EMTALA Questions

[docB]

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I’ve had a few questions in mind about EMTALA lately and I thought they might make for interesting discussion. For the more junior among us who don’t know much about EMTALA this might be a chance to learn. For those who are thinking “What’s EMTALA?” you should do some research as there will be a test later.

Ok. Here’s the scenario:

An EP at hospital A sees an ortho patient. The EP examines the patient and feels that an immediate ortho consult is warranted. He calls the ortho on call. The ortho on call listens to the description of the case and disagrees that an immediate consult is needed. The ortho instructs the EP to discharge the patient to follow up in the ortho’s office. The EP insists that the ortho see the patient immediately. The ortho ultimately refuses to come in and see the patient. No other orthos are available so the EP transfers the patient to hospital B as a higher level of care for ortho services. As is required by EMTALA the EP documents the refusal of the ortho and puts his name on the transfer paperwork. Also as required by EMTALA hospital B files an EMTALA complaint against the ortho and hospital A. Now the twist. The EP at hospital B examines the patient and discusses the case with his ortho on call. They agree that no emergent consult is required and discharge the patient.

So who, if anyone, is in violation? Clearly the ortho on call at hospital A failed to come in to see the patient but his opinion that no consult was warranted has been validated by the receiving hospital’s EP and ortho. So is he in the clear? Is the transferring EP now in violation for transferring something inappropriately?

 

[DogFaceMedic]

Good scenario.
I don't think there is an EMTALA violation by anyone because each provider made the best decision with factrs at hand. The EP's judgement was not to discharge and was responsible, so he tranferred care so that ortho B was now responsible to decide in his best judgement.

Whether they made the right medical judgement is one issue, but they did make the right EMTALA judgements.

THe now damaged relationship between EP and ortho A is a different can of worms. But I would never trust a consult over the phone, when my judgement says otherwise. When in doubt CYA, there are lawyers out there.

 

[kungfufishing]

but is it possible to accurately assess an emergency patient on the phone? I dont think that the fact that Ortho A ended up being correct removes the fact that he placed the patient at an increased risk - lack of timely evaluation as well as an unnecessary transfer.

 

[FoughtFyr]

I’ve had a few questions in mind about EMTALA lately and I thought they might make for interesting discussion. For the more junior among us who don’t know much about EMTALA this might be a chance to learn. For those who are thinking “What’s EMTALA?” you should do some research as there will be a test later.

Ok. Here’s the scenario:

An EP at hospital A sees an ortho patient. The EP examines the patient and feels that an immediate ortho consult is warranted. He calls the ortho on call. The ortho on call listens to the description of the case and disagrees that an immediate consult is needed. The ortho instructs the EP to discharge the patient to follow up in the ortho’s office. The EP insists that the ortho see the patient immediately. The ortho ultimately refuses to come in and see the patient. No other orthos are available so the EP transfers the patient to hospital B as a higher level of care for ortho services. As is required by EMTALA the EP documents the refusal of the ortho and puts his name on the transfer paperwork. Also as required by EMTALA hospital B files an EMTALA complaint against the ortho and hospital A. Now the twist. The EP at hospital B examines the patient and discusses the case with his ortho on call. They agree that no emergent consult is required and discharge the patient.

So who, if anyone, is in violation? Clearly the ortho on call at hospital A failed to come in to see the patient but his opinion that no consult was warranted has been validated by the receiving hospital’s EP and ortho. So is he in the clear? Is the transferring EP now in violation for transferring something inappropriately?

EP A is not in violation at all. He transferred a patient for whom appropriate care was not available (or willing to come in) at hospital A. The ortho at hospital A is still in violation. The violation occurs when the EP asks him/her to come in and they refuse. The actions taken by hospital B (in terms of patient treatment) do not matter.

Let me give you an example. Hospital A only has one neurologist/neurosurgeon who is on vacation. At that time, hospital A is "uncovered" for neuro problems. A patient comes in - 45 yo F with a history of migraines comes in with a 30 minute course of the worst migraine of her life and left arm weakness. The EP on duty immediately transfers the patient to hospital B where both neurology and neurosurgery are available (I think we'd all agree appropriately). By the time the patient arrives at hospital B, all symptoms have resolved, including the headache. The EP at hospital B discharges the patient with a dx of "complex migraine" - without a neuro consult. Does that make the EP from hospital A wrong to transfer the patient?

- H

 

[Faebinder]

This is the EM forums and I am not an EP (nor will be)... but I see two extremes here.

EP labeled as consult *****....

Ortho labeled as an arrogant jerk and an a$$...

What was done was by ortho was inappropriate....

However... I would like to know more about the case... Maybe the EP was truly truly being rediculous.. EP are trained to handle everything minor and some moderate things without the need for consults.... so the question that jumps to mind is..... Was this a case of "Why are you wasting my time?" and I need to know if the people involved were residents or attendings (sounds like attendings).

If this was truly the case.... then the ortho should have taken it up the proper channels... there is no need for to directly piss down the EP throat.

If this was in the morning.... call the chairman of the EM department and discuss this BS. If this continue, then discuss it with the chair of ortho and the rest of the ortho attendings and have a meeting between the chairs of the department and a hospital adminstrator on what is acceptable and not acceptable.

