SCOPE This Procedure applies to all PeaceHealth Divisions (PHDs). PURPOSE The Purpose of this Procedure is to establish clear guidelines for complying with the federal Act (EMTALA). TABLE OF CONTENTS: EMTALA Signage Request for Services Stabilizing Treatment Transfers Registration Records and Logs Physician Call Special Circumstances Reporting Violations Referring to On-Call Physician Offices PROCEDURE This Procedure implements Act Compliance Policy. 1. EMTALA Signage 1.1. Location. Signs providing notice to patients of their right to a Medical Screening Examination are posted conspicuously in places where patients wait for examination or treatment, including the Emergency Department (ED), Labor and Delivery (L&D) and in other places likely to be observed by patients presenting with a possible Emergency Medical Condition. 1.2. Languages. Signage is posted in English and other languages when more than 5% of the community s population has limited English proficiency (LEP) and speaks another language. 1.3. Appearance and Content: 1.3.1. Signs in lobbies or waiting areas must be posted in such a way that they are conspicuous and visible to patients in those areas. 1.3.2. Signs posted in registration, triage, or examination rooms may be smaller than those in the waiting areas, but must be clearly readable from the patient s position. Printed copies of this document may not be the most current version. Use caution when Page 1 of 14
1.4. Content: Signs must clearly state that the Medical Center participates in the Medicaid program; and: IT S THE LAW IF YOU HAVE A MEDICAL EMERGENCY OR ARE IN LABOR, YOU HAVE THE RIGHT TO RECEIVE, within the capabilities of this Medical Center s staff and facilities: An appropriate MEDICAL SCREENING EXAMINATION; Necessary STABILIZING TREATMENT (including treatment for an unborn child) and, if necessary; and An appropriate TRANSFER to another facility even if YOU CANNOT PAY or DO NOT HAVE MEDICAL INSURANCE or YOU ARE NOT ENTITLED TO MEDICARE OR MEDICAID. This Medical Center DOES participate in the Medicaid program. 2. Request for Services. The Medical Center provides an appropriate Medical Screening Examination (MSE) by physicians or qualified medical persons (QMP) as defined by the Governing Board, within the capability and capacity of the Medical Center, regardless of the person s insurance status or ability to pay when: (Table of Contents) 2.1. An individual comes to a dedicated ED or Labor & Delivery and requests examination or treatment. The request for services may be made by the patient or by another person on the patient s behalf. 2.2. Regardless of whether it is requested, if, by the person s appearance or behavior, a reasonably prudent layperson would conclude that an emergency medical condition exists, a MSE is provided. 2.3. Persons, who present for emergency care within the Medical Center, but outside the ED, are assisted to the Emergency Department. 2.4. Patients found on Medical Center grounds, including sidewalks, driveways, and parking lots, or otherwise within 250 yards of the Medical Center, requesting emergency care or in obvious need of emergency care, are assisted by a Workforce member to whom they present, within the skills of the Workforce member, and taken or directed to the ED. Printed copies of this document may not be the most current version. Use caution when Page 2 of 14
2.5. Persons who present to off-campus Medical Center sites without dedicated emergency departments and request emergency care, are managed according to that site s policies and procedures for responding to and evaluating an emergency, within their capability and capacity. 2.6. Special Patient Presentations 2.6.1. Minor Patients 2.6.1.1. If a minor comes to the ED requesting medical attention, Workforce members will not delay the MSE while attempting to obtain parental consent. If, after screening, an emergency medical condition does not exist, Workforce members may wait for parental consent before proceeding with further treatment. 2.6.1.2. If, in the discretion of the treating provider, the minor s best interest is not served by involving the parent or guardian, the Medical Center follows relevant statutory law and Network or Community policy on treatment and consent of minors. 2.6.2. Women who are over 20 weeks pregnant and present to the ED with a chief complaint related to their pregnancy, are immediately transported to the Labor & Delivery area. 2.6.2.1. In the Labor & Delivery area, the screening examination is performed by either a qualified RN, Certified Nurse Midwife (CNM) who is a LIP with Workforce privileges, or by a physician with obstetric privileges. 2.6.2.2. When an RN conducts an MSE on a pregnant woman, he or she contacts the physician or QMC to provide information and data from the MSE, to assist the physician or QMP in making appropriate medical decisions for the patient s care and treatment. 3. Stabilizing Treatment (Table of Contents) 3.1. A patient is stabilized for EMTALA purposes if, within reasonable medical probability, no material deterioration of their condition is likely to result from or occur during transfer of the individual, or, with a laboring woman, delivery is complete (including the placenta). 3.2. The Medical Center provides necessary stabilizing treatment for emergency medical conditions and laboring women within its capability and capacity. Printed copies of this document may not be the most current version. Use caution when Page 3 of 14
