) Medical Screening Examination: An examination within the capability of the hospital s dedicated emergency department, including ancillary services routinely available to determine whether the individual has an emergency medical condition Qualified Medical Personnel: An individual designated by the governing body of the hospital to conduct screening examinations and stabilizing treatment, as documented in the bylaws or rules and regulations approved by the governing body Stabilize: To provide such medical treatment of the condition necessary 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 individual from the facility, or that, with respect to a pregnant woman having contractions, the woman has delivered the child and the placenta Transfer: The movement (including the discharge) of an individual outside the hospital s property at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the hospital, but does not include the movement of an individual who has (i) been declared deceased, or (ii) leaves the hospital without the permission of any such person Triage: The process of determining the order in which individuals will be seen, not the screening process that determines the presence or absence of an emergency medical condition IV. PROCEDURE A. Medical Screening Examination All individuals that present at a hospital s dedicated emergency department and request examination or treatment for a medical condition, or any individual that presents on hospital property and requests examination or treatment for what may be an emergency medical condition, or has such a request made on his or her behalf, or would appear to a prudent layperson observer to need examination or treatment for a medical condition, will be provided a medical screening examination to determine if an emergency medical condition exists. The medical screening will be performed within the capacity and capabilities of the hospital, including ancillary services, resources routinely available, and on-call providers, as may be indicated. The
physician or qualified medical personnel shall determine if an emergency medical condition exists. Any request for insurance information or authorization must not delay the medical screening examination. After the initial examination, the treating physician may contact an on-call physician to provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition. The on-call list will clearly delineate on-call coverage. If participating in a community call plan, the on-call list will include when each hospital participating in the plan is responsible for on-call coverage. When contacted, the on-call physician(s) will: Provide appropriate orders, if applicable. Appear within a reasonable time as circumstances allow and may be applicable, given the individual s presentation when requested by the ED physician. Assume responsibility for the individual s care and/or transfer, when appropriate. If the on-call physician is not available in a timely manner because they are performing a procedure or caring for a patient at another hospital while they are on-call, the treating physician will make the necessary arrangements (such as calling a back-up on-call physician for facilities that have the resources) for the individual to receive appropriate evaluation and stabilizing treatment, and if necessary, transfer of the individual pursuant to EMTALA requirements (and/or transfer agreements with neighboring hospitals). Rationale for treatment decisions will be clearly documented in the medical record. If the on-call physician is on-call for a community call plan and practices at a different hospital, the individual will receive a medical screening examination and stabilizing treatment and then may be appropriately transferred to the hospital where the on-call physician practices. If the on-call physician is on-call for a community call plan and practices at the hospital were the individual is located, the individual will receive a medical screening examination and stabilizing treatment. The treating physician and on-call physician will determine if the individual should be transferred, taking into consideration what is best for the individual and what action will maintain the on-call physician s availability to other patients. If the hospital permits the on-call physician to send a licensed non-physician representative to the hospital to perform an assessment or stabilizing treatment, the decision to send a nonphysician representative will be based on the individual s medical condition and the state s scope of practice laws. If the treating physician requests the on-call physician to appear in person, the on-call physician will appear in person. The on-call physician remains ultimately responsible for the care provided to the individual by the non-physician provider. Note: If an individual must be transferred because an on-call physician refused to come to the emergency department when requested, the treating physician will list the on-call physician s name on the EMTALA Medically Indicated Transfers form. (The risk manager or administrator on-call will be notified if an on-call physician refuses to come to the ED when requested). Continued monitoring shall occur according to the individual s needs and shall continue until the individual is stabilized or appropriately transferred. Monitoring activities shall be documented in the medical record.
If an individual or legal representative on behalf of the individual refuses to allow a medical screening examination, including the refusal of any ancillary services conducted in the course of the examination or treatment, the following shall occur: The physician shall attempt to determine the individual s decisional capacity to refuse a medical screening examination. The physician shall inform the individual (or legal representative) of the hospital s obligation to perform a medical screening examination, the benefits of the examination, and the significant known risks of refusing such examination. If the individual is determined to have the capacity to make informed decisions and thus able to make a decision to refuse the examination, the individual will be requested to sign the EMTALA Informed Refusal of Examination, Treatment or Transfer form. If the individual refuses to sign the form, this shall be documented on the form and placed in the medical record. The individual shall be invited to return at any time. If the individual is determined to be incapacitated and unable to make a decision to refuse the examination, the hospital shall detain the individual until a medical screening examination has been performed. A description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual shall be documented in the medical record. B. Transfer of Unstable Individuals Stabilizing Treatment All reasonable efforts to stabilize or treat the individual s emergency medical condition or labor will be attempted utilizing resources customarily available to the hospital, including on-call physicians or other personnel available, until the individual is transferred. Stabilizing treatment will be provided in an attempt to resolve or stabilize the individual s emergency medical condition. Reasons for Transfer If the individual s emergency medical condition cannot be stabilized because the hospital does not have the capability or capacity to provide the necessary stabilizing treatment, the unstable individual may be transferred to another facility if: The physician determines that the medical benefits of treatment at the receiving facility outweigh the risks to the individual s medical condition associated with the transfer. The individual or legal representative requests the transfer after being informed of the hospital s obligations under EMTALA and the foreseeable risks of the transfer. Individual-Requested Transfer If the individual or legal representative requests the transfer, the physician will attempt to determine the individual s decision-making capacity and explain to the individual the hospital s responsibilities and obligations under EMTALA, as well as the foreseeable risks of transfer. The request for transfer must be documented on the EMTALA Individual-Requested Transfer form, indicating the reasons for the request and acknowledging the risks and benefits, if any, of transfer.
If the physician is opposed to the transfer or does not recommend the transfer for medical reasons, the capacitated individual will be transferred against medical advice using the EMTALA Individual-Requested Transfer form, noting that the transfer is against medical advice (AMA). If the physician opposes the transfer of an incapacitated individual (requested by a legal representative) and believes the legal representative s decision may jeopardize the individual s well-being and/or is not made in the best interest of the individual, do not arrange for the transfer and contact the risk manager or administrator on-call for determination if possible court intervention is to be undertaken. Transfer Guidelines If the individual will be transferred to another facility, the receiving facility will be contacted to determine and ensure acceptance of the individual. The emergency or attending physician will complete and document the following on the EMTALA-Physician Transfer Orders and Certificate for Medically Indicated Transfers form or the EMTALA Individual-Requested Transfer form: Personal contact with the attending physician at the receiving facility to verify with the physician that he/she agrees to assume (or arrange for) the care of the individual Verification with the receiving facility that they have available space and qualified personnel to handle the transferring individual Identification of the mode of transfer, life support equipment, and qualified personnel necessary (e.g., level of expertise, physician support, ACLS-certified paramedics, medically appropriate life support measures) for transfer based on the nature and severity of the individual s condition and the expected duration of the transport (All transfers of unstable individuals will occur by ambulance or other appropriate emergency medical transportation [e.g., helicopter].) Attempts to obtain consent by the individual or legal representative for transfer following disclosure of the foreseeable risks and benefits of transfer although implied consent is acceptable under the emergency consent doctrine When a transfer is medically indicated, a statement that, based on the information available at the time of transfer, the medical benefits of the transfer of the individual to another medical facility outweigh the risks That the transfer is requested by the individual and against medical advice, if such is the case A qualified medical person (if other than the ED physician) may sign the physician certification section of the EMTALA-Physician Transfer Orders and Certificate for Medically Indicated Transfers form after consulting with the physician and once the physician has determined that the benefits of the transfer outweigh the risks. The physician must subsequently countersign the certification in a timely manner. The RN or other healthcare provider will follow the physician s or qualified medical person s direction by doing the following: Call in a report to the receiving facility s emergency department or patient care unit and document in the medical record the name of the receiving facility, unit called, time called and name of person accepting the report. Call an ambulance or air transport and arrange for appropriate support, personnel, supplies and equipment, based on the physician s assessment of the individual s condition and duration of the transport. If hospital personnel accompany the individual during transport, medical record documentation (e.g., progress notes) will continue until responsibility for care is transferred to the receiving facility.