If this is at night, then just go the next day and present the case and complaint to an adminstrator and the chairman of the department... and follow the same process... Draw your lines....

The above I think is the sane way to do it... some people dont know how to be sane.

 

[kungfufishing]

EMTALA is the required by law way to do it.

 

[DogFaceMedic]

I don't think ortho A's inaction is a violation if the case was a judgement call. If he clearly was being lazy then it is a violation. But, if it is a reasonable difference of opinion, then he's OK - and still lazy.

Much of the debate hangs on whether it was a reasonable vs a lazy decision. Reasonable and wrong is usually OK; unreasonable and wrong attracts flies.

 

[deleted109597]

Ortho A can probably get off if he has some EBL stating that cases where this angulation, etc, were successfully followed up as an outpatient. Or, if the EP states that he/she was able to reduce the fracture, then the ortho guy can probably follow up OP as well. There are so many vagueries in EMTALA, that barring some negative/adverse outcome, nothing will happen to the Ortho guy.

Unless he/she does it a dozen times.

 

[cbrad]

Refusing to come and consult on a patient that is deemed emergent by the emergency physician when you are on call that results in a transfer is in my opinion an EMTALA violation

 

[docB]

This is the EM forums and I am not an EP (nor will be)... but I see two extremes here.

EP labeled as consult *****....

Ortho labeled as an arrogant jerk and an a$$...

What was done was by ortho was inappropriate....

However... I would like to know more about the case... Maybe the EP was truly truly being rediculous.. EP are trained to handle everything minor and some moderate things without the need for consults.... so the question that jumps to mind is..... Was this a case of "Why are you wasting my time?" and I need to know if the people involved were residents or attendings (sounds like attendings).

This was a hypothetical case. I didn't give it a specific injury because then we get away from the EMTALA issues and into a discussion about the specific injury and if that injury is routinely or ever in a million years seen as an outpt.

 

[FoughtFyr]

Ortho A can probably get off if he has some EBL stating that cases where this angulation, etc, were successfully followed up as an outpatient. Or, if the EP states that he/she was able to reduce the fracture, then the ortho guy can probably follow up OP as well. There are so many vagueries in EMTALA, that barring some negative/adverse outcome, nothing will happen to the Ortho guy.

Unless he/she does it a dozen times.

Doesn't matter. Ortho A is wrong at the time EP A says "come in" and he doesn't. From: http://www.physiciansnews.com/law/706kothmann.html

"Disagreement Between Emergency Physician and On-Call Specialist. While the emergency physician and the on-call specialist may need to discuss the best way to meet the individual’s medical needs, any disagreement regarding the need for an on-call physician to come to the hospital and examine the individual must be resolved by deferring to the medical judgment of the emergency physician or other practitioner who has personally examined the individual". {emphasis added}​

What ends up happening at hospital B does NOT effect the liability of ortho A.

- H

 

[RuralMedicine]

Without knowing further details:

-EP A may be bordering on inept or may not but is not in violation of EMTALA (they felt the patient needed emergent orthopedics consultation and facilitated what their patient needed).
-Ortho A is in violation of EMTALA basically they either needed to reassure EP A over the phone that their plan was sound or come and see the patient in the ED and then D/C home if indicated. They are allowed a cathartic scream enroute and they are allowed to go through appropriate channels to address EP A's ineptitude (if it exists). Ortho A may also consider resigning privileges at Hospital A if the situation is not resolved to their liking. However, since Ortho A would not come see the patient when they were on call they are indeed in violation of EMTALA (and I would presume are losing privileges at Hospital A).
-EP B accepted the patient and provided appropriate care. No EMTALA or clinical problems it appears.
-Ortho B evaluated the patient in the ED and gets a gold star for playing nicely with the other EP. The fact that Ortho B agreed with Ortho A's plan may support Ortho A in his disciplinary hearing, however, it doesn't change the fact that he would not come in when requested by EP A.

Actually the above scenario played out at our institution recently with one critical difference...Ortho on call came in to see the patient, wrote a nifty consultation note, discharged the patient. Apparently they have had recurrent problems with the physician in question and made a futile final attempt to resolve the situation. As their attempt was futile they resigned privileges 48 hours after the incident. We now have minimal orthopedics coverage....

 

[docB]

Ok. Here's another one:

Hospital A is a small, non-trauma center, community hospital with an ED that is building a medical office building on its campus. A construction worker falls three stories. EMS responds and finds him with several open long bone fractures, a grossly unstable pelvis and a GCS of 6. He is successfully intubated on scene and packaged in full C-spine. HR 128, BP 92/40, Resp BVM.

Where should EMS transport this patient?

If EMS transports to the trauma center without talking to the ED at hospital A has either EMS or Hospital A comitted an EMTALA violation?

If EMS calls the ED at hospital A and hospital A directs EMS to transport to the trauma center have they violated EMTALA?

 

[kungfufishing]

I think EMTALA specifies "on campus", which means this patient should be stabilized at the nearby hospital and transported. However, I think this should be a med control decision and depends on where the trauma center is - the facility described as closest certainly is not the most appropriate, and if the trauma center is nearby you can run IVF wide open in the back of a truck just like you could in this hospital's exam room, observing it come out the other side.

