CMS fact sheet seeks to allay concerns about EMTALA, H1N1
CMS fact sheet seeks to allay concerns about EMTALA, H1N1
Some are worried about restrictions if extraordinary surge occurs
With the prospect of an H1N1 pandemic, "many stakeholders perceive that EMTALA [the Emergency Medical Treatment and Labor Act] imposes significant restrictions on hospitals' ability to provide adequate care when EDs experience extraordinary surges in demand," according to the Centers for Medicare & Medicaid Services. Recognizing that fact, CMS has issued a fact sheet to allay those fears. However, say ED experts, the fact sheet does not eliminate all of the challenges that would be presented.
For example, CMS notes that under certain circumstances, EMTALA requirements can be waived, but ED managers need to be very clear about what those circumstances are, warns Dan Hanfling, MD, FACEP, director, emergency management and disaster medicine, Inova Health System in Falls Church, VA. "While they do describe waivers as being a possibility, what they also say is that it's not likely, particularly in the context of what we're seeing right now," he says. "In my reading of this, the EMTALA medical screening exam [MSE] and stabilization requirement that goes with it are only to be waived if there is a presidential declaration and the Secretary of Health and Human Services declares a public health emergency." In addition, he says, the declaration must include a specific waiver of EMTALA requirements.
"Those are the steps required under the EMTALA law; it is by no means automatic," Hanfling says. "The difficulty is how to decide when and where to do it. You're talking about the complete and total suspension of EMTALA law."
If an EMTALA waiver is granted in the case of a pandemic, the waiver is maintained until the termination of the declaration or only for 72 hours after the hospital has activated its disaster plan, he says. "It's also my reading that in order to get EMTALA waivers, you are going to have to demonstrate significant and sustained ED operations interruption," Hanfling adds.
However, the CMS clarification was important in that it noted if communities establish screening capabilities outside of the hospital, EMTALA regulations will not apply there, he says. "If you coordinate with the public health department and EMS and set up a flu screening clinic somewhere off campus — even if it is a hospital-controlled site off campus, they don't apply," he explains.
Judgment in play
The MSE does not have to take place in the ED proper, but if the facility is in the hospital, then it still has to comply with EMTALA, Hanfling says. However, he notes, the physician's judgment comes into play here. "The way I read this is if I lay eyes and ears on a patient and get key vital signs, I can pretty much determine they are stable, so I have basically fulfilled the requirement," Hanfling says.
For this reason and others, it is more desirable to handle such patients in the ED or somewhere on campus, says John L. Hick, MD, a faculty physician in the ED at Hennepin County Medical Center in Minneapolis and associate professor of emergency medicine at the University of Minnesota, Minneapolis. "The main thing to remember with H1N1 is that we are seeing really challenging outpatient volumes of relatively low-acuity patients," Hick says. "As long as you are seeing them on campus, then you are providing definitive care for them and there are no issues with EMTALA."
However, if you were to screen patients at a triage point and then seek to refer them to an off-site location, you still have to do the MSE and document that the patient was assessed and referred, he says. "If that's the case, you may as well recoup revenue by providing the definitive care," Hick says. Because a lot of these patients will have a very minor influenza-like illness, "if you create a screening sheet, get some patient flow strategies in place for low-acuity illness, and have pre-printed prescription forms and discharge forms, you can make lot of headway" on patient flow, Hick says.
In short, he says, "It's in the institution's best interest to see how they can accommodate larger volumes of patients who are not seriously ill and turn them around very quickly using template charting and other strategies. By the time you meet the EMTALA requirements, you might as well be able to bill for Level III emergency care."
For more information on the H1N1 surge response, contact:
- Dan Hanfling, MD, FACEP, Director, Emergency Management and Disaster Medicine, Inova Health System, Falls Church, VA. Phone: (703) 776-3002. Fax: (703) 776-2893. E-mail: [email protected].
- John L. Hick, MD, Hennepin County Medical Center, Minneapolis. Phone: (612) 873-3020. Fax: (612) 904-4241. E-mail: [email protected].
Community clinics help meet surge
In the event of a significant surge of patients due to H1N1, "I think that mandates that we really ought to be looking at establishing off-campus, community-based flu or triage centers," suggests Dan Hanfling, MD, FACEP, director, emergency management and disaster medicine, Inova Health System in Falls Church, VA. "This could help avoid a potential hospital shutdown."
Based on the experiences of this spring and summer, he continues, such a need could arise even without the presence of a pandemic. "One of the key lessons we learned from the first wave is that this was primarily an outpatient surge of condition. It really taxed our EDs much more significantly than inpatient areas," Hanfling says. "And while there were certainly pockets of quite severe illness, we also had the 'worried well' and the 'worried ill.'"
Accordingly, Hanfling advises the following: "Within the hospital, we really ought to be looking at stand-alone flu triage wards, or a flu evaluation fast-track where we essentially can process people coming for flu and preserve the ED rooms and staff and throughput for those patients who need to be dealt with on a time-critical basis."
These facilities, he notes can be placed in re-purposed space, such as an underused outpatient clinic. In addition, he says, the ED should not have to run it alone. "You should have shared responsibility. Draw on other staff and personnel from the hospital," he suggests.
Take a phased approach to surge, says John L. Hick, MD, a faculty physician in the ED at Hennepin County Medical Center in Minneapolis and associate professor of emergency medicine at the University of Minnesota, Minneapolis. "I think facilities that have clinics need to recognize it's likely there will be a lot of self-triage of patients who have dermatology appointments or elective surgeries and won't come into the hospital if there's an epidemic." As this occurs, Hick points out, those clinics might provide more capacity for ambulatory acute care.
Communicate to potential patients what you will and will not do for them, he says. "We are up front, telling healthy patients we are not doing any testing or providing treatment, and we say that with a pamphlet we hand out in triage," Hick says. "You've got to try to manage expectations, because people can become frustrated if they are not getting antivirals or specific testing for H1N1." [A copy of the pamphlet is available.]
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