Attempt to contact appropriate family members to notify them of the transfer, when appropriate. Forward a copy of the medical records with the individual to the receiving facility: o The records will include, when applicable, laboratory results, X-ray results, consent forms, transfer forms (including physician certification), and other forms and results, such as available history, a description of the emergency medical condition, observations, o preliminary diagnosis, treatment provided, and diagnostic test results. If pertinent records or results are not available at the time of transfer, they should be phoned or faxed to the receiving facility as they become available, and then sent as soon as possible after transfer. Continue to monitor and care for the individual, as well as recheck his/her vital signs prior to transporting the individual. Document the above activities on the EMTALA Nursing Transfer Report form. C. Refusal of Individual to Accept Treatment and/or Transfer Against Medical Advice If the individual or legal representative refuses treatment or a medically appropriate transfer to another facility, the physician shall: Inform the individual of the benefits of treatment and/or transfer, the known risks of refusing treatment and/or transfer, and alternative treatment available. Attempt to determine whether the individual is capacitated and able to make a decision to refuse treatment and/or transfer. o If the individual is determined to be capacitated, he/she will be asked to sign the EMTALA-Informed Refusal of Examination, Treatment, And Transfer form; if the o individual refuses to sign the form, this shall be documented on the form. If the individual is determined to be incapacitated and unable to make a decision to refuse treatment or transfer, the hospital shall detain the individual until treatment has been given or transfer has been made. Document in the medical record a description of the proposed treatment and/or transfer that was refused by or on behalf of the individual. D. Transfers from Other Facilities When the hospital is contacted by another facility and requested to accept and receive the transfer of an individual with an emergency medical condition, the hospital shall accept the transfer so long as it has the capacity and specialized capabilities/facilities and staff members necessary to treat the individual. E. Inappropriate Transfers from Other Facilities Personnel who believe that the hospital may have received an improperly transferred individual from another hospital shall notify risk management or the supervisor/administrator on-call immediately. Risk management personnel or a designee will conduct an investigation and, in coordination with legal counsel and administration, determine whether it is necessary to contact (or file a complaint with) governmental agencies.
F. Documentation and Record Keeping All medical records related to the transfer will be maintained for a minimum of five years. The physician on-call list and community call plan in effect at the time of examination and treatment will be maintained for a minimum of five years. A central log for all individuals who come to the dedicated emergency department(s) will be maintained for a minimum of five years. The log will include disposition of all individuals. Signs will be posted in conspicuous locations in all dedicated emergency department(s), stating the rights of individuals with emergency medical conditions and women in labor who come to the dedicated emergency department for health services, and indicate on the signs whether the hospital participates in the Medicaid program. The sign(s) must be posted in a place or places likely to be noticed by all individuals entering the emergency department, as well as those individuals waiting for examination and treatment (e.g., entrance, admitting area, waiting room, treatment area). The following forms shall be used for documentation purposes as identified above (sample forms are available in this section): o EMTALA Medically Indicated Transfers o EMTALA Individual-Requested Transfer o EMTALA Transfer Checklist o EMTALA Informed Refusal of Examination Treatment and/or Transfer o EMTALA Transfer Order Form V. Managing Extraordinary ED Surges A. The hospital will initiate the disaster plan. B. If there is a surge related to an influenza-like illness (ILI), hospital leaders may choose to implement one or all of the following alternatives: 1. Set up alternative screening sites on campus The MSE does not have to take place in the ED. A hospital may set up alternative sites on its campus to perform MSEs. o Individuals may be redirected to these sites after being logged in. The redirection and logging can even take place outside the entrance to the ED. o The person doing the directing should be qualified (e.g., an RN) to recognize individuals who are obviously in need of immediate treatment in the ED. The content of the MSE varies according to the individual s presenting signs and symptoms. It can be as simple or as complex, as needed, to determine if an EMC exists. MSEs must be conducted by qualified personnel, which may include physicians, nurse practitioners, physician s assistants, or RNs trained to perform MSEs and acting within the scope of their State Practice Act. The hospital must provide stabilizing treatment (or appropriate transfer) to individuals found to have an EMC, including moving them as needed from the alternative site to another on-campus department. 2. Set up screening at off-campus, hospital-controlled sites The hospital and community officials may encourage the public to go to these sites instead of the hospital for screening for influenza-like illness (ILI). However, staff will not tell individuals who have already come to its ED to go to the off-site location for the MSE.