 

[Seaglass]

This would qualify as "on campus" I would think and the patient should be seen in the local ED. I disagree that transfer to another hospital, even if close, would be OK. This patient is certainly unstable and may have other acute processes that can be quickly corrected and stabilized prior to transfer. There is certainly the argument that what he needs is an OR, but you can still do that in a timely manner I think. Just my 2 cents.

 

[Seaglass]

Also I think it becomes and issue when EMS says "We want to come to you, little hospital" and the little hospital guys refuse. If EMS spontaneously takes him to Mega Hospital then I doubt it is an issue.

 

[Flopotomist]

Ok. Here's another one:

Hospital A is a small, non-trauma center, community hospital with an ED that is building a medical office building on its campus. A construction worker falls three stories. EMS responds and finds him with several open long bone fractures, a grossly unstable pelvis and a GCS of 6. He is successfully intubated on scene and packaged in full C-spine. HR 128, BP 92/40, Resp BVM.

Where should EMS transport this patient?

If EMS transports to the trauma center without talking to the ED at hospital A has either EMS or Hospital A comitted an EMTALA violation?

If EMS calls the ED at hospital A and hospital A directs EMS to transport to the trauma center have they violated EMTALA?

I am a bit confused about the scenario. The worker fell on the campus of the medical center - yet EMS got there and found him before ED staff that responds to medical emergencies found him? Sounds like the EMTALA issue is the least of the hospital's concerns!

 

[NinerNiner999]

😕

 

[flighterdoc]

Ok. Here's another one:

Hospital A is a small, non-trauma center, community hospital with an ED that is building a medical office building on its campus. A construction worker falls three stories. EMS responds and finds him with several open long bone fractures, a grossly unstable pelvis and a GCS of 6. He is successfully intubated on scene and packaged in full C-spine. HR 128, BP 92/40, Resp BVM.

Where should EMS transport this patient?

If EMS transports to the trauma center without talking to the ED at hospital A has either EMS or Hospital A comitted an EMTALA violation?

If EMS calls the ED at hospital A and hospital A directs EMS to transport to the trauma center have they violated EMTALA?

EMTALA only applies when a hospital is responsible for the patient - and a building under construction doesn't qualify as 'on campus', it's NOT a medical facility (yet).

EMS should transport to whichever facility their local medical command has designated in their protocols - it sounds like a trauma center call to me, but if the transport time is too long or the patient is too unstable (as determined by medical control) then take them to the nearest APPROPRIATE hospital.

 

[flighterdoc]

I am a bit confused about the scenario. The worker fell on the campus of the medical center - yet EMS got there and found him before ED staff that responds to medical emergencies found him? Sounds like the EMTALA issue is the least of the hospital's concerns!

ED personnel are not trained nor equipped to rescue and stabilize people from accident sites - EMS / Fire is. Aside from not knowing what the hell they're doing in a rescue, what about the risk to the ED 'rescuers' in going into an accident site without PPE? Thats an OSHA violation.

 

[flighterdoc]

Also I think it becomes and issue when EMS says "We want to come to you, little hospital" and the little hospital guys refuse. If EMS spontaneously takes him to Mega Hospital then I doubt it is an issue.

Thats right...unless EMS is owned by the Big Hospital...then it gets complicated

 

[FoughtFyr]

EMTALA only applies when a hospital is responsible for the patient - and a building under construction doesn't qualify as 'on campus', it's NOT a medical facility (yet).

EMS should transport to whichever facility their local medical command has designated in their protocols - it sounds like a trauma center call to me, but if the transport time is too long or the patient is too unstable (as determined by medical control) then take them to the nearest APPROPRIATE hospital.

I hate to disagree with you, but coming from EMS in Chicago (Ravenswood was the site of the PR disaster that led to this rule) I am certain that the building does qualify as a hospital. In fact, by EMTALA, EMS shouldn't be involved.

The 250-yard rule comes from the definition of "Campus" found at 42 CFR 413.65:

"Campus means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider’s campus."

You can read more at: http://www.emtala.com/250yard.htm

I do agree with you however, that the OSHA would have a field day if a medical response team went to pick up this patient. "Alphabet soup fights" are always entertaining if you are not involved. But as the question regarded EMTALA, by EMTALA EMS should not have been involved. The hospital's medical response team should have scooped the patient to the ED and transferred as appropriate.

- H

 

[docB]

So as expected we have lots of divergent opinions about this. It goes to show how complicated EMTALA is and how difficult compliance can be. My opinion on this one is that the construction project is on campus and the pateint should go to the small ED first and be transferred as needed. I think it is appropriate for EMS to be called as the ED doesn't have equipment or in most cases expertise in extrication and scene safety to get this pt. It could be argued that the proper sequence would be for the people on scene to call the ED and then for the ED to request EMS assistance.

