EMTALA question

[miacomet]

Would it be an EMTALA violation if a hospital reserves beds for scheduled, non-emergent surgical patients, but transfers ER patients requiring admission to another hospital to keep those beds reserved for the high-paying elective surgery patients?

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[VA Hopeful Dr]

Even if not, that sounds kinda shady

 

[miacomet]

Even if not, that sounds kinda shady

Agreed. Hoping SouthernDoc would chime in.

 

[southerndoc]

Seems shady, but I think you'd have a hard time getting an EMTALA violation out of it. You'd have to show the hospital wasn't stabilizing the patients or that they were refusing to treat them when in fact they had capacity. Simply not admitting someone doesn't mean it's an EMTALA violation. It would be up to the receiving facility to file a complaint after receiving an inappropriate transfer. This could be a hot issue if you find that uninsured patients were being transferred and insured were kept at the facility.

Also, just because they have reserved beds, it doesn't mean they have the staff to take care of the patient at the time they were there. If they staff the beds for day hours, but patients are held in the ER or transferred during the night when the bed isn't staffed by a nurse, then the hospital still doesn't have capacity to treat them.

 

[miacomet]

Seems shady, but I think you'd have a hard time getting an EMTALA violation out of it. You'd have to show the hospital wasn't stabilizing the patients or that they were refusing to treat them when in fact they had capacity. Simply not admitting someone doesn't mean it's an EMTALA violation. It would be up to the receiving facility to file a complaint after receiving an inappropriate transfer. This could be a hot issue if you find that uninsured patients were being transferred and insured were kept at the facility.

Also, just because they have reserved beds, it doesn't mean they have the staff to take care of the patient at the time they were there. If they staff the beds for day hours, but patients are held in the ER or transferred during the night when the bed isn't staffed by a nurse, then the hospital still doesn't have capacity to treat them.

What if they have an ability to call in a nurse, and they have the service requested?

 

[southerndoc]

What if they have an ability to call in a nurse, and they have the service requested?

Again, it would be difficult to prove.

 

[Hamhock]

Yeah, this seems pretty common...annoying to the ED and maybe ethically "grey", but doubt this is an EMTALA violation.

In fact, I can't think of a single hospital (except the county hospital I did residency at) of the many I worked at that wasn't doing something like this. Perhaps they weren't transferring patients to another hospital; but they all are (1) keeping patients in the ED to keep a bed ready for the elective surgery patient to fill in the afternoon or keeping patients in the ED and (2) not calling in available nurses who might require 1.5 time or some other bonus.

HH

 

[BAM!]

Often stable patients are transferred to other hospitals due to their insurance carriers contracting with an outside hospital network. Even if they have open beds upstairs. This practice is common and not an EMTALA violation.

 

[southerndoc]

Often stable patients are transferred to other hospitals due to their insurance carriers contracting with an outside hospital network. Even if they have open beds upstairs. This practice is common and not an EMTALA violation.

This is an EMTALA violation if the transferring hospital has the capacity to treat and the transfer is initiated by the physician. You have to ask the patient if they want to be transferred to an in-network hospital or if they would rather be admitted to your facility as an out-of-network provider. Nearly all will say to transfer because most insurances don't pay but 20-50% for out-of-network hospitalizations. Then, the transfer is by patient request.

 

[thegenius]

Would it be an EMTALA violation if a hospital reserves beds for scheduled, non-emergent surgical patients, but transfers ER patients requiring admission to another hospital to keep those beds reserved for the high-paying elective surgery patients?

Depending on the details above, I do think this is an inappropriate transfer...
- if the patient has an emergency medical condition requiring stabilization; AND
- the hospital has the ability to stabilize the patient; AND
- the patient does not request transfer,

then I think it's an inappropriate transfer.
The corollary is true. A receiving hospital cannot deny an appropriate transfer because they are holding beds for future use. I know there is case-law about that.
Patients wait in the ER for a variety of reasons prior to getting a bed and still get stabilizing care.

I think the question here is "ability to stabilize" and "availability of nurses". The hospital has available nurses because they are in the ED and the patient was already taken care of. Nursing is a recognized critical resource in hospitals and it's virtually impossible for patients to receive any medical care, no matter how simple or advanced, without a nurse. The mechanism of discovery of an emergency medical condition invariably involves nursing. The patient has a emergency and is getting stabilizing treatment initially in the ED.

I think holding onto empty beds is for elective patients (while common) and not giving them to patients who have an emergency medical condition is a violation based on what I wrote above.

Now I'm not a lawyer, but have probably read more about EMTALA than the average doctor. If I were a lawyer for a hospital I definitely WOULD NOT want to adjudicate this issue in court.


OP, do you have any details you want to share? I'm curious!

 

[DocEspana]

Necro bumping because I have an EMTALA question and don't want to make a new thread.

This has come up a couple times lately for some reason and everyone I talk to has such extremely varied opinions on it.

A nearby hospital calls you to request to transfer a patient to you because of continuity of care. The situation each time is something different, but it's also always similar in the sense that it doesn't NEED to be transferred. The example we had today was a patient who had a surgery with our facility a week or two ago and had a wound vac and had some wound vac related issue. I *KNOW* this hospital can manage a wound vac but they want to send it because it was our surgeon who worked on the patient and they say their surgeon doesn't want to even be consulted on it since it wasn't his surgery.

The obvious questions: is this an EMTALA violation? Is this patient stabilized and thus it doesn't even apply? Is it EMTALA adjacent but if the patient has the request for transfer in writing and we CHOOSE to accept it's okay?

It's not a test. I have an opinion but I want to hear other people's thoughts.

 

[southerndoc]

Necro bumping because I have an EMTALA question and don't want to make a new thread.

This has come up a couple times lately for some reason and everyone I talk to has such extremely varied opinions on it.

A nearby hospital calls you to request to transfer a patient to you because of continuity of care. The situation each time is something different, but it's also always similar in the sense that it doesn't NEED to be transferred. The example we had today was a patient who had a surgery with our facility a week or two ago and had a wound vac and had some wound vac related issue. I *KNOW* this hospital can manage a wound vac but they want to send it because it was our surgeon who worked on the patient and they say their surgeon doesn't want to even be consulted on it since it wasn't his surgery.

