Transcript Slide 1

The Emergency Medical Treatment
and Active Labor Act 2006
[ 42 USC 1395dd ]
[ 42 CFR 489.24 ]
Jorge A. Martinez, MD, JD
Clinical Professor of Medicine
LSU School of Medicine
EMTALA – Basic Scheme
42 US 1395 dd
Individual
“Comes to” emergency department
Appropriate medical screening examination
No Emergency Medical Condition
EMTALA obligations ends
Emergency Medical Condition exists
Stabilizing treatment
Transfer
Important Terms
Individual “comes to” the ED

Must perform MSE – includes ancillary
services

Must determine if emergency medical
condition exists

If EMC exists = must stabilize before
transfer
“Comes to” the ED
42 CFR 489.24 (b)
• Has presented at hospital’s dedicated ED
and requests examination or treatment or
request is made on his behalf, or a
prudent layperson would believe that the
individual needs an examination
• Has presented on hospital property other
than hospital’s dedicated ED and requests
examination or treatment…
“Comes to” the ED
42 CFR 489.24 (b)
• If transported by ambulance owned and
operated by the hospital… even if the
ambulance is not on hospital grounds.
• This provision does not apply if the
hospital-owned ambulance is operating
under community wide EMS protocols that
direct it to transport the individual to
another hospital…
“Comes to” the ED
42 CFR 489.24 (b)
• Nonhospital-owned ambulance – if the
individual arrives on hospital property for
examination and treatment of a medical
condition at the hospital’s dedicated ED…
Dedicated Emergency Department
42 CFR 489.24 (b)
1) Is licensed by the state as an emergency
department
2) Is held out to the public (by name, advertising,
posted signs, other means) as a place that
provides care to emergency situations on an
urgent basis without an appointment
3) During the previous year provided at least 1/3 of
visits for emergency treatment without requiring
a scheduled appointment
Hospital Property
Sec 413.65(a)
• Hospital property includes the entire
hospital campus
• Encompasses any part of the hospital
other than the dedicated emergency
department
• Includes hospital departments, parking lot,
sidewalk and driveway, and any buildings
owned by the hospital that are within 250
yards of the hospital
Emergency Medical Condition
1395dd (e)
A medical condition with acute
symptoms (including pain, psychiatric
sx’s, or substance abuse) where the
lack of immediate medical attention
could reasonably be expected to:
1) Place health of individual or unborn child in
serious jeopardy
2) Cause serious impairment of bodily function
3) Cause serious dysfunction of body
organ/part
Caution!!
Some intoxicated individuals may meet
the definition of “emergency medical
condition”because the absence of
medical treatment may place their
health in serious jeopardy or result in
serious dysfunction of a bodily organ.
Further, it is not unusual for intoxicated
individuals to have unrecognized
trauma.
Caution!!
Likewise, an individual expressing suicidal
or homicidal thoughts or gestures, if
determined dangerous to self or others,
would be considered an “emergency
medical condition.”
What is an Acceptable
Medical Screening?
CMS Interpretive Guidelines state the following;
• Individuals coming to the emergency room must
be provided a medical screening beyond initial
triage.
• The medical screening must be the same
medical screening that the hospital would
perform on any individual coming to the
hospital’s emergency room with those signs and
symptoms, regardless …………..to pay.
What is an Acceptable
Medical Screening?
• A medical screening examination is the process
required to reach with reasonable clinical
confidence, the point at which it can be
determined whether a medical emergency does
or does not exist.
• Depending upon the patient, this process will
vary from only a brief H&P to a complex process
involving ancillary studies and specialty
consultations.
What is an Acceptable
Medical Screening?
• A medical screening is not an isolated event. It
is an ongoing process.
• Hospital and Department medical staff should
address, through policy and medical standards,
how best to provide the screening.
• Medical Screenings are required to be
documented.
• If it isn’t written down, it never happened!!
Medical Screening
Documentation
• Need to document why the patient is now stable
enough to be transferred.
 Is patient hemodynamically stable to the best of
our capabilities?
 Has psychiatric condition been evaluated and
treated to the best of our capabilities?
 Have any abnormal test (EKGs) been repeated if
the first one was abnormal and the patient has
been in our care for a lengthy period of time?
Caution!!
• Regardless of a positive or negative patient
outcome, a hospital will be in violation of the
anti-dumping statute if it fails to meet any of the
medical screening requirements.
• If a misdiagnosis occurs, but the hospital utilized
all of its resources, a violation of the screening
requirement does not occur.
CAUTION!!!!!!
• Case history has not been kind to
hospitals who utilized non-physician
medical screeners even though by law it is
allowed.
• TRAIGE IS NOT CONSIDERED TO BE A
MEDICAL SCREENING!!!!!
Stabilization