 

[emtp6811]

I had a similar situation about a year and a half ago, from the EMS perspective. A man goes to the little community ED (read: urgent care clinic) and doesn't quite make it in from the parking lot. Code blue on July 4th. All of our ambulances are very busy at that point in the evening, and the county is stretched thin. So we get the call for a code blue in the parking lot just outside the bay doors of this hospital even though we are easily a 15-20 minute response time away. FYI, a local 911 helicopter is stationed behind this hospital with a coupe IFT ambulances b/c there is more room than at the main hospital downtown. So we get motating, but we are wondering why the ED doesn't just go out there, throw him on a gurney and take him in. Or better yet, have the flight team respond. It took us about 5-7 minutes into the response to express this to dispatch. Only after our suggestion was the flight team able to respond, with a couple ED nurses in tow. Apparently, nobody other than fire or EMS is allowed to respond to a 911 call unless given specific permission by EMS, unless it is *inside* the hospital.

I won't go into the clusterf*ck that took place when ED nurses tried to help the flight crew. Suffice it to say that ED personnel are not sufficiently trained for out-of-hospital care, as flighterdoc pointed out.

Granted, this may be a very local thing. Our county EMS agency has a death grip on the EMS turf here, and far more power than I think is appropriate. But EMTALA still applies, so food for thought.

 

[flighterdoc]

I hate to disagree with you, but coming from EMS in Chicago (Ravenswood was the site of the PR disaster that led to this rule) I am certain that the building does qualify as a hospital. In fact, by EMTALA, EMS shouldn't be involved.

The 250-yard rule comes from the definition of "Campus" found at 42 CFR 413.65:

"Campus means the physical area immediately adjacent to the provider’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the HCFA regional office, to be part of the provider’s campus."

You can read more at: http://www.emtala.com/250yard.htm

I do agree with you however, that the OSHA would have a field day if a medical response team went to pick up this patient. "Alphabet soup fights" are always entertaining if you are not involved. But as the question regarded EMTALA, by EMTALA EMS should not have been involved. The hospital's medical response team should have scooped the patient to the ED and transferred as appropriate.

- H

And if you look at the entire regulation, you'll see that it applies only to facilities for which "provider based status is sought". A building under construction is not a medical facility (yet). It can only be classified a medical facility when a certificate of occupancy by the local building department is issued, and when an appropriate license by whomever licenses medical facilities in the jurisdiction. The proximity of a 50' hole in the ground, surrounded by personnel barricades is irrelevant to the discussion.

A remodel to an existing facility may be a different situation. Stupid laywers (also known as politicians) write bad laws.

Further, taking a patient in critical conditon (GCS 6) to a hospital that cannot care for them, when a more appropriate facility is nearby, is malpractice.

Another example: The VAMC hospital in West Los Angeles is a fairly modern hospital with ED (kind of) that is immediately adjacent to Interstate 405 at Wilshire Blvd in Los Angeles. Traffic accidents on the freeway or Wilshire Blvd are not taken to the VA hospital despite it's being within 250 yards of the freeway, in fact a 9-1-1 call on the VA campus (including within 250 yards of the hospital itself) are taken to UCLA Medical Center (which is perhaps 1.5 road miles away). No EMTALA violation accrues.

This section applies to all facilities for which provider-based status is sought, including remote locations of hospitals, as defined in paragraph (a)(2) of this section and satellite facilities as defined in § 412.22(h)(1) and § 412.25(e)(1) of this chapter, other than facilities described in paragraph (a)(1)(ii) of this section.

 

[FoughtFyr]

And if you look at the entire regulation, you'll see that it applies only to facilities for which "provider based status is sought". A building under construction is not a medical facility (yet). It can only be classified a medical facility when a certificate of occupancy by the local building department is issued, and when an appropriate license by whomever licenses medical facilities in the jurisdiction. The proximity of a 50' hole in the ground, surrounded by personnel barricades is irrelevant to the discussion.

Actually, the ED is the facility that has "provider based status". Additionally, the case provided said nothing about the ED being "under construction".

"Hospital A is a small, non-trauma center, community hospital with an ED that is building a medical office building on its campus. A construction worker falls three stories. EMS responds and finds him with several open long bone fractures, a grossly unstable pelvis and a GCS of 6. He is successfully intubated on scene and packaged in full C-spine. HR 128, BP 92/40, Resp BVM.​

A ED located in a building where remodeling is occuring is certainly subject to EMTALA for those injured during construction. The "provider based status" speaks to being a medicare/medicaid provider, not a healthcare provider for the injured patient. the rule that applies with specific regard to the patient in question is: "A person who presents anywhere on the hospital campus and requests emergency services, or who would appear to a reasonably prudent person to be in need of medical attention, must be handled under EMTALA.". A reasonably prudent person would conclude that the patient in the example required medical care.

Further, taking a patient in critical conditon (GCS 6) to a hospital that cannot care for them, when a more appropriate facility is nearby, is malpractice.

Now keep in mind that I am am paramedic (who has now gone to medical school). I'm sorry to tell you that the law (good or bad), considers any emergency department physician (regardless of the type residency training) to be superior to an EMT-P in stabilizing a patient. Second, under EMTALA, an unstable patient shouldn't be transferred. Malpractice is a legal term. You are mis-applying it here. If it were my family, I would agree with you. Go to the trauma center - do not pass go, do not collect $200.