3.3. If the Medical Center is not capable of providing stabilizing treatment, it provides an appropriate transfer, regardless of the patient s ability to pay. 3.4. Each Community follows its own procedure to resolve any internal disagreements. 3.5. Once the Medical Center has, in good faith, admitted the patient, the Medical Center has satisfied its EMTALA obligations and the patient is treated according to the Medical Center s inpatient policies. 3.6. Patient s Right to Refuse. Patients have a right to refuse any offered medical screening and stabilizing treatment. Medical center Workforce members: 3.6.1. Explain the risks and benefits of screening and treatment; 3.6.2. Make reasonable attempts to obtain the patient s signed written refusal of examination and treatment, but the patient s signature is not required; 3.6.3. Do not suggest to patients that they cannot leave the ED waiting room or treatment areas or go elsewhere for care; and 3.6.4. Do not require the patient to sign a waiver of liability prior to leaving without being seen. 3.7. For purposes of transferring a patient from one facility to a second facility for psychiatric conditions, the patient is considered to be stable when he/she is protected and prevented from injuring himself/herself or others. 4. Transfers. A transfer is appropriate if: (Table of Contents) 4.1. The transferring Medical Center has provided stabilizing medical treatment within its capability, that minimizes the risks to the individual s health, and in the case of a woman in labor, the health of the unborn child; 4.2. The receiving facility has: 4.2.1. Available space and qualified Workforce members for the treatment of the individual; and 4.2.2. A physician at that facility has agreed to accept transfer of the individual and to provide appropriate medical treatment. 4.3. The transferring facility has completed the EMTALA transfer form; and Printed copies of this document may not be the most current version. Use caution when Page 4 of 14
4.4. Sent to the receiving facility, copies of all medical records related to the emergency condition available at the time of the transfer, including at least: Available history and physical; Records related to the individual s emergency medical condition; Observations of signs and symptoms; Preliminary diagnosis; Results of diagnostic tests or studies or telephone reports of the studies; Description of the treatment provided; List of medications given; A description of the patient s condition and vital signs just prior to transfer; A copy of the EMTALA form, including the patient s informed written consent to transfer; and Certification of the transfer. 4.5. Other records not readily available at the time of the transfer are sent as soon as practical. 4.6. The transfer is accompanied by qualified Workforce members and by appropriate means of transport and transportation equipment, including the use of necessary and medically appropriate life support measures and devices during transfer. Emergency medical technicians may not always be qualified Workforce members for purposes of transferring an individual. 4.7. The physician at the transferring Medical Center has the responsibility to determine appropriate mode, equipment, and attendants for transfer. 4.8. The intra-facility transfers from one PeaceHealth Medical Center to another PeaceHealth Medical Center are considered transfers from one licensed Medical Center to another and EMTALA transfer rules apply. Specifically, patient movement between Sacred Heart RiverBend and Sacred Heart University District are transfers for EMTALA purposes, as are transfers to and from Cottage Grove Community Medical Center and Peace Harbor Medical Center. 4.9. An unstable patient may not be transferred unless the individual requests the transfer to another Medical Center, and/or refuses further treatment at the Medical Center. 4.9.1. In such cases, Medical Center Workforce members document the patient s request for transfer and/or refusal of care including the information provided to the patient about the specific risks and benefits of their options. 4.9.2. Medical Center Workforce members should make a reasonable attempt to have the patient sign his or her request for transfer or refusal of care. Printed copies of this document may not be the most current version. Use caution when Page 5 of 14
4.10. If the Medical Center transfers emergent patients due to the on-call physician s failure to respond or present as requested, the name of that physician must be noted on the transfer documents. 4.11. Transfer Form. An EMTALA Transfer Form is completed by the physician to document 4.11.1. A description of and reason for the proposed transfer. 4.11.2. The consent, request, or refusal of transfer by the patient/legal representative. 4.11.3. Physician s written certification that the physician explained the specific risks and benefits of the transfer for the patient. 4.11.3.1. If the physician certifying the transfer is not physically present at the time of transfer, the qualified medical Workforce member, in consultation with the physician, may complete the EMTALA Transfer Form and the physician countersigns the certification. 4.11.3.2. Physician certification cannot simply be implied from the findings in the medical record. 4.11.3.3. Certifications may not be backdated. 4.11.4. The name of the accepting facility and physician. 4.11.5. The written documentation must state the reasons for the individual s refusal. 4.11.6. Discharge vital signs. 5. Registration (Table of Contents) 5.1. Registration of the patient may be started after the initial nurse triage as long as it does not delay the medical screening examination. 5.2. Insurance authorization is not sought until after the medical screening examination and necessary stabilizing treatment has begun, and then, only if the process does not delay treatment or unduly discourage the patient from remaining for further treatment. 5.3. If the screening examination reveals the patient has an emergency medical condition, only information that is necessary for the patient s care is collected. Printed copies of this document may not be the most current version. Use caution when Page 6 of 14
