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[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 Greg Freeman, 4880 Lower Roswell Road, Suite 165, No. 210, Marietta, GA 30068-4385. Phone: (770) 998-8455. E-mail: Free6060@bellsouth.net.]
Question: Our in-house policy states that when our hospital campus is used for helicopter rendezvous with EMS [emergency medical services], the patient must be brought into our ED for a medical screening examination. Many local hospitals allow EMS to rendezvous with the helicopter services on their campus helipad, and the ED physician never sees the patient. Is this an EMTALA violation?
Answer: No, according to Robert A. Bitterman, MD, JD, FACEP, director of risk management and managed care for the department of emergency medicine at Carolinas Medical Center in Charlotte, NC.
For EMTALA to apply, the patient must "come to the ED" of the hospital and request a medical screening examination (MSE) or treatment for a medical condition, he says. "Both prongs must be met before EMTALA applies to the situation," says Bitterman.
In the helipad scenario, the patient has "come to the ED," as defined by the Centers for Medicare & Medicaid Services, by virtue of being on hospital property, he explains. "However, neither the patient, nor someone on behalf of the patient, has requested an MSE from your hospital; therefore, you have no duty under the law to provide one," he says.
If the patient’s condition deteriorates, or if the medics believe the services of your ED are necessary to examine or stabilize the patient prior to helicopter transport (such as secure the airway, insert a central line or chest tube, or provide blood), then the medics’ request constitutes the second legal prong — that of a request on behalf of the patient, which triggers an EMTALA duty upon the hospital to screen and stabilize, Bitterman explains.
EMS providers, helicopter transport crews, and hospital personnel should not feel hamstrung by EMTALA in this situation, he advises. "They should do what, in their judgment, is in the patient’s best interest, and then carefully document their actions and reasoning, just in case their decision making is reviewed retrospectively," he says.
As for mandating that the patient be brought into the ED for an MSE, let the EMS personnel and medical control decide whether the patient needs to be examined or treated in your facility prior to helicopter transport elsewhere, Bitterman says. "EMTALA does not require the patient be brought into your ED, and in many cases, to do so would jeopardize the health of the patient by delaying access to the appropriate level of services required by the patient," he adds.
If there has been no request for your services to screen or stabilize the individual, then you have no duty under EMTALA to provide those services, regardless of where the person is on your hospital campus, explains Bitterman. "The operational and communication issues you raise, however, should be addressed in advance through policy, procedure, and the education of all involved parties," he adds.
Question: When a combative patient with altered mental status presented to our ED, the nurses and doctor were unable to draw blood to medically clear him because he was combative even after being medicated. The ED physician attempted to have police remove the patient from our ED and sent to a psychiatric ED to be evaluated. At that point, the patient suddenly became more cooperative, and blood was drawn and sent for analysis. If this patient had been sent to the other facility without being medically cleared, would it have constituted a transfer under EMTALA, and would this have been a violation?
Answer: "Yes, this is an EMTALA violation, and worse, it’s bad medicine," says Bitterman. First, you have a legal and medical duty to appropriately screen the person to determine if an emergency medical condition exists, he emphasizes.
"Involve security and/or the police, but do whatever it takes to sedate and control the individual in your ED, in order to do an adequate medical screening exam as required by the law," says Bitterman. This advice is simply good medicine, he says. "What would you want done if the patient was a member of your family?" Bitterman asks. Furthermore, psychiatric facilities typically do not have the necessary medical resources or expertise of a full-service ED to adequately evaluate patients for organic causes of their psychotic behavior, he adds.
Sending the patient to another facility for evaluation does constitute a transfer, says Bitterman. If for some reason the hospital’s ED and staff are unable to stabilize the patient’s condition, and it is medically required that they transfer the patient to a higher level of care, then they must arrange the transfer as an "appropriate" transfer, as defined by EMTALA, he adds. "That would include formally obtaining the receiving hospital’s acceptance of the patient and transporting the patient via appropriate personnel and equipment," Bitterman says.
However, he notes that EMTALA does not require a physician to accept the patient in transfer, only that the hospital accept the patient in transfer. The hospital may delegate its duty to accept transfers to whomever it deems most appropriate, explains Bitterman. "Typically that’s a physician, either the ED physicians or the on-call physicians, but it could be a nurse or hospital administrator," he says.
However, some states, such as California and Texas, do require physician-to-physician contact for all transfers, notes Bitterman. "The circumstances of the case coupled with the local standard of care may mandate physician-to-physician contact, but EMTALA does not," he says. "It is a common misconception."