COBRA/EMTALA Laws ================= þ New definition of "stabilized": þ Blood Alcohols, Labs and Minor Treatments in the ED: Is a Medical Screening Exam Required by EMTALA? [ACEP News, July 1998] þ Supreme Court case: þ Optional plastic closure next day? Must _not_ do any financial screening in the office if so. Plan of care failed in one similar situation, and thus a COBRA violation -- so must get an AMA _or_ make sure the plastic surgeon will not ask for payment. þ Don't use STABLE or UNSTABLE on transfer forms -- at risk or not at risk for deterioration during transfer. [Stephen Frew, JD, April 1998] þ Unmanagable delays in waiting room may result in a COBRA violation (Jim George, MD, JD) þ Seeking preauthorization is now [April 1998] per se a COBRA violation. þ COBRA signage - Must be readable from 20' - Must be at all public entrances to ED, not just main entrance to ED - Must be in multiple languages [Stephen Frew, JD, 1998 PaACEP Conference] þ Transfers to Physician Offices - Simple nondisplaced fractures -- cannot be triaged out without examination and x-rays, but must have standard evaluation as everyone else in the ED gets. A case where a child was sent to the orthopedic office with what looked like a nondisplaced fracture, but no x-rays done, was a COBRA violation because the patient didn't receive a full evaluation. - Can't transfer to physician office for care _now_ unless there is special equipment in the office that's not in the ED (e.g., ophthalmologist). But should be done with a transfer form. [Stephen Frew, JD, 1998 PaACEP Conference] - OK if the office is in the hospital, the physician is an employee, and _everyone_ goes to the office rather than receiving such care in the ED; physician convenience is not an acceptable reason for a transfer. Such transfers need to have uniformity, and nothing different based on financial status. - COBRA violation resulting in Letter of Termination: "Patient presented after being struck in eye by a tree needle. The examination showed obvious penetration of the cornea and "probable glove penetration." After a call to the ophthalmologist, the patient was sent by personal vehicle ot the ophthalmoologist at a clinic, where the patient was treated. The hospital was cited for failure to provide the medical screening examination of the patient on-site." [ACEP Patient Transfers: How to Comply with The Law, 2E. Appendix 3, Summary of EMTALA Violations, #164] þ Offsite testing: - Must be round-trip. - Must certify that the benefits outweigh the risks. - Sometimes, patient stays after testing, when unstable. þ Logs - "Discharged to doctor's office" entries in log are a red flag - Whiteout is a red flag þ Diversion - In Chicago, a patient arrived at a "closed" hospital and the ED physician came out, waving a pistol and saying "I told you we were closed." COBRA violation. - In Chicago, a hospital turned away, via radio, a 2-year-old in arrest 2 blocks away because the PICU was full, and sent the patient to a hospital 10 miles away -- one which didn't even have a PICU. COBRA violation. þ COBRA and Patients Arriving at a Hospital for Helicopter Transfer - We do have this in writing from HCFA official out of San Francisco. If a patient comes onto hospital property for the purposes of rendezvous with a helicopter and the purpose is to deliver a patient elsewhere (as part of an organized EMS trauma system or EMS-C for example), then that is not a COBRA violation. Ken Simpson is the HCFA official who wrote this opinion. Joe Barger, MD, Contra Costa EMS, Martinez CA, jbarger@ix.netcom.com þ Mercy's Policy: þ COBRA and asking about insurance - Yes this is exactly what Region II HCFA representatives and NYS-DOH told us at a meeting last year. If you tell anyone that they may be responsible for the bill... and they leave without a "screening exam"... it may be viewed as "economic coercion". -- Michael A. Shapiro MD V. Chairman Dept. of Emergency Medicine WCA Healthcare System Jamestown NY 14701 mshapiro@madbbs.com - "Financial screening prior to medical screening exam" cited as sole reason for COBRA/EMTALA Letter of Termination. [ACEP Patient Transfers: How to Comply with The Law, 2E. Appendix 3, Summary of EMTALA Violations, #143] þ COBRA and non-EPs seeing ED patients: - There is an excellent article in "ED Legal Letter" vol. 8, number 4, April 1997, pages 35-44, about COBRA laws and screening exams. It is written by Robert A. Bitterman, MD, JD, FACEP. It gives an explaination of the laws and the responsibilities of hospitals and doctors COBRA states: If "any individual" "comes to the emergency department" and a request is made on the individual's behalf for examination and treatment, the hospital must provide an appropriate medical screening exam within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition exists. All physicians who treat patients in a Medicare-participating hospital, not just emergency physicians, are subject to the legal duties of COBRA. Physicians are deemed to be agents of the hospital and the duties attach to physicians by virtue of the accepting hospital medical staff privileges and responsibilities. HCFA's regulations state that anyone on hospital property is deemed to have "come to the ED" for purposes of COBRA. The request for examination or treatment of a patient can be made by anyone on behalf of the patient. It does not have to come from the actual patient, a family member, or legal guardian. Requests for drug testing or police blood alcohol concentration sampling may be sufficient to constitute a "request for examination or treatment" under COBRA. If a hospital designates physicians to do it's medical screening exams it does not mean that an emergency physician must do the exam. Many times other members of the hospital's medical staff will meet their regular or "private" patients in the ED; that private physician's evaluation of the patient then constitutes the hospital's required medical screening exam. However, the hospital should have prearranged procedures for handling private patients that do not unduly delay a patient's screening exam, or the hospital will be liable under COBRA for failing to provide an "appropriate" MSE. The article quotes cases and the outcomes. It also stresses the ambiguity of some parts of the law, and the ability of HCFA to interpret it differently on a case by case basis. The preceding paragraphs are just a small overview of what is in this very informative article, a must read for anyone in Emergency Medicine. Anita Hennesy RN -------------------------- A couple of pertinent quotes from the draft form of "Interpretive guidelines-responsibilities of medicare participating hospitals in emergency cases" "Hospitals may not attempt to coerce individuals into making judgments against their best interest by informing them that they will have to pay for care if they remain...." (p. V-23, under tag A407) "If the medical screening examination is appropriate and does not reveal an emergency medical condition, the hospital has no further obligations under Section 489.24." (p. V-18, under tag A406) If a screened patient is determined to be stable, nothing more in COBRA applies. He can be sent to another hospital without paperwork, even without informing anyone of his arrival. Such a move would be deplorable, but would not violate COBRA. COBRA mandates a MSE. Once done, the additional requirements pertain only to the unstable patient. --Ed Berman