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[Editor’s note: If you have a question about the Emergency Medical Treatment and Active Labor Act (EMTALA) that you’d like answered, contact Staci Kusterbeck, Editor, ED Management. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: StaciKusterbeck@aol.com.]
Question: Is it acceptable for a satellite ED to transfer a patient to the main ED if the patient needs a surgical consult? Or must there be an accepting physician and a direct admission? Even if there is an accepting physician, can the patient be transferred to the ED?
Answer: This is state-specific, and some states do not favor ED-to-ED transfers, says Stephen Frew, JD, president of the Rockford, IL-based Frew Consulting Group, which specializes in EMTALA compliance. "EMTALA does not specify, and allows hospitals to design their own acceptance flow, subject to state law," he explains.
However, transfers from the satellite to the main campus for specialist consultations are appropriate because the satellite doesn’t have the capabilities to provide them, according to Jonathan D. Lawrence, MD, JD, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. "Remember, EMTALA does not prohibit ED-to-ED transfers," he says. The commonly accepted notion that ED-to-ED transfers are forbidden comes from the Centers for Medicare and Medicaid Services’ (CMS) reimbursement rules that will not pay for two ED workups in one day, he explains.
"It may be totally appropriate for the continued MSE [medical screening exam] to take place physically in the ED of the receiving hospital," says Lawrence. The accepting physician doesn’t necessarily have to be the physician who admits the patient, should that become necessary, he adds.
Question: We often have patients from area nursing homes brought to the main campus for evaluation. These patients are often noncommunicative, and their attending physician is a physician at our satellite campus. Our Department of Health has cited us for transferring patients from the main campus to the satellite campus to the care of their attending, stating that it is a transfer to a lower level of care and therefore not permitted under EMTALA. Once it is determined that an emergency medical condition that would require the services of the main campus does not exist, would the transfer be OK?
Answer: EMTALA requires the hospital with the patient to provide all diagnostic and stabilizing care (including admissions and surgeries) within their capabilities, says Lawrence. Therefore, transfer to a lower level of care would not be appropriate under EMTALA, and physician preference or continuity of care are not adequate transfer justifications under EMTALA, he explains. "These are legally unstable patients with emergency medical conditions ... even if some physician says they are stable’ medically," he adds.
The idea of higher and lower levels of care has caused much confusion among physicians, administrators, and enforcers alike, says Lawrence. "One needs to differentiate between transfers for the [MSE], and transfers once an emergency medical condition has been identified." If a transfer is being made for the MSE, it is clear that a transfer must be to a facility with a higher level of capability, says Lawrence. "If the satellite has not determined that an emergency medical condition exists, having exhausted its capabilities, a transfer to the main campus is appropriate whether or not the patient has been stabilized," he says.
Under such circumstances, a transfer the other way — from the main campus to the satellite — clearly would be inappropriate, says Lawrence. "However, once the emergency medical condition has been identified and the patient stabilized, the patient may certainly be transferred to a facility with less, though still appropriate, capabilities," he says.
An unresponsive patient should not be put at risk of transfer — an inherently destabilizing situation in the best of conditions — and subjected to an ambulance trip to go back to his or her own doctor, says Frew. "The physician does not own them," he adds. "The main hospital must provide all necessary care under EMTALA, and patient request will not work." It would be almost impossible to justify the benefits as outweighing the risks, says Frew. "And it would be almost impossible to structure an adequate statement of risks that would still get a family to approve the movement."
In the case where no one is available to request the return (except the physician), it would be impossible to structure movement of the patient back to the rural setting, notes Frew. "I am not surprised that someone cited this practice," he adds. "The hospital has been very lucky so far that it has not had serious litigation and malpractice losses from such a practice."
• Stephen Frew, JD, Frew Consulting Group, 6072 Brynwood Drive, Rockford, IL 61114. Telephone: (815) 654-2123. Fax: (815) 654-2162. E-mail: email@example.com.
• 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.