EMTALA

Purpose:

To ensure compliance with Emergency Medical Treatment and Active Labor Act (“EMTALA”) and related laws and requirements.

Definitions:

Board:

The Board of Trustees of Woodlawn Hospital.

Campus:

The physical area immediately adjacent to the hospital building and other hospital controlled areas and structures not strictly contiguous to the hospital building but located within 250 yards of the hospital building , including the hospital parking lot, sidewalk and driveway, but excludes other areas or structures that are not part of or controlled by the hospital, such as other non-medical facilities.

Capabilities:

Capabilities of the staff means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses and includes on-call Physicians or Licensed Independent Practitioners (LIP’s). Capabilities of the facilities available to the hospital include physical space, equipment, supplies and specialized services that the hospital provides as well as ancillary services routinely available to the hospital.

Capacity:

The ability of the hospital to accommodate the individual requesting emergency care including such things as availability of qualified staff, beds, and equipment, and the hospital’s past practice of accommodating additional patients in excess of its licensure occupancy limits, or patients needing specialized care or services.

Central Log:

The hospital logs reflecting all patients who are on campus seeking emergency medical services, including those maintained by the ED, and the obstetrical department. Hospital logs are part of, and incorporated into, the central log.

Emergency Department (ED):

The department of the hospital, located on the main hospital campus that:

Is licensed by the state as an ED;
Is held out to the public (by name, signage, advertising or other means) as a place that provides care for emergency medical conditions on an urgent basis without requiring a previously scheduled appointment; or
Any facility owned and operated by Woodlawn Hospital that, during the previous calendar year, based on a representative sample of patient visits that occurred during that year, provided at least one-third of all its outpatient visits for the treatment of emergency medical conditions on an urgent basis without requiring a previously scheduled appointment.

Diversionary Status:

The period during which, in the good faith judgment of Hospital administration, after consultation with Physicians or LIP’s and nursing staff, as deemed appropriate, the hospital is “saturated” or lacks capacity to handle additional patients in general or patients needing specific services.

Emergency Medical Condition (EMC):

A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain and/or a psychiatric emergency) such that the absence of immediate medical attention could reasonably be expected to result in:

Placing the individual (or with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy
1. With respect to a pregnant woman who is having contractions (true labor is presumed unless the Physician/LIP/QMP, after a period of observation, certifies the presence of false labor): Inadequate time to effect a safe transfer to another hospital before delivery; or transfer may pose a threat to the health or safety of the woman or unborn child.
Serious impairment to bodily functions
Serious dysfunction of any bodily organ or part.

Hospital Campus:

Any facility, organization or Physician or LIP office located on the hospital’s property and within 250 yards of the hospital building that has been determined by CMS to be a department of the hospital under 42 C.F.R. Section 413.65 (i.e., operating under the hospital’s Medicare number, licensed as a part of the hospital, and furnishing some of the same health care services as are provided in the main hospital building. Services of the “same type” are those services in a category of Medicare covered services that are provided by the Hospital at its main campus).The entire main hospital building, including the land, parking lot, sidewalk, and driveway, within 250 ft of the hospital building but excluding other areas or structures that are not part of the hospital, such as other non-medical facilities, land, sidewalks, driveways more than 250 ft from the main hospital building or not owned or controlled by the hospital..

Labor:

The process of childbirth beginning with the latent or early phase of labor and continuing through the delivery of the placenta.

Off-Campus Department:

Any facility, organization or Physician or LIP office located off of the Hospital Campus that has been determined by CMS to be a department of the hospital under 42 C.F.R. Section 413.65 (i.e., operating under the hospital’s Medicare number, licensed as a part of the hospital, and furnishing some of the same health care services as are provided at the main campus of the hospital services of the “same type” are those services in a category of Medicare covered services that are provided by the Hospital at its main campus).

EMTALA On-Call List:

A list of Physician’s or LIP’s who are on call to provide stabilizing treatment of emergency medical conditions as defined herein.

