Updated EMTALA rule eases hospitals’ risk

A final rule regarding hospital obligations to patients under the Emergency Medical Treatment and Labor Act (EMTALA) clarifies that the law applies to sites that are emergency departments or are operated to treat emergency medical conditions without an appointment.

Other provisions of the rule state that in a national emergency, hospitals in the emergency area will not be penalized if they transfer patients elsewhere in a way that otherwise would technically violate EMTALA, and that EMTALA will not apply to inpatients, including those admitted through the ED. Violating the law can result in a fine of $50,000 for each violation, and hospitals and doctors can be prevented from participating in Medicare. Patients also are permitted to sue hospitals that violate the law.

The new rule, issued Aug. 29 by the Centers for Medicare & Medicaid Services (CMS), was published in the Sept. 9 edition of the Federal Register and will become effective Nov. 10.

The revisions to EMTALA are "designed to ensure that people will receive appropriate screening and emergency treatment, regardless of their ability to pay, while removing barriers to the efficient operation of hospital emergency departments," according to a statement by CMS.

The American Hospital Association said it "welcomes the helpful and practical guidance" provided by the rule. However, some patient advocates fear the changes could make obtaining emergency care even more difficult for very vulnerable patients who might need specialized services or seek care at off-site, hospital-affiliated clinics.

The rule expands the definition of emergency department to mean any department or facility of the hospital, whether situated on or off the main hospital campus, that: 1) is licensed by the state as an emergency room or emergency department; 2) is held out to the public as providing care for emergency medical conditions without requiring an appointment; or 3) during its previous calendar year, has provided at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis.

The final rule clarifies that EMTALA does not apply to individuals who come to off-campus outpatient clinics that do not routinely provide emergency services or to those who have begun to receive scheduled, nonemergency outpatient services at the main campus — for example, routine laboratory tests.

In addition, the rule clarifies that EMTALA does not apply after a patient has been seen, screened, and admitted for inpatient hospital services, unless the admission is made in bad faith to avoid the EMTALA requirements.

Other provisions of the final rule include:

• Clarification of the circumstances in which physicians, particularly specialty physicians, must serve on hospital medical staff on-call lists. Under the revised regulations, hospitals will have discretion in developing their on-call lists. In keeping with traditional practices of "community call," physicians will be permitted to be on call simultaneously at more than one hospital, and to schedule elective surgery or other medical procedures during on-call times.

• Clarification that hospital-owned ambulances may comply with citywide and local community protocols for responding to medical emergencies and thus be used more efficiently for the benefit of their communities.

• Permission for hospital departments that are off-campus to provide the most effective way of caring for emergency patients without requiring that the patient be moved to the main campus — when this would not be best for the patient.

For more information, visit www.cms.gov.

Johns Hopkins program loses its accreditation

The Accreditation Council for Graduate Medical Education (ACGME), the organization that monitors medical residency programs at academic medical centers, has announced it is stripping the internal medicine residency program at Baltimore-based Johns Hopkins Hos-pital of its accreditation due to violations of rules on how long residents in the program can work, The Wall Street Journal reported on Aug. 28.

The program, with 110 current residents, will lose its accreditation on July 1, 2004.

David Nichols, vice dean for education at Johns Hopkins School of Medicine told the newspaper the ACGME review took issue with the program’s practice of putting a resident on a night-call shift every other night for a short period of time, provided the resident is on call only one night out of three, averaged over a four-week period.

The council ruled that "no every-other-night call is ever allowed."

The ACGME has been under pressure in recent years to more stringently enforce resident work-hour guidelines and to reduce the number of hours residents work due to public concerns about the quality of care exhausted residents might provide. (See "Reduced Resident Work Hours: Tough Enough?" Medical Ethics Advisor, August 2002, p. 88.)

Last year, the ACGME limited resident work hours to no more than 80 hours per week, with no one shift longer than 30 hours, and a guaranteed one day off in every seven.

However, the rules could be averaged over a month’s time. So theoretically, a resident could be required to work a 100-hour week and then get time off at the end of the month.

The Hopkins citation may indicate the council is taking a more strict interpretation of its regulations. The hospital now has the option of appealing the council’s decision or submitting a new accreditation application.

AMA to provide ethics alerts’ to MDs

Got an ethics question? If you have a handheld personal digital assistant (PDA) and subscribe to content via the ePocrates Rx on-line service, you can receive free "ethics alerts" from the American Medical Association (AMA).

The AMA announced Sept. 8 that it would provide the alerts to physicians via the ePocrates’ DocAlert messaging system for PDAs.

According to the AMA, the alerts are intended to increase understanding of the AMA’s Code of Medical Ethics, and thus provide physicians with practical guidance on dealing with ethical challenges in medical practice.

The AMA’s Ethics Standards Division will create the content for bimonthly ethics messages, which ePocrates Rx users will receive when they "hotsync" their handheld devices. The concise alerts, which can be stored for future reference, will provide links to in-depth coverage of current issues in ethics featured on the AMA web site.

The content of each alert will be written by medical and ethics professionals in the AMA’s Professional Standards Group.

"Practicing physicians frequently face ethical challenges," said AMA President Donald J. Palmisano, MD, JD, in a statement announcing the program. "We believe that having information at hand from the Code of Medical Ethics will help inform physicians and support them in their decisions."