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[Editor’s note: This column is an ongoing series that will address reader questions about the Emergency Medical Treatment and Active Labor Act (EMTALA). If you have a question you’d like answered, contact Editor Staci Kusterbeck. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: StaciKusterbeck@aol.com.]
Question: Our facility is comprised of two campuses: a main campus with a Level II ED, and a satellite campus 25 miles away with an ED that provides limited acute care. This satellite facility has a different provider number, but it operates under the same governance and policies. The medical staff is the same. Do transfers from the satellite facility fall under EMTALA regulations?
Answer: Hospitals that are licensed separately are not the same provider under the outpatient prospective payment system, and therefore, they are separate hospitals, says Stephen Frew, JD, president of the Rockford, IL-based Frew Consulting Group, which specializes in compliance with EMTALA.
"While the two staffs are merged, it is necessary to clearly delineate privileges at only the location for which the individual is responsible for on-call services, or you will have serious call problems," he adds.
With a different provider number and a distance of 25 miles, it is a toss-up whether a transfer from the satellite to the main campus would be considered an interfacility or an off-campus intrafacility transfer, says Jonathan D. Lawrence, MD, JD, ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. "My inclination is that, under these facts, a transfer would be considered the former," says Lawrence. "In either case, EMTALA still applies. The difference is only the process, policies, and procedures that are used."
For an interfacility transfer, the well-known EMTALA regulations apply, including stabilizing if possible, attestation by the transferring physician, acceptance by the receiving facility, and provision of an appropriate transfer method, says Lawrence. For an intrafacility transfer, the new regulations require additional institutional policies and procedures to make the transfer safe, but do not require attestations or acceptance by the receiving facility, he explains.
Question: The satellite ED is staffed by a nurse practitioner. Can that individual sign for the transfer, or must it be a physician?
Answer: The nurse practitioner (NP) can sign for the transfer because there is no physician on duty, but the NP must be formally designated by the board and must have phone contact with a physician who must thereafter countersign the order, generally within 48 hours, says Frew.
Remember that no institution is required to perform a medical screening examination (MSE) beyond its capabilities, says Lawrence.
Thus the patient who requires a computed tomography (CT) to complete an MSE may be transferred once all the usual transfer requirements are met, he explains. EMTALA clearly allows a nonphysician, such as a nurse practitioner, to perform the MSE and attest to the need for transfer if appropriate policies, procedures, and guidelines delineate how this is to be done, he adds.
It is unclear why these patients would need to be transferred to the ED unless their condition is unstable, though there is nothing prohibiting a transfer to the ED, Lawrence notes. A transfer directly to the radiology department also would be appropriate, he says. "If the CT shows an emergency medical condition, then admission to the main campus hospital could be the next step," he adds.
If the emergency medical condition can be handled at the satellite hospital, and the patient is stable, there is no prohibition to transferring the patient back, Lawrence adds. "If the CT shows no emergency medical condition, EMTALA no longer applies," he says.
For more information about EMTALA, contact:
• Jonathan D. Lawrence, MD, JD, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 90813. Telephone: (562) 491-9090. E-mail: firstname.lastname@example.org.