1395dd (e)
• No material deterioration of the
condition, within reasonable medical
probability, will result from or occur
during the transfer of the individual
• Pregnant woman who is having
contractions: To deliver the fetus and
placenta
Transfer
1395dd (e)
• The movement (including the
discharge) of an individual outside of
the ED facilities at the direction of any
person employed by or affiliated or
associated, directly or indirectly, with
the hospital
• Does not include
– the movement of a dead body
– person who leaves AMA
Transfer
• Rule = 1395 dd (c)(1) = Must stabilize
before transfer
• Only exceptions to stabilize before
transfer rule
1) patient requests (without coercion)
1395 dd (c)(1)(A)(i)
2) benefits of transfer outweigh risks of
transfer 1395 dd (c)(1)(A)(ii)
3) MD refuses or fails to appear 1395 dd
(d)(1)(C)
Appropriate transfer
1395 dd (c) (B)
1) Before transfer to another hospital – must
contact receiving hospital
2) Receiving hospital must accept patient
before he/she can be transferred
3) Patient must be transferred by
appropriate means (including personnel)
4) Receiving hospital must report transfer
without approval to CMS
Transfer Documentation
• Must show that the transfer was initiated by
either a written request by the patient (or his/her
representative) or a physician’s certification.
• Must state the reason for the transfer.
• The receiving facility and the accepting
physician. Recommendation: Include a brief
statement that the patient’s full condition was
discussed with the accepting physician.
• The risk and benefits of the transfer.
Transfer Documentation
Risk & Benefits!!
• Need to be realistic and pertinent to the case.
• MVA is not usually a true risk of the transfer that
needs to be documented in most cases.
• Worsening of condition, lack of medical
equipment, increase of pain, increase exposure
to infection and no physician for intervention are
some examples of true risk.
Delay in examination or treatment
42 CFR 489.24 (d)(4)
• Hospital may not delay providing MSE or
medical examination and treatment to
inquire of method of payment
• Hospital may not seek, or direct an
individual to seek, authorization until after
MSE and medical examination and
treatment has been initiated
Delay in examination or treatment
42 CFR 489.24 (d)(4)
• Hospitals may follow reasonable
registration processes as long as it does
not delay screening or treatment
– Registration processes may not discourage
individuals from remaining for further
evaluation
• Practitioner may contact individual’s
physician to seek information or advise
relevant to the medical treatment
Inpatients
42 CFR 489.24 (d)(2)
• If a hospital has screened an individual
under paragraph (a), found to the
individual to have an EMC, and admits the
individual as an inpatient in good faith in
order to stabilize the EMC, the hospital
has satisfied its responsibilities
• Not applicable to individuals admitted on
an elective/nonemergent basis
On-call physicians
42 CFR 489.24 (j)
• Each hospital must maintain MD on-call list that
best meets the needs of its patients
• The hospital must have written policies and
procedures that
– Respond to situations where a particular specialty
is not available or the on-call MD cannot respond
because of circumstances beyond MD’s control
– Assures emergency services are available
if it elects to permit on-call physicians to
schedule elective surgery when they are oncall or to permit simultaneous on-call duties
EMTALA and psych patients
• Psychiatric emergency medical condition
– patient is danger to self or others
– patient has potential to be danger to self or others
– substance abuse
• Psychiatric emergency medical condition is
stabilized when patient is no longer danger
to self or others
EMTALA and psych patients
• Screening essentials
– Physician must screen for
•
•
•
•
physical and mental illness
history of violence to himself or others
suicide attempt or voiced suicidal ideation
danger to herself or others by making violent
acts, gestures, or threats
• signs of confusion or mental status changes
• substance abuse that can affect the patient’s
cognition or judgment
EMTALA and psych patients
• EMTALA does not require the patient to
have laboratories or radiographies
performed to ensure medical stability.
• It does require that psychiatric patients
with medical problems are transferred to
a psychiatric facility that is equipped to
handle the patients’ medical problem.
Moy, MM: EMTALA and Psychiatry in The EMTALA Answer Book
2nd Edition. Gaithersburg, MD:Aspen; 2000
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Short mental status examinations
• Mini-Mental State Exam
• The Brief Mental Status Examination
• Short Portable Mental Status
Questionnaire
• Cognitive Capacity Screening
Examination
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Short mental status exams in the ED
• Used the Brief Mental Status Examination
in an inner city ED.
• Score 0-8 normal, 9-19 mildly impaired,
20-28 severely impaired
• 100 randomly selected subjects
• 100 subjects with indications for the exam
• 72% sensitivity and 95% specificity in
identifying impaired individuals in the ED