Another example: The VAMC hospital in West Los Angeles is a fairly modern hospital with ED (kind of) that is immediately adjacent to Interstate 405 at Wilshire Blvd in Los Angeles. Traffic accidents on the freeway or Wilshire Blvd are not taken to the VA hospital despite it's being within 250 yards of the freeway, in fact a 9-1-1 call on the VA campus (including within 250 yards of the hospital itself) are taken to UCLA Medical Center (which is perhaps 1.5 road miles away). No EMTALA violation accrues.

The VAs are an exception to EMTALA throughout. But that is besides the point. Remember that stores, restaurants, etc. within 250 yards of an ED are exempt. I think that a street or freeway is clearly a "non-medical business". The bottom line is that, according to EMTALA, but against common sense, the construction worker in the example must be stabilized at the hospital where he was injured.

- H

 

[deleted109597]

At least they have fixed the hospital owned EMS problem that existed in EMTALA.

 

[kungfufishing]

This was a good case, I thought last night as I sat there unable to sleep (havent had that happen in months but it was bad!).

My thought was that this is a scenario in which EMTALA could actually contribute to M&M if the trauma center and OR this patient needs are close by but the law requires him to be evaluated/"stabilized" in ED A.

 

[FoughtFyr]

This was a good case, I thought last night as I sat there unable to sleep (havent had that happen in months but it was bad!).

My thought was that this is a scenario in which EMTALA could actually contribute to M&M if the trauma center and OR this patient needs are close by but the law requires him to be evaluated/"stabilized" in ED A.

True, but the question really becomes (in the setting of blunt trauma) is there an evidence based increase in morbidity or mortality by the outside facility stabilization. Remember, the patient can be transferred "unstable" if the benefits outweigh the risks, but in theory, even the small ED should be able to place CVA, chest tubes, and ETs. That will buy you a few minutes in most cases.

- H

 

[kungfufishing]

I think there is too much variability across non trauma centers to come up with good EBM, hence my suggestion that in an ideal world this should be a med control decision. The EMTP cant offer the dude a sheath or blood but say he could get 2 big peripherals and needle him if need be AND the trauma center is 5 minutes away.

OK I just like to hear myself type. In general of course I agree.

 

[dawg44]

I’ve had a few questions in mind about EMTALA lately and I thought they might make for interesting discussion. For the more junior among us who don’t know much about EMTALA this might be a chance to learn. For those who are thinking “What’s EMTALA?” you should do some research as there will be a test later.

Ok. Here’s the scenario:

An EP at hospital A sees an ortho patient. The EP examines the patient and feels that an immediate ortho consult is warranted. He calls the ortho on call. The ortho on call listens to the description of the case and disagrees that an immediate consult is needed. The ortho instructs the EP to discharge the patient to follow up in the ortho’s office. The EP insists that the ortho see the patient immediately. The ortho ultimately refuses to come in and see the patient. No other orthos are available so the EP transfers the patient to hospital B as a higher level of care for ortho services. As is required by EMTALA the EP documents the refusal of the ortho and puts his name on the transfer paperwork. Also as required by EMTALA hospital B files an EMTALA complaint against the ortho and hospital A. Now the twist. The EP at hospital B examines the patient and discusses the case with his ortho on call. They agree that no emergent consult is required and discharge the patient.

So who, if anyone, is in violation? Clearly the ortho on call at hospital A failed to come in to see the patient but his opinion that no consult was warranted has been validated by the receiving hospital’s EP and ortho. So is he in the clear? Is the transferring EP now in violation for transferring something inappropriately?

When do you ultimately trust that the ortho guy knows what he's talking about or vice versa? There has to be a middle ground between demanding an orthopod come tap a knee or deal with a nailbed vs. refusing to see an open tibia as you talked about in an earlier thread which obviously would get me out of bed. At home digital radiology helps a ton just because sometimes Xray description is atrocious. Yes, there is a big difference between the Radial Head and Radial Styloid. But I won't deny there are lazy orthopods as with members of all branches of medicine or sometimes people just don't hear the pager. In reality the ortho guy doesn't care about a possible EMTALA violation as much as if harm was done that is where his or her real liability is. Oh well it is nice to bypass all of this and be courtesy staff only and do almost all surgeries at a surgicenter.

 

[docB]

When do you ultimately trust that the ortho guy knows what he's talking about or vice versa?

EPs are pretty up on what the standard of care is for things. That's why we are really resistant to sending home "troponin leaks" and so on. Most EPs are pretty good about sending out stuff with quick follow up. When we are uncomfortable sending stuff out most of us a willing to admit it to the doc's service to be seen whenever they want given that we've documented what we think should happen. If even that isn't good enough because the consultant doesn't want to be bothered with the patient perion then the problems begin.

In reality the ortho guy doesn't care about a possible EMTALA violation as much as if harm was done that is where his or her real liability is. Oh well it is nice to bypass all of this and be courtesy staff only and do almost all surgeries at a surgicenter.

Both parts of this are true. Specialists don't care about EMTALA and don't think it applies to them until they get fined. Specialists can opt out of EMTALA obligations by dumping their hospital priveledges. That's how EMTALA has cost us all our specialty call panels. And to be honest if EPs could opt out of EMTALA lots of us would too.

