POLICY The policy of the El Paso County Hospital District (EPCHD) is to provide services in compliance with applicable federal and state laws, rules and regulations regarding the appropriate medical screening examination, stabilization and appropriate transfer of patients in a medically appropriate manner. RESPONSIBLE Hospital Associates Medical Staff, Residents and Allied Health Professionals (AHPs) Emergency Department Labor and Delivery Department Respiratory Care Services Department Guest Services Department AODs POLICY REFERENCES CP-43 Records Retention and Destruction Policy and Schedule L-13 Searches of Patients NC-ED-58 Triage NC-ED-73 Medical Emergency Team NHC-CL-04 Medical Emergency Procedures NC-NS-10 Overload to EMS P-1 Resuscitation P-7 Patient Transfers P-5 Admission S-EM-001 Emergency Management Plan DEFINITIONS Capability type of personnel and equipment necessary to care for the particular demands of a patient s medical condition and may include things such as specialty care equipment and physicians privileged for certain procedures Capacity - Ability of the hospital to accommodate: 1. an individual requesting examination or treatment or Page 1 of 11
2. treatment of a transferred patient,, including number and availability of qualified staff, beds, and equipment and the hospital s past practices of accommodating additional patients in excess of its occupancy limits. Emergency Medical Condition - 1. A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: a. 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; or b. serious impairment to bodily functions; or c. serious dysfunction to any bodily organ or part. 2. With respect to a pregnant woman who is having contractions; a. that there is inadequate time to effect a safe transfer to another hospital before delivery; or b. that transfer may pose a threat to the safety or health of the woman or unborn child. EMTALA Emergency Medical Treatment and Active Labor Act. Emergency Medical Team team consisting of an Emergency Department (ED) Registered Nurse (RN), Respiratory Care Services Associate and an on-duty Guest Services Associate (Security). Hospital Property - The entire main hospital campus, including the parking lots, sidewalk, driveway but excluding other areas or structures that are not strictly contiguous to, but are located within 250 yards of the hospital s main building. 1. This includes the Annex Building, tunnels/bridges contiguous to the hospital building, the parking structures, sidewalks and driveways. 2. This excludes other areas or structures that are not part of the hospital, such as, physician offices, or other entities that participate separately under Medicare Page 2 of 11
(Texas Tech, areas of the East Tower occupied by El Paso Children s Hospital) or other non-medical facilities such as retail restaurants, or shops. Inpatient - An individual admitted to the hospital for bed occupancy for the purposes of receiving inpatient hospital services with the expectation that s/he will remain at least overnight and occupy a bed even though the situation later develops that the individual can be discharged or transferred to another hospital and does not actually use a hospital bed overnight. Labor - 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 certifies, after a reasonable time of observation that the woman is in false labor. Medical Screening Examination an examination, within the hospital s Capability, including ancillary services routinely available to the Emergency Department or the Labor and Delivery Department, to determine whether an Emergency Medical Condition exists. Patient - An individual who has begun to receive outpatient services at the hospital, other than an encounter that the hospital is obligated to provide under this policy or an individual who has been admitted as an inpatient as defined in this policy. To Stabilize - 1. In general, regarding a patient with an Emergency Medical Condition, other than a pregnant woman having contractions, to stabilize means to provide such medical treatment as may be necessary to assure, within medical probability, that no medical deterioration of the condition is likely to result from or occur during the transfer from the hospital; 2. In pregnant women, to stabilize means to deliver, including the placenta. 3. Medical deterioration includes but is not limited to death or loss or serious impairment of a bodily function, part or organ. Stabilized With respect to a an emergency medical condition, that no material deterioration of the condition is likely, within reasonable medical probability, to result from or occur during the transfer of the individual from a facility, or, in pregnant women, that the woman has delivered, including the placenta. Page 3 of 11
Transfer - Movement of an individual, including discharge, outside the hospital s facilities 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 (1) has been declared dead or (2) leaves the facility without the permission of any such person. Triage - Serves to classify and assess the chief complaint of a patient on arrival to the emergency department. All patients will be classified according to the E.D. Triage policy, NC-ED-58. The goal is to determine priorities for therapeutic interventions for a given patient. PROCEDURE A. General Requirements 1. Each individual who comes to EPCHD s Emergency Department, or Labor and Delivery, or presents elsewhere on Hospital property, and requests examination or treatment for a medical condition, including active labor, must be, without delay, accepted, evaluated and stabilized when necessary, regardless of the individual s ability to pay. 2. In the absence of an actual request for services, if a prudent layperson observer would believe, based on the individual s appearance or behavior, that the individual needs an examination or treatment for a medical condition, the person must be accepted and evaluated for treatment. 3. If the EPCHD s Emergency Medical Plan, policy S-EM-001, has been activated, individuals may be transferred prior to being stabilized if, based on the circumstances of the emergency, EPCHD is unable to provide proper care, treatment or services. 4. EPCHD may not delay screening or treatment under this policy to inquire about an individual s method of payment or insurance status. B. Medical Screening Exam All patients covered by this policy shall receive a medical screening exam (MSE) by qualified medical personnel that include providing all necessary testing and on-call services within the capability and capacity of EPCHD to reach a diagnosis. 1. If the Emergency Medical Plan is activated, individuals may be redirected or relocated for a medical screening exam. Page 4 of 11
