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Effective Date: November 4, 2020
The purpose of this policy is to set forth guidelines, policies and procedures for compliance with state and federal requirements related to EMTALA.
It is the policy of Wellstar Health System to comply with the Emergency Medical Treatment & Active Labor Act (EMTALA) 42 CFR § 489.24, 42 CFR § 489.20 and subsequent federal interpretive guidelines and state regulations. If a patient “Comes to the Emergency Department.”
All Transfer Requests will be conducted through the Transfer Center.
Wellstar Windy Hill Hospital does not have a dedicated Emergency Department and does not accept acute care transfers.
The hospital may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment in order to inquire about the individual’s method of payment or insurance status.
Triage is not a Medical Screening Exam.
Patients should be arrived or quick registered into the Electronic Medical Record (EMR) system upon presentation to the Emergency Department (ED). This “arrival or quick registration” provides the ability of the ED and or Labor and Delivery team to document provision of care before patient’s demographic and insurance status is obtained.
Patient is “arrived” in the EMR utilizing two patient identifiers (Name, DOB, Social Security Number).
As soon as practical after arrival, individuals who come to the Emergency Department should be triaged in the order they arrive or based on the chief complaint as stated by the patient or on the patient’s behalf to determine the acuity of the patient and the order in which they will receive a medical screening examination.
Triage is not a medical screening examination, as it does not determine the presence or absence of an emergency medical condition, but rather, simply determines the acuity and the order in which individuals will receive a medical screening examination.
The hospital may not delay the provision of an appropriate medical screening examination or any necessary stabilizing medical examination and treatment to inquire about the individual's method of payment or insurance status.
The reasonable registration process including insurance status occurs once the patient is placed in a treatment space and understands that they will receive a medical screening examination or the medical screening examination has been initiated by a qualified medical person (QMP).
Medical Screening examination may be performed in locations other than the Emergency Department. For example, a pregnant woman may be moved to the Labor and Delivery Triage for the medical screening exam. The Medical Screening Exam is a separate process from triage and should be two distinct functions.
All patients with the same chief complaint receive the same Medical Screening Exam regardless of their ability to pay, insurance status, cultural or ethical differences.
The hospital shall provide a medical screening examination to all individuals who have “Come to the Emergency Department.”
The MSE is the examination of the patient by the QMP required to determine within reasonable clinical confidence whether an emergency medical condition (EMC) does or does not exist.
The examination should be tailored to the patient’s complaint, and depending on the presenting symptoms, the medical screening examination may represent a spectrum ranging from a simple process involving only a brief history and physical examination, to a complex process that also involves performing ancillary studies, procedures etc.
Monitoring must continue until the individual is stabilized or appropriately admitted or transferred.
The MSE, and ongoing patient assessment and stabilizing treatment, must be documented in the medical record.
The medical screening examination must be provided in a nondiscriminatory manner.
The examination provided to an individual must be the same MSE that the QMP would provide to any individual coming to the hospital’s dedicated ED with those signs and symptoms, regardless of ability to pay.
The central log must be maintained for all areas that are covered under EMTALA. Examples include but are not limited to the ED and Labor & Delivery.
The hospital must maintain a central log of individuals who “Comes to the Emergency Department” (and any other department that qualifies as an ED like Labor and Delivery) and include in such log whether such individuals refused treatment, left without being seen, were refused treatment, or whether such individuals were treated, admitted, stabilized, and/or transferred or were discharged.
The log must register all patients who present for examination or treatment, even if they leave prior to triage or MSE.
The Hospital has the discretion to maintain the central log in a form that best meets the needs of the Hospital. Accordingly, the central log must include, directly or by reference, patient logs from other areas of the hospital where a patient might present for emergency services or receive a medical screening examination instead of in the traditional ED.
These additional logs must be available in a timely manner for surveyor review. The hospital may also keep its central log in an electronic format.
The central log must be kept five years as required by Centers for Medicare and Medicaid Services (CMS).
The central log will include any additional information required by state law.
If, after the MSE, it is determined that an individual has an EMC, the hospital shall:
If, after the MSE is completed, a physician or other qualified medical person determines that an individual does not have an EMC, the individual may be discharged.
Discharged individuals who do not have an EMC must receive at the time of discharge, follow-up instructions with written or electronic home care instructions.
If the hospital offers the MSE, further examination and treatment and informs the individual or the person acting on the individual’s behalf of the risks and benefits of not receiving the examination and treatment, but the individual or person acting on the individual’s behalf refuses the examination and treatment, the hospital shall take all reasonable steps to have the individual or the person acting on the individual’s behalf acknowledge their refusal of further examination and treatment in writing (against medical advice form).
