EMTALA and EMS

[Riblett]

I wrote this for school, but I think it is an interesting topic for field providers. Feedback and discussion are encouraged

The Role of Emergency Medical Services in the Emergency Medical Treatment & Active Labor Act: Innocent Bystanders or Culpable Party?

By Candice Ryan, EMT-P, AS

February 22, 2011

Nova Southeastern University

BHS 3160: Health Policy

Abstract

The Emergency Medical Treatment & Active Labor Act (EMTALA) governs patient access to emergency medical care with respect to the hospital and emergency departments. At the most basic level it guarantees all patients who present for emergency care the right to proper screening and stabilization and governs patient transfers to other facilities. While the specific role of Emergency Medical Services (EMS) is not directly addressed by EMTALA, it does govern EMS and hospital interactions and regulates the actions of hospital in those instances. This paper will discuss four key EMTALA related issues which involve EMS providers, including hospital diversion, inter-facility transfers, ‘parking’ of patients with EMS crews within the emergency department, and ambiguity surrounding when a patient formally presents for emergency care with respect to ambulance transport.

The Emergency Medical Treatment and Active Labor Act (EMTALA) was passed in 1986 and was designed to prevent disparities in emergency care for those lacking the ability to pay for care. It is a federal regulation applying only to hospitals participating in the Medicare or Medicaid program. Only a small number of private specialty hospitals do not participate in these programs, such as Saint Jude’s Children’s Hospital and Shiners’ Hospitals (Wolfberg, 2006). Under EMTALA, all patients who present to hospital for care have the right to a medical screening exam by qualified personnel to determine if an emergency medical condition exists without regard for ability to pay. The law does not specify the level of training which the person conducting the screening must have, leaving hospital policy to make this determination. If it is determined that a medical emergency does exist, the patient is entitled to treatment to stabilize their condition and the condition of an unborn child, also without regard to ability to pay. EMTALA also imposes heavy regulations on the transfer of patients to other hospitals (Scully, 2003).

In considering the role and responsibility of Emergency Medical Services (EMS) under EMTALA, we find that both the original 1986 laws and subsequent revisions give EMS no implicit responsibility. It does make very specific provisions for interactions between EMS providers and hospitals, but it mandates the actions of the hospitals and emergency departments, rather than EMS providers. In order to be patient advocates, EMS providers need to be aware of EMTALA issues as they affect us and our patients. There is the potential for legal liability if we are party to an inappropriate transfer or illegal diversion, particularly if it results in patient injury or death.

EMTALA specifies that any patient presenting to a hospital emergency room (ER) is subject to regulation. The original law was vague in terms of what actually constitutes presentation for care, making no specific provision for patients transported to the (ER) by ambulance. According to a regulations revision in 1994 by the Centers for Medicare and Medicaid Services (CMS), a person in an ambulance owned by the hospital is considered to have presented to the hospital for care even if the ambulance is not located on hospital property. A person in a non-hospital owned ambulance is not considered to have presented to the hospital, even if radio, telephone, or telemetry contact has been established (Scully, 2003). Hospital owned ambulances operating in the community response capacity are subject to additional guidelines, such as local EMS protocols. These local guidelines may mandate that patients be taken to the closest facility or hospital that is able to deliver specialized care in cases of a particular patient condition. If a patient is brought to the ER by that hospital’s ambulance service, they would be considered to have “presented for care” and as such are subject to EMTALA requirements for medical screenings, stabilization, and transfer regulations in order to be taken to a different hospital. In an updated ruling by CMS, a person in a hospital owned ambulance is not considered to have presented to the hospital if that ambulance is “operating in a community response capacity and functioning under community-wide protocols which dictate hospital destination” (Scully, 2003). In this case, the person is considered to present for care when the ambulance arrives on hospital property in the same way a non-hospital owned unit would. This ruling also extends to air ambulances and medical helicopters owned by hospitals (Scully, 2003).

There is an important exception to the rule of air ambulances. If the hospital is being used solely as a meeting point for ground transport and air transport, use of the hospital helipad does not constitute the patient presenting for care despite being present on hospital property (Wolfberg, 2006). EMS may proceed in turning over care directly to air transport, without being subject to EMTALA regulations for inter-facility transfer.

