Ends
Point 6 of 17
4007
On-Call System
Under EMTALA, hospitals must have an on-call system.
Specialty physicians must be on-call at all times to stabilize patients with EMCs.
Let’s take a closer look at:
• The on-call list
• The on-call physician
• On-call violations
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The On-Call List
The on-call list must have names of specific physicians.
The list must give each physician’s on-call time and specialty.
All hospital specialties must be covered at all times.
The call list must be posted in a visible place in the emergency department.
Call lists must be stored for five years, to keep a record of who was on-call when.
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Point 8 of 17
4009
The On-Call Physician: Obligation to Respond
On-call physicians must:
• Respond promptly when called
• Provide care at the hospital
On-call physicians may not have an emergency patient transferred to a more convenient location, such as their office.
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The On-Call Physician: Substitutes
An on-call physician is allowed to send a substitute when called.
This substitute may be a:
• Physician’s assistant (PA)
• Nurse practitioner (NP) However:
• The physician must be the person listed for call. The physician may not permanently put the name of a PA or NP on the on-call list.
• The physician may not routinely send a substitute for call.
The physician must receive full information about the patient. With full information, the physician must decide whether it is safe for a PA or NP to take the call.
• If the physician decides to send a PA or NP, the clinician at the hospital must agree that this is a safe decision.
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Point 10 of 17
4011
The On-Call Physician: Potential Conflicts with Call (1)
EMTALA allows for certain potential conflicts with call.
These conflicts are:
• A physician may be on-call at more than one hospital at the same time.
• A physician may schedule non-emergency appointments or surgery during on-call time.
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The On-Call Physician: Potential Conflicts with Call (2)
EMTALA allows for potential conflicts with call.
However:
• Physicians must inform hospitals of potential conflicts.
• Hospitals must plan for situations that could come up. For example, Hospital X needs an on-call physician. The physician cannot respond because she is already with an emergency patient at Hospital Y. Hospital X must have a backup plan.
• Physicians must be prepared to leave non-emergency patients to respond to call.
• Physicians must respond to call by going to the patient’s current location. For example, a physician is seeing non-emergency patients at Hospital Y. Hospital X calls the physician to provide emergency care. The physician must go to Hospital X. The physician may not have the
emergency patient transferred to Hospital Y.
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Point 12 of 17
4013
The On-Call Physician: Failure to Respond to Call
Many EMTALA investigations and citations happen when on-call physicians do not respond to call.
If an on-call physician does not respond to call:
• The physician’s name and address must be documented in the patient’s record and in any transfer papers.
• The physician must be disciplined.
• The hospital must document the discipline.
Remember: It is okay for a physician not to respond to call if the physician is already with a patient who cannot be left. In this case, the physician does not need to be written up or disciplined.
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On-Call System: Citable Practices
Remember: EMTALA citations often happen because physicians do not respond to call.
In addition, EMTALA citations often happen when:
• A PA or NP responds to call for a specialty assessment, when the on-call physician should have responded.
• A PA or NP routinely responds to call for specialty assessments.
• A patient must be transferred to another hospital because a physician does not respond to call.
• The transferring hospital does not record the name and address of a non-responding physician in a patient’s transfer papers.
• A hospital has uncovered call time. [glossary]
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Point 14 of 17
4015 Review
For a patient to be stable, all abnormal findings must be normalized.
a. True b. False
TRUE / FALSE INTERACTION
Correct: B
A: Incorrect. Abnormal findings must be normalized or explained away.
B: Correct. Abnormal findings must be normalized or explained away.
Review
Under EMTALA:
a. Uncovered call time is allowed, as long as it is kept to a minimum.
b. The call list must have the names of specific physicians, NPs, or PAs.
c. The call list must cover all hospital specialties at all times.
d. All of the above e. None of the above
MULTIPLE CHOICE INTERACTION
Correct: C
A: Incorrect. The correct answer is C. The on-call list must have names of specific physicians. The list must give each physician’s on-call time and specialty. All hospital specialties must be covered at all times.
B: Incorrect. The correct answer is C. The on-call list must have names of specific physicians. The list must give each physician’s on-call time and specialty. All hospital specialties must be covered at all times.