 

[dawg44]

EPs are pretty up on what the standard of care is for things. That's why we are really resistant to sending home "troponin leaks" and so on. Most EPs are pretty good about sending out stuff with quick follow up. When we are uncomfortable sending stuff out most of us a willing to admit it to the doc's service to be seen whenever they want given that we've documented what we think should happen. If even that isn't good enough because the consultant doesn't want to be bothered with the patient perion then the problems begin.

Both parts of this are true. Specialists don't care about EMTALA and don't think it applies to them until they get fined. Specialists can opt out of EMTALA obligations by dumping their hospital priveledges. That's how EMTALA has cost us all our specialty call panels. And to be honest if EPs could opt out of EMTALA lots of us would too.

EMTALA fines hospitals not Specialists though

 

[FoughtFyr]

EMTALA fines hospitals not Specialists though

Wrong. In the case described (a specialist on call refuses to come in) the specialist can and will be fined. 42 USC §1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he/she is assigned as the on-call physician.

- H

 

[kungfufishing]

"when do you ultimately trust that the Ortho guy knows what he is talking about" is best answered after the surgeon has actually seen the patient.

 

[dawg44]

Wrong. In the case described (a specialist on call refuses to come in) the specialist can and will be fined. 42 USC §1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he/she is assigned as the on-call physician.

- H

A physician who is on call and who fails or refuses to appear after being called by an E.R. physician (or other physician) may be subject to a penalty under the statute, or may subject his hospital to a penalty. The wording of this section [1395dd(d)(1)(C)] is so garbled as to be virtually indecipherable.

exactly clear as mud

The essential provisions are:

A hospital which negligently violates the statute may be subject to a civil money penalty (i.e., a fine, but without criminal implications) of up to $50,000 per violation. If the hospital has fewer than 100 beds, the maximum penalty is $25,000 per violation.

The hospital bears the brunt.

Section 1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he is assigned as the on-call physician. This is the only obligation placed on physicians governing the obligation to respond to an emergency situation. This provision does not require that a particular physician or particular specialty provide coverage on a call basis.

With a couple of exceptions, the statute and regulations impose all of their obligations on hospitals. This area is no exception. The expectations of CMS and of the courts in construing EMTALA are directed at hospitals. Hospitals are left to their own devices as to how to ensure compliance by members of their medical staffs.

 

[dawg44]

"when do you ultimately trust that the Ortho guy knows what he is talking about" is best answered after the surgeon has actually seen the patient.

Exam and history are overrated in ortho everyone knows that. Its actually the surgeon that has seen the XRAY that knows best in orthopedics. Unless you are talking about a compartment syndrome then I only trust a fellow orthopod or resident period. Even medical students know all of the ortho buzzwords. How easily you forget I said vice versa but you conveniently left that out. Last time I try to give a little credit, jeez. Personally the only thing I have ever refused is the "open fracture" of the distal phalanx, but I have come in and said "yeah sew that up." or "Yeah put that in a splint" and left a couple of minutes after arriving to fulfill EMTALA which is always an option.

 

[FoughtFyr]

Section 1395dd(d)(1)(C) imposes a penalty on a physician who fails to respond to an emergency situation when he is assigned as the on-call physician. This is the only obligation placed on physicians governing the obligation to respond to an emergency situation. This provision does not require that a particular physician or particular specialty provide coverage on a call basis.

With a couple of exceptions, the statute and regulations impose all of their obligations on hospitals. This area is no exception. The expectations of CMS and of the courts in construing EMTALA are directed at hospitals. Hospitals are left to their own devices as to how to ensure compliance by members of their medical staffs.

Case law has held that the "emergency situation" is the call from the EP. The idea of the law is that a physician who has agreed to be "on-call" can not defer to see a patient (thus preventing that physician from not seeing un- or underinsured patients). Remember these are legal definitions of "emergency situation" not medical ones. You are right, EMTALA does not force "Dr. A" to be on call, but it does regulate his/her actions if they agree to be "on-call".

- H

 

[docB]

OK. Another question:

Hospital A has an ICU but no neurosurgeon. A patient is admitted for pneumonia and on the floor has sudden onset of altered mental status and respiratory failure. The patient is intubated and moved to the ICU. CT head shows a big subdural bleed. The internist on the floor attempts to arrange transfer to Hospital B which has neurosurgical capability.

Is Hospital B obligated to accept the transfer (assuming it has capacity) because it can provide the higher, needed level of care?

The internist wants to move the patient back to the ER so that an ER to ER transfer to a higher level of care can be executed. What should the EP do?

No facility accepts transfer. The only physician on staff who is priveledged to intervene is the EP who didn't read his DOP application and got priveledged for burr holes. The internist consults the EP. Is the EP obligated to see the patient under EMTALA?

Let's say Hospital A has neurosurgeons on staff but no neurosurgeon will see the patient because he's uninsured. Are the specialists obligated under EMTALA to consult on the patient?

If one of the neurosurgeons is on call is he obligated under EMTALA to see the patient?

 

[FoughtFyr]

OK. Another question:

Hospital A has an ICU but no neurosurgeon. A patient is admitted for pneumonia and on the floor has sudden onset of altered mental status and respiratory failure. The patient is intubated and moved to the ICU. CT head shows a big subdural bleed. The internist on the floor attempts to arrange transfer to Hospital B which has neurosurgical capability.