The obvious questions: is this an EMTALA violation? Is this patient stabilized and thus it doesn't even apply? Is it EMTALA adjacent but if the patient has the request for transfer in writing and we CHOOSE to accept it's okay?

It's not a test. I have an opinion but I want to hear other people's thoughts.

This is an EMTALA violation unless the patient requests transfer or the transferring facility doesn't have the capability to properly handle it.

It doesn't matter if hospital A did 20,000 surgeries on the patient, if the patient presents to hospital B and has a medical condition requiring treatment for stabilization, then hospital B must treat despite surgeon preference if hospital B has capacity and capability to do so.

 

[DocEspana]

This is an EMTALA violation unless the patient requests transfer or the transferring facility doesn't have the capability to properly handle it.

It doesn't matter if hospital A did 20,000 surgeries on the patient, if the patient presents to hospital B and has a medical condition requiring treatment for stabilization, then hospital B must treat despite surgeon preference if hospital B has capacity and capability to do so.

There is a counter argument that this patient has been stabilized* as they are at no acute risk of impending decompensation and this is now a matter of "lack of physician familiar with the surgical case" justifying better care if they were sent across a few town lines. A stabilized patient is no longer applicable for EMTALA and can be transferred to anyone willing to accept them.

*the government doesn't see the word stabilized like this though.

They view the word stabilized as equivalent to "dischargeable." Which is why I don't buy this argument, though I've seen it used and it is very articulate and based on the law itself. Its just also wrong. But I get SO MUCH push back for not buying the BS I listed above and I never know why I get that pushback.

 

[Siggy]

Assuming the patient requests it, would it be a EMTALA (fixed typo) violation to refuse the transfer?

The patient isn’t helped by being admitted to a hospital where the specialist is being cagy because they’re being expected to fix a different specialist’s mistake.

 

[BoardingDoc]

Assuming the patient requests it, would it be a HIPAA violation to refuse the transfer?

The patient isn’t helped by being admitted to a hospital where the specialist is being cagy because they’re being expected to fix a different specialist’s mistake.

I assume you meant EMTALA and not HIPAA, but the answer is no.

A patient requesting transfer can be used as a reason for transferring an "unstabilized" patient which would otherwise produce a EMTALA violation.
E.g. Wound vac guy has an infection requiring surgical debridement. My hospital can handle it, but the patient wants to go to where it was performed and requests so. The other hospital accepts. Everyone wins.

If, however, in the same scenario the other hospital REFUSES... that's fine. Again, this assumes that my hospital is capable of providing the required treatment, even though staff AND the patient would prefer that the patient go elsewhere.

In that scenario, the patient is of course free to sign out AMA and then self present to the original hospital.

 

[Dr Mantis Toboggan]

I assume you meant EMTALA and not HIPAA, but the answer is no.

A patient requesting transfer can be used as a reason for transferring an "unstabilized" patient which would otherwise produce a EMTALA violation.
E.g. Wound vac guy has an infection requiring surgical debridement. My hospital can handle it, but the patient wants to go to where it was performed and requests so. The other hospital accepts. Everyone wins.

If, however, in the same scenario the other hospital REFUSES... that's fine. Again, this assumes that my hospital is capable of providing the required treatment, even though staff AND the patient would prefer that the patient go elsewhere.

In that scenario, the patient is of course free to sign out AMA and then self present to the original hospital.

Yup for all these non higher level of care transfers (out of network insurance, continuity of care, patient request) I’m always careful to say on the recorded line that we do have capacity to treat the patient but transfer is requested due to XYZ. They can (and do at times when they have no beds) say no and then my consultants can suck it up and they can get admitted at my hospital.

 

[southerndoc]

I assume you meant EMTALA and not HIPAA, but the answer is no.

A patient requesting transfer can be used as a reason for transferring an "unstabilized" patient which would otherwise produce a EMTALA violation.
E.g. Wound vac guy has an infection requiring surgical debridement. My hospital can handle it, but the patient wants to go to where it was performed and requests so. The other hospital accepts. Everyone wins.

If, however, in the same scenario the other hospital REFUSES... that's fine. Again, this assumes that my hospital is capable of providing the required treatment, even though staff AND the patient would prefer that the patient go elsewhere.

In that scenario, the patient is of course free to sign out AMA and then self present to the original hospital.

Actually it's a double-edged sword. If the receiving hospital refuses it (even if the transferring hospital has capability to treat), it is an EMTALA violation. Basically the ONLY reasons you can refuse a transfer request is if you do not have capacity or capability to handle the situation. The receiving hospital must accept even in the transferring hospital is causing an EMTALA violation, and then the receiving hospital is required to file an EMTALA violation against the transferring hospital (or else the receiving hospital can be fined).

As mentioned previously, stabilization isn't stabilizing vital signs. It's basically definitive care as how CMS has applied it in the past. Appendicitis with normal vital signs that gets antibiotics and discharged by recent literature? EMTALA violation if the patient perforates and has complications. Acute headache that sits in the waiting room for 6 hours and doesn't get a CT and has a subarachnoid hemorrhage? EMTALA violation for failure to perform an MSE (the MSE in this case includes the CT).

EMTALA is very complicated. I've spent years looking at the ins and outs of it, and even now I have to consult legal counsel to interpret some things. Even questions directed to CMS are sometimes not answered with a clear answer.

 

[RoyBasch]

Often stable patients are transferred to other hospitals due to their insurance carriers contracting with an outside hospital network. Even if they have open beds upstairs. This practice is common and not an EMTALA violation.

This is 100% an EMTALA violation unless the transfer is CLEARLY documented as PATIENT REQUESTED. I would go the extra mile and write in my documentation that the patient was offered whatever treatment they needed at your facility and they CHOSE to go elsewhere. You need to check the "right" box on the actual transfer form confirming the patient "requests" to transfer rather than "consents" to physician recommended transfer.

 

[RoyBasch]

Necro bumping because I have an EMTALA question and don't want to make a new thread.

This has come up a couple times lately for some reason and everyone I talk to has such extremely varied opinions on it.

A nearby hospital calls you to request to transfer a patient to you because of continuity of care. The situation each time is something different, but it's also always similar in the sense that it doesn't NEED to be transferred. The example we had today was a patient who had a surgery with our facility a week or two ago and had a wound vac and had some wound vac related issue. I *KNOW* this hospital can manage a wound vac but they want to send it because it was our surgeon who worked on the patient and they say their surgeon doesn't want to even be consulted on it since it wasn't his surgery.

The obvious questions: is this an EMTALA violation? Is this patient stabilized and thus it doesn't even apply? Is it EMTALA adjacent but if the patient has the request for transfer in writing and we CHOOSE to accept it's okay?

It's not a test. I have an opinion but I want to hear other people's thoughts.

I feel like the case you are discussing occurs every day for me. Patient has surgery at different hospital and comes to my ER with a post surgical problem. Why do they come to my ER instead of the one they had surgery at, because they are *****s, it doesn't really matter why they are at the different hospital. All that matters is now they are in your ER and you now have a responsibility for them.

In the eyes of EMTALA "continuity of care" does NOT constitute a "higher level" of care. Thus transferring a patient to maintain continuity of care and have them evaluated by their original surgeon would absolutely be an EMTALA violation. The "out" for this case is as I noted in my post above is a "patient requested" or initiated transfer. Basically I explain to the patient that we have the same surgeon at our facility and they "could" help them with this problem. The patient "prefers" to maintain continuity of care and thus they "request" transfer.

I put all of these terms in quotations because of course if I call our surgeon about some other surgeon's problem/complication they will throw a fit, loose their ****, generally be a baby, and not want to help. In my experience surgeons have no clue about their EMTALA responsibilities. Obviously the right thing to do is maintain continuity of care with the original operating surgeon, but this is not the right thing in the eyes of the law.

Technically the sending hospital is committing an EMTALA violation if they have the same kind of surgeon unless they document as a patient initiated transfer. Obviously you CAN refuse a patient requested transfer (as it is not "necessary" because not a higher level of care), although I probably would not if it were me because I see it as a good idea to maintain continuity of care.

The second issue is the question of "stability." Stability in the context of EMTALA is NOT the same as medical stability. When you ask an ER physician if a patient is "stable" it usually has to do with hemodynamics, airway protection, respiratory status, etc. So an awake and alert patient with normal vitals and no anticipated rapid decline is "stable." BUT, for EMTALA purposes "stable" means their medical problem real or imagined is completely treated or ruled out. For example a medically stable patient with chest pain, but a possible ACS is not EMTALA stable until all of their troponins are negative and ACS is considered ruled out +/- cardiology consult, stress test, whatever. Essentially stable enough to discharge from the hospital entirely.

Anything else is considered an "unstable" (and potentially inappropriate) transfer in the context of EMTALA. So if for the wound vac issue is so minor that from your point of view the patient can be discharged to follow up in their surgeon's office, than they are EMTALA stable. If you transferred the patient to the other hospital to facilitate being seen by their surgeon, this is a gray area, and personally I would not do it. If you are worried enough about the vac issue they need to be seen "right now" by their surgeon that implies it might not be EMTALA stable.

So at this point you have to make a call, go the route of "patient preference/initiated" transfer for stat eval by their surgeon or discharge and maybe make a phone call to arrange close follow up. Any outpatient stuff/patient discharged is now no longer under the umbrella of EMTALA.

 

[turkeyjerky]

I think most of you guys are being a little too conservative with your interpretations (understandably). Here's the definition of 'stablized' for transfer, from the statute:

'To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B) [a pregnant woman who is having contractions], to deliver (including the placenta).'

So, whiny wound vac pt (who doesn't even need to be in the ER in the first place--I'm pretty sure they did surgery before those were invented) can be considered stabilized. What material deterioration is likely to happen during, or as a result from, the transfer? Loss of a few cc's of serosanguineous fluid?

Guy w/ postoperative nec fasc, that's a different story...

Of course, as a lateral transfer, the original hospital may not actually have a duty, under emtala, to accept the whiny wound vac guy. But, then the surgeon opens him or herself up to accusations of patient abandonment and medical malpractice.

 

[thegenius]

Necro bumping because I have an EMTALA question and don't want to make a new thread.

This has come up a couple times lately for some reason and everyone I talk to has such extremely varied opinions on it.

A nearby hospital calls you to request to transfer a patient to you because of continuity of care. The situation each time is something different, but it's also always similar in the sense that it doesn't NEED to be transferred. The example we had today was a patient who had a surgery with our facility a week or two ago and had a wound vac and had some wound vac related issue. I *KNOW* this hospital can manage a wound vac but they want to send it because it was our surgeon who worked on the patient and they say their surgeon doesn't want to even be consulted on it since it wasn't his surgery.

The obvious questions: is this an EMTALA violation? Is this patient stabilized and thus it doesn't even apply? Is it EMTALA adjacent but if the patient has the request for transfer in writing and we CHOOSE to accept it's okay?

It's not a test. I have an opinion but I want to hear other people's thoughts.

Ok this is interesting. I see there are a 1/2 dozen responses but I haven't read them yet. So this is my unbiased response and this is what I think:

1) this guy doesn't have an emergency medical condition. he needs no stabilization. Let's say the wound vac is leaking or some other nonsense. Because there is no emergency medical condition, he doesn't even fall under EMTALA. Thus the receiving hospital will not win a claim that there is an EMTALA violation (despite the fact they might try.)

2) at this point...if I'm the receiving ER and I get a phone call from the transferring ER...I would not accept. This guy either goes to the inpatient team or nowhere else.

3) if the transferring ER claims there is an emergency medical condition, which is their right and I technically can't refute that...then I say "please call our inpatient team and transfer them there". This is a lateral transfer and not to a higher level of care.

4) technically this guy can just be discharged from the transferring ER. I think it would be legally OK if the transferring ER said "Dude, you don't have an emergency. I'm discharging you. I recommend you go to the other hospital." (despite that being cheesy.)

5) If I were an insurance company, I would not pay for the ambulance transport if he is shipped from the transferring ER to another hospital. he doesn't have an emergency. He can drive himself or find some other way to get to the other hospital.

 

[southerndoc]

I think most of you guys are being a little too conservative with your interpretations (understandably). Here's the definition of 'stablized' for transfer, from the statute:

'To provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to an emergency medical condition described in paragraph (1)(B) [a pregnant woman who is having contractions], to deliver (including the placenta).'

So, whiny wound vac pt (who doesn't even need to be in the ER in the first place--I'm pretty sure they did surgery before those were invented) can be considered stabilized. What material deterioration is likely to happen during, or as a result from, the transfer? Loss of a few cc's of serosanguineous fluid?

Guy w/ postoperative nec fasc, that's a different story...

Of course, as a lateral transfer, the original hospital may not actually have a duty, under emtala, to accept the whiny wound vac guy. But, then the surgeon opens him or herself up to accusations of patient abandonment and medical malpractice.

I agree with your interpretation of the statute, but CMS' interpretation and OIG interpretation have been two different things.

Tell me how that statute applies to a hospital who was cited for not admitting a patient to its own psychiatric facility while awaiting placement to an in-network facility. Did the patient have unstable vital signs? Was there likely material deterioration of the condition during transfer? Yet, the hospital was fined $1.3 million and almost lost their ability to participate in Medicare. Patients were kept in the ER for suicidal ideation and were deemed to not have been stabilized by keeping them in the ER instead of admitting to their own psychiatric unit. (AnMed Health System, 2015)

The reality is that CMS and OIG interpret stabilization much, much different than what we as emergency physicians interpret as stabilization. In some cases, medical screening exams have included laboratory testing and CT imaging. Stabilization has included failure to admit and failure to treat. Many inspectors view the statute as "stabilized or resolved" and not just stabilized.

With regards to transferring patients to another facility because they had prior surgery, this very example has been tested and cited in 2018 with a $52,414 fine (Piedmont Newnan Hospital, 2018). Granted, this patient deteriorated by the time she arrived at the receiving facility. Are you really going to risk transferring a wound vac complication when there is a chance the patient could develop septic shock enroute? This is especially true with some EMS systems experiencing 6-12 hour response times for interfacility transfers. Now if the patient requests the transfer, then EMTALA doesn't apply (unless the patient was unstable and you didn't document risks).

Any transfer you do should be by patient request (in-network facility, to their own surgeon, etc.) or because your facility does not have capacity or capability to treat the patient. Any other transfer that the physician or other medical staff initiates besides capacity/capability/patient request is an EMTALA violation. The orthopedic surgeon who doesn't want to touch another surgeon's complications and refuses to evaluate the patient in the ER when asked commits an EMTALA violation.

 

[thegenius]

The second issue is the question of "stability." Stability in the context of EMTALA is NOT the same as medical stability. When you ask an ER physician if a patient is "stable" it usually has to do with hemodynamics, airway protection, respiratory status, etc. So an awake and alert patient with normal vitals and no anticipated rapid decline is "stable." BUT, for EMTALA purposes "stable" means their medical problem real or imagined is completely treated or ruled out. For example a medically stable patient with chest pain, but a possible ACS is not EMTALA stable until all of their troponins are negative and ACS is considered ruled out +/- cardiology consult, stress test, whatever. Essentially stable enough to discharge from the hospital entirely.

What about a patient with a UTI? You can give them antibiotics but they are not completely treated, as you write. Treatment has been initiated.
There is no reason to expect a routine, uncomplicated UTI, will decompensate after initiating antibiotics.

Same with a wound vac. if there is some cellulitis around it, and vitals are normal and there is no leukocytosis...basically you can give Abx and not transfer them. They can see their surgeon in the next few days.

 

[southerndoc]

What about a patient with a UTI? You can give them antibiotics but they are not completely treated, as you write. Treatment has been initiated.
There is no reason to expect a routine, uncomplicated UTI, will decompensate after initiating antibiotics.

Same with a wound vac. if there is some cellulitis around it, and vitals are normal and there is no leukocytosis...basically you can give Abx and not transfer them. They can see their surgeon in the next few days.

The sad thing is you just roll the dice. Severe migraine headache that responds to pain medication? All is well. Doesn't respond and you don't CT? Well, bad outcome could trigger an EMTALA.

You never know which patient will trigger an EMTALA. Those that are stable upon discharge for atypical chest pain, go home and die could trigger an EMTALA. It's all who you get for inspector and how OIG interprets things.

For the most part, if the patient is not likely to have deterioration when you discharge the patient, then you're good. If the patient is being transferred, then a different set of standards apply. For one, do you have capability and capacity to care for the condition at your hospital? Admission to the hospital doesn't always get you out of EMTALA either. If CMS/OIG can show that you admitted the patient strictly to get out of EMTALA obligations, then they can still apply EMTALA.

I've been studying EMTALA for >8 years and it still is open to interpretation. When I offer expert opinion on the matter, I cite cases. I have >100 cases of EMTALA that I've accumulated. The list keeps growing exponentially every year.

 

[thegenius]

The sad thing is you just roll the dice. Severe migraine headache that responds to pain medication? All is well. Doesn't respond and you don't CT? Well, bad outcome could trigger an EMTALA.

You never know which patient will trigger an EMTALA. Those that are stable upon discharge for atypical chest pain, go home and die could trigger an EMTALA. It's all who you get for inspector and how OIG interprets things.

For the most part, if the patient is not likely to have deterioration when you discharge the patient, then you're good. If the patient is being transferred, then a different set of standards apply. For one, do you have capability and capacity to care for the condition at your hospital? Admission to the hospital doesn't always get you out of EMTALA either. If CMS/OIG can show that you admitted the patient strictly to get out of EMTALA obligations, then they can still apply EMTALA.

I've been studying EMTALA for >8 years and it still is open to interpretation. When I offer expert opinion on the matter, I cite cases. I have >100 cases of EMTALA that I've accumulated. The list keeps growing exponentially every year.

Sounds like it's more about standard of care than whether you "stabilized" the patient.

Which makes discharging low risk chest pain problematic, for instance. Because I can quote all the HEART score and Kaiser data of 200,000 people showing that discharging low risk chest pain is actually extremely safe...but if there is a bad outcome which had a probability of 0.8% per the literature...then the OIG can say you didn't do the standard of care and stabilize the patient (even to this day...a lot of ER physicians admit low risk chest pain despite excellent data that it doesn't need to be admitted.)

You really need to write publish a book on all those 100 EMTALA cases. Each one can be summarized on 1 page. I would pay for that book. I would pay $50 for that. I'm serious! There has to be something, somewhere, that gives a cliff-notes version of numerous EMTALA cases. Get 10,000 people to pay $50...and gross margins are $500,000. Maybe you make 35% of that?!?!



I suffered an EMTALA violation against me once. Thankfully it didn't result in a fine just a slap on the wrist to me and my hospital. One of the hospitals I work at is not a trauma center. But the level 1 county trauma center is literally 5 minutes away from my hospital. EMS brought in some dude who was beat up with a baseball bat or pipe, and had an obvious maxillary fracture, nasal fracture and other things. They brought him in on a stretcher and I took one look at this guy and said "Why the F$@#K did you bring this guy here? The level one trauma center is 5 minutes away!" They gave me some non-sense answer like he wasn't all that bad.

Nurses got vitals...i look at the guy and at his face. He was talking to me normally, not altered, his vitals were normal. I never did a formal MSE. I never got him off the gurney and told EMS to take him to the trauma center 5 minutes away. I learned later on that he had an orbital wall Fx, required oculoplastics, and had some other non-life threatening injuries to his face. Nothing to the C/A/P. he got appropriate and timely care.

I think the other hospital learned about it and talked to our hospital, and my hospital apologized...but the other hospital didn't call in an EMTALA violation. I think our hospital did it pre-emptively against itself.

One of the things the nurse inspector said was "Did you listen to his lungs?" I did not...but what I said was he had no thoracic symptoms (pt admitted that), normal vital signs, normal respiratory motion and effort and that effectively excluded a life-threatening injury to the chest wall cavity and contents underneath it. Nobody hides a tension pneumothorax with no symptoms, normal vitals and normal visual thoracic exam. She didn't like that. She said I "needed to put a stethoscope to his chest."

Anyway...we argued that the patient got the absolute best, timely care by taking him immediately to a trauma center. His care would have suffered and been delayed had he stayed at my facility and I had to arrange a transfer. They acknowledged that and also said it doesn't matter. I think I was told that they understand that can be a limitation of the law but it's the law nonetheless.

We got a slap on the wrist...we all had to watch an EMTALA video. No fines. However what EMTALA violations do is uncover your entire documentation process and they were really pissed that our ER, for years, were not filling out the EMTALA forms properly for actual real, legit, accepted transfers.

 

[Siggy]

I assume you meant EMTALA and not HIPAA, but the answer is no.

A patient requesting transfer can be used as a reason for transferring an "unstabilized" patient which would otherwise produce a EMTALA violation.
E.g. Wound vac guy has an infection requiring surgical debridement. My hospital can handle it, but the patient wants to go to where it was performed and requests so. The other hospital accepts. Everyone wins.

If, however, in the same scenario the other hospital REFUSES... that's fine. Again, this assumes that my hospital is capable of providing the required treatment, even though staff AND the patient would prefer that the patient go elsewhere.

In that scenario, the patient is of course free to sign out AMA and then self present to the original hospital.

Sorry, yes, EMTALA...

 

[DrSnips]

Learning a lot about EMTALA in this thread.

Question: At one point my boss said not to accept transfers from outside hospitals unless our hospital offered a service not available at the outside hospital (e.g. IR, endoscopy, etc.). It sounds like it would potentially be an EMTALA violation to do this?

Scenario: Outside hospital calls me with a transfer. Patient admitted there with bad psoriasis flare, now under better control. They want to transfer him to my hospital to get him "plugged in" with a very well-known dermatologist. The patient is ready for discharge from their standpoint, but they think he won't follow up with the well-known dermatologist unless he sees them in the hospital first. I declined the transfer. Was the patient's readiness for discharge at the sending hospital the only thing that prevents this from being an EMTALA violation? As in, if they were still treating him (with derm consult available at their hospital) it would have been an EMTALA violation to refuse the transfer?

 

[Dr Mantis Toboggan]

Learning a lot about EMTALA in this thread.

Question: At one point my boss said not to accept transfers from outside hospitals unless our hospital offered a service not available at the outside hospital (e.g. IR, endoscopy, etc.). It sounds like it would potentially be an EMTALA violation to do this?

Scenario: Outside hospital calls me with a transfer. Patient admitted there with bad psoriasis flare, now under better control. They want to transfer him to my hospital to get him "plugged in" with a very well-known dermatologist. The patient is ready for discharge from their standpoint, but they think he won't follow up with the well-known dermatologist unless he sees them in the hospital first. I declined the transfer. Was the patient's readiness for discharge at the sending hospital the only thing that prevents this from being an EMTALA violation? As in, if they were still treating him (with derm consult available at their hospital) it would have been an EMTALA violation to refuse the transfer?

Playing with fire if you routinely deny transfers IMO.

 

[southerndoc]

Sounds like it's more about standard of care than whether you "stabilized" the patient.

Which makes discharging low risk chest pain problematic, for instance. Because I can quote all the HEART score and Kaiser data of 200,000 people showing that discharging low risk chest pain is actually extremely safe...but if there is a bad outcome which had a probability of 0.8% per the literature...then the OIG can say you didn't do the standard of care and stabilize the patient (even to this day...a lot of ER physicians admit low risk chest pain despite excellent data that it doesn't need to be admitted.)

You really need to write publish a book on all those 100 EMTALA cases. Each one can be summarized on 1 page. I would pay for that book. I would pay $50 for that. I'm serious! There has to be something, somewhere, that gives a cliff-notes version of numerous EMTALA cases. Get 10,000 people to pay $50...and gross margins are $500,000. Maybe you make 35% of that?!?!



I suffered an EMTALA violation against me once. Thankfully it didn't result in a fine just a slap on the wrist to me and my hospital. One of the hospitals I work at is not a trauma center. But the level 1 county trauma center is literally 5 minutes away from my hospital. EMS brought in some dude who was beat up with a baseball bat or pipe, and had an obvious maxillary fracture, nasal fracture and other things. They brought him in on a stretcher and I took one look at this guy and said "Why the F$@#K did you bring this guy here? The level one trauma center is 5 minutes away!" They gave me some non-sense answer like he wasn't all that bad.

Nurses got vitals...i look at the guy and at his face. He was talking to me normally, not altered, his vitals were normal. I never did a formal MSE. I never got him off the gurney and told EMS to take him to the trauma center 5 minutes away. I learned later on that he had an orbital wall Fx, required oculoplastics, and had some other non-life threatening injuries to his face. Nothing to the C/A/P. he got appropriate and timely care.

I think the other hospital learned about it and talked to our hospital, and my hospital apologized...but the other hospital didn't call in an EMTALA violation. I think our hospital did it pre-emptively against itself.

One of the things the nurse inspector said was "Did you listen to his lungs?" I did not...but what I said was he had no thoracic symptoms (pt admitted that), normal vital signs, normal respiratory motion and effort and that effectively excluded a life-threatening injury to the chest wall cavity and contents underneath it. Nobody hides a tension pneumothorax with no symptoms, normal vitals and normal visual thoracic exam. She didn't like that. She said I "needed to put a stethoscope to his chest."

Anyway...we argued that the patient got the absolute best, timely care by taking him immediately to a trauma center. His care would have suffered and been delayed had he stayed at my facility and I had to arrange a transfer. They acknowledged that and also said it doesn't matter. I think I was told that they understand that can be a limitation of the law but it's the law nonetheless.

We got a slap on the wrist...we all had to watch an EMTALA video. No fines. However what EMTALA violations do is uncover your entire documentation process and they were really pissed that our ER, for years, were not filling out the EMTALA forms properly for actual real, legit, accepted transfers.

Was this in 2019?

I've thought about writing a book. Maybe I'll do so.

You highlight an important point: a nurse does the initial review and a CMS regional medical director reviews their findings before sending to OIG.

 

[southerndoc]

Learning a lot about EMTALA in this thread.

Question: At one point my boss said not to accept transfers from outside hospitals unless our hospital offered a service not available at the outside hospital (e.g. IR, endoscopy, etc.). It sounds like it would potentially be an EMTALA violation to do this?

Scenario: Outside hospital calls me with a transfer. Patient admitted there with bad psoriasis flare, now under better control. They want to transfer him to my hospital to get him "plugged in" with a very well-known dermatologist. The patient is ready for discharge from their standpoint, but they think he won't follow up with the well-known dermatologist unless he sees them in the hospital first. I declined the transfer. Was the patient's readiness for discharge at the sending hospital the only thing that prevents this from being an EMTALA violation? As in, if they were still treating him (with derm consult available at their hospital) it would have been an EMTALA violation to refuse the transfer?

No, this is not an EMTALA violation. EMTALA does not apply to admitted inpatient transfers (yet). I say yet because there is always a test case that can bend the rules as many of the previous EMTALA violations don't really violate the statute as it reads.

 

[Arcan57]

Learning a lot about EMTALA in this thread.

Question: At one point my boss said not to accept transfers from outside hospitals unless our hospital offered a service not available at the outside hospital (e.g. IR, endoscopy, etc.). It sounds like it would potentially be an EMTALA violation to do this?

Scenario: Outside hospital calls me with a transfer. Patient admitted there with bad psoriasis flare, now under better control. They want to transfer him to my hospital to get him "plugged in" with a very well-known dermatologist. The patient is ready for discharge from their standpoint, but they think he won't follow up with the well-known dermatologist unless he sees them in the hospital first. I declined the transfer. Was the patient's readiness for discharge at the sending hospital the only thing that prevents this from being an EMTALA violation? As in, if they were still treating him (with derm consult available at their hospital) it would have been an EMTALA violation to refuse the transfer?

So the biggest misconception for receiving hospitals is that they get to pick and choose what they accept based on circumstances other than capacity and capability. They don't. As mentioned before, if you have capacity (beds, OR availability, etc) and capability (you can currently offer that service to your own patients) then you have to accept the patient. You can turn around and file a complaint against the transferring facility but you have to take the patient.

In the case mentioned above, the patient was admitted in good faith to an inpatient facility and in most cases that's going to end the EMTALA obligation. So in most cases, EMTALA will not apply to inpatient transfers. If the same patient was in the ED, you'd need to take them and sort it out on the backend.

 

[dadaddadaBATMAN]

Learning a lot about EMTALA in this thread.

Question: At one point my boss said not to accept transfers from outside hospitals unless our hospital offered a service not available at the outside hospital (e.g. IR, endoscopy, etc.). It sounds like it would potentially be an EMTALA violation to do this?

Scenario: Outside hospital calls me with a transfer. Patient admitted there with bad psoriasis flare, now under better control. They want to transfer him to my hospital to get him "plugged in" with a very well-known dermatologist. The patient is ready for discharge from their standpoint, but they think he won't follow up with the well-known dermatologist unless he sees them in the hospital first. I declined the transfer. Was the patient's readiness for discharge at the sending hospital the only thing that prevents this from being an EMTALA violation? As in, if they were still treating him (with derm consult available at their hospital) it would have been an EMTALA violation to refuse the transfer?

That’s beyond absurd.

If they aren’t going to follow up having them seen once by derm helps nothing.

And how (and WHY) the hell did someone admit a psoriasis flair? Is that code for missed sjs or something? Or was it initially misdiagnosed as cellulitis?

 

[sunshinefl]

That’s beyond absurd.

If they aren’t going to follow up having them seen once by derm helps nothing.

And how (and WHY) the hell did someone admit a psoriasis flair? Is that code for missed sjs or something? Or was it initially misdiagnosed as cellulitis?

Not the one you responded too but I’ve had a patient on our service primarily admitted for psoriasis that was so bad it was multi layer scaling covering 68% of his body, with multiple open sores, and made it hard for him to move.

 

[dadaddadaBATMAN]

Not the one you responded too but I’ve had a patient on our service primarily admitted for psoriasis that was so bad it was multi layer scaling covering 68% of his body, with multiple open sores, and made it hard for him to move.

Huh. Never seen anything even close to that extensive, I believe it though. I imagine that would be fairly high risk for superinfection as well. Maybe I’ve been away from the tertiary/quartenary for too long

 

[DrSnips]

Playing with fire if you routinely deny transfers IMO.

