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You must determine the ED’s role in three key scenarios to comply with new Emergency Medical Treatment and Active Labor Act (EMTALA) requirements, says Stephen A. Frew, JD, president of the Rockford, IL-based Frew Consulting Group, which specializes in EMTALA compliance:
• code responses within the 250-yard zone;
• non-code responses within the 250-yard zone;
• telephone supervision or direct action to off-site locations when the ED is contacted by the remote site with an emergency.
In the case of code and non-code response in the 250-yard zone, your ED will be expected to assume significant response requirements, Frew warns. "These will have to be carefully planned, including adequate personnel, alerting, field communications, and equipment for what is, in essence, an EMS-type field response," he explains.
Here are ways to ensure compliance:
• Determine who will provide the medical screening examination at each site.
Perhaps the most difficult issue for many hospitals will be determining when they need to have a qualified medical provider’ capable of performing a medical screening examination, says Todd Taylor, MD, FACEP, an attending ED physician at Good Samaritan Regional Medical Center in Phoenix. "Administrators will have to go to the trouble of getting these personnel approved by the hospital governing board," he says.
• Determine whether the remote site must follow the "250-yard" rule or the outpatient department rule.
Any entity owned and operated by the hospital within 250 yards of the main hospital campus must comply with EMTALA, Yeh says. "That includes provider-based entities which are under the name and ownership of the hospital but provide different services," she says.
In that case, the rules require that the off-site policy be geared to the level of the personnel on-site and available to provide medical screening, stabilization, and make necessary transfer arrangements, Frew explains.
However, outpatient departments that provide similar services to the hospital must follow additional rules, Yeh notes. "They are now required to screen and stabilize patients within the capability of the total campus, not just the outpatient location," she explains.
The response mechanism has to be consistent, whatever level of care is provided, says Porto. "For example, you may make arrangements for patients to receive an MRI at your main location," she suggests.
In some cases, you might need to develop response teams for certain outpatient sites, Yeh suggests.
• Provide appropriate training for all staff.
Staff will have to be trained throughout the hospital to prepare for responding to an EMTALA case at a remote site, stresses Frew. He warns that ED managers must comply with the following inservice requirements:
— Security. Security and other people who are likely to be involved must have first responder, first aid, and cardiopulmonary resuscitation training, Frew advises.
— Telephone operators or radio control personnel. These individuals must be trained in their communications role in each of the above situations, says Frew. "For example, this may include alerting key individuals, coordination of EMS response, and scene-to-ED communications," he explains.
— ED staff. All staff members who are potentially responsible for zone response duty should be trained in first responder or EMT-level courses, Frew says.
Staff must be familiar with field conditions and active involvement with EMS at a scene, says Frew. "They have the medical skills but have to learn to apply them in a foreign environment," he explains.
• Give instructions to remote sites for all EMTALA cases.
For remote sites, the regulations specifically state that the home ED must be called for instructions, says Frew. "The ED physician should be giving instructions and assisting in obtaining necessary transfers. The ED is experienced in these issues, while remote sites are not," he adds.
For instance, this would be crucial for an outpatient laboratory that is manned by technicians only, says Frew. "The personnel at this site would be absolutely in over their heads if a person walked in off the street with a major emergency, like a gunshot wound, heart attack, or sudden labor," he explains.
The rule requires that the off-site location have policies and procedures in place to deal with this, Frew advises. "These might include immediate lifesaving aid, call 911, and call the home ED for instructions," he says.
The role of the home ED should be first to walk the remote site staff through whatever care they can and should provide, Frew says. "If the patient will need to go to a nearer hospital, the people at this lab are not going to be familiar with numbers to call or procedures to follow to get acceptance for transfers, let alone properly complete transfer forms," he warns.
With the goal of complying with EMTALA, Frew recommends the home ED remain on the line to coach and reassure the laboratory personnel. "Meanwhile, the ED physician makes the call to the other ED, gets acceptance, and faxes over a transfer form," he explains.