EMTALA On-Call Roster:

A list of Physician’s or LIP’s who serve in on call rotation to provide stabilizing treatment of emergency medical conditions as defined herein.

Patient:

An individual who presents anywhere on the the Hospital Campus requesting treatment for or appearing to be experiencing an EMC. Patient does not include an individual who has been admitted as an inpatient nor an individual who has begun to receive outpatient services as part of an encounter other than an encounter for an EMC. An individual includes an infant, that is born alive who, after expulsion or extraction, breathes or has a beating heart, pulsation of the umbilical cord, or definite movement of voluntary muscle regardless of whether the umbilical cord has been cut, and regardless of whether the expulsion or extraction occurs as a result of natural or induced labor, caesarean section, or induced abortion.

Psychiatric Emergency:

Those situations where a patient is a danger to himself or others by reason of aggressive conduct to inability to perceive or appreciate danger. Symptoms of substance abuse (drug and/or alcohol) requiring immediate detoxification are also considered within the definition of an EMC, and stabilizing treatment will be rendered.

Qualified Medical Personnel (QMP):

A practitioner in a category of providers approved by the Hospital Board to perform medical screening examinations and who has been approved by the Medical Staff to perform Medical Screening Evaluations (MSEs).

Representative:

The patient’s legally authorized representative acting on the patient’s behalf.

Specialized Capabilities or Facilities:

Facilities such as burn units, neonatal ICU’s and, regional referral centers.

Stabilizing Treatment:

The treatment necessary to stabilize an EMC.

Stable for Transfer:

The determination of a Physician or LIP or the QMP that the patient’s EMC is unresolved, but a transfer may be made as no material deterioration of the patient is likely and the receiving facility has the capability of managing the patient, including any foreseeable complications which might arise.

Stable for Discharge:

The determination of a Physician or LIP or QMP, within reasonable clinical confidence, that the patient has reached a point where continued care, including diagnostic work-up and/or treatment, can be reasonably performed as an outpatient or later as an inpatient. A patient may be stable for discharge even though the underlying medical condition persists.

Transfer:

The movement of an individual in an ED to facilities outside the hospital at the direction of any person employed by or affiliated with the hospital, including medical staff members. (Transfer includes discharge, but does not include moving an individual who has been declared dead or who leaves without permission).

Policy:

