EMTALA Q&A
EMTALA Q&A
[Editor’s Note: This column is part of an ongoing series that will address reader questions about the Emergency Medical Treatment and Labor Act (EMTALA). If you have a question you’d like answered, contact Staci Kusterbeck, Editor, ED Management, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: [email protected].]
Question: If patients are triaged as "nonemergent" and leave after six to eight hours without treatment, is the facility at risk for an EMTALA violation?
Answer: Yes, according to Gloria Frank, JD, former lead enforcement official on EMTALA for the Centers for Medicaid and Medicare Services (CMS). She points to a 1999 Special Advisory Bulletin from CMS and the Office of Inspector General that clarified this issue.
Triage is considered a prioritization of care and not a medical screening examination (MSE), says Mary Kay Boyle, RN, JD, risk manager at North Penn Hospital in Lansdale, PA. "Patients must receive a MSE in order to determine if an emergency medical condition exists," she explains. If upon completion of a MSE, the patient is determined to be nonurgent, then the determination is that an emergency medical condition does not exist and EMTALA no longer applies, says Boyle. She adds that patients who are triaged and leave without receiving a medical screening examination because of a long time delay could be considered a constructive discharge, and there is a risk for an EMTALA violation. "In other words, the patient had no choice but to seek attention at another facility because of the time delay," says Boyle.
Question: If the patient collapses but was on their way to the ED within a 250-yard range, can you send a security guard and do basic life support, or are you held to an ED code response?
Answer: The response does not have to be to the same level as the response in-house, says Boyle. "It has to be what is reasonable and has to be consistent," she says. The hospital needs to develop a policy as to who will respond and the level of expertise, Boyle adds. "A hospital may elicit the assistance of EMS through calling 911," she says. Boyle adds that this should be discussed with the local EMS and a clear policy generated with the response team. "Realize, however, that 911 cannot be your only level of response in all situations," she cautions.
Question: Orthopedic injuries are routinely stabilized in the ED, then referred to their primary care provider. Is the facility at risk for a disparate care EMTALA violation, if these patients are not given appropriate and timely definitive care by an orthopedic specialist?
Answer: Not as long as the patient is stable for discharge, says Frank. She points to a recent court ruling on this issue.1 "The patient was on Medicaid and had to get follow-up care for an orthopedic injury and eventually had to go 190 miles away to get surgery," says Frank. The court ruled that this was not an EMTALA violation, because the patient was stable when he left the hospital, she explains. CMS has said it is not interested in this issue, adds Frank, referring to a recent U.S. General Accounting Office report on EMTALA. (See "Resources" at the end of this article for information on obtaining the report.)
Presuming a screening exam is done on all orthopedic patients in a similar manner, there is nothing wrong with sending them to their primary care provider once stabilized, says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. "The key here is to remember the EMTALA definition of stabilized,’" he says. "Stabilized under EMTALA is a condition under which no reasonable expectation of deterioration will take place once the patient is transferred." He notes that "transfer" also means discharge under EMTALA.
According to Lawrence, most fractures are thus stabilized once immobilized, and there is a window of several days for definitive orthopedic attention. "If the patient is not stable — for example, he or she has an open fracture requiring OR irrigation, or one associated with neuro or vascular compromise — then naturally an orthopedist must be consulted from the ED," he says. If the fracture does not require immediate attention, referral to a primary care provider can be appropriate, Lawrence adds. "The ED is not a guarantor that the primary care provider will do the right thing," says Lawrence. If the standard in the community is for a primary care provider or clinic to refer fractures to an orthopedist, they must meet that standard, he explains.
Referral to an orthopedist is considered a transfer, notes Boyle. "If patients are not treated in an appropriate and timely fashion, this could be considered disparate care," he says. Boyle says that the best way to overcome this problem is to make sure that the ED maintains an on-call schedule for consults and referrals. "Physicians on this schedule need to understand their responsibilities," she underscores. "If there are problems with physician response, the issues need to be addressed through the appropriate hospital channels."
Reference
1. Phipps v. Bristol Regional Medical Center, 117 F.3rd 1421, Sixth Circuit, 1997.
Sources
For more information about the Emergency Medical Treatment and Labor Act, contact:
• Mary Kay Boyle, RN, JD, North Penn Hospital, 100 Medical Campus Drive, Lansdale, PA 19446. Telephone: (215) 361-4591. Fax (215) 412-5002. E-mail: [email protected].
• Gloria Frank, JD, P.O. Box 1340, Ellicott City, MD 21041. Telephone: (410) 480-9111.
• 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].
Resources
The U.S. General Accounting Office (GAO) June 22, 2001, report titled Emergency Care: EMTALA Implementation and Enforcement Issues, can be downloaded from the GAO web site (www.gao.gov). Click on "GAO Reports," then "Find GAO Reports." In the box, "Find reports by report number," enter GAO-01-747. Single copies are available at no charge. To order a copy, contact: U.S. General Accounting Office, P.O. Box 37050, Washington, DC 20013. Telephone: (202) 512-6000. Fax: (202) 512-6061.
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