2. For patients covered by managed care contracts, prior authorization may be obtained after medical screening examination and stabilization services are completed. This does not preclude qualified medical staff from consulting with the patient s private physician as long as the consultation does not inappropriately delay required medical services. C. Emergency Medical Condition(s) If it is determined that a patient has an emergency medical condition, EPCHD must provide, within its capabilities and capacity, any necessary stabilizing treatment, an appropriate transfer under federal and state laws and regulations, or admit the patient as an inpatient for further treatment D. Consent 1. EPCHD meets its requirements under EMTALA if EPCHD offers the individual further medical examination and treatment and informs the individual, or a person acting on the individual s behalf, of the risks and benefits to the individual of the examination and treatment, but the individual, or person acting on the individual s behalf, does not consent to the examination or treatment. 2. The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. 3. EPCHD must take all reasonable steps to secure the individuals written informed refusal (or that of the person acting on his or behalf). The written document should indicate that the person has been informed of the risks and benefits of the examination or treatment, or both. E. On-Call List 1. Pursuant to policy P-7, Patient Transfers, EPCHD will provide and maintain an on-call list of practitioners who are on EPCHD s medical staff, or who have privileges at EPCHD, and are available to provide treatment necessary to stabilize individuals with emergency medical conditions who are receiving services required under this policy after the initial examination. 2. Each participating Medical Staff department shall provide patient registration with a monthly on-call list, updated as necessary. The Hospital Operator shall be contacted to verify the on-call status of a particular physician if the need arises. Page 5 of 11
3. The Emergency Department or the Labor and Delivery physician shall contact oncall physicians when their services are needed. After an on-call physician has been called, the Emergency Department physician or the Labor and Delivery physician involved shall have a continuing duty to provide care, including examination, treatment or transfer if necessary, until the on-call physician arrives and assumes responsibility for the patient. 4. An on-call physician shall be physically at the hospital providing services to the patient within 30 minutes of receiving a call from the Emergency Department physician or the Labor and Delivery physician requesting services. An on-call physician may provide consultation to the Emergency Department physician or the Labor and Delivery physician by radio or telephone, but such consultation shall not be considered to fulfill the on-call physician s obligation to be present to provide treatment. 5. In situations in which a particular specialty is not available, or the on-call physician cannot respond because of circumstances beyond the physician s control, an appropriate transfer will be initiated. F. Medical Records 1. EPCHD will maintain medical and other records related to individuals transferred to and from EPCHD in accordance with federal and state laws. 2. All records will be maintained pursuant to EPCHD policy and procedure CP-43, Records Retention and Destruction Policy and Schedule. G. EPCHD will maintain a log of individuals who come to the Emergency Department or Labor and Delivery seeking treatment, in accordance with federal and state law and regulations. H. Signage 1. EPCHD will post a sign specifying rights of individuals under Federal law and regulations with respect to examination and treatment for emergency medical conditions and women in labor and that the District participates in a Medicaid program under a state plan approved under Title XIX. 2. The sign/s will be posted conspicuously in the Emergency Department and Labor and Delivery, or in a place or places likely to be noticed by all individuals entering the Emergency Department or Labor and Delivery, as well as those individuals waiting for examination and treatment in areas other than a traditional Page 6 of 11
emergency department, such as entrance, admitting area, waiting room, and treatment areas. I. All patient transfers will be in accordance with EPCHD s transfer policy, P- 7, Patient Transfers. J. If an individual comes to the EPCHD Emergency Department or Labor and Delivery and a request is made on his or her behalf for treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, EPCHD is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition. K. A person whose blood specimen is taken at the request of law enforcement as described in Section D of Policy L-13, Searches of Patients (under arrest for DWI or similar charge), is not considered to be present in the Hospital for medical screening or treatment unless the appropriate Hospital personnel determine that medical screening or treatment is required for proper medical care of the person. L. Ground or Air Ambulances 1. An individual in a non-hospital owned ambulance on Hospital property is considered to have come to the Hospital s Emergency Department. 