EMTALA is 30 years old this year, and with the social status for docs being the brightest and best, you would think that all of our ED docs would have figured out its requirements by now, right? But NO… a segment of Emergency Department physicians (primarily in smaller hospitals or busy community hospitals) still finds some rationalization to go out on the ambulance apron and direct the EMS crew to a different “better” hospital or issue a radio diversion order.
You know what? Sometimes, it actually would be better in some cases to send them to the trauma center or the bigger hospital down the road. The problem is that is generally ILLEGAL.
I am probably singing to the choir here, but these cases are cropping up more and more often, and a good hospital client of mine just got burned because of one of these “glance-and-go” ambulance apron encounters. They failed to report the other hospital within the 72 clock-hours mandated by the CMS regulations, and they got cited along with the original hospital — more about that in another frustrated sermon.
So, let’s go over this again for the benefit of some probably-well-intentioned ED docs who don’t want the ambulance to unload or even arrive at their ED.
- If the ambulance crosses the outer boundaries of your campus, you have to take them in for a full EMTALA-compliant visit
- If the ambulance calls in and says they are coming to your facility, you cannot redirect the ambulance unless your ED is on formally declared diversion
- If you divert the ambulance but they come to you anyway, you have to take the patient in for a full EMTALA-compliant visit
- You cannot short-cut the MSE or testing to get the patient transferred sooner.
- You cannot discharge the patient and tell them to go to the other hospital.
- Even if you are in the middle of a full-fledged declared disaster, you have to follow your disaster protocols, assess the patient, provide care consistent with your disaster plan, and document where you transferred the patient.
I have heard the explanations or rationalizations:
“But was better for the patient.” Maybe, but it is still illegal.
“In my medical opinion…” Your medical opinion does not over-ride the law.
“Well it should…” Tell it to Congress.
“It is burning the golden hour.” Yes it is. But, the golden hour is over-ruled by an Act of Congress like EMTALA.
“We just couldn’t safely handle another patient.” That is what activating an internal disaster plan is about.
In some cases, I would be tempted for a second to agree with these arguments, but not at the price of a CMS notification of termination from Medicare, law suits, and even an ultimate worst case of criminal charges. In these days of the “Federal Government knows best” and swat teams showing up to collect past-due debts, you just are not going to get away with trying to reason your way around the federal EMTALA law.
Steve, I understand this frustration, however I did find certain comments degrading and insulting to the medical profession. I have always enjoyed your articles and have generally found you to be objective with your thoughts and would feel it unfortunate if you lost readers due to perceived maligning of a this profession. Those are just my two cents and I hope that you take it in the honest, yet humble, manner that I have intended. Thank you, Beth Gomez, RN,, BSN, JD
Beth, I appreciate your directness, and I feel it was offered in exactly the same concern as I offered my comments. These issues are either a systemic failure to educate physicians on EMTALA or a individual’s total disregard for policies and laws. Either way, hospitals are getting cited, fined, sued, and suffering a loss of reputation based on actions that should never occur through the acts of a few physicians — even if committed with the best of intentions. If I addressed it in a politically incorrect manner, that would be entirely consistent with my style — I tend to speak directly in what I consider the most truthful manner possible. Sometimes, I lay the fault at the feet of CMS, but in this case the rules seem clear, and the blame lies with some ED docs. I do not intentionally insult anyone, but if someone takes insult from my labeling incorrect and dangerous conduct it will not be the first time — nor the last. I do appreciate your taking the time to comment.
Steve, I did not find your article insulting nor degrading. It seems political correctness has gone amuck,
continue writing the way you do. Seems like everyone today needs to be coddled. Some (ER) docs are dense or stupid not to follow the EMTALA laws that have been on the books for years. Agree or disagree with CMS, the laws are what they are and have to be followed, period. You have not lost this reader for sure.
Jack Henriquez, MD, FACEP.
What about the reverse? An ED physician goes into the ambulance on hospital property to evaluate a patient who is in the unit awaiting rendezvous with a helicopter for a direct transfer to a Level 1 Trauma Center. Neither the patient nor the EMS crew are “coming to the ED” or requesting a MSE. If the doctor examines the patient or gives treatment orders to the paramedics, does that obligate him/her to perform a full MSE and perform an EMTALA-compliant transfer?
Great question. My answer is NEVER, NEVER, NEVER do that unless SPECIFICALLY REQUESTED by the ambulance or air medical crew. Once hospital personnel intercede in the evaluation or care of the patient, you become responsible for full EMTALA compliance for MSE, care and transfer. That means that the helicopter may be stuck for an hour or more while you do your EMTALA compliance, get new acceptance at the destination hospital, etc.
EMTALA regulations from CMS created the helipad exception to avoid this issue. The helipad rule is that an ambulance or helicopter coming to a helipad for the sole purpose of effecting a transfer does not trigger EMTALA for the hospital whose helipad is being used UNLESS the ambulance or helicopter crew requests MEDICAL assistance.
The key here is the concept of MEDICAL assistance. For instance: