Use algorithm to avoid EMTALA violations
Are you confident that everyone on your staff understands how to comply with the requirements of the Emergency Medical Treatment and Active Labor Act (EMTALA)? If you’re like most ED managers, the answer is a resounding "no," says Todd Taylor, MD, FACEP, an attending ED physician at Good Samaritan Regional Medical Center in Phoenix.
"Even today, experienced hospital staff continue to violate EMTALA due to a lack of basic understanding of the law," he explains.
An algorithm can help convey basic EMTALA compliance information, according to Taylor, who developed an EMTALA algorithm. "The use of an algorithm may help in providing at least basic understanding and illuminating cases that need further consultation when the algorithm does not seem to resolve the issue," he notes.
Every ED employee needs to understand EMTALA requirements, stresses Denise Casaubon, RN, owner and president of DNR Medical-Legal Consultants, a Fountain Hills, AZ-based company specializing in health care corporate compliance. "All staff have the potential for violations," warns Casaubon, who also developed an algorithm for EMTALA.
EMTALA violations can yield significant penalties, she stresses. The fine for a hospital that negligently violates EMTALA can be up to $50,000 or, for hospitals with fewer than 100 beds, up to $25,000. Civil money penalties also apply to physicians.
The algorithm format guides the ED staff to make proper decisions for patient care that comply with EMTALA regulations, says Casaubon. "An algorithm is easier to understand because the format is a picture view’ that walks you through the steps, making it easier to comprehend," she explains.
The verbiage in the federal regulations can be difficult to understand, she says. "But remember, an algorithm cannot address all of the situations that arise in the ED related to EMTALA. An algorithm is only a guide to assist staff to perform duties in the correct order."
Algorithms have limitations, explains Taylor. "Algorithms often do not help with cases for which you really need guidance," he says. "Some cases are more complicated than any algorithm can address."
However, Taylor developed the EMTALA algorithm because so many ED managers requested it. "I believe its best use would be in the basic EMTALA education for ED nurses, physicians, and registration staff on how to manage a patient in the ED with respect to EMTALA," he says.
The algorithm probably would not be the best tool to deal with complex EMTALA issues that arise from time to time, he cautions. "Such issues are best dealt with by personal consultation with the hospital’s EMTALA coordinator or risk management."
The algorithm is straightforward and accounts for the various steps required by the federal EMTALA law, he says. "The overriding principle of EMTALA is to take care of the patient,’" he notes. If anything interrupts your ability to accomplish this (for example, the patient refuses treatment), have the patient read and sign your documented understanding of the situation, Taylor advises.
Consider this example
An example in which the algorithm probably would not help involves a woman who suffers an intracerebral hemorrhage and is initially seen at a rural ED without neurosurgery capability, says Taylor. Arrangements are made with a referral hospital to transfer the patient, and the neurosurgeon and family are expecting the patient to arrive at that hospital. The ambulance crew inadvertently takes the patient to a different hospital with equal neurosurgery capability as the original referral hospital.
The patient arrives at the ED, is unconscious, and no family is available. What should that ED do? There are only two options, according to Taylor:
1. Keep the patient, make alternative arrangements with the neurosurgery staff at the hospital, and run the risk of the family’s objection.
2. Transfer the patient to the hospital originally designated, where the neurosurgeon is standing by ready to receive her, but run the risk of transferring an unstable patient under EMTALA without consent of the patient/family.
Two national EMTALA experts have given opposite opinions on how to handle that situation, Taylor notes. "In this type of instance, an algorithm does not help."
Here are key points conveyed in the algorithm:
• Emergency medical condition. It is important for ED staff to understand that a medical screening exam must be done to determine if the patient has an emergency medical condition, says Casaubon. "This includes patients with psychiatric disturbances and/or substance abuse and women in labor," she explains.
• Prior authorization. The key thing to remember is not to obtain prior authorization before the medical screening examination is completed, period, she says.
• Patient refusal of transfer or treatment. Documentation in the clinical record of all of the events surrounding the patient’s treatment up to the refusal is paramount, says Casaubon. That would include the following, she notes:
— patient notification of the risks and benefits of the treatment the patient is refusing;
— the treatment that had be administered up to the point of the refusal;
— the attempt to obtain written refusal.
Reasonable measures must be taken to obtain the written informed refusal of the transfer or treatment
by the patient or the patient’s representative, she says.
• Patient transfer: The sending facility must be sure the receiving facility agrees to accept and treat the patient, she explains. If the recipient facility does not agree to accept and treat a patient who was transferred, the receiving facility has an obligation to report the sending facility to the Health Care Financing Administration in Baltimore or the state agency for an EMTALA violation.
• Registration: The ED staff must know what information can be collected and when it can be collected, Casaubon says. "To perform registration functions that discourage an individual from remaining in the ED for treatment is a violation."
[Editor’s note: American Health Consultants, publisher of ED Management, is offering a telephone seminar, The Expanding Scope of EMTALA: Why Every Hospital Department Must Learn the Rules and Comply, Nov. 15, 2000, at 2:30 EST. For more information or to register, contact customer service at (800) 688-2421 or customerservice@ahcpub.com.]