2. An individual in a non-hospital owned ambulance off Hospital property is not considered to have come to the Hospital s Emergency Department, even if a member of the ambulance staff contacts the Hospital by telephone or telemetry communications and informs the Hospital that they want to transport the individual to the Hospital for examination and treatment. In such situations, the Hospital may direct the ambulance to another facility if it is in overload status, that is, it does not have the staff or facilities to accept any additional emergency patients. Exception: if the ambulance staff disregards the Hospital s instructions and transports the patient onto Hospital property, the individual is considered to have come to the Emergency Department. 3. If EPCHD s helipad serves as a point of transit for individuals who have received a medical screening exam prior to transfer to the helipad, UMC-El Paso is not obligated to perform another medical screening exam prior to the individual s continued travel to the recipient hospital. If the individual s condition deteriorates while at the helipad, UMC-El Paso must provide another medical screening and stabilizing treatment within its capacity if requested by medical personnel accompanying the individual. Page 7 of 11
M. If EPCHD admits an individual as an inpatient for further treatment to stabilize the emergency medical condition, EPCHD s obligation under this policy ends. N. The Medical Emergency Team (MET) will respond to emergent injuries and illnesses on Hospital property other than the EPCHD Emergency Department or Labor and Delivery. 1. Any UMC-El Paso Associate or volunteer witnessing a potentially emergent event on Hospital property will dial 5555 or 544-1200, extension 5555. a. The caller will give the PBX Operator the exact location of the event, identify themselves and provide a description of the event. b. The PBX operator will notify: 1) MET members by page and text message; 2) Emergency Department Charge Nurse directly by phone; and 3) AOD by phone and/or text message 2. MET member roles a. The MET Emergency Department Registered Nurse (RN) will assume the role of response Director. b. The Respiratory Services Associate will bring an oxygen tank, appropriate regulator, tubing and mask along with adult, pediatric and neonatal ambu bags. c. Guest Services will be responsible for site safety and traffic control and will assist in patient transport if needed. d. The patient will be transported to the Emergency Department of their choice. If the patient elects transportation to a hospital other than UMC-El Paso, Emergency Medical Services (EMS) will be notified. e. Upon arrival of EMS, the Emergency Department RN will remain with the patient until the patient is transported to UMC-El Paso s Emergency Department, transported to another emergency department or refuses treatment. Page 8 of 11
f. If the emergent event occurs within the main hospital buildings, the MET will transport the patient to the Emergency Department via wheelchair or stretcher. g. UMC-El Paso will conduct quarterly exercises and MET members will maintain current certification in Basic Life Support (BLS) for healthcare providers (CPR and AED Program) in accordance with American Heart Association guidelines. h. Appropriate equipment and supplies will be located in centrally accessible areas within the Emergency Department to respond to emergent events. i. Event documentation 1) All responses by the MET will be documented on a Medical Emergency Team Response form by the Emergency Department RN. The form will be made part of the medical record unless medical treatment is refused. 2) A copy of the Medical Emergency Team Response form will be forwarded to the Chairperson of the Code Blue Committee. 3) The Guest Services member of the MET will complete an Incident Report form and forward a copy to Risk Management. O. Off-Campus Departments of the Hospital If a person arrives at the off-campus department during its regular hours of operation, requesting or a request is made on the individual s behalf for examination or treatment of a potential emergency medical condition, the department Associates will follow policy NHC-CL-04, Medical Emergency Procedures and contact 911, as per policy. P. Reporting Alleged Violations 1. Any Hospital Associate, member of the Medical Staff, Resident or Allied Health Professional who believes in good faith that any healthcare provider may have failed to comply with state or federal law as it relates to Emergency Medical Conditions or patients in active labor will report their concerns to the EPCHD Compliance Hotline, (888) 310-3434, within 72 hours of an alleged violation if possible. Page 9 of 11
2. The Compliance Auditor review of the events related to the alleged violation will be conducted and a preliminary report prepared. 3. If the preliminary report indicates that an EMTALA violation may have occurred, the report will be provided to the Compliance Officer and the Legal Unit. In the absence of the Compliance Officer, the Director of Care Management will receive the report. 4. If the Compliance Officer and the Legal Unit agree that an EMTALA violation may have occurred, a recommendation will be made to the President and Chief Executive Officer (CEO). The Director of Care Management will act in the absence of the Compliance Officer. 5. If the CEO agrees that an EMTALA violation may have occurred, the CEO or designee will submit a report within 72 hours of discovery to the Center for Medicare and Medicaid Services and/or the Texas Department of State Health Services. 6. The hospital cannot penalize or take adverse action against any individual for reporting a suspected EMTALA violation 7. The Compliance Officer and the Director of Care Management will provide a report of alleged EMTALA violations and their resolution to the Medical Executive Committee semi-annually. Page 10 of 11
El Paso County Hospital District Policy and Procedure Committee Chairperson Date President and Chief Executive Officer Date Chief of Medical Staff Date Chairperson, Board of Managers Date P&P Committee Legal Review Review/Revision History: Medical Executive Committee Administrative Team Board of Managers 12/00 12/00 02/01 02/17 03/17 09/04 09/04 02/05 02/08 01/08 02/08 10/09 09/09 10/09 12/12 06/12 01/13 07/16 12/12 07/16 01/16 Page 11 of 11