Question: We frequently move ED patients to other beds when our 5 ED beds are in danger of filling up. In this case we admitted a patient to an observation bed on the unit awaiting the results of testing to complete the MSE. We then transferred this patient to a larger facility upon acceptance from their ED physician. The receiving facility is now saying we violated EMTALA by transferring from in-patient to their ED. Is that true?
ANSWER: If you complied with transfer regulations, transfer to the ED does not violate EMTALA. You had advance acceptance. The patient was delivered to the receiving facility, and it is up to them where they want to see and treat the patient. While they are free to have their own acceptance rules for their internal procedures, you complied with EMTALA, and EMTALA says nothing about what door or floor the patient has to be accepted at.
I personally believe the patient is probably better served by delivery to an ED for initial evaluation of their condition following transfer than being sent to a floor with no physician in attendance, but the down-side of using the ED as the transfer destination is that on-call physicians often leave the ED hanging with specialty patients so the on-call specialist can delay his or her response — but that is also true of specific unit and bed designations for transfers. When the ambulance gives its in-bound report, the on-call specialist should be on their way in.
Now, there are rumors that one or two states have rules that would ban transfers from in-patient to ED, but under the EMTALA definition of an admitted patient this patient would not be deemed admitted regardless of what the paperwork said because they were simply moved to another bed for management with the expectation of transfer. Under CMS definition, an admitted patient is one that is admitted to an inpatient area with the expectation and intent that they will be hospitalized in that bed for at least overnight. Holding a patient in a different bed with the intent or expectation of transfer is still an ED patient for CMS purposes.
The only way movement of that patient could become EMTALA in my opinion would be if the state rule banned all transfers to hospital EDs. In that case, EMTALA would incorporate the state law by reference under the COP that you must operate in compliance with state laws.
When a patient is being transported via ambulance from one inpatient bed to another bed, is it a violation to admit the patient to the bed prior to their arrival, especially in cases where patients are charged by the hour as they are done in ICU and Observation admissions.
Under EMTALA, CMS expects the receiving hospital will put a name on a bed when they accept a transfer for that bed. How it is appropriately billed is entirely different from whether it is EMTALA compliant. Even though both are administered by CMS, they are different divisions and frequently follow differing rules or interpretations. I don’t claim a general expertise in billing and coding, so you would have to direct the billing aspect of your question to the hospital coding consultant.
When a patient is transferred from a small ED to another facility for a higher level of care does the transfer have to be ED to ED or can it be ED to floor?
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If a patient is accepted and admitted to the hospitalist but upon assessment, the hospitalist seems he is unable to care for the patient due to a specialist needed that is not available at this hospital. He cancels the admit order and transfers back to the ED. The patient is then transferred from ED to an ED with this specialty. Is this a violation?
Once the patient is admitted to the hospitalist, he cannot pretend it did not happen, but if there is a legitimate reason to transfer the patient, it becomes the hospitalist’s job to transfer the patient. Refusing the patient and sending them back to the ED is likely to get cited by CMS as a violation.