This policy ceases to apply if/when:
1. The moment the patient is admitted for inpatient or observation care.
2. A patient arrives at the hospital for outpatient treatment purposes such as outpatient surgery, outpatient diagnostic imaging, outpatient clinic visits, outpatient specimen collection, outpatient chemotherapy, outpatient rehabilitation services, etc,
3. The moment a MSE conducted by a QMP fails to show the patient has an EMC.
4. The patient, once advised of their right to an MSE, declines it.
5. The patient, once advised of the existence of an EMC, declines treatment.
6. The EMC is stabilized.
Medical Screening Examination (MSE).
1. An appropriate MSE will be offered to patients on the Hospital Campus who:
  1. requests emergency medical services, or,
  2. on whose behalf such services are requested, or,
  3. whose appearance or behavior would cause a prudent layperson observer to believe that such individuals may need emergency examination or treatment.
2. Where the individual requires obstetrical services, the MSE may be rendered in the OB department by Qualified Medical Personnel (QMP) as defined in the Medical Staff Rules and Regulations.
3. When an EMS provider brings an individual to the hospital and the hospital does not have the capacity or capability to provide an immediate MSE and if needed, stabilizing or an appropriate transfer, the hospital will still assess the individual upon arrival to ensure that the individual is appropriately prioritized based on presenting signs and symptoms and whether the EMS can appropriately monitor the individual’s condition.
4. Triage establishes the order in which an individual will be evaluated and is not considered an MSE.
5. A MSE will be conducted to determine whether the patient has an EMC. The hospital will conduct a consistent MSE, in a nondiscriminatory manner, for all patients with similar medical conditions.
6. The MSE is an ongoing process requiring continuing monitoring based upon the patient’s needs and will continue until:
  1. the QMP determines the patient does not have an EMC, or
  2. the patients EMC is stabilized, or
  3. the patient is admitted, or
  4. the patient is appropriately transferred.
7. A MSE and stabilizing treatment of an EMC, within the capabilities of the hospital:
  1. will be provided to all individuals regardless of their ability to pay.
  2. will not be delayed to obtain payment or insurance information.
  3. will be conducted on minors without waiting for parental consent. Once it is determined that the minor does not have an EMC, staff may await parental consent to conduct a further assessment or treatment.
  4. will be provided to all individuals brought to the hospital by law enforcement seeking clearance for incarceration.
  5. will be provided to all individuals who come to the Hospital Campus for a condition addressed by a prearranged community plan (e.g., psychiatry, high risk OB, sexual assault, trauma)
  6. will be provided to all individuals who come to the Hospital Campus and requests treatment during a declared state of emergency or crisis where the Hospital has activated its emergency management plan(s)
    1. The hospital will perform such screening as necessary to determine whether the individual falls into the category for which the community has a specified screening site (e.g., toxin exposure) and may refer the individual to the designated facility.
8. Reasonable registration processes, including gathering of insurance information, may be followed as long as individuals are not unduly discouraged from remaining for further evaluation and the gathering of such information does not delay the MSE or stabilizing treatment of an EMC.
9. A MSE is not required where an individual:
  1. Comes to the Hospital Campus and requests non-emergent tests
  2. Comes to the Hospital Campus for outpatient services specified in an order from a Physician or LIP (such as blood draws, diagnostic tests, medication/pharmaceutical services, scheduled procedures).
  3. Requests only medication/pharmaceutical services ordered by a QMP.
  4. Requests services that are not for a medical condition, such as preventative care services (immunizations, allergy shots, flu shots, employer mandated blood/breath alcohol testing).
  5. Is brought to the Hospital Campus by law enforcement seeking only blood/breath alcohol testing or evidence collection for law enforcement purposes and does not require examination or treatment and does not appear to need an examination.
An individual may be moved to a different part of the Hospital for screening or stabilizing care provided that:
1. All individuals are moved in such circumstances regardless of ability to pay (e.g., OB triage);
2. There is a bona fide reason to move the individual; and appropriate personnel accompany the individual.
The scope of the MSE includes the use of ancillary services routinely available to the hospital along with available personnel, which includes on-call LIP’s, in determining whether an EMC exists.
A Physician, LIP or QMP will medically screen Patients.
1. Where a QMP performs the MSE, such QMP will consult with the patient’s Physician or LIP during, or at an appropriate time after, the completion of the MSE as necessary.
2. The on-call Physician or LIP shall be contacted and consulted about the patient’s condition as necessary when the patient does not have a Physician or LIP on the medical staff or after hours as determined by the medical staff.
3. A Physician, LIP, QMP, or other hospital personnel may contact the patient’s Physician or LIP to seek advice regarding the patient’s medical history and needs that may be relevant to the MSE or treatment, provided that such consultation does not inappropriately delay the MSE or stabilizing treatment.
Patients will be provided with an MSE and stabilizing treatment regardless of managed care/payor requirements.
1. Managed care plans/payors may be notified of the individual’s presentation and asked to identify an attending LIP, but any request for authorization may not in any way delay the MSE or stabilizing treatment of an EMC.
Patients on the Hospital Campus presenting for, or appearing to require, emergency care will be given a MSE and, if an EMC exists, stabilizing treatment, even when the hospital is on diversionary status.