Kaufman, DM, and Zun, LS: A Quantifiable, brief mental status
examination for emergency patients: J Emerg Med, 13:449-456,
1995.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Brief Mental Status Examination*
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Questions:
Score
(number of errors) x (weight) =
What year is it now?
0 or 1
x4
=
What month is it?
0 or 1
x3
=
Present memory phase after me and remember it:
John, Brown, 42, Market Street, New York
About what time is it?
(Answer correct if within 1 hour)
0 or 1
x3
=
Count backwards from 20 to 1.
0.1. or 2
x2
=
Say the months in reverse
0, 1, or 2 x2
=
Repeat the memory phase
(each underlined portion is worth 1 point)
0,1,2,3,4 or 5
x2 =
Final score [equal to the sum of the total(s)]
=
* Katzman, R, Brown, T, Fuld, P, Peck, A, Schechter, R, Schimmel, H: Validation of a short orientation-memory
concentration test of cognitive impairment. Am J Psych 1983; 140:734-9.
Need laboratory studies
• 46% of psychiatric patients had unrecognized
medical illness.
• Hall, RC, Gardner, ER, Popkin, MK, et. al: Unrecognized physical
illness prompting psychiatric admission: A prospective study. Am J
Psych 1981; 138: 629-633.
• 92% of one or more previously undiagnosed
physical diseases.
• Bunce, DF: Jones, R, Badger, LW, Jones, SE: Medical Illness in
psychiatric patients: Barriers to diagnoses and treatment. South
Med J 1982: 75:941-944.
• 43% of psychiatric clinic patients had one or
several physical illnesses.
• Koranyi, E: Morbidly and rate of undiagnosed physical illness in a
psychiatric population. Arch Gen Psych 1979; 36: 414-419.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Need laboratory studies
• Retrospective review of 158 patients, 6% of
the psych patients had undiagnosed physical
illness that might contribute to psychiatric
illness.
• Skelcy, K, Wagner, MJ: Medical clearance of the psychiatric patient, ACEP
Research Forum, 2000.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
New onset psych presentation
• 100 consecutive patients aged 16-65 with new
psychiatric symptoms
• 63 of 100 had organic etiology for their symptoms
–
–
–
–
–
History (100)
PE
(100)
CBC
(98)
SMA-7 (100)
Drug
screen (97)
– CT scan (82)
– LP
(38)
53% ABN
64% ABN
72% ABN
73% ABN
27% sign
6% sign
5% sign
10% sign
37% ABN
28% ABN
55% ABN
29% sign
10% sign
8% sign
• Point: Patients may need extensive laboratory and
radiographic evaluations including CT and LP
Hennenman, PL, Mendoza, R, Lewis, RJ: Prospective evaluation of emergency
department medical clearance. Ann Emerg Med 1994;24:672-677.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Medical workup not necessary
• Most laboratories, EKG and radiographic testing
should be abandoned in favor of a more
clinically driven and cost effective process.
• Allen, MH, Currier, GW: Medical assessment in the psychiatric
emergency service. New Directions in Mental Health Services
1999;82:21-28.
• Patients with primary psychiatric complaints
with other negative findings do not need
ancillary testing in the ED.
• Korn,CS, Currier, GW, Henderson, SO: “Medical Clearance” of
psychiatric patients without medical complaints in the emergency
department. J Emerg Med 2000;18:173-176.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Medical workup not necessary
• Medical and substance abuse problems
identified by initial vital signs along with a
basic history and physical examination
• Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO:
Medical clearance and screening of psychiatric patients in the
emergency department. Acad Emerg Med 1997;4:124-128.
• Universal laboratory and toxicological
screening are low yield
• Olshaker, JS, Browne, B, Jerrard, DA, Prendergast, H, Stair, TO:
Medical clearance and screening of psychiatric patients in the
emergency department. Acad Emerg Med 1997;4:124-128.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Poor documentation of medical aspect of
Medical Screening Examination
in psych patients
• 298 charts reviewed in 1991 at one hospital
• Triage deficiencies
– Mental status
56%
• Physician deficiencies
–
–
–
–
Cranial nerves
Motor function
Extremities
Mental status
45%
38%
27%
20%
• “Medically clear” documented in 80%
Tintinalli, JE, Peacodk, FW, Wright, MA: Emergency medical evaluation
of psychiatric patients. Ann Emerg Med 1994; 23:859-862.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
“Medically Clear”
• “Medically stable” vs “medically clear”
• Both terms have great capacity to mislead
– Concern about misdiagnosis, premature referral, and
misunderstandings
• Better to write Discharge Note
–
–
–
–
–
–
History and physical examination
Mental status and neurologic exam
Laboratory results
Treatment plan
Transfer/discharge instructions
Follow up plans
Weissberg, M: Emergency room clearance: An educational problem.
Am J Psych 1979;136:787-789.
www.uic.edu/com/ferne/slides/Boston0503/Evaluation%20of%20Psych%20Patients.pps
Medical Clearance Checklist
Patient’s name _______
Date _________________
Gender ________________
Race ______________
Date of birth________
Institution _____________
Yes
1. Does the patient have new psychiatric condition?

