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									DEPARTMENT: Risk & Insurance                          POLICY DESCRIPTION: EMTALA –
                                                      Medical Screening
PAGE: 1 of 10                                         REPLACES POLICY DATED:
APPROVED: November 12, 1998                           RETIRED:
EFFECTIVE DATE: January 1, 1999                       REFERENCE NUMBER: RI.001

SCOPE: All Company facilities including hospitals and any entities operating under the hospital’s
Medicare Provider Number including, but not limited to, the following:

All Clinical Departments                               Administration
Ancillary Services                                     Quality Management
Admitting/Registration                                 Risk Management
Employed Physicians                                    Emergency Department
Hospital owned Medical Office Buildings                Urgent Care Centers/clinics
Hospital owned emergency vehicles                      Ambulatory Care Facilities

PURPOSE: To ensure that all patients coming to the hospital requesting emergency services receive
an appropriate Medical Screening Examination as required by the Emergency Medical Treatment and
Active Labor Act (“EMTALA”), 42 U.S.C., Section 1395 and all Federal regulations and interpretive
guidelines promulgated thereunder.

POLICY: Any patient who comes to the hospital requesting emergency services is entitled to and
will receive a Medical Screening Examination performed by individuals qualified to perform such
examination to determine whether an emergency medical condition exists.

Some states have separate emergency services laws that may apply additional legal requirements to
the Medical Screening Examination, diagnostic testing, or stabilizing emergency medical treatment.
Consult with your Operations Counsel to identify and comply with any such additional legal
mandates.

PROCEDURE:

I. DEFINITIONS:
Appropriate transfer occurs when: (i) the transferring hospital provides medical treatment within its
capacity that minimizes the risks to the individual’s health and in the case of a woman in labor, the
health of the unborn child; (ii) the receiving facility has the appropriate space and qualified personnel
for the treatment of the individual and has agreed to accept transfer of the individual and to provide
appropriate medical treatment; (iii) the transferring hospital sends to the receiving hospital all
medical records (or copies thereof) related to the emergency medical condition including available
history that are available at the time of transfer pertaining to the individual’s emergency medical
condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or
telephone reports of the studies, treatment provided and the informed written consent or certification
required, name and address of any on-call physician who has refused or failed to appear within a
reasonable time to provide necessary stabilizing treatment, and that any other records that are not
readily available at the time of transfer are sent as soon as practicable after the transfer; and (iv) the
DEPARTMENT: Risk & Insurance                          POLICY DESCRIPTION: EMTALA –
                                                      Medical Screening
PAGE: 2 of 10                                         REPLACES POLICY DATED:
APPROVED: November 12, 1998                           RETIRED:
EFFECTIVE DATE: January 1, 1999                       REFERENCE NUMBER: RI.001

transfer is effected through qualified medical personnel and transportation and equipment, as
required, including the use of necessary and medically appropriate life support measures during the
transfer.

Capabilities refer to the hospital’s physical space, equipment, supplies and services (e.g. trauma care,
surgery, intensive care, pediatrics, obstetrics, burn unit, neonatal unit or psychiatry), including
ancillary services, that the facility provides. The capabilities of the facility’s staff mean the level of
care that the hospital’s personnel can provide within the training and scope of their professional
licenses.

Capacity means the ability of the hospital to accommodate the individual requesting examination or
treatment of the transferred individual. Capacity encompasses number and availability of qualified
staff, beds, equipment and the hospital’s past practices of accommodating additional patients in
excess of its occupancy limits.

Central Log is a log that a hospital is required to maintain of all individuals who come to its
emergency room seeking assistance and the disposition of such individuals, whether the persons were
or are refused treatment, transferred, admitted and treated, stabilized and transferred or discharged.
The purpose of the central log is to track the care provided to each individual who comes to the
hospital seeking care for an emergency medical condition. The central log includes, directly or by
reference, patient logs from other areas of the hospital, such as pediatrics and labor and delivery,
where a patient might present for emergency services or receive a medical screening examination
instead of in the emergency department.

Comes to the Emergency Department with respect to an individual requesting examination and
treatment means that the individual is on the hospital property or premises.

Emergency Medical Treatment and Active Labor Act (“EMTALA”) refers to Sections 1866 and 1867
of the Social Security Act, 42 U.S.C. Section 1395dd, which obligates hospitals to provide medical
screening, treatment and transfer of individuals with emergency medical conditions or women in
labor. It is also referred to as the “anti-dumping” statute and COBRA.

