Ambulatory Care Quarterly
Regs up EMTALA ante: Help remote site’ staff comply
If a security guard has a stroke in your hospital parking lot, would your emergency department (ED) staff know how to respond? If a woman goes into labor at a hospital clinic across the street from your ED, do you have a policy to address that scenario?
If your answer is "no," you’re not in compliance with new requirements for the Emergency Medical Treatment and Active Labor Act (EMTALA), warns Charlotte Yeh, MD, FACEP, medical director for Medicare policy at the National Heritage Insurance Co. in Hingham, MA. As of this month, EMTALA regulations have changed dramatically, she says.
The outpatient prospective payment system regulations issued by the Health Care Financing Administration (HCFA) have expanded EMTALA to include hospital outpatient facilities, which now are required to give anyone with a potential emergency condition a medical screening exam. Staff at these remote sites also must stabilize and, if necessary, transfer the patient. The new regulations became effective Jan. 10, 2001.
"It’s now very clear that EMTALA is not just an ED law," Yeh emphasizes.
The new requirements significantly "up the EMTALA ante," says Larry B. Mellick, MS, MD, FAAP, FACEP, chair and professor for the department of emergency medicine at the Medical College of Georgia in Augusta. "This new regulation should finally push hospitals to get seriously organized to comply with EMTALA," he states. "The complexity of management and the opportunity for failure have now increased significantly."
Most ED managers are not in compliance with the new rules for remote sites, says Stephen A. Frew, JD, president of the Rockford, IL-based Frew Consulting Group, which specializes in EMTALA compliance. "Most do not realize their EMTALA exposures with this new set of regulations."
Here are ways to comply with the new EMTALA regulations:
• Make sure all ED staff understand that EMTALA cases at remote sites are their responsibility. Your ED probably will be responsible for direct field control of the people involved at the remote sites, according to Frew. "The ED should be making the transfer contacts if the patient has to go to another facility closer than the home facility," he says.
Staff need to realize that the patient being treated at the remote site is a crisis for the ED, says Frew. "The ED is responsible to enable the lesser trained personnel in the remote site to give good patient care, comply with the safety plan, and comply with EMTALA."
It’s essential that all ED staff accept this responsibility, even though the patient didn’t come to the ED for care, says Frew. "The biggest thing I fear is that ED staff will consider these calls to be someone else’s problem and not handle them appropriately."
You must remind remote site staff that 911 may not be used as a sole source of response, Yeh stresses. "If someone comes in to the lab or surgicenter complaining of chest pain, staff may not simply call 911 and consider their obligation complete," she says. "You may call 911 for support, but you must begin initial stabilization procedures until ambulance personnel arrive."
• Consider how other hospitals are handling the new requirements. It’s not enough for you to make sure that your hospital is complying with the new regulations, warns Todd Taylor, MD, FACEP, an attending ED physician at Good Samaritan Regional Medical Center in Phoenix. "If another hospital has a facility which falls under these regulations near your hospital, you will need to decide how you will deal with requested transfers from such facilities," he says. "You will also need to deal with requests to sign transfer agreements as required by the regulations."
Previously, urgent care centers basically were exempt from EMTALA, says Taylor. "In some cases, that will now change," he notes. "So hospitals will need to know when they have a duty to report suspected EMTALA violations for dumping’ from these urgent care centers," he says.
If a patient is deteriorating rapidly, movement from the remote site back to the main campus is not appropriate, and if it is in the patient’s best interest to be transferred, you must have prearranged transfer agreements with closer hospitals, says Yeh. The off-site location must provide appropriate transportation, equipment, and personnel to transfer the patient to the second, closer hospital, Yeh adds.
• Address billing, signage, and record-keeping practices of remote sites. EMTALA regulations state that you may not delay treatment for preauthorization requests or to collect copayments, Yeh says. "This is especially important for outpatient departments, surgicenters, and lab areas where typically you request copays prior to seeing the patient. If it’s an EMTALA-related service, the remote sites should not be doing copays prior to service." Anyone who does intake registration and screening or who might receive questions about payment or copays needs to understand the implications of EMTALA, Yeh advises. "They need to ensure that no one is turned away because of the ability to pay."
Under EMTALA, you need to keep records for five years and post nondiscrimination notices in the ED and admitting area, says Yeh. "Now, this applies to all sites. So outpatient sites must have the same record keeping and nondiscrimination notices and the same on-call availability, as well."
Increased signage for staff at the off-campus departments is needed to remind them of their obligations, recommends Mellick. "Additionally, mandatory educational schedules, job aids, and checklists are needed in an area that will be highly vulnerable to oversight," he stresses.
• Establish individualized protocols for dealing with emergencies at all off-site locations. Your plan has to be commensurate with the location’s ability to provide treatment, explains Grena Porto, ARM, CPHRM, director of clinical risk management for VHA, a Berwyn, PA-based alliance of more than 2,000 community-owned health care organizations. "If the location has physicians and nurses, you’ll be required to provide a higher level of screening than a facility that does not have that resource available," she says.
It’s not expected that every single freestanding location will be able to provide the same level of care. You must have emergency response protocols individualized to each site’s capabilities, says Yeh. "For example, if the site has a physician and nurse, then they are required to do stabilization. If there is no physician or nurse, then personnel must be trained to place a call to the ED describing the patient’s condition and begin to initiate transfer requirements if necessary," she says.
• Make sure that patient consent for transfer is obtained. Remote site staff will need to obtain consent from patients with an emergency medical condition for transfer to another facility, says Porto. "This is not a time when you can rely on implied consent. This is a challenge for outpatient settings where you often do not have written informed-consent forms."
When transferring a patient, written documentation is critical, Porto underscores. "If it’s an outpatient setting and they do not have a physician there, then you need a policy stating who will initiate the transfer documentation."
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