Unless the off-campus site is already a dedicated ED (DED) of the hospital, as defined under EMTALA regulations, EMTALA requirements do not apply. The hospital will not hold the site out to the public as a place that provides care for EMCs in general on an urgent, unscheduled basis. They may hold it out as an ILI screening center. The off-campus site should be staffed with medical personnel trained to evaluate individuals with ILI. If an individual needs additional medical attention on an emergent basis, the hospital staff will arrange referral/transfer. The hospital will coordinate with local emergency medical services (EMS) prior to setting up the off-campus screening site and develop transport arrangements. 3. Set up screening clinics at sites not under the control of a hospital There is no EMTALA obligation at these sites. The hospital and community officials may encourage the public to go to these sites instead of the hospital for screening for ILI. However, the hospital will not tell individuals who have already come to its ED to go to the off-site location for the MSE. The sites will be staffed with medical personnel trained to evaluate individuals with ILIs. The community disaster plan may be implemented and include referral and transport of individuals needing additional medical attention to the hospital on an emergent basis. VI. Emergency Waivers EMTALA sanctions for an inappropriate transfer or for directing or relocating an individual to an alternate location for the medical screening examination may be waived under certain emergency circumstances, to wit: 489.24(a)(2) (i) When a waiver has been issued in accordance with Section 1135 of the Act that includes a waiver under Section 1135(b)(3) of the Act, sanctions under this section for an inappropriate transfer or for the direction or relocation of an individual to receive medical screening at an alternate location, do not apply to a hospital with a dedicated emergency department if the following conditions are met: (A) The transfer is necessitated by the circumstances of the declared emergency in the emergency area during the emergency period. (B) The direction or relocation of an individual to receive medical screening at an alternate location is pursuant to an appropriate State emergency preparedness plan or, in the case of a public health emergency that involves a pandemic infectious disease, pursuant to a State pandemic preparedness plan. (C) The hospital does not discriminate on the basis of an individual's source of payment or ability to pay. (D) The hospital is located in an emergency area during an emergency period, as those terms are defined in Section 1135(g)(1) of the Act. (E) There has been a determination that a waiver of sanctions is necessary. (ii) A waiver of these sanctions is limited to a 72-hour period beginning upon the implementation of a hospital disaster protocol, except that, if a public health emergency involves a pandemic infectious disease (such as pandemic influenza), the waiver will
continue in effect until the termination of the applicable declaration of a public health emergency, as provided under Section 1135(e)(1)(B) of the Act. 1 Interpretive Guidelines for 489.24(a)(2): [in part] In accordance with Section 1135 of the Act, an EMTALA waiver may be issued only when: The President has declared an emergency or disaster pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act; and The Secretary has declared a public health emergency (PHE) pursuant to Section 319 of the Public Health Service Act; and The Secretary has exercised his/her waiver authority pursuant to Section 1135 of the Act and notified Congress at least 48 hours in advance of exercising his/her waiver authority. In exercising his/her waiver authority, the Secretary may choose to delegate to the Centers for Medicare & Medicaid Services (CMS) the decision as to which Medicare, Medicaid, or CHIP requirements specified in Section 1135 should be temporarily waived or modified, and for which health care providers or groups of providers such waivers are necessary. Specifically, the Secretary may delegate to CMS decisionmaking about whether and for which hospitals/cahs to waive EMTALA sanctions as specified in Section 1135(b)(3). In addition, in order for an EMTALA waiver to apply to a specific hospital or CAH: The hospital or CAH must activate its disaster protocol; and The State must have activated an emergency preparedness plan or pandemic preparedness plan in the emergency area, and any redirection of individuals for an MSE must be consistent with such plan. It is not necessary for the State to activate its plan statewide, so long as it is activated in the area where the hospital is located. It is also not necessary for the State plan to identify the specific location of the alternate screening sites to which individuals will be directed, although some may do so. Reference: 1. Department of Health & Human Services, Centers for Medicare and Medicaid Services (CMS), State Operations Manual, Appendix V Interpretive Guidelines Responsibilities of Medicare Participating Hospitals in Emergency Cases, Rev. 60, 07/16/2010.