Emergency Medical Condition means:
(i)   A medical condition manifesting itself by acute symptoms of sufficient severity (including
      severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the
      absence of immediate medical attention could reasonably be expected to result in

               (A) Placing the health of the individual (or, with respect to a pregnant woman, the
                   health of the woman or her unborn child) in serious jeopardy;
DEPARTMENT: Risk & Insurance                        POLICY DESCRIPTION: EMTALA –
                                                    Medical Screening
PAGE: 3 of 10                                       REPLACES POLICY DATED:
APPROVED: November 12, 1998                         RETIRED:
EFFECTIVE DATE: January 1, 1999                     REFERENCE NUMBER: RI.001

               (B) Serious impairment to bodily functions; or
               (C) Serious dysfunction of any bodily organ or part; or

(ii)   With respect to a pregnant woman who is having contractions –

               (A) That there is inadequate time to effect a safe transfer to another hospital before
                   delivery; or
               (B) That transfer may pose a threat to the health or safety of the woman or the unborn
                   child.

Hospital means a Medicare facility certified as a hospital with its own provider number, including a
rural primary care hospital.

Hospital with Emergency Department is a hospital that offers services for emergency medical
conditions within its capabilities, regardless of whether or not the hospital has an established
emergency department. If a hospital offers emergency services for medical, psychiatric or substance
abuse emergency conditions, it is required, within its capability and capacity, to comply with all the
anti-dumping statutory requirements.

Hospital Property or Premises includes the entire main hospital campus, including the parking lot,
sidewalk, driveway, as well as any facility that is located off the main hospital campus but has been
determined to be a department of the hospital and/or operates under the hospital Medicare Provider
Number and any ambulance owned and operated by the hospital, even if the ambulance is not on
hospital grounds.

Hospital-Owned Facility which is Contiguous means any area within the hospital (or a hospital-
owned facility) on land that touches land where a hospital’s emergency department sits.

Labor means the process of childbirth beginning with the latent or early phase of labor and continuing
through the delivery of the placenta. A woman is in true labor unless a physician or qualified medical
personnel certifies that, after a reasonable time of observation, the woman is in false labor.

Medical Screening Examination is the process required to reach with reasonable clinical confidence,
the point at which it can be determined whether or not an emergency medical condition exists or a
woman is in labor. Such screening must be done within the facility’s capabilities and available
personnel, including on-call physicians. The medical screening examination is an ongoing process
and the medical records must reflect continued monitoring based on the patient’s needs and continue
until the patient is either stabilized or appropriately transferred.
DEPARTMENT: Risk & Insurance                          POLICY DESCRIPTION: EMTALA –
                                                      Medical Screening
PAGE: 4 of 10                                         REPLACES POLICY DATED:
APPROVED: November 12, 1998                           RETIRED:
EFFECTIVE DATE: January 1, 1999                       REFERENCE NUMBER: RI.001

On-Call List refers to the list that the hospital is required to maintain that defines those physicians
who are “on-call” for duty after the initial medical screening examination to provide further
evaluation and/or treatment necessary to stabilize an individual with an emergency medical condition.
The purpose of the on-call list is to ensure that the emergency department is prospectively aware of
which physicians, including specialists and subspecialists, are available to provide treatment
necessary to stabilize individuals with emergency medical conditions. If a hospital offers a service to
the public, the service should be available through on-call coverage of the emergency department.

Physician means: (i) a doctor of medicine or osteopathy; (ii) a doctor of dental surgery or dental
medicine who is legally authorized to practice dentistry by the State and who is acting within the
scope of his/her license; (iii) a doctor of podiatric medicine to the extent that he/she is legally
authorized to perform by the State; (iv) a doctor of optometry to the extent that he/she is legally
authorized to perform by the State with respect to services related to the condition of aphakia or (v) a
chiropractor who is licensed by the State or authorized to perform by the State but only with respect
to treatment by means of manual manipulation of the spine to correct a subluxation demonstrated to
exist by x-ray.

Physician Certification refers to written certification by the treating physician ordering the transfer
and prior to the patient’s transfer, that based on the information available at the time of transfer, the
medical benefits reasonably expected from the provision of appropriate medical treatment at another
facility outweigh the increased risks to the individual or, in the case of a woman in labor, to the
woman or the unborn child, from effecting the transfer. The certification must include a summary of
the risks and benefits upon which the certification is based and the reason(s) for the transfer. If the
physician is not physically present at the time of transfer, qualified medical personnel can sign the
certification as long as qualified medical personnel is in consultation with and the physician is in
agreement with the certification and subsequently, countersigns the certification.

Qualified Medical Personnel refers to those non-physician individuals defined by