Documentation in the medical record should include information provided to the individual or to the person acting on the individual’s behalf.
Documentation in the medical record should include information related to the MSE, further examination, and treatment that is being offered to the individual including the risk and benefits of not continuing the examination and treatment.
The hospital shall maintain a list of physicians who are on-call for duty, who will after the initial medical screening examination provide further evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.
The hospital has the discretion to maintain the on-call list in accordance with the resources available to the hospital, including the availability of on-call physicians.
In determining on-call responsibilities, the hospital will consider all relevant factors, including the number of physicians on staff in a particular specialty, other demands on these physicians, and the frequency with which individuals typically require services of on-call physicians.
On-call roster exemptions for senior staff members which recognize years of service or physician age are permitted as long as the exemption does not affect patient care adversely.
A determination as to whether an on-call physician must physically assess the individual in the emergency department is the decision of the treating emergency physician.
If a physician on the on-list is called by the emergency department physician to provide emergency evaluation and/or treatment, the physician must respond by phone and if requested by the Emergency Department Physician to come to the Emergency Department to evaluate and/or treat the patient, based on time frames established in the Wellstar Medical Staff Rules and Regulations.
If the on-call physician is unable to respond due to situations beyond the physician’s control (i.e. transportation failure, personal illness, etc.) it is the responsibility of the on-call physician to notify the ED physician of the situation and assist in arranging care for the patient.
If the on-call physician refuses or fails to arrive within the required response time the chain of command should be initiated in an effort to obtain treatment for the patient with an EMC.
If the individual is required to be transferred as a result of the on-call physician’s failure to appear, the hospital is required by EMTALA to document in the medical record the name and address of the physician who failed to appear.
The receiving facility should also be informed of the name of the on-call physician who failed to respond resulting in the transfer.
Transfer denials that result from physician refusal should be referred to peer review for evaluation in accordance with Medical Staff Bylaws and policies.
A decision regarding patient transfer may be made by either physician certification or patient request.
An individual may be transferred if the individual or the person acting on the individual’s behalf is fully informed of the risks of the transfer, the alternatives (if any) to the transfer, and of the hospitals obligations to provide further examination and treatment sufficient to stabilize the individual’s EMC, and to provide for an appropriate transfer.
The transfer may then occur if the individual or person acting on the individual’s behalf:
The individual may be transferred if a physician or, should a physician not physically be present at the time of the transfer, another QMP in consultation with a physician, has certified that the medical benefits expected from transfer outweigh the risks.
The date and time of the certification should be close in time to the actual transfer. A certification that is signed by a non-physician QMP shall be countersigned by the responsible physician within 24 hours.
The hospital shall, within its capability, provide medical treatment that minimizes the risks to the individual’s health and, in the case of a woman who is having contractions, the health of an unborn child.
The transferring hospital shall receive from a representative of the receiving hospital confirmation that:
The hospital shall send to the receiving facility copies of all pertinent medical records available at the time of transfer, including:
The transferring physician is responsible to ensure that the transfer is affected through appropriately trained professional and transportation equipment including the use of the necessary and medically appropriate life support measures during the transfer. The transferring physician is responsible for determining the appropriate mode of transport, equipment, and transporting professionals to be used for the transfer.
If the hospital offers an appropriate transfer and informs the individual or the person acting on the individual’s behalf of the risks and benefits to the individual of the transfer, but the individual or the person acting on the individual’s behalf does not consent to the transfer, the hospital shall take all reasonable steps to have the individual or person acting on the individual’s behalf acknowledge such refusal in writing.
The medical record shall contain a description of the proposed transfer that was refused by the individual or refused on behalf of the individual.
To the extent the hospital has specialized capabilities (including available through the hospital’s on-call roster) or facilities, such as a trauma unit or a neonatal intensive care unit, that are not available at the transferring facility, the hospital shall accept appropriate transfers of an individual needing such specialized capabilities or facilities if the hospital has the capacity to treat the individual.
Patients with EMCs will be accepted by the appropriate physician on call or Emergency Department physician.
Any Denial of a transfer request with an EMC will require the administrator on call’s (AOC) approval unless:
A log of all transfer requests will be maintained for each facility, with documentation of the result of the request i.e. acceptance, denial, consult or withdrawn.
Non-emergency medical condition transfers or inpatient transfers may be accepted or denied by the appropriate specialist and administrator on call delegate (example case management or admit nurse).
