QUESTION: Radiology evaluations for ultrasound are not read except during “office hours” and the ED physician has to rely on only the tech summary at night. Is that an EMTALA issue?
ANSWER:
CMS generally requires that all services that are available routinely in the hospital must be made available on-call to the emergency department within the capabilities of the hospital. All specialties, including the radiologists, must be on-call if they are on the medical staff, even if there is only one Radiologist. The number in a specialty, however, may effect whether this specialty must be on call 24/7 or on a lesser frequency. Times when the on-call specialist is subject to call must be posted, changes noted on an ongoing basis, and the call list must be kept for 5 years. When the on-call specialist is not scheduled for call coverage, that must be noted on the call list as well. Policies and procedures must be in place for call response in timely manner and for procedures when no on-call is available. Call may not be restricted to office hours per CMS regulations.
Ultrasound is clearly required for some medical screening examinations under EMTALA. If you have radiologists, they must be on-call and be availble online or in person to assist in the evaluation of an ultrasound if requested. If you have radiologists but no radiology coverage at all, your facility would likely be in violation of the on-call requirements. If you have on-call radiology coverage but they choose not read ultrasounds at night, that is likely be a violation also.
If you have only one, two, or three radiologists, you are likely to have scheduled gaps in coverage and there may be no radiologist available at a given time to review the ultrasound results. That leaves your facility with the policy choices of having to secure off-site reading services, transferring ultrasound patients to other facilities for testing and evaluation, or training and authorizing ED physicians to do preliminary ultrasound reads with radiology over-reads first thing the next day. A number of EDs are using ED ultrasounds by emergency physicians with varying results.
While there is no absolute rule that says EMTALA will not let the ED physician rely on the tech summary, it is within CMS authority to evaluate a specific case and determine that it fell below the standard for an appropriate medical screening exam because necessary testing was not completed appropriately. That scenario also poses the threat of malpractice suit, for instance, if the tech misses an ectopic pregnancy, the ED physician sends the patient home, and an adverse outcome occurs.
Please note that if the facility chooses to use off-site night coverage for reading ultrasounds, most states require the off-site physician to be licensed in the state where the patient and the hospital are located. Off-site coverage is not an automatic defense to failing to have radiologists from your own staff on-call if you have sufficient staff to cover 24/7, but it will be up to the CMS “case-by-case” analysis.
Regardless of the option selected, careful attention must be given to the creation of policies and procedures to address the compliance, documentation, and risk issues raised by EMTALA, reimbursement regulations, state regulations, licensing boards, and malpractice litigation.