1. Hospital personnel will respond to an individual presenting for or appearing to require emergency care on the Hospital Campus other than the in the ED in a manner that is in the individual’s best interests, taking into consideration the needs of the individual, the location of the individual, access to the individual, and needs of other patients. When appropriate, 911 may be called.
2. When an individual on the Hospital Campus requires rescue, stabilization, and/or transport, EMS may be called to assist when to do so is in the best interest of the individual.
Stabilizing Treatment
1. If the MSE demonstrates that an EMC exists, the Hospital will provide stabilizing treatment within the hospital’s capabilities.
  1. Even if the hospital must transfer the patient, an on-call Physician or LIP is expected to present to the hospital to stabilize and treat a patient with an EMC when requested by a Physician, LIP or a QMP.
2. A Patient with an EMC is stabilized when the LIP/QMP determines that:
  1. The patient is stable for discharge
  2. The patient is stable for transfer
  3. With regard to a pregnant patient in active labor, stabilization means the delivery of the fetus and placenta unless:
    1. Delivery is contraindicated or
    2. Transfer is appropriate.
  4. With regard to a psychiatric EMC, stabilization means protecting the patient and preventing him/her from harming him/herself or others.
Patient Registration and Financial Issues.
1. The hospital will not delay the MSE to request payment or insurance information. The hospital may complete its routine registration process, including inquiries about insurance coverage, provided that the inquiry does not delay medical screening or stabilizing treatment.
2. The hospital may not seek or receive payment as part of its routine request process prior to conducting the MSE and initiating stabilizing care.
3. Prior to the MSE and initiating stabilizing care, the hospital may not inform individuals that their care will be free or at a lower cost if they transfer to another hospital.
4. The hospital will train personnel to respond to individual inquiries about their financial liability.
5. Trained personnel will respond as fully as possible to individual inquiries about their financial liability.
6. Patients will be informed of the hospital’s willingness and obligation to provide a MSE and stabilizing treatment, if necessary.
7. Hospital staff will encourage Patients believed to have an EMC to remain for a MSE and treatment. Hospital staff will encourage Patients to defer questions about financial liability until after the MSE has been completed.
8. Where the Patient withdraws his/her request for examination and treatment, the refusal of examination form shall be completed. (See paragraph O below.)
9. Managed care plans/payors may not be contacted for payment authorization until the MSE has been completed and stabilizing treatment has been initiated.
On-Call and Attending Physicians and LIPs.
1. The hospital shall maintain an EMTALA on-call roster of Physicians and LIPs to serve on the EMTALA on-call list in a manner that best meets the needs of its patients in accordance with available resources, including the availability of on-call Physicians and LIPs.
2. The EMTALA on-call roster and EMTALA on-call list will reflect coverage for the types of services routinely offered at the Hospital.
3. The EMTALA on-call roster and EMTALA on-call list will include individual Physicians and LIPs names. Physicians and LIPs group names are not acceptable.
4. The hospital will strive to provide adequate specialty on-call coverage consistent with the services provided at the hospital and the resources that are available.
  1. Where the hospital lacks available Physician and LIP resources to provide 24/7 coverage, the hospital shall consider various factors in developing the EMTALA on-call list and on call coverage times, including the supply of specialty at the hospital and in the area, other demands on these Physicians and LIPs, the frequency with which a particular service is provided at the hospital, and the availability of specialty care at other nearby hospitals.
    1. A Physician or LIP may not refuse to serve on the on-call list, or to selectively take calls, when on-call coverage in the Physicians and LIPs specialty is inadequate.
5. The attending or on-call Physicians and LIPs will come to the hospital to examine and provide necessary stabilizing care for a patient with an EMC when requested to do so by the Physician, LIP, or QMP performing the MSE of the Patient.
6. On call Physicians and LIPs will respond to calls from the Physician, LIP, or QMP performing the MSE of the Patient and provide direct examination of the Patient within 30-60 minutes of being informed the Patient has or may have an EMC.
  1. The hospital shall report to the medical staff any Physicians and LIPs failure to respond timely and appropriately to the request to do so from the LIP or QMP.
7. Where appropriate and permitted by medical staff policies, the on-call Physician or LIP may direct a Physician or LIP extender with privileges to go to the hospital for the Physician or LIP.
  1. The on-call Physician or LIP remains ultimately responsible for providing the necessary services to the patient, regardless of whether the Physician or LIP extender provides the services.
  2. In the event that the QMP performing the MSE of the Patient disagrees with the Physician or LIP’s decision to send a Physician or LIP extender and requests the actual appearance of the on-call Physician or LIP, the on-call Physician or LIP will respond within 30-60 minutes to the best of their ability after being informed of the patient situation.
8. The QMP performing the MSE of the Patient, attending Physician or LIP, or on-call Physician or LIP may use telemedicine services for further evaluation and/or treatment necessary to stabilize an EMC.
Lack of Capacity or Physician or LIP On-Call Coverage.
1. Where the hospital lacks Capacity or Physician or LIP On-Call Coverage it will transfer patients to other providers as it customarily does to accommodate patients in excess of its occupancy, staff Physician or LIP limits.
2. The hospital may notify emergency medical services and other healthcare providers, as appropriate, in the event the hospital is on diversionary status or lacks Physician or LIP coverage.
Discharge Requirements.
