Question: We have a hospital 25 miles away that can provide a higher level of critical care for trauma then what we can provide. We recently signed an agreement with them that allows our community-owned ambulance (basic life support) team to call them to dispatch their paramedic squad for an intercept for trauma situations that the ambulance crew feels we cannot handle at our local hospital. Even though the ambulance is community-owned and housed downtown, all the dispatching comes from the hospital. In these situations, the crew call us back and let us know that they are arranging an intercept and will not be bringing the patient to our hospital even if we are closer than the higher level of care. Are we triggering an EMTALA violation? Is there something more we can do to protect ourselves in this arrangement?

Answer: You’re not violating EMTALA, explains Robert A. Bitterman, MD, JD, FACEP, director of risk management and managed care in the department of emergency medicine at Carolinas Medical Center in Charlotte, NC. The reason is that the law does not apply to community-owned ambulances. According to the regulations promulgated by the Centers for Medicare & Medicaid Services (CMS), EMTALA applies only to ambulance services that are owned and operated by a hospital. In the arrangement you describe, the methods of transportation or where the community-owned ambulance chooses to transports patients is not governed by EMTALA.

"Furthermore, you are transporting the patient to the appropriate facility, which is simply good medicine," he adds. "Also, you are taking patients to a higher level of care according to established protocols and not moving patients based on economic or other nonmedically indicated considerations." Health care providers sometimes think that EMTALA applies to emergency medical services systems and ambulances, Bitterman says. Some of this confusion may have arisen since CMS’s final EMTALA rule talks about how hospital-owned ambulances must comply with EMTALA.

If in your scenario, the transport unit was a hospital-owned and operated ambulance, CMS would say the patient had come to the hospital’s ED and EMTALA applied to that encounter. However, CMS would deem you in compliance with the law because you were operating the ambulance according to established community protocols. "CMS is essentially granting you a safe harbor if you’re operating in good faith under community protocols and those protocols are based on medical indications, not insurance status, doctor-patient relationships, managed care contracts, or other discriminatory reasons," Bitterman says.

As for whether there is anything else to be done to protect your system in this arrangement, he advises keeping good documentation. Demonstrate that you’re moving patients according to protocol to provide the best medical care possible under the circumstances and are appropriately utilizing the resources in the community to benefit the patients.

"Also, use physician telemetry or backup to help you decide where to go in tough situations, because undoubtedly difficult scenarios will arise in the field," he says.