UTSW/BioTel Policy: EMTALA

Purpose: The purpose of this policy is to ensure that UTSW/BioTel Paramedics adhere to Federal EMTALA Guidelines.

1. "EMTALA” is the Emergency Medical Treatment and Labor Act enacted by Congress in 1986. EMTALA is a federal law requiring that anyone who comes to an emergency department requesting emergency medical evaluation be stabilized and treated, regardless of their insurance status or ability to pay. The statute is commonly referred to as the “anti-dumping” law.  It was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a documented medical screening examination or “MSE” and stabilizing treatment within the capability of the hospital.  This statute is vigorously enforced by the Centers for Medicare and Medicaid Services (CMS) and by the Office of the Inspector General of the U.S. Department of Health & Human Services (OIG). 
2. The CMS defines a dedicated hospital emergency department as an area of the hospital that meets one of three tests:  it is licensed by the state as an emergency department, it holds itself out to the public as providing emergency care, or, in a calendar year, it treats at least one-third of its outpatient visits for an emergency medical condition.  Hospitals have three obligations under EMTALA:
   1. Any individual who comes to the hospital and requests examination or treatment must receive an appropriate medical screening examination within the capability of the hospital to determine whether an emergency medical condition exists. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage. Emergency departments must also post signs notifying patients and visitors of their rights under the statute.
      
      
   2. If it is determined that a medical emergency condition exists, the hospital must provide stabilizing treatment within its capability until the emergency medical condition is resolved or stabilized.  If a hospital does not have the capability to stabilize the emergency medical condition, it must arrange an “appropriate” transfer of the patient to another hospital in accordance with the EMTALA statute and the regulations promulgated by the CMS. Hospitals with specialized capabilities are obligated to accept transfers from hospitals that lack the capability to treat an unstable medical condition, and this last requirement applies even to hospitals that do not have emergency departments.
      
      
   3.  Hospitals must report to CMS or to the state survey agency any time they have reason to believe they may have received an individual who has been transferred in an unstable emergency medical condition from another hospital in violation of EMTALA. 
3. EMTALA directly affects EMS agency providers in two major ways:
   1. Under EMTALA, a patient “comes to” the hospital when an ambulance that contains the patient crosses the threshold of the hospital’s property.  Once the ambulance “comes to” the receiving hospital, the patient may not be removed from that hospital by paramedics until the receiving hospital has complied with EMTALA and has, at a minimum provided a medical screening exam for that patient, even if the patient requests that paramedics take them somewhere else. Once an ambulance has arrived at a hospital, meaning it has crossed the threshold of the hospital’s property, that ambulance shall not leave the hospital with that patient without first seeking approval from an EMS Supervisor AND from BioTel.
      
      
   2. Patients who are found at hospital-based out-patient clinics (meaning the clinic is on the grounds of that hospital) that are not equipped to handle the patient’s medical emergency must be transported to the emergency department of the hospital they are associated with, UNLESS the clinic treating physician has made arrangements for acceptance at another hospital emergency department. In such instances, clinic staff shall provide the paramedics with a “Memorandum of Transfer” indicating that the patient has been accepted at that hospital emergency department. Paramedics must give this document to ED staff upon arrival. Paramedics shall not deviate from these transfer arrangements without first consulting BioTel.
      
      
   3. If a clinic is not on the grounds of a particular hospital, AND no arrangements have been made in advance by clinic staff for acceptance of the patient at a particular hospital’s emergency department, paramedics shall utilize standard system guidelines for determining patient destination.
      
      
   4. SPECIAL CIRCUMSTANCES RELATED TO PARKLAND HOSPITAL and CHILDREN’S MEDICAL CENTER (CMC):  At times, paramedics will transport both an adult and a pediatric patient in the same ambulance, most commonly associated with motor vehicle collisions (MVCs). In these instances, paramedics shall transport both patients either to the Parkland Hospital ambulance bay or to the CMC ambulance bay, depending upon which of their two patients is felt to be most critical.  In these instances, paramedics may then “split” the patients, taking the adult patient to the Parkland Hospital ED and the pediatric patient to CMC, utilizing the corridor connecting Parkland Hospital and CMC, turning the care of the pediatric patient over to CMC triage staff and the adult patient to Parkland Hospital ED triage staff.
      
      
   5. SPECIAL CIRCUMSTANCES RELATED TO PARKLAND CLINICS LOCATED ADJACENT TO PARKLAND HOSPITAL: Because of the proximity of Parkland Hospital’s “Amelia Court” outpatient clinic (1936 Amelia Court at Harry Hines Blvd.) and the Ambulatory Surgery Center (4900 Harry Hines Blvd. at Medical District Drive) to Parkland Hospital, patients seen at these facilities MUST be transported to the Parkland Hospital ED, UNLESS the clinic treating physician has made arrangements for acceptance at another hospital emergency department. In such instances, clinic staff shall provide the paramedics with a “Memorandum of Transfer” indicating that the patient has been accepted at another hospital emergency department. Paramedics must give this document to ED staff upon arrival. Paramedics shall not deviate from these transfer arrangements without first consulting BioTel and notifying their EMS Supervisor.
      
      
   6. Finally, hospital helipads are exempt from EMTALA requirements. If a local EMS agency meets a helicopter at the site of a hospital helipad, the patient does NOT need to go to that hospital’s emergency department, if the sending hospital has made arrangements for transfer of the patient to another nearby hospital, OR if coming from a “scene”, the ultimate point of delivery is a different hospital that is the appropriate destination for that patient. Consider the helipad a load/unload waypoint and nothing more.
4. In the event that a paramedic in the UTSW/BioTel system has reason to believe that there may be an EMTALA issue regarding his/her patient, the paramedic should immediately contact the Medical Command Physician at BioTel and their EMS Supervisor for further direction.  Paramedics shall not engage in discussions with hospital or clinic personnel either at the transferring hospital/clinic or at the receiving hospital regarding any EMTALA issues, unless specifically instructed to do so by the Medical Command Physician.  In such instances, they shall notify their EMS Supervisor of such occurrences.