1. A patient may be discharged if, following the MSE, the QMP determines that the patient does not have an EMC or is stable for discharge.
  1. Prior to discharge, the patient with an EMC who is stable for discharge is given a plan of care and discharge instructions, including a plan for appropriate follow-up care, if necessary.
Re-Screening.
1. Any Patient returning to the Hospital Campus presenting for, or appearing to require,emergency care will be provided a MSE, regardless of the time interval since his/her prior visit, to determine whether an EMC exists.
Patient Transfer Requirements
The hospital will provide medical treatment within its capacity that minimizes the risks to the Patient’s health and, in the case of a woman in labor, the health of the unborn child, likely to occur as a result of transfer.
1. Transfer of a Patient may be considered under the following circumstances:
  1. The Patient or patient representative requests transfer after being informed of the hospital’s obligation to provide stabilizing care and the risks and benefits of transfer; or
  2. The Patient requires a higher level of care; or
  3. The Patient requires specialty care or services not provided by the hospital, or
  4. The hospital lacks capacity to treat the Patient.
2. The Patient may be transferred to another hospital if:
  1. The Physician or LIP in attendance, or QMP determines that the patient is stable for transfer; or
  2. The Physician or LIP in attendance, or QMP in consultation with the Physician or LIP, determines that the benefits of transfer outweigh the risks; or
  3. The hospital is unable to stabilize the Patient within its capacity; or
  4. The Patient or his/her representative requests transfer after being advised of the hospital’s obligation to provide care and the risks and benefits of transfer.
  5. A Patient in labor may not be transferred unless she or her representative consents to or requests transfer as provided in section III.N.1 above per the Physician or LIP or QMP, in consultation with a Physician or LIP, certifies that the benefits to the Patient and/or the unborn child outweigh the risks.
3. Transfer of the patient will occur as per Nursing Administration Patient Transfer policy.
  1. Where the Patient is transferred because of the refusal or failure of the on-call Physician or LIP to come to the hospital within a reasonable period of time to provide necessary stabilizing treatment, the name and address of the on-call Physician or LIP will be sent to the accepting facility with the Patient.
  2. A Patient who is not stable for transfer will not be transferred for the convenience of the Physician or LIP.
  3. A Patient who is not stable for transfer may be transferred to the Physician’s or LIP’s office only if:
    1. A Physician or LIP has examined the Patient and determined that it is in the patient’s best interest to render further care in the office setting, or
    2. The hospital does not have access to specialized equipment, e.g., ophthalmic equipment, to fully evaluate and treat the Patient, or
    3. The Physician’s or LIP’s office is a provider-based part of the hospital (i.e., a department of the hospital sharing the same CMS certification as the hospital), provided that
      1. all Patients with the same medical condition, regardless of ability to pay, are similarly moved to the Physician’s or LIP’s office, and
      2. that there is a genuine medical reason to move the Patient, and
      3. that appropriate medical personnel accompany the Patient to the office.
  4. When the hospital transfers the patient who is not stable for transfer to another hospital for a diagnostic procedure not available at the hospital, the same transfer requirements will be met.
Refusal of Examination/Treatment or Transfer.
1. If a Patient or his/her representative has refused examination/treatment or transfer, the following will occur:
  1. The Patient will be informed of the hospital’s obligations under the EMTALA law, and the willingness of the hospital to provide a MSE and render stabilizing treatment.
  2. The risks and benefits of refusing stabilizing treatment are explained by the RN, Physician or LIP, or QMP.
  3. See hospital nursing administration policy AMA Patient Departure. The refusal of treatment or transfer form is signed, indicating what aspects of care are refused, the risks of refusal and the reasons for the refusal. If the individual/representative refuses to sign, documentation relative to the above is noted in the medical record along with the steps taken to try to secure the written informed refusal.
2. If an individual leaves without examination, attempts will be made to locate the individual on the Hospital Campus.
  1. The hospital will document information on any known individual who chooses to leave without examination.
Hospital Obligation To Accept Transfers.
1. Any hospital with specialized capabilities or facilities or regional referral centers that serve rural areas and that has capacity, regardless of whether the hospital has a dedicated emergency department, will accept an appropriate transfer of an unstable patient who requires the specialized capabilities of the hospital from any referring hospital, regardless of financial consideration or proximity of other hospitals. The hospital may not delay acceptance of a Patient with an un-stabilized EMC pending receipt or verification of financial information.
2. The hospital with specialized capabilities or facilities cannot delay or refuse the transfer based on the transport services selected by the transferring hospital.
3. Hospital staff may not deliberately delay moving the patient from an EMS stretcher or releasing EMS personnel unless warranted by the other circumstances in the hospital.
4. After the patient has been accepted and the acceptance has been documented, financial information may be requested and alternative transfer sites may be suggested which are consistent with the patient’s insurance.
5. A patient with an unstable EMC will not be refused care because of any financial or insurance concerns, and the transfer will not be delayed to obtain financial/insurance information.
6. The hospital need not accept the transfer of a patient from a transferring hospital that has the capability and capacity to stabilize the individual.
7. The hospital may not refuse to accept the patient because it does not have a dedicated ED.