5.4. Patients who ask about Medical Center charges and payment arrangements are advised that they have a right to receive a screening examination and necessary treatment to treat an emergency condition, regardless of their ability to pay. ED facilities in Washington State must provide the patient with information about possible approximate charges upon request. 6. Records and Logs (Table of Contents) 6.1. Each facility maintains a central log of individuals who come to the Emergency Department or Labor & Delivery seeking assistance, and indicate whether these individuals: 6.1.1. Refused treatment; 6.1.2. Were denied treatment; 6.1.3. Were stabilized, admitted, transferred, or discharged; or 6.1.4. Left the ED prior to being seen. 6.2. The log contains the following information: the patient s name, date of log entry, medical record and account numbers of patients transferred to or from the Medical Center. 6.3. Medical and other records related to individuals transferred to or from the Medical Center are maintained for 5 years from the date of transfer. 6.4. Facilities maintain a log of telephone calls received from other facilities requesting to transfer patients and, if the transfer is refused, why the PeaceHealth facility lacked either the capacity or capability to accept the patient. 6.5. A log is maintained of refusals from other facilities to accept PeaceHealth transfer requests, including the person communicating the refusal, the reason for the refusal, the date and time of the log entry and the name of the person making the log entry. 7. Physician Call. Medical Staff Bylaws, Rules and Regulations or policies and procedures, include a requirement for Medical Staff Member physicians to take call as part of their membership duties and responsibilities. The requirement includes the following: 7.1. Medical or surgical specialty on-call coverage is provided in a manner that best meets the needs of Medical Center patients and the availability of the specialists in the community. 7.2. Medical Center on-call lists are compiled and maintained by each department or service line. Printed copies of this document may not be the most current version. Use caution when Page 7 of 14
7.3. The on-call list must identify the specific physician on-call by name, not by the name of the physician s practice group. 7.4. Medical staff, including specialty service staff members and Medical Center administration, collaborate to determine what specialties will be on-call, the number of on-call days per month or portions of days if not 24/7, and the on-call rotation/schedule. 7.5. The on-call list is readily available to Workforce members in the dedicated ED, Labor & Delivery, and elsewhere as appropriate. 7.6. Changes to the on-call list must be made in advance of the scheduled call time and noted on the on-call list. 7.7. Facilities must have written policies and procedures to provide for back-up plans to address emergency situations when a particular specialty is not available or the on-call physician cannot respond because of situations beyond his or her control. 7.8. Non-critical access hospital physicians may perform surgery while on-call. 7.8.1. Physicians who are paid to provide on-call coverage at Critical Access Hospitals may not concurrently perform elective procedures during their on-call shift. 7.8.2. When a physician who is on-call is unavailable due to a scheduled elective surgery or a situation beyond his/her control, he/she must notify the Medical Center at the earliest possible time. 7.9. Response Times and Types. When an on-call physician is contacted by the ED and requested to respond, the physician must: (Table of Contents) 7.9.1. Be available by telephone within 10 minutes of receiving call or page if the ED physician indicates the need for an urgent response. In any event, no longer than 20 minutes of receipt of call or page. 7.9.2. Respond in person to Medical Center, if requested, within 30 minutes of receiving request. 7.9.3. The ED physician, in consultation with the on-call physician, determines the need for the on-call physician to personally evaluate the patient. 7.9.4. The determination of the ED physician is decisive. 7.9.5. The on-call physician must come to the Emergency Department if requested by the ED physician. If the on-call physician believes the request to personally Printed copies of this document may not be the most current version. Use caution when Page 8 of 14
