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If a security guard has a stroke in your parking lot, would your staff know how to respond? If a woman goes into labor in your surgery center, do you have a policy to address that scenario?
If your answer is "no," you are not in compliance with new requirements for the Emergency Medical Treatment and Active Labor Act (EMTALA), warns Charlotte Yeh, MD, FACEP, medical director for Medicare Policy at the National Heritage Insurance Co. in Hingham, MA. EMTALA regulations have changed dramatically, she says.
The outpatient prospective payment system regulations issued by the Health Care Financing Administration have expanded EMTALA to include hospital outpatient facilities, which now are required to give anyone with a potential emergency condition a medical screening exam. Staff at these remote sites also must stabilize and, if necessary, transfer the patient.
"It’s now very clear that EMTALA is not just an ED [emergency department] law," Yeh emphasizes.
The new regulations are effective as of the hospital’s first cost reporting following Jan. 10, 2001, says Eric Zimmerman, JD, associate with McDermott, Will, & Emery in Washington, DC. Only surgery centers that are provider-based will have to comply with EMTALA requirements, he says.
"A surgery center that is affiliated with a hospital — for example, wholly or partly owned by a hospital but certified as a freestanding ASC — will not need to comply with EMTALA," he says. "Additionally, surgery centers that are Medicare certified as freestanding, and which have no relationship with a hospital, do not need to comply."
EMTALA obligations may vary depending on the type of facility and the hospital with which it is affiliated, Zimmerman says. "Facilities that think that they may be affected should seek advice from counsel, preferably one who understands the nuances of EMTALA," he suggests. "If the hospital with which they are affiliated has a general counsel, that would be a logical place to start."
In the meantime, here are some suggestions from EMTALA experts:
• Don’t rely on 911. Calling 911 may not be used as a sole source of response, Yeh stresses. "If someone comes into the lab or surgicenter complaining of chest pain, staff may not simply call 911 and consider their obligation complete," she says. "You may call 911 for support, but you must begin initial stabilization procedures until ambulance personnel arrives."
For remote sites, the regulations specifically state that the home ED must be called for instructions, says Stephen A. Frew, JD, president of the Rockford, IL-based Frew Consulting Group, which specializes in EMTALA compliance. "The ED physician should be giving instructions and assisting in obtaining necessary transfers," he says. "The ED is experienced in these issues, while remote sites are not."
The rule requires that the off-site location have policies and procedures in place to deal with this situation, Frew advises. "These might include: [Provide] immediate lifesaving aid, call 911, and call the home ED for instructions."
If a patient is deteriorating rapidly, movement from the remote site back to the main campus is not appropriate, and if it is in the patient’s best interest to be transferred, you must have prearranged transfer agreements with closer hospitals, says Yeh. The off-site location must provide appropriate transportation, equipment, and personnel to transfer the patient to the second closer hospital, she adds.
Consider providing an outside emergency phone for persons having an emergency who arrive at the facility after hours and expect emergency treatment to be available, says Mark Mayo, executive director of the Illinois Freestanding Surgery Center Association in St. Charles. "If you are closed, the patient has no way to call for emergency care," Mayo says.
• Address billing, signage, and record-keeping practices. EMTALA regulations state that you may not delay treatment for preauthorization requests or to collect copayments, Yeh says. "This is especially important for outpatient departments, surgicenters, and lab areas where typically you request copays prior to seeing the patient," she adds. "If it’s an EMTALA-related service, the remote sites should not be doing copays prior to service."
Anyone who does intake registration and screening or who might receive questions about payment or copays needs to understand the implications of EMTALA, Yeh advises. "They need to ensure that no one is turned away because of the ability to pay."
Under EMTALA, you need to keep records for five years and post nondiscrimination notices in the ED and admitting area, says Yeh. "Now, this applies to all sites, so outpatient sites must have the same record keeping and nondiscrimination notices and the same on-call availability as well."
Increased signage for staff at the off-campus surgery centers is needed to remind them of their obligations, recommends Larry B. Mellick, MS, MD, FAAP, FACEP, chair and professor for the department of emergency medicine at the Medical College of Georgia in Augusta. "Additionally, mandatory educational schedules, job aids, and checklists are needed in an area that will be highly vulnerable to oversight," he stresses.
• Establish individualized protocols for dealing with emergencies. Your plan has to be commensurate with your facility’s ability to provide treatment, explains Grena Porto, ARM, CPHRM, director of clinical risk management for VHA, a Berwyn, PA-based alliance of more than 2,000 community-owned health care organizations. "If the location has physicians and nurses, you’ll be required to provide a higher level of screening than a facility that does not have that resource available," she says.
You must have emergency response protocols individualized to your facility’s capabilities, says Yeh. "For example, if the site has a physician and nurse, then they are required to do stabilization," she says. "If there is no physician or nurse, then personnel must be trained to place a call to the ED describing the patient’s condition and begin to initiate transfer requirements if necessary."
• Make sure that patient consent for transfer is obtained. Surgery center staff will need to obtain consent from patients with an emergency medical condition for transfer to another facility, says Porto. "This is not a time when you can rely on implied consent."
When transferring a patient, written documentation is critical, Porto underscores. "If it’s an outpatient setting and they do not have a physician there, then you need a policy stating who will initiate the transfer documentation," she explains.
For more information about EMTALA regulations and hospital outpatient facilities, contact:
• Stephen Frew, JD, Frew Consulting Group, 6072 Brynwood Drive, Rockford, IL 61114. Telephone: (815) 654-2123. Fax: (815) 654-2162. E-mail: firstname.lastname@example.org.
• Larry B. Mellick, MS, MD, FAAP, FACEP, Department of Emergency Medicine, Medical College of Georgia, 1120 15th St., AF 2036, Augusta, GA 30912. Telephone: (706) 721-7144. Fax: (706) 721-7718. E-mail: LMELLICK@mail.mcg.edu.
• Grena Porto, ARM, CPHRM, VHA, 200 Berwyn Park, Suite 202, Berwyn, PA 19312. Telephone: (610) 296-2558. Fax: (610) 296-9406. E-mail: email@example.com.
• 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: firstname.lastname@example.org.