EMTALA On-Call Roster and List Development

The list of Physicians or LIPs who are on the active staff of Woodlawn Hospital comprise the EMTALA on-call roster as defined herein.
Each Physician or LIP on the EMTALA on-call roster must participate in the provision of on call services as required by this policy. The EMTALA on-call list shall identify who is on call for any service at any given time.
On-Call Coverage
1. The EMTALA on-call list and hours of coverage will reflect coverage for the types of services routinely offered at the hospital.
2. The EMTALA on-call roster and EMTALA on-call list will include individual Physician or LIP names and contact information. Physician or LIP group names are not acceptable.
3. The hospital will generally provide adequate specialty on-call coverage consistent with the services provided at the hospital and the resources that are available.
  1. Where the hospital lacks available Physician or LIP resources to provide 24/7 coverage, the hospital shall consider various factors in developing the EMTALA on-call list and on call coverage times, including the supply of specialty Physicians or LIPs at the hospital and in the area, other demands on thesePhysicians or LIPs, the frequency with which a particular service is provided at the hospital, and the availability of specialty care at other nearby hospitals.
    1. A Physician or LIP may not refuse to serve on the on-call list, or to selectively take calls, when on-call coverage in the Physician’s or LIP’s specialty is inadequate.
    2. In general, when there are three or more providers on the EMTALA on-call roster who provide the same or very similar clinical services, there will be 24/7 coverage for that service.
    3. In general, when there are less than three providers on the EMTALA on-call roster who provide the same or very similar clinical services, the EMTALA on-call list of coverage will not show 24/7 coverage but shall proportionally reflect the coverage of three providers covering 24/7. Example: If the hospital has two providers on the EMTALA on-call roster who provide general surgery, the EMTALA on-call list will generally show coverage for 60% to 70% or more of the time coverage is needed.
General clinical areas of coverage and percentage of time covered:*
1. For purposes of this policy, the hospital has identified the following general clinical service areas which will have on-call coverage.
  1. Medicine 100%
  2. Obstetrics 100%
  3. Orthopedic Surgery 60% or more
  4. Pediatrics 100%
  5. General Surgery 20% or more
  6. Anesthesia 100%
  7. Emergency Medicine 100%
  8. Gynecology 20% or more
  9. Radiology 100%
  10. Caesarean Section 100%
    
