EMTALA Q&A
Question: There are two hospitals within the same foundation, approximately 40 miles apart. The smaller hospital has limited bed capacity. What guidelines must be followed for transfer of patient from one ED to the other?
Answer: If the smaller hospital is operating as a remote campus of the larger hospital under one license and Medicare provider number, then policies and procedures must exist for medical screening and stabilization at the smaller hospital, consultation with the larger ED, and appropriate medical transport of patients between the two sites, says Stephen Frew, JD, president of the Rockford, IL-based Frew Consulting Group, which specializes in compliance with the Emergency Medical Treatment and Active Labor Act (EMTALA).
"I would recommend that full EMTALA compliance be observed for documentation, even with the issue being one of bed availability, just so the situation is adequately documented as meeting patient safety requirements," he adds.
Frew notes that if the hospital is licensed separately, then it cannot be provider-based, and every movement of the patient between the two related hospitals is governed by EMTALA concepts. "Lack of beds may be a bona fide reason to transfer, but full documentation will be required, just as if sending to an unrelated facility," he says.
Question: A facility transfers four types of patients after initial medical care: patients requiring invasive cardiac procedures, and neurosurgery, multiple-trauma, and high-risk OB patients. Could you please give an example of proper documentation for risk and benefits for these patients?
Answer: There are no magic words to use for documentation to pass muster, nor is a lengthy manuscript required, says Jonathan D. Lawrence, MD, JD, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. What is required is sufficient documentation to allow a reviewer to easily understand why the transfer to another institution is necessary, he explains. "Remember that this certification of risks and benefits is required only for those patients who are being transferred in a non-stabilized state," he adds.
In other words, the certification is required when the transferring institution has provided care to the best of its capabilities to minimize the risk to the patient, yet additional care is required elsewhere to complete the stabilization process, says Lawrence. "All four classes of patient transfers cited in the question are typical of patients that require a high level of care, often at tertiary centers," he notes.
He offers the following sample phrases to use for each condition:
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Lawrence also notes that the patient or the patient’s representative must agree with the transfer, after going through the same risk/benefit discussion.
Question: An ED is adjacent to the hospital entrance. Often, patients without an emergency condition enter through the ED door and state, "I want to see a doctor." Is it a violation of EMTALA to walk them over to the adjoining clinic (attached to the hospital) to have them seen by the on-call physician in the clinic? Or do they need to be admitted to the ED, screened by the nurse, and then be seen by the on-call physician, who would then need to be summoned over to the ED from the clinic?
Answer: In this scenario, sending the patients to the clinic would be an EMTALA violation, says Lawrence. A patient coming to the hospital seeking medical attention is precisely the patient who is required to have a screening examination to determine whether an emergency medical condition exists, he stresses. "The question implies that these patients do not have a pre-existing appointment," he says. "This is a different situation than the patient who mistakenly walks into the ED and states they have an on-campus appointment with Dr. Smith and can be directed to Dr. Smith’s office."
The question implies that someone is making the decision that the patient does not have an emergency medical condition before walking the patient over to the drop-in clinic, notes Lawrence. "Who is making this decision, and what criteria are being used?" he asks.
There is no question that nurses qualify under EMTALA to do screening examinations provided the hospital has set up precise protocols to be followed, he says. "If the hospital has such protocols, non-urgent patients can be identified by the screening examination and sent to the walk-in clinic for treatment."
[Editor's note: This column is an ongoing series that will address reader questions about the EMTALA. If you have a question you'd like answered, contact Editor Staci Kusterbeck. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: [email protected].]
Sources
For more information about EMTALA, contact:
• Stephen Frew, JD, Frew Consulting Group, 6072 Brynwood Drive, Rockford, IL 61114. Telephone: (815) 654-2123. Fax: (815) 654-2162. E-mail: [email protected].
• Jonathan D. Lawrence, MD, JD, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 90813. Telephone: (562) 491-9090.
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