examine the patient was inappropriate, he/she may request Medical Staff review only after he or she has personally provided the requested examination. 7.9.6. Response to trauma calls by trauma providers is in accordance with the applicable regulatory and facility requirements for trauma service under the facility s state law. 8. Special Circumstances (Table of Contents) 8.1. Diversion Status 8.1.1. When a facility lacks capability or capacity to accept patients, it notifies emergency services that the facility is on diversion. 8.1.2. If an ambulance arrives at the ED despite notice of diversion status, the Medical Center stabilizes the patient, provides emergency services and determines appropriate disposition of the patient. 8.2. Medical Center as Point of Transit 8.2.1. If the facility is serving as a point of transit for patients who have already received a MSE and stabilizing treatment, the Medical Center is not obligated to perform another MSE prior to the patient s continued travel. 8.2.2. If, while at the helipad, the individual s condition deteriorates, the facility must provide another MSE and stabilizing treatment within its capability and capacity, if requested by the medical personnel accompanying the individual. 8.3. National Disaster 8.3.1. In a national disaster, including a bioterrorism disaster, the Medical Center may transfer or refer patients in accordance with a community disaster plan initiated by a state or local government, which supersedes the Medical Center s normal plan for providing emergency care. 8.3.2. Medical screening examinations performed during disasters are the same MSEs that the Medical Center performs in assessing any individual coming to the ED or L&D with the same signs and symptoms. 9. Reporting Possible EMTALA Violations 9.1. Reports to the CMS regional office in Seattle, WA, or to the applicable state health authority acting under the supervision of the CMS regional office, are made when there Printed copies of this document may not be the most current version. Use caution when Page 9 of 14
is substantial reason to believe a facility either inappropriately transferred a patient or refused to accept a patient in violation of EMTALA rules. 9.2. Workforce members who identify a possible EMTALA violation document the occurrence and immediately notify, the on-call Risk Manager for their facility. 9.3. The Director of Risk Management notifies the System Risk Management Director of a possible EMTALA event. 9.4. The event is reported to CMS upon the recommendation of the Director of Risk Management, System Director of Risk Management, System Legal, and/or the Community President or their designee. 9.5. An EMTALA investigation is generally conducted within 72 hours of the time the incident report is received by Risk Management, and promptly reported if circumstances verify that a violation of EMTALA may have occurred. 9.6. If the Community determines it has possibly failed to meet its own EMTALA requirements, the Director of Risk Management: 9.6.1. Notifies the Community President and Community Leadership, the System Director of Risk Management, and System Legal; 9.6.2. Collaborates with System Legal in obtaining outside counsel if appropriate; 9.6.3. Ensures investigation utilizing quality improvement tools occurs, including a Root Cause Analysis, if indicated. 10. Referring to On-Call Physician Offices. On-call physicians may not refer emergency patients to their offices for evaluation and treatment unless: (Table of Contents) 10.1. The office has specialized equipment not available in the ED (e.g., ophthalmology); 10.2. The office is a Medical Center-owned facility on contiguous land or on the Medical Center campus; or 10.3. For medically appropriate reasons, every patient presenting with the same medical condition are sent to this office for examination or treatment. DEFINITIONS Printed copies of this document may not be the most current version. Use caution when Page 10 of 14
Capability means the skill of the facilities Workforce members and the level of care they provide based on their training and the scope of their professional practices, the specialized services that the facility provides and the availability of on-call specialists. Capacity means the facility s ability to accommodate patients needing transfer or admission. It may include the number and availability of qualified staff, beds and equipment. Capacity includes whatever a Medical Center customarily does to accommodate patients in excess of its occupancy limits, by whatever means it has customarily used (e.g., moving patients to other units, calling in additional Workforce members, borrowing equipment from other facilities.) Emergency Medical Condition means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances, and/or symptoms of intoxication or substance abuse) such that the absence of immediate medical attention could reasonably be expected do any of the following: 1. Jeopardize the health of the individual, including the health of a woman and/or her unborn child. 2. Seriously impair any body functions. 3. Cause serious dysfunction of any organ or body part or to a pregnant woman who is having contractions. 4. An EMC exists if there is inadequate time to affect a safe transfer of the laboring mother to another Medical Center before delivery. Act (EMTALA) means the federal law enacted by Congress in 1986 to ensure public access to emergency services regardless of patients ability to pay. 1. Section 1867 of the Social Security Act imposes specific legal obligations on Medicareparticipating Medical Centers that offer emergency services, to provide a medical screening examination, stabilizing treatment or appropriate transfer for an emergency medical condition, including active labor, regardless of an individual's ability to pay. 2. If a Medical Center is unable to stabilize a patient within its capability or if the patient or legal representative requests, an appropriate transfer should be implemented. Medical Center for purposes of EMTALA means the main campus of the health care Medical Center including: 1. Facilities that are off of the main campus that bill under the same Medicare provider number. Printed copies of this document may not be the most current version. Use caution when Page 11 of 14