Another important issue known as patient “parking” is responsible for a great deal of conflict between EMS providers and ER staff, so much so that it has been the subject of several recent memos published by CMS and a target of legislation in the state of Nevada. CMS stated that they have received multiple disturbing reports of hospitals “routinely preventing EMS staff from transferring patients from their ambulance stretchers onto a hospital bed or gurney. Reports include patients being left on an EMS stretcher (with EMS staff in attendance) for extended periods of time” (Hamilton, 2006). The problem seems to stem from hospital staff mistakenly believing that EMTALA regulations are not in effect until they formally assume care of the patient from the EMS crew. Not only does this compromise patient care, but the community also has to pay for the continued patient care by EMS. EMS workers are also at risk of being liable if they don’t assert their patient’s rights under EMTALA and the patient suffers a bad outcome (Wolfberg, 2006). One particularly disturbing example is report of EMS crews waiting six to eight hours for ER staff to assume care of patients in Las Vegas area hospitals (Ludwig, 2006).

To address this issue, the CMS published several memos in 2006 and 2007 asserting that “the EMTALA responsibility of a hospital with a dedicated ED begins when the individual arrives on hospital property (ambulance arrival) and not when the hospital ‘accepts’ the individual from the gurney. An individual is considered to have ‘presented’ to a hospital when he/she arrives at the hospitals dedicated ED or on hospital property” (Hamilton, 2007). The CMS further condemns the hospitals actions, stating that they raise “serious concerns for patient care and the provision of emergency services within the community” (Ludwig, 2006).

As if there weren’t enough concerns around EMS and EMTALA, another topic subject to much debate in the medical community is that of hospital diversion. When hospital emergency departments make the determination that they lack the resources and capacity to accept any additional patients, they divert ambulances to other hospitals. It is important to note that this procedure does not relieve them of caring for patients who present to the hospital. Even if EMS providers disregard diversion orders, the hospital must still accept the patient as this constitutes presenting for care (Ludwig, 2006).

Ambulance crews are faced with difficult choices when diversion status interferes with hospital destination protocols. EMS systems suffer decreases in efficiency as they are forced to transport patients to further hospitals and system status can be adversely affected if areas are left underserved due a lack of available units. They can even face potential liability involving hospital diversions, such as in the case of Arrington v. Wong. In this case, an ambulance carrying a patient in severe respiratory distress was diverted to a further hospital by a medical control physician and the patient died en route. The EMS crew was implicated in the negligence lawsuit in addition to the hospital and medical control physician, although the case was not actually taken to trial (Kuehl, 2002).

Lastly, community based EMS providers and private medical transport providers must be aware of the EMTALA rules and regulations surrounding transfer of patients from the ER to another hospital. EMTALA regulations require a specific form to be filled out and signed by the transferring physician. Before the transfer can take place, the receiving hospital must be aware of the proposed transfer and another physician at the receiving hospital must formally accept care of the patient. The patient must be stabilized prior to transport and the risks of the transport must not outweigh the benefits.

On the EMS side, only appropriately qualified personnel can conduct the transport, meaning that the ambulance must be equipped and staffed at a level that can reasonably meet the necessary standard of care (Scully, 2003). Basic life support ambulance units are obviously not appropriate for patients requiring advanced interventions or monitoring and such transports would be in violation of EMTALA regulations. Additionally, according to a 2007 memo by CMS a receiving hospital cannot condition their acceptance of an EMTALA regulated transfer based on the utilization of a specified transport service (Hamilton, 2007). For example, a receiving hospital cannot mandate that patients being transferred to their facility must use the receiving hospital’s own helicopter or ground transport service.

As briefly demonstrated in this discussion, the Emergency Medical Treatment & Active Labor Act has a massive impact on EMS systems and practitioners. Many of the EMTALA-related issues between EMS and hospitals are addressed in the regulations, but ignorance of both the hospital practitioners and EMS practitioners can create situations that are at best in a gray-area or at worst are in direction violation of EMTALA and put patient care at risk. From the perspective of an EMS practitioner, the best course of action is to be explicitly knowledgeable of EMTALA and always be your patient’s strongest advocate. The Centers for Medicare and Medicaid Services are also helping to address the more difficult issues, like patient parking, with their own explicit guidance and interpretation.