Is Hospital B obligated to accept the transfer (assuming it has capacity) because it can provide the higher, needed level of care?

The internist wants to move the patient back to the ER so that an ER to ER transfer to a higher level of care can be executed. What should the EP do?

No facility accepts transfer. The only physician on staff who is priveledged to intervene is the EP who didn't read his DOP application and got priveledged for burr holes. The internist consults the EP. Is the EP obligated to see the patient under EMTALA?

Let's say Hospital A has neurosurgeons on staff but no neurosurgeon will see the patient because he's uninsured. Are the specialists obligated under EMTALA to consult on the patient?

If one of the neurosurgeons is on call is he obligated under EMTALA to see the patient?

Hey docB, are you studying for a Master's in Health Policy or what? The short answer to your question is yes, EMTALA applies under the 2000 and 2003 revisions.

"(2) Application to inpatients--admitted emergency patients.
(i) When an individual has been screened under paragraph (a) of
this section and found to have an emergency medical condition, and the
individual has not been stabilized as defined in paragraph (b) of this
section, the provisions of this section would apply, even if the
hospital admits the patient as an inpatient. Admitting an individual
whose emergency medical condition has not been stabilized does not
relieve the hospital of further responsibility to the individual under
this section.
(ii) If a hospital admits an individual with an unstable emergency
medical condition for stabilizing treatment, as an inpatient,
stabilizes that individual's emergency medical condition, and this
period of stability is documented by relevant clinical data in the
individual's medical record, the hospital has satisfied its special
responsibilities under this section with respect to that individual. If
the patient is stable for a transfer of the type usually undertaken
with respect to patients having the same medical conditions, the
hospital's special responsibilities under this section are satisfied,
even if no transfer occurs and the individual remains at the hospital
as an inpatient for followup care. If, after stabilization, the
individual who was admitted as an inpatient again has an apparent
decline of his or her medical condition, either as a result of the
injury or illness that created the emergency for which he or she
initially came to the dedicated emergency department or as a result of
another injury or illness, the hospital must comply with the conditions
of participation for hospitals under part 482 of this chapter but has
no further responsibility under this section with respect to the
individual.
(iii) A hospital has no responsibility under this section with
respect to an inpatient who was admitted for elective (nonemergency)
diagnosis or treatment. If such an inpatient has an abrupt
deterioration of his or her medical condition after admission, the
hospital must comply with the conditions of participation for hospitals
under part 482 of this chapter and is not required to comply with the
special responsibilities of this section."{emphasis added}​

- H

 

[docB]

Hey docB, are you studying for a Master's in Health Policy or what?

Reading a book on EMTALA. Know thy enemy.

 

[pseudoknot]

Reading a book on EMTALA. Know thy enemy.

What's the book's title? Do you recommend it?

 

[kungfufishing]

wasn't that written by Milton?

 

[docB]

It's The EMTALA Answer Book by Mark Moy

http://www.amazon.com/Emtala-Answer...id=1166959881/ref=sr_11_1/002-6911145-0645635

It's pretty good. You need to know something about EMTALA before you start because it doesn't start from the ground up. It takes key elements of the law and then asks questions. Not scenarios. It asks stuff like "What does it mean to 'come to the hospital'?" and "What is required in a medical screening exam."

 

[RuralMedicine]

OK. Another question:

Hospital A has an ICU but no neurosurgeon. A patient is admitted for pneumonia and on the floor has sudden onset of altered mental status and respiratory failure. The patient is intubated and moved to the ICU. CT head shows a big subdural bleed. The internist on the floor attempts to arrange transfer to Hospital B which has neurosurgical capability.

Is Hospital B obligated to accept the transfer (assuming it has capacity) because it can provide the higher, needed level of care?

The internist wants to move the patient back to the ER so that an ER to ER transfer to a higher level of care can be executed. What should the EP do?

No facility accepts transfer. The only physician on staff who is priveledged to intervene is the EP who didn't read his DOP application and got priveledged for burr holes. The internist consults the EP. Is the EP obligated to see the patient under EMTALA?

Let's say Hospital A has neurosurgeons on staff but no neurosurgeon will see the patient because he's uninsured. Are the specialists obligated under EMTALA to consult on the patient?

If one of the neurosurgeons is on call is he obligated under EMTALA to see the patient?

We run into this all the time and perhaps I'm interpreting this incorrectly but the internist can not transfer the patient back to the ED and you can not transfer ED to ED after the patient has been admitted. What ends up happening is your internist gets stuck trying to keep the patient alive and arrange transport at the same time. It's really not fun. Are you saying that EMTALA obligates hospital B to accept the patient in transfer if hospital A doesn't have neurosurgical capacity? If that's the case it would make my life (and more importantly my patients' lives) a ton easier.