2. Parking lots, sidewalks and driveways two hundred fifty (250) yards beyond the medical campus. 3. Dedicated Emergency Departments (DED) that are defined by meeting any one of the following criteria: 3.1. Licensed by the state as an emergency room or emergency department; 3.2. Held out to the public by name, signage, 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 3.3. Based on a representative sample of patient visits within the immediately preceding calendar year, at least one-third of all its outpatient visits are for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment. 4. The Medical Center may also include ambulances owned and operated by the Medical Center, even if the ambulance is not on Medical Center grounds, unless the ambulance is operating under a regional EMS plan that controls medical care decisions. 5. The term Medical Center does not include: 5.1. Physician offices, rural health clinics, skilled nursing facilities, or other entities that participate in Medicare separately from the Medical Center. 5.2. Businesses such as on-site restaurants, shops, and other non-medical activities. Labor means the process of childbirth beginning with the latent or early phase of labor and continuing through to the delivery of the placenta. A woman is in true labor unless a physician or QMP certifies that, after a reasonable time of observation, the woman is in false labor. Medical Screening Examination (MSE) means the process required to determine, with reasonable clinical confidence, whether or not an emergency medical condition exits. 1. MSE is not an isolated event but is an ongoing process with continued monitoring according to the patient s needs. 2. TRIAGE IS NOT A MSE. Performing patient triage is not equivalent to performing a medical screening examination, as triage merely determines the order in which patients are seen, not the presence or absence of an emergency medical condition. Printed copies of this document may not be the most current version. Use caution when Page 12 of 14
PeaceHealth Division (PHD) means a Medical Center, clinic, operating unit, or operating division of PeaceHealth that maintains day-to-day management oversight of a designated portion of PeaceHealth System operations. PHDs may be based on a geographic market or dedication to a service line or business. Qualified Medical Professionals means individuals designated by the Medical Staff as qualified to conduct emergency Medical Screening Examinations. Stabilize means a patient is stabilized for EMTALA purposes if, within reasonable medical probability, no material deterioration of their condition is likely to result from, or occur during transfer of the individual, or, with a laboring woman, delivery is complete (including the placenta). For purposes of discharging a patient with psychiatric conditions, the patient is considered to be stable when he/she is no longer considered to be a threat to him/herself or to others. Stabilization for Transfer means within reasonable medical probability, no material deterioration is likely to result from or occur during the transfer of the individual or, with respect to a pregnant woman, that she has delivered the child and the placenta. 1. For purposes of transferring a patient with psychiatric conditions, the patient is considered to be stable when he or she is protected and prevented from injuring himself/herself or others. 2. Stable for transfer does not require the final resolution of the emergency medical condition. Stabilization for Discharge means within reasonable clinical confidence, it is determined that the patient has reached the point where his or her continued care, including diagnostic work-up 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 the discharge instructions. Workforce means employees (caregivers), volunteers, trainees, and other persons whose conduct, in the performance of work for PeaceHealth, is under the direct control of PeaceHealth, whether or not they are paid by PeaceHealth. HELP Further guidance concerning this Procedure may be obtained from your Community Risk Manager. RELATED MATERIAL Forms: EMTALA Transfer Form English Printed copies of this document may not be the most current version. Use caution when Page 13 of 14
EMTALA Transfer Form Spanish EMTALA Transfer Form Visually Impaired Job Aids & Tools: Electronic Incident Report EMTALA Transfer Guidelines Laws & Regulations: Revised Emergency Medical Treatment and Labor Act (EMTALA) Interpretive Guidelines (May 29, 2009) PeaceHealth Policies & Procedures: Act CompliancePolicy No. Communication of Unanticipated Outcomes Policy No. 101.356.12 Refer to Community Medical Staff policies for Physician Call. Practice Advisories, Guidelines, and Statements: S & C Letter- Critical Access Medical Center Emergency Services and Telemedicine; Implications for Emergency Services Condition of Participation (CoP s) and Emergency Medical Treatment and Labor Act (EMTALA) On-Call Compliance (June 7, 2013) S&C-02-04 Q & A Relating to Bioterrorism & EMTALA (Nov 8, 2001) S&C-02-06 Medical center Capacity- EMTALA (November 29, 2001) S&C-02-14 Certification of False Labor- EMTALA (January 16, 2002) S&C-02-34 On-Call Requirements EMTALA (June 13, 2002) S&C-02-35 Simultaneously On-Call (June 13, 2002) S&C-04-10 EMTALA Interim Guidance (November 7, 2003) Web Sites: EMTALA Online Health Law Resource Center APPROVALS Initial Approval: Risk Management Work Group, May 26, 2016. Subsequent Review/Revision(s): Printed copies of this document may not be the most current version. Use caution when Page 14 of 14