No

2. Any history of active medical illness needing evaluation?


3. Any abnormal vital signs prior to transfer


Temperature >101oF
__
__
Pulse outside of 50 to 120 beats/min
__
__
Blood pressure<90 systolic or>200;>120 diastolic
__
__
Respiratory rate >24 breaths/min
__
__
(For a pediatric patient, vital signs indices outside the normal range for his/her age and
sex)
4. Any abnormal physical exam (unclothed)
a. Absence of significant part of body, eg, limb
__
__
b. Acute and chronic trauma (including signs of abuse)
__
__
c. Breath sounds
__
__
d. Cardiac dysrhythmia, murmurs
__
__
e. Skin and vascular: diaphoresis, pallor, cyanosis, edema
__
__
f. Abdominal distention, bowel sounds
___
___
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g. Neurological with particular focus on:
i. Ataxia ____
ii. pupil symmetry, size ___
iii. Nystagmus ___
iv. Paralysis ___
v. meningeal signs ___
vi. Reflexes ___
5. Any abnormal mental status indicating medical illness such as lethargic, stuporous,
comatose, spontaneously fluctuating mental status? _____
If no to all of the above questions, no further evaluation is necessary. Go to question #9
If yes to any of the above questions go to question #6, tests may be indicated.
6. Were any labs done?


What lab tests were performed? ________________________________
What were the results?
________________________________
Possibility of pregnancy ?


What were the results?
________________________________
7. Were X-rays performed?


What kind of x-rays performed? _________________________________
What were the results? ________________________________________
8. Was there any medical treatment needed by the patient prior to medical clearance?


What treatment? ________________________________________________
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9. Has the patient been medically cleared in the ED? _________


10. Any acute medical condition that was adequately treated in the
emergency department that allows transfer to a state operated
psychiatric facility (SOF)?


What treatment? _________________________________________
11. Current medications and last administered?
_____________________________________________________________
_____________________________________________________________
12. Diagnoses: *Psychiatric________________________________________
*Medical____________________________________________________
*Substance abuse____________________________________________
13. Medical follow-up or treatment required on psych floor or at SOF?
___________________________________________________________
14. I have had adequate time to evaluate the patient and the patient’s
medical condition is sufficiently stable that transfer to ___SOF or ___
psych floor does not pose a significant risk of deterioration. (check one)
____________________________________MD/DO
Physician Signature
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Case
A local law enforcement agency presents to
the ER with a subject whom they have
arrested. They request a psychiatric
evaluation on the subject. The hospital is
on psychiatric diversion due to no beds.
The triage nurse advises the law officers
of this and they voluntarily take the subject
to another hospital.
Is this a violation of EMTALA?
EMTALA Violation?
Answer --- YES
Why ?
The patient was present on hospital grounds and a
request for services was made. At a minimum,
the patient should have had a medical screening
completed and documented. If the law officers
voluntarily decide to leave without a medical
screening, it should be documented with the
appropriate details that the patient left without
being seen.
Rules of Thumb
Never turn a patient away once they are
on hospital property.
Always perform an appropriate medical
screening if the patient (or representative)
is requesting medical services.
Document Everything!!
Make Sure You Document Everything!!
Document, document, document!!!!!