All hospital medical staff and employees, in particular those who work in a dedicated ED who receive an inappropriate transfer in violation of the law, shall report the incident to the AOC as soon as possible.
Any hospital medical staff member or employee who believes that the hospital received an inappropriate transfer from another facility in violation of the law, or that hospital violated EMTALA, shall report the incident to the Administrator on Call (AOC) as soon as possible for investigation.
The AOC will notify the Compliance Department.
If, based on the investigation, the Compliance Department, Hospital Administration, in consultation with the Legal Department, determines that an inappropriate transfer has been received by the hospital, notification to CMS or the state survey agency will occur.
Reports of inappropriate transfers should be made to CMS within 72 hours of determination of inappropriate transfer.
Any violation of EMTALA by a Wellstar Hospital, determined in conjunction with the Compliance Department, will be reported to the Chief Compliance Officer.
The hospital shall post conspicuously, in the “dedicated emergency departments” and all areas in which individuals routinely present for treatment of emergency medical conditions and wait prior to examination and treatment, (such as entrance, admitting areas, waiting room or treatment room) signage that specify rights of an individual under the law with respect to examination and treatment for emergency medical conditions and of women who are pregnant and are having contractions.
The hospital shall conspicuously post signs stating whether or not the hospital participates in the Medicaid program.
All signs must be posted in all the major languages that are common to the population of the hospital’s service area.
All employees whose responsibilities include the procedures described above are expected to be familiar with the basic procedures and responsibilities created by this policy. Failure to comply with this policy will be subject to appropriate disciplinary action pursuant to all applicable policies and procedures, up to and including termination. Such disciplinary action may also include modification of compensation, including any merit or discretionary compensation awards.
Capacity - encompasses such things as numbers and availability of qualified staff, beds and equipment, as well as the hospital’s past practices of accommodating patients in excess of its occupancy limits.
Capability - defined as the staff, equipment and specialty or specialist services available to care for a patient with an emergency medical condition.
Comes to the Emergency Department - for purposes of this policy, an individual is deemed to have “come to the emergency department” if the individual:
Dedicated Emergency Department - is defined as any department or facility of the hospital, regardless of whether it is located on or off the main hospital campus that meets at least one of the following requirements:
Examples of “Dedicated Emergency Departments” may include licensed EDs, labor and delivery units, psychiatric departments, provider based urgent care centers.
Diversion – A notification to Emergency Medical Services (EMS) that the facility emergency department (ED) is beyond capacity. Diversion is just a notification about the ED capacity and EMS and/or the patient can still decide to be transported to the ED that is on diversionary status. Patients that are on the property of the facility cannot be diverted. Diversion status only applies to patients being transported by EMS.
Emergency Medical Condition means:
Hospital Property - means the entire main hospital campus, including the physical area immediately adjacent to the hospital’s main buildings (e.g., parking lots, sidewalks, and driveways), and other areas and structures that are not attached to the hospital’s main buildings but are located within 250 yards of the hospital’s main buildings. Hospital property excludes areas or structures of the hospital’s main building that are not part of the hospital, such as physician offices, rural health centers, skilled nursing facilities, or other entities that participate separately under Medicare, or restaurants, shops, or other non-medical facilities.
Labor - means the process of childbirth beginning with the latent or early phase and continuing through the delivery of the placenta. A woman is in true labor unless a physician or other qualified medical person certifies, after a reasonable period of observation that she is in false labor. Certification of false labor by a non-physician (i.e., physician assistant, nurse practitioner, or qualified registered nurse) requires physician certification.
Medical Screening Examination (MSE) - Is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an Emergency Medical Condition or not. A Medical Screening Examination is not an isolated event. It is an ongoing process that begins, with the initial assessment by a Qualified Medical Person and ends when enough information has been gathered to determine the patient does not have an Emergency Medical Condition.
Qualified Medical Person or Qualified Medical Personnel (QMP) - means an individual or individuals in one of the following professional categories who has demonstrated current competence to perform a Medical Screening Examination.
To Stabilize or “Stabilize” or “Stabilized” means:
"Examination and treatment for emergency medical conditions and women in labor." Retrieved from Social Security Act § 1867.
"Special responsibilities of Medicare hospitals in emergency cases." Retrieved from 42 CFR § 489.24.
"Basic commitments." Retrieved from 42 CFR § 489.20.
This replaces all previous LD-108 and all previous LD-108 shall automatically terminate upon the effective date set forth above.