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Do you think you know the meaning of "stabilize" or "transfer?" You might know the obvious medical definitions, but don’t assume they’re the same under the Emergency Medical Treatment and Active Labor Act (EMTALA), warns Gloria Frank, JD, owner of EMTALA Solutions, an Ellicott City, MD-based consulting firm, and former lead enforcement official on EMTALA for the Health Care Financing Administration (HCFA).
Many of the terms used in EMTALA regulations also have commonly used medical definitions, which are very different, says Charlotte Yeh, MD, FACEP, medical director for Medicare Policy at the National Heritage Insurance Co. in Hingham, MA. "In order to comply, you must be sure to understand the legal definitions that are used," she urges.
The legal definitions are frequently different than what you’d assume, warns Grena Porto, ARM, CPHRM, director of clinical risk management for VHA, a Berwyn, PA-based alliance of health care organizations. "Recent case law and advisory bulletins have defined some of these terms."
Here are some terms and their definitions under EMTALA:
• Emergency medical condition. According to EMTALA, emergency medical condition includes labor (whether or not active), drug abuse, psychiatric illness, and intoxication, says Porto. "Most nurses think of an emergency medical condition as something that is serious and life-threatening in the short term, but not according to EMTALA."
• Stabilization. Stabilized means no material deterioration of the condition is likely to occur during or as a result of the transfer or discharge of the patient, Frank says. "Most ED nurses would think of "stable" very differently: They would look at the patient’s vital signs at that moment." This means that you have a duty to provide treatment that ensures that deterioration is unlikely after transfer or discharge, Porto underscores. "For pregnant patients, this means the delivery of baby and placenta."
The law does not require the final resolution of the emergency medical condition, just that deterioration during the process is unlikely, says Porto. "Also [the law requires] that the receiving facility can manage the condition and complication which arise," she adds. "You are not required to guarantee the outcome, but you do have to reasonably foresee what might happen and plan for that."
The transferring facility must provide appropriate equipment and qualified personnel for transfer, says Porto. The receiving hospital must accept the patient unless it can prove it does not have capacity or sufficient resources, she adds.
• Medical screening exam. This exam includes not only the physical assessment, but also any X-rays, lab tests, or other diagnostics necessary to determine whether the patient has an emergency medical condition, Porto explains. "The main thing to remember is that triage is not a medical screening exam, even though many nurses may think of it that way," she says. The exam has to be performed by an individual granted authority under the hospital’s bylaws, she adds.
While nonphysicians can give medical screening exams, this practice has resulted in numerous citations and litigation, says Stephen A. Frew, JD, president of Rockford, IL-based Frew Consulting Group, which specializes in EMTALA compliance. "Typically, the problems arise from an assumption that nurses can simply be assigned to triage, and that triage classifications are sufficient for medical screening," he explains.
Every person who presents must get triage and a medical screening examination, stresses Frew. "This generally amounts to a full ED visit." He says the following areas fall under EMTALA and are required to give a medical screening examination:
— hospital-owned urgent care centers; walk-in clinics; obstetrics, newborn, employee health, and psychiatric assessment units; and anywhere patients present for unscheduled care;
— as of Jan. 10, 2001, all off-site locations that are covered by the new outpatient prospective payment system within a 250-yard zone surrounding the main hospital.
The medical screening exam must include all tests necessary to rule out the emergency medical condition, says Porto. "If the patient presents with abdominal pain, and the eventual diagnosis is appendicitis, the medical screening exam may include X-rays, blood work, and so on."
If the standard of care requires an MRI to rule out a particular condition, then all patients have to receive it regardless of whether payers will reimburse you for it, says Porto. "You cannot get financial authorization before the medical screening exam unless you are prepared to show that it in no way delayed treatment, and that may be a huge hurdle to overcome."
For more information about EMTALA definitions, contact:
• 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.
• Grena Porto, ARM, CPHRM, VHA, 200 Berwyn Park, Suite 202, Berwyn, PA 19312. Telephone: (610) 296-2558. Fax: (610) 296-9406. E-mail: firstname.lastname@example.org.
• Charlotte Yeh, MD, FACEP, Medical Director, Medicare Policy, National Heritage Insurance Co., 75 Sgt. William Terry Drive, Hingham, MA 02043. Telephone: (781) 741-3122. Fax: (781) 741-3211. E-mail: email@example.com.