ED-to-ED transfer not always an EMTALA violation
State law must be followed, unless it conflicts
Question: Can a patient be transferred from an intensive care unit (ICU) of one hospital to the emergency department (ED) of another hospital, based on an accepting physician’s request? What if the ED receiving the patient is holding patients waiting to be admitted?
Answer: In part, the answer to this question lies with state regulations, since several states take the position that transfers to the ED from an ICU represent a transfer to a lower level of care or an abandonment of the patient, says Stephen Frew, JD, risk management consultant at Physicians Insurance Co. of Wisconsin, based in Loves Park, IL.
Hospitals are required to comply with their state laws and regulations, to the extent that they do not conflict with the Emergency Medical Treatment and Labor Act (EMTALA) requirements, he explains. "This requirement then makes this type of transfer a violation in those states that have the rule," he says.
Frew recommends checking with your state hospital inspector to determine your state’s regulations regarding transfers. However, Frew adds that EMTALA does not specifically forbid transfers to the ED. In fact, he says recent citations suggest that if there is a long transfer or deterioration, the ED should provide a medical screening examination to the transfer patient before sending patients to the floor.
EMTALA requires that the receiving hospital accept the patient, but it does not specifically indicate who the accepting person is, says Frew. "Some states require an accepting physician in addition to the EMTALA requirement," he adds. "In the absence of state standards, EMTALA does not say where or how the patient must be accepted."
Frew emphasizes that EMTALA requires that the hospital provide necessary further care and stabilization of patients who are known to have an unstable or emergency medical condition. "These terms are defined by law and are much broader than medical terminology," he notes. "It is relatively safe to state that all patients coming from an ICU in need of a higher level of care have an emergency medical condition and are unstable, as defined by EMTALA."
The Centers for Medicare & Medicaid Services will look at whether the hospital promptly and appropriately provided necessary evaluation and stabilizing care to the transfer patient, says Frew. "If that care is rendered, it is unlikely in most states that the hospital would be cited," he says.
Question: We are a rural hospital and transfer most of our neurological, cardiac, and trauma patients. One of the hospitals makes us wait several hours for bed availability. If we have an acute myocardial infarction and an accepting doctor from the hospital, is there anything we can do to speed up the transfer process? Would it be an EMTALA violation if we sent the patient to the hospital ED?
Answer: That depends on the stability of the patient, according to Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk-management liaison at St. Mary Medical Center in Long Beach, CA. For unstable patients, the receiving hospital has no excuse for delaying the transport of a patient to a facility for a higher level of care if a physician accepts the patient and the hospital has the equipment and personnel to treat the problem, says Lawrence. "This is the kind of patient that typically will go straight to the OR [operating room], cath lab, or for other acute diagnostic or therapeutic intervention," he adds.
Lawrence stresses that the admitting office or other administrative personnel should have no veto or delaying power over this type of transfer. A case could be made that any nonmedically based delay by the receiving hospital is tantamount to a refusal to accept, which may subject the receiving hospital to statutory punishments, he adds.
On the other hand, Lawrence adds that a stable patient (defined by EMTALA as one in which no reasonable expectation of deterioration is expected as a result of the transfer) may be held at the sending hospital for a reasonable length of time at the sending hospital while the receiving hospital checks on bed and personnel availability.
"There is no recognized time limit of reasonableness,’" he says. These patients will typically be admitted to a hospital bed without immediate therapeutic or diagnostic interventions, and it is not unreasonable to allow the receiving hospital to assess its resources and ability to care for the patient, says Lawrence.
Contrary to popular myth, there is no EMTALA prohibition of an ED-to-ED transfer, says Lawrence. "If the receiving hospital wishes to receive transferred patients, stable or unstable, into its ED, it may do so," he notes. The so-called prohibition against ED-to-ED transfers is a business-office rule, since Medicare and many insurance carriers will not pay for a second ED visit on the same day for the same problem, explains Lawrence.
[For more information about the Emergency Medical Treatment and Labor Act (EMTALA), contact:
- Stephen Frew, JD, Risk Management Consultant, Physicians Insurance Co. of Wisconsin, P.O. Box 15665, Loves Park, IL 61132. Telephone: (815) 654-2123. Fax: (815) 654-2162. E-mail: [email protected]. Web: www.medlaw.com.
- Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 90813. Telephone: (562) 491-9090. E-mail: [email protected].]
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