Yeah, I feel like I accept 99% of them. I try to give the benefit of the doubt.

So in most cases, EMTALA will not apply to inpatient transfers. If the same patient was in the ED, you'd need to take them and sort it out on the backend.

Well that's fortunate, as I mostly get called about inpatient to inpatient. And virtually all of the ER to inpatient ones I've gotten are no brainers to accept anyway because it's for some specialist consult they don't have. But now I know there's not even really a choice to decline them, so I will keep that in mind. I feel like no one ever educated us about this aspect of EMTALA in med school or residency.

 

[dadaddadaBATMAN]

Yeah, I feel like I accept 99% of them. I try to give the benefit of the doubt.


Well that's fortunate, as I mostly get called about inpatient to inpatient. And virtually all of the ER to inpatient ones I've gotten are no brainers to accept anyway because it's for some specialist consult they don't have. But now I know there's not even really a choice to decline them, so I will keep that in mind. I feel like no one ever educated us about this aspect of EMTALA in med school or residency.

Honestly I think I learned more from my director first year out of residency about emtala than I did from anyone in residency.

 

[RoyBasch]

What about a patient with a UTI? You can give them antibiotics but they are not completely treated, as you write. Treatment has been initiated.
There is no reason to expect a routine, uncomplicated UTI, will decompensate after initiating antibiotics.

Same with a wound vac. if there is some cellulitis around it, and vitals are normal and there is no leukocytosis...basically you can give Abx and not transfer them. They can see their surgeon in the next few days.

If it is a completely uncomplicated UTI, why would you be transferring the patient at all? EMTALA does not apply to discharged patients.

Same with the wound vac, if you think it is a simple wound infection, and you call their surgeon and they advise discharge them on antibiotics to follow up, then there is no need to transfer at all and EMTALA does not apply.

The problem starts if you feel the wound vac problem is complicated enough that a surgeon has to see and consult on them today. Ultimately the wound vac problem may be deemed trivial and the surgeon--after evaluating the patient--may determine the patient clear for discharge with no further care. However, once you decide the patient needs to see a surgeon, they are no longer "EMTALA-stable" UNTIL the surgeon sees them. Remember until the actual problem is treated until patient is dischargable, or the imagined problem is ruled out (and in this case the rule out requires a surgical consultation). And now the EMTALA games begin, if you want to transfer for eval.

 

[southerndoc]

If it is a completely uncomplicated UTI, why would you be transferring the patient at all? EMTALA does not apply to discharged patients.

Same with the wound vac, if you think it is a simple wound infection, and you call their surgeon and they advise discharge them on antibiotics to follow up, then there is no need to transfer at all and EMTALA does not apply.

The problem starts if you feel the wound vac problem is complicated enough that a surgeon has to see and consult on them today. Ultimately the wound vac problem may be deemed trivial and the surgeon--after evaluating the patient--may determine the patient clear for discharge with no further care. However, once you decide the patient needs to see a surgeon, they are no longer "EMTALA-stable" UNTIL the surgeon sees them. Remember until the actual problem is treated until patient is dischargable, or the imagined problem is ruled out (and in this case the rule out requires a surgical consultation). And now the EMTALA games begin, if you want to transfer for eval.

EMTALA can and has been applied to discharged patients when you fail to provide a medical screening exam or stabilize their condition.

 

[alphaholic06]

Would it be an EMTALA violation if a hospital reserves beds for scheduled, non-emergent surgical patients, but transfers ER patients requiring admission to another hospital to keep those beds reserved for the high-paying elective surgery patients?

I think every place I’ve ever worked did some version of this.

 

[southerndoc]

I think every place I’ve ever worked did some version of this.

I initially missed the question by @miacomet , but yes, reserving a bed for a surgical patient and then transferring a patient for lack of capacity while you have an available/scheduled bed is an EMTALA violation. However, if the bed isn't staffed at the time, but will be staffed by scheduling in a few hours, then no, it's not an EMTALA violation.

Likewise, failure to accept a transfer while you're holding a bed means you had capacity and committed an EMTALA violation. If the patient is already on the premises (i.e., in the OR), then that bed isn't scheduled but is considered to be in use.

 

[thegenius]

Was this in 2019?

I've thought about writing a book. Maybe I'll do so.

You highlight an important point: a nurse does the initial review and a CMS regional medical director reviews their findings before sending to OIG.

Could have been, why? I don't remember the exact year.

 

[southerndoc]

Could have been, why? I don't remember the exact year.

Just wondering if it was the case I have on file. There were two that year similar to what you presented.

 

[bravotwozero]

So I got a question for you guys.

I work at a level 3 trauma center, where you have Neuro Surgery on call. Thing is, these guys never do anything, and make us transfer everything out for 'higher level of care', this includes brain bleed, almost all spinal fractures, cord compressions, etc. The excuse alway given to me is 'we don't have the capability/facilities to handle these conditions', which I don't find very convincing.

Given that these guys are on call, we technically have Neurosurgical capabilities, wouldn't this constitute an EMTALA violation?

I'm inclined to talk to my medical director about this, and tell him to run this by the hospital's legal team. If/when they concur that what NSG is doing is a bad idea, he can maybe get med exec to tell them either start doing their jobs or get off the call list - frankly i'd prefer the latter, since we'd be on much stable ground there EMTALA wise.

Let me know your thoughts.

 

[Arcan57]

So I got a question for you guys.

I work at a level 3 trauma center, where you have Neuro Surgery on call. Thing is, these guys never do anything, and make us transfer everything out for 'higher level of care', this includes brain bleed, almost all spinal fractures, cord compressions, etc. The excuse alway given to me is 'we don't have the capability/facilities to handle these conditions', which I don't find very convincing.

Given that these guys are on call, we technically have Neurosurgical capabilities, wouldn't this constitute an EMTALA violation?

I'm inclined to talk to my medical director about this, and tell him to run this by the hospital's legal team. If/when they concur that what NSG is doing is a bad idea, he can maybe get med exec to tell them either start doing their jobs or get off the call list - frankly i'd prefer the latter, since we'd be on much stable ground there EMTALA wise.

Let me know your thoughts.