C: Correct. The on-call list must have names of specific physicians. The list must give each physician’s on-call time and specialty. All hospital specialties must be covered at all times.
D: Incorrect. The correct answer is C. The on-call list must have names of specific physicians. The list must give each physician’s on-call time and specialty. All hospital specialties must be covered at all times.
E: Incorrect. The correct answer is C. The on-call list must have names of specific physicians. The list must give each physician’s on-call time and specialty. All hospital specialties must be covered at all times.
Point 16 of 17
4017 Summary
You have completed the lesson on stabilizing care.
Remember:
• Under EMTALA, Medicare hospitals must provide stabilizing care to all patients with EMCs.
• A woman in active labor is stable only after delivering both the baby and the placenta.
• Other patients with EMCs are stable only after all abnormal findings are normalized through treatment or explained away.
• A patient is not stable if his or her condition could worsen because of, during, or shortly after transfer.
• When a patient is stable, the hospital’s EMTALA duty to the patient ends.
• Under EMTALA, hospitals must have an on-call system. Specialty physicians must be on-call at all times to stabilize patients with EMCs.
• The on-call list must have names of specific physicians. The list must give each physician’s on-call time and specialty. The list must be posted in the emergency department.
• On-call physicians must respond promptly when called.
• On-call physicians may send a substitute (PA or NP) for call. However, certain
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5001
Introduction & Objectives
Welcome to the lesson on transfers under EMTALA.
After completing this lesson, you should be able to:
• Identify the features of a medically appropriate transfer under EMTALA
• Recognize what receiving hospitals must do to comply with EMTALA
• Determine the point at which a transferring hospital’s EMTALA duty ends
FLASH ANIMATION: Lesson Map
Lesson 5: Appropriate Transfer
• Criteria for appropriate transfer
• The role and responsibility of the receiving hospital
Point 1 of 16
5002
Transfer Requirements
Under EMTALA, Medicare hospitals must:
• Provide medically appropriate transfers
• Accept requests for incoming transfers Let’s take a closer look at:
• The definition of a medically appropriate transfer
• The role and responsibility of receiving hospitals Note: An emergency patient may refuse to give consent for transfer. If that happens, the hospital is not required to provide transfer. The patient’s refusal must be carefully documented in the medical record. An “Informed Consent to Refuse” form should be used. This form should list the potential benefits of accepting the offered services. It should also list the risks of refusal. It must be signed by the patient or his or her legal representative.
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Medical Necessity
Under EMTALA, a transfer is appropriate only for medical reasons.
For example, an emergency patient is at Hospital X. Special medical equipment is needed to stabilize the patient. Hospital X does not have this equipment. Hospital Y does have the
equipment. For this patient, transfer from Hospital X to Hospital Y would be medically appropriate.
A transfer is not appropriate for:
• Financial reasons
• Physician or hospital convenience
FLASH ANIMATION: 5003.SWF
Transfer Reason Appropriate under EMTALA?
Medical reasons Yes
Financial reasons No
For convenience No
Point 3 of 16
5004
Physician Certification or Patient Request
Transfers must be certified or requested.
Certified: The treating physician must certify that the expected benefits of transfer outweigh the risks.
The specific benefits and risks must be:
• Documented
• Supported by the patient’s medical record Requested: The patient may request a transfer.
In this case, the hospital must make sure that the patient understands two things. The hospital must explain:
• Its EMTALA duty to provide stabilizing care
• The potential risks of transfer
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Prior to the Transfer
Before a transfer:
• The transferring hospital must provide medical treatment to make the transfer as safe as possible.
• The receiving hospital must agree to the transfer. It must have personnel and space to meet the needs of the patient.
IMAGE: 5005.jpg
Point 5 of 16
5006
Documentation
Under EMTALA, transferring hospitals must send documentation to receiving hospitals.
The patient’s emergency medical records must be sent. These should include:
• Signs and symptoms
• Any diagnosis made
• Any treatment given
• Results of any lab tests or imaging studies The transferring hospital also must send:
• The physician’s certification for transfer or the patient’s request for transfer
• The name and address of the on-call physician who did not respond to call (if any)
IMAGE: 5006.GIF
Personnel and Equipment
The transferring hospital must send the patient with all necessary equipment and personnel.