About 6 months ago one of my colleagues had a patient who had an IJ CVL placed by one of the ED physicians. Unfortunately said CVL ended up in the carotid artery instead of the IJ but the ED physician apparently was unaware of that (and my colleague who wasn't present when the line went in had no idea). I inherited the patient in weekend coverage and when RT was unable to obtain an ABG while I was in the process of placing a CVL in another patient I suggested they just obtain a VBG from the CVL because I was more worried about PCO2 since the O2 sats were great and the patient had extubated to minimal O2 requirements. The VBG had a PO2=90 and when I had them hook up a CVP line we got a very nice arterial tracing. We have general surgeons but not vascular surgeons and surgery on call quickly deferred any intervention to vascular. I spoke with a vascular surgeon at our usual tertiary referral center who agreed that yes since the line had been in for 2-3 days now he would likely have to place a stitch in the carotid when he removed it so if Gen Surg would admit he would consult and take care of it. Well Gen Surg wouldn't admit. I spoke with him again and he said that was too bad but he didn't want the patient on his service. About 3 hours later I finally found a vascular surgeon to accept the patient (mainly because he was an old med school buddy of my colleague who was the primary attending) and we transferred there. Ultimately the patient had the CVL removed and the artery repaired and did well.

 

[FoughtFyr]

We run into this all the time and perhaps I'm interpreting this incorrectly but the internist can not transfer the patient back to the ED and you can not transfer ED to ED after the patient has been admitted. What ends up happening is your internist gets stuck trying to keep the patient alive and arrange transport at the same time. It's really not fun. Are you saying that EMTALA obligates hospital B to accept the patient in transfer if hospital A doesn't have neurosurgical capacity? If that's the case it would make my life (and more importantly my patients' lives) a ton easier.

Yes, EMTALA applies, but most folks don't realize that. Hospital B is under the same obligations as they would be if the patient were in the ED. But realize that is a result of amendments from 2000 and 2003. Many folks are not aware. Check the section of the CFR I posted above.

About 6 months ago one of my colleagues had a patient who had an IJ CVL placed by one of the ED physicians. Unfortunately said CVL ended up in the carotid artery instead of the IJ but the ED physician apparently was unaware of that (and my colleague who wasn't present when the line went in had no idea). I inherited the patient in weekend coverage and when RT was unable to obtain an ABG while I was in the process of placing a CVL in another patient I suggested they just obtain a VBG from the CVL because I was more worried about PCO2 since the O2 sats were great and the patient had extubated to minimal O2 requirements. The VBG had a PO2=90 and when I had them hook up a CVP line we got a very nice arterial tracing. We have general surgeons but not vascular surgeons and surgery on call quickly deferred any intervention to vascular. I spoke with a vascular surgeon at our usual tertiary referral center who agreed that yes since the line had been in for 2-3 days now he would likely have to place a stitch in the carotid when he removed it so if Gen Surg would admit he would consult and take care of it. Well Gen Surg wouldn't admit. I spoke with him again and he said that was too bad but he didn't want the patient on his service. About 3 hours later I finally found a vascular surgeon to accept the patient (mainly because he was an old med school buddy of my colleague who was the primary attending) and we transferred there. Ultimately the patient had the CVL removed and the artery repaired and did well.

Again, that is an EMTALA violation. See the section above. They tertiary center can not legally refuse.

- H

 

[docB]

Ok. Another question:
A mother walks into the main lobby of Hospital A carrying her sick child. She encounters a housekeeper. She askes the housekeeper to direct her to the Pediatric ER. The housekeeper talls her that Hospital A does not have a pediatric ER and says she would do better to go down the street to Hospital B which does. At Hospital B mom tells the staff what happened at Hospital A.

Has Hospital A comitted an EMTALA violation?

What if the person in the lobby was a nurse instead of a housekeeper?

What if it was the ER waiting room instead of the main lobby?

Is Hospital B obligated to report Hospital A?

 

[docB]

Cool site originally linked by docbooboo on another thread:

http://www.medlaw.com/healthlaw/EMTALA/education/20-common-practices-that-.shtml

So here's a question about #9

9. When asked to come in to see an E.D. patient, declining on the basis that the specialist physician is "not interested" in a case of that type.

The on-call specialist is required to respond to all patients presenting.

This basically means a specialist can't pick and choose patients. However, all the orthos at my hospital dropped their hand priveledges just so they could avoid being stuck with hand cases. They don't do any hand surgeries at the hospital and they are barred from taking a hand case to the OR even if they wanted to. When they refuse hand cases while on call for general ortho are they in violation of EMTALA?

 

[Jeff698]

They don't do any hand surgeries at the hospital and they are barred from taking a hand case to the OR even if they wanted to. When they refuse hand cases while on call for general ortho are they in violation of EMTALA?

I wouldn't think so. They're not credentialed for hand so it isn't a capability they have. They're not picking or choosing hand patients based on their ability to pay which is the key thing that can get them in trouble.

Take care,
Jeff

 

[Flopotomist]

It's The EMTALA Answer Book by Mark Moy

http://www.amazon.com/Emtala-Answer...id=1166959881/ref=sr_11_1/002-6911145-0645635

It's pretty good. You need to know something about EMTALA before you start because it doesn't start from the ground up. It takes key elements of the law and then asks questions. Not scenarios. It asks stuff like "What does it mean to 'come to the hospital'?" and "What is required in a medical screening exam."

The book sounded interesting... but why on EARTH is the book nearly $200.00?? For a paperback?