We were in same boat back when I was at a Level 3. We actually did have a SDH that the surgeon evacuated once. The nursing staff managed to traumatically remove the ventric drain in the elevator after surgery. Patient died. That was the end of us trying to take care of ICH at our facility.

 

[RoyBasch]

EMTALA can and has been applied to discharged patients when you fail to provide a medical screening exam or stabilize their condition.

Yes you are correct.

I assumed in the cases above the patients were seen and a medical screening exam done. If you decline to see the patient entirely then definitely an EMTALA violation.

 

[RoyBasch]

So I got a question for you guys.

I work at a level 3 trauma center, where you have Neuro Surgery on call. Thing is, these guys never do anything, and make us transfer everything out for 'higher level of care', this includes brain bleed, almost all spinal fractures, cord compressions, etc. The excuse alway given to me is 'we don't have the capability/facilities to handle these conditions', which I don't find very convincing.

Given that these guys are on call, we technically have Neurosurgical capabilities, wouldn't this constitute an EMTALA violation?

I'm inclined to talk to my medical director about this, and tell him to run this by the hospital's legal team. If/when they concur that what NSG is doing is a bad idea, he can maybe get med exec to tell them either start doing their jobs or get off the call list - frankly i'd prefer the latter, since we'd be on much stable ground there EMTALA wise.

Let me know your thoughts.

Curious as well, I’ve had similar grey areas at level II and III trauma centers that give me a lot of anxiety. Generally I call the surgeon, and if they say they/we can't do a certain thing, then I don't feel l can tell them what their scope of practice is. I just document in my note the surgeon (full name, title, time and date of contact) informed me they could not deal with that problem and requested transfer. Therefore if EMTALA stuff blows back it will be pretty clear who compelled (surgeon) the transfer. But yeah a neurosurgeon telling me they (or the institution) cant handle a SDH definitely makes me uncomfortable.

 

[WheezyBaby]

Piggybacking on the emtala thread. In a prior employment situation, I was staff at both a major academic medical center and a community hospital run under the same organization. If I was currently at the community hospital and thought a patient in an ED would be better cared for at the academic center (sometimes for "soft" reasons, eg currently meeting admission criteria for the community hospital, but perceived likelihood of eventually needing academic center resources), I would coordinate admission to the academic center instead. Was this running EMTALA risk?

 

[thegenius]

Piggybacking on the emtala thread. In a prior employment situation, I was staff at both a major academic medical center and a community hospital run under the same organization. If I was currently at the community hospital and thought a patient in an ED would be better cared for at the academic center (sometimes for "soft" reasons, eg currently meeting admission criteria for the community hospital, but perceived likelihood of eventually needing academic center resources), I would coordinate admission to the academic center instead. Was this running EMTALA risk?

I don't think so because this has something to do with what CMS hospital ID your hospitals work under. If your hospital's legal identity is called "EMTALA SUCKS HEALTH CENTER" and you operate 4 hospitals all within a region and it's all under the same CMS ID...I think you can freely transfer patients from one center to another with EMTALA concerns.

It's like transferring someone from the hospital floor to the ICU. That isn't an EMTALA violation.

 

[RoyBasch]

The sad thing is you just roll the dice. Severe migraine headache that responds to pain medication? All is well. Doesn't respond and you don't CT? Well, bad outcome could trigger an EMTALA.

You never know which patient will trigger an EMTALA. Those that are stable upon discharge for atypical chest pain, go home and die could trigger an EMTALA. It's all who you get for inspector and how OIG interprets things.

Im genuinely asking here because I think you are one of the better authorities on EMTALA on this board:

How can the headache patient and chest pain patient's trigger EMTALA?

Assuming the patient is seen and examined (a MSE is performed) the EMTALA requirement is satisfied correct?

You could still commit malpractice, i.e. not meet standard of care in your treatment plan and miss a diagnosis and patient suffer a bad outcome, but I don't see how this is also am EMTALA violation.

For example. You have a chest pain patient. You perform a complete history and exam, vital signs are performed. MSE is done. You suspect it to be GERD. You determine that a medical emergency is ruled out by your history and exam. At this point the imagined medical emergency has been ruled out. You are not transferring the patient and you do not think they need any further inpatient or ER care. So you discharge the patient with PPI and GI follow up. They go home and die of a missed ACS. Yes there may be a medical error here. Yes some reviewing experts would say that there were risk factors or whatever and you should have gotten a troponin and EKG. Or maybe you got those and they were normal, but said experts could say that wasn't an adequate workup as the patient was higher risk than you thought and they should have been admitted, etc.

My thought is the problem here is potential malpractice, but I'm not understanding how EMTALA applies as the patient was seen, thought to be stable, and no transfer was requested.

 

[gutonc]

Im genuinely asking here because I think you are one of the better authorities on EMTALA on this board:

How can the headache patient and chest pain patient's trigger EMTALA?

Assuming the patient is seen and examined (a MSE is performed) the EMTALA requirement is satisfied correct?

You could still commit malpractice, i.e. not meet standard of care in your treatment plan and miss a diagnosis and patient suffer a bad outcome, but I don't see how this is also am EMTALA violation.

For example. You have a chest pain patient. You perform a complete history and exam, vital signs are performed. MSE is done. You suspect it to be GERD. You determine that a medical emergency is ruled out by your history and exam. At this point the imagined medical emergency has been ruled out. You are not transferring the patient and you do not think they need any further inpatient or ER care. So you discharge the patient with PPI and GI follow up. They go home and die of a missed ACS. Yes there may be a medical error here. Yes some reviewing experts would say that there were risk factors or whatever and you should have gotten a troponin and EKG. Or maybe you got those and they were normal, but said experts could say that wasn't an adequate workup as the patient was higher risk than you thought and they should have been admitted, etc.

My thought is the problem here is potential malpractice, but I'm not understanding how EMTALA applies as the patient was seen, thought to be stable, and no transfer was requested.

The answer to your questions is in the last sentence of the post from @southerndoc that you quoted.

The flaw in your analysis is that you're expecting rational, educated behavior on the part of all involved parties. Which is clearly not the norm.

A completely reasonable question to ask is "where would the EMTALA complaint come from?". But lawyers gonna lawyer, so there's that.