References

Hamilton, T.E. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2006). EMTALA-"parking" of EMS patients in hospitals (S&C-06-21)

Hamilton, T.E. Department of Health and Human Services, Centers for Medicare and Medicaid Services. (2007). EMTALA issues related to emergency transport services (S&C-07-20)

Kuehl, A.E. (2002). Prehospital systems and medical oversight. Dubuque, IA : Kendall Hunt Publishing.

Ludwig, G. (2006). CMS opinion frees up ambulances. Journal of Emergency Medical Services, 31(4), 22.

Scully, T. A. Department of Health and Human Services, Centers for Medicare & Medicaid Services. (2003). Clarifying polices related to the responsibility of Medicare-participating hospitals in treating individuals with emergency medical conditions (CMS-1063-F)

Wolfberg, D.M. (2006). Ems caught in the crossfire: EMTALA and ER diversions. Texas Department of State Health Services, Retrieved from http://www.dshs.state.tx.us/emstraumasystems/Wolfberg_CaughtCrossfire.pdf

[FireMedic65]

Very well written and informative research. When I went through medic school our lecture was brief on EMTALA, but the instructor (an MD/lawyer) made it clear it was important.

There were a few things I was not aware of before reading this. It might be dry subject matter, but I believe it should be taught and explained in detail for your own good ant the patients.

[HERBIE1]

Well done.

When I teach this topic to firefighters, I get the usual- "Why do I need to know this stuff?"

I explain to them that during the course of their FF duties, unless they commit a crime, they have essentially zero chance of jeopardizing their career. If they make a mistake, maybe a room sustains more water damage than it should, or an extra room is damaged because they did not get the building ventilated quick enough. Most mistakes are forgiven- fire is unpredictable, and unless you are familiar with fire ground tactics, few folks would ever know a problem occurred. An error would mean retraining, increased drills, maybe good natured ribbing from rheir peers- but nothing that would mean a loss of income or their job.

I then show them examples of the bad things that can happen within EMS- and the concept of EMTALA is a big part of that- especially with private providers. I teach in the context of being an administrator, so I also frame the discussion on potential liability to their organization/municipality. Besides EMTALA, In EMS we also have medical protocols, local, state, and federal guidelines to follow, with various consequences for failure to abide by those rules. That means anyone associated with EMS- full time, cross trained, part time, volunteer, or along the periphery of the profession needs to be fluent in the rules which govern our job.

[Bieber]

Wow, great post! I remember reading about it very briefly during EMT and paramedic school, but not anywhere in as much detail as what you've just provided.

Thanks for sharing!

[crotchitymedic1986]

Only thing I can add, although I can not site the reference to the actual case, hospital property is either defined as within 75 or 100 yards of the physical property (the case involved someone attempting to drive to walk to hospital, made it to edge of property but not physically on property, and hospital staff refused to come assist the pt. off property). Also, a screening exam is just that (basically triage by a nurse), if no life threatening stabilization is required, there is some grey area as to how long they can "park" a patient, once that exam has occurred. One of the grayest areas is when the patient is at an outpatient facility or clinic that is distant to the main facility, and there is a closer non-related facility nearby. The patient by EMTALA should go to the base-related-hospital, but it may be in the patient's best interest to go to the closer non-related facility.

[Riblett]

You are right Crochity, it does not spell out the extent of the screening. Triage by an RN generally serves this purpose. What I don't understand is why we continue to treat ear infections, dental abscesses, etc, in the ER when it is clearly not mandated. Especially for patients who cannot or will not be paying for these services there needs to be a stopping point. When the ER is so full that those actually needing services are suffering medically unacceptable wait times we need to start telling people that we are not treating their minor complaints and they need to seek primary care service elsewhere. EMTALA mandates a screening and stabilization of emergent conditions without regard to ability to pay. I have studied the original law and all the updates rather extensively; no where does it mandate treatment of non-emergency issues without regard to ability to pay.