    *The percent of time covered may change without change to this policy based on changes in medical staff active member’s privileges and the ability of the active member to provide coverage due to serious health issues or other serious events that may affect a Physician’s or LIP’s ability to provide this coverage.
Clinical expectations of the EMTALA On-Call Physician or LIP
1. The EMTALA on-call Physician or LIP is expected to provide care commensurate with their
  1. Credentials
  2. Training
  3. Usual practice patterns
    1. If the EMTALA on-call Physician or LIP typically provides a service or procedure as part of their regular practice patterns, they are expected to provide the same level of care to the Patient with an EMC
      1. Example 1: A family practice LIP who normally provides obstetric services, but does not do C-Sections, would be expected to manage the labor and delivery of a patient with an EMC. If they determine the patient requires a C-Section, they would request the EMTALA on-call Physician or LIP for caesarean section to consult.
      2. Example 2: A general surgeon who normally does not do caesarean sections would not be expected to provide that service as the EMTALA on-call Physician or LIP.
      3. Example 3: An orthopedic surgeon who normally does not provide surgical intervention for compartment syndrome would not be expected to provide that service as the EMTALA on-call Physician or LIP however would be expected to assist with diagnosing and stabilizing this condition if requested to do so by the ED LIP or QMP.
      4. Example 4: A family practitioner who normally provides care to adult patients except for those with unstable or severe respiratory disease, would not be expected to provide that service as the EMTALA on-call Physician or LIP.
    2. Case histories will be utilized to determine if the EMTALA on-call Physician or LIP normally provides a given service or procedure.
Development of the EMTALA on-call List
1. The Director of Woodlawn Medical Professionals, in consultation with individual Physicians or LIP,s will develop and publish the EMTALA on-call list on the hospital intranet site designated for that purpose.
  1. Any changes to the EMTALA on-call list must be communicated to the nursing supervisor prior to the time the change is effective and must include when the change in the EMTALA on-call list will start and when the change will end and the EMTALA on-call list will return to its base schedule.
    1. The nursing supervisor will update the EMTALA on-call list on the hospital intranet site as soon as practical after receiving notice of the change.
  2. If, due to unplanned circumstances, such as illness, travel delays, family emergencies, etc. the EMTALA on-call Physician or LIP cannot meet the requirements of this policy, they must inform the nursing supervisor immediately and assist in developing a plan to provide coverage for the on call time missed. This includes the Physician or LIP calling other Physicians or LIPs for coverage unless they are absolutely not able to do so.
  3. EMTALA on-call Physicians or LIP’s may schedule elective surgery or other procedures during the time they are on call provided that the EMTALA on-call LIP and the nursing supervisor have a back-up plan when the EMTALA on-call LIP is unable to respond in the time frames identified in this policy.
  4. EMTALA on-call Physicians or LIP’s may be on call for another hospital during the time they are the EMTALA Physician or LIP on-call for Woodlawn Hospital provided that the EMTALA on-call Physician or LIP and the nursing supervisor have a back-up plan when the EMTALA on-call Physician or LIP is unable to respond in the time frames identified in this policy. (Simply transferring the patient to another hospital is not an acceptable back up plan. There must be another practitioner to take the on call time.)
  5. The hospital may permit exemptions from call for Physicians or LIPs provided that such exemptions do not affect patient care adversely.

Reporting Requirements

If the hospital has reason to believe it has received a patient with an unstable EMC who has been transferred by another hospital in violation of EMTALA requirements, the Director of Regulatory Affairs and the administrator on call will be informed immediately.
The hospital will notify CMS/state agency within 72 hours if reporting is deemed necessary.

Signage Requirements.

Signage will be posted in a place or places likely to be noticed in the ED, admitting, and in such other locations where individuals are waiting for examination and treatment specifying:
1. The rights of individuals with EMC’s and women in labor and
2. Whether the hospital participates in the applicable state Medicaid program.

Documentation Requirements

Logs will be maintained and will reflect all individuals who present seeking emergency medical services and whether each individual refused treatment or was refused treatment, was transferred, was admitted and treated, was stabilized and transferred, or was discharged. Logs may be maintained in areas other than the ED (i.e., obstetrical department or psychiatric intake office).
1. Such logs are a part of the hospital’s central log and will be retained as per the hospital’s Records Retention policy
An EMTALA on-call list will be maintained and will reflect the specialties routinely available at the hospital. The on-call lists will be retained as per the hospital’s Records Retention policy.
Refusal of examination, treatment or transfer forms and certification of transfer forms will be completed as appropriate and will be retained as per the hospital’s Records Retention policy.
Medical and other records related to patients transferred to or from the hospital will be retained as per the hospital’s Records Retention policy.
The documentation applicable to the following events should contain, at a minimum, the following information:
1. Triage:
  1. Clinical assessment of the presenting signs and symptoms at the time of arrival.
  2. Presenting complaint including extent, frequency and duration.
  3. Re-question when concerned about a change in the individual’s condition.
  4. Re-question when there is a prolonged wait for an EMC.
2. Medical Screening Exam:
  1. Physician or LIP/QMP assessment and orders.
  2. Intervention/treatments.
  3. Patient/fetus response to treatment.
  4. Results of continued monitoring.
3. Refusal of Examination:
  1. Patient name, encounter date and time.
  2. Patient signature or legally authorized representative (if willing).
  3. Time of attempt(s) made to locate patient (if applicable).
4. Refusal of Treatment or Transfer:
  1. Risk and/or benefits.
  2. Patient signature or legally authorized representative (if willing).
  3. Reason for refusal (if obtained).
5. If applicable, name of the on-call LIP who refused or failed to respond to a patient with an EMC when requested:
  1. Physician or LIP name(s).
  2. Time or attempt(s) of contact.
  3. Reason they could not respond or failure to respond.
  4. Any other Physician or LIP(s) contact made.
6. Transfer of Unstable Patient to Another Facility:
  1. Certification.
  2. Risk and benefits upon which the certification is based for transfer.
  3. Patient Request/Consent to Transfer.
7. Transfer Acceptance by a Receiving Facility:
  1. Accepting Physician or LIP or authorized person.
  2. Name of person contacted in admission department.
  3. Time contacted.
8. Notification to Receiving Facility:
  1. Patient report given to staff. Time of report.
  2. Copies of relevant portions of medical records sent.
  3. If applicable, name of the on-call LIP who refused or failed to respond when requested.
  4. Mechanism of transfer, and any special equipment or personnel being utilized to facilitate a safe transfer.

Off-Campus Departments without a Dedicated Emergency Room.

Off-campus departments that meet the definition of an ED will provide an appropriate MSE and stabilizing treatment within its capability to any individual who requests emergency medical services or on whose behalf such services are requested or whose appearance or conduct would suggest to the prudent layperson observer that such individual needs examination or treatment for a medical condition.

Practitioner and Employee Protection.

No negative job action shall be taken against a Physician or LIP or QMP who refuses to authorize the transfer of a patient with an EMC that has not been stabilized.
No negative job action shall be taken against any employee, in compliance with this policy, reports an EMTALA violation.

Applicability.

This policy applies to all Woodlawn Hospital departments, all facilities owned and operated by Woodlawn Hospital, and all providers employed by Woodlawn Hospital.

References:

Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), 42 U.S.C. Statute 1395 dd (1986)
Born Alive Infants Protection Act 200

Woodlawn Health EMTALA Policy