This includes:
• Any medical attendants needed to make the transfer as safe as possible for the patient
• Any life-support equipment needed
• Proper transport vehicle (ambulance)
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Point 7 of 16
5008
Appropriate Transfer: Summary
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The Receiving Hospital: Duty to Accept
Under EMTALA, a Medicare hospital must accept a request for incoming transfer if:
• The hospital has everything needed to treat the patient.
• The transferring hospital is less able to treat the patient.
IMAGE: 5009_a
.jpg
Point 9 of 16
5010
The Receiving Hospital: Duty to Report
Receiving hospitals must report possible EMTALA violations within 72 hours.
For example, an emergency patient is at Hospital X. The patient needs a specialist. The specialist on-call at Hospital X does not respond to call. As a result, the patient must be transferred to Hospital Y. Hospital Y must report this transfer within 72 hours.
IMAGE: 5010.JPG
The Receiving Hospital: Declining a Request
Hospitals are allowed to decline requests for incoming transfer under certain circumstances.
These are:
• The patient does not need the medical services of the hospital.
• The hospital does not have space for the patient.
• The transferring hospital is able to treat the patient fully.
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Point 11 of 16
5012
Declining a Request: Potential EMTALA Violation
Hospitals are allowed to decline requests for incoming transfer under certain circumstances.
However: declining a request for incoming transfer can be risky.
CMS expects receiving hospitals to do everything possible to accept incoming transfers.
For example, it may be possible for the hospital to:
• Use on-call personnel to treat the patient.
• Use step-down beds or early discharge to make room for the patient.
If possible, the hospital must take these steps. Otherwise, CMS may cite the hospital for an EMTALA violation.
IMAGE: 5012.GIF
Appropriate Transfer: EMTALA Duty
After an appropriate transfer, the transferring hospital has no further EMTALA duty to the patient.
IMAGE: 5013.GIF
Point 13 of 16
5014 Review
Before a transfer, the transferring hospital must make sure that:
a. The receiving hospital will accept the transfer.
b. The receiving hospital has space for the patient.
c. The receiving hospital has personnel who can treat the patient.
d. All of the above e. None of the above
MULTIPLE CHOICE INTERACTION
Correct: D
A: Not quite. The best answer is D. Before a transfer, the transferring hospital must check with the receiving hospital. The receiving hospital must accept the transfer. The receiving hospital also must have space and personnel to meet the needs of the patient.
B: Not quite. The best answer is D. Before a transfer, the transferring hospital must check with the receiving hospital. The receiving hospital must accept the transfer. The receiving hospital also must have space and personnel to meet the needs of the patient.
C: Not quite. The best answer is D. Before a transfer, the transferring hospital must check with the receiving hospital. The receiving hospital must accept the transfer. The receiving hospital also must have space and personnel to meet the needs of the patient.
D: Correct. Before a transfer, the transferring hospital must check with the receiving hospital. The receiving hospital must accept the
Review
FLASH INTERCTION: 5015.SWF
Complete the table by dragging and dropping terms from the word bank.
EMTALA duty to a patient ends: EMTALA duty to a patient continues:
When the MSE does not find an EMC When the MSE finds an EMC
When the patient is stable As long as abnormal findings of the MSE remain and cannot be explained away After an appropriate transfer When the risks of transfer outweigh the
potential benefits When the patient is admitted to the
hospital
When the patient remains in a DED with an emergency condition
Point 15 of 16
5016 Summary
You have completed the lesson on appropriate transfers.
Remember:
• Under EMTALA, Medicare hospitals must provide appropriate transfers.
• An appropriate transfer is:
• For medical reasons only
• Certified by a physician or requested by the patient
• Pre-approved by a receiving hospital capable of treating the patient
• Accompanied by documentation
• Performed using all necessary equipment and medical personnel
• In most cases, hospitals must accept requests for incoming transfer.
• Receiving hospitals must report transfers that may violate EMTALA.
• After an appropriate transfer, the transferring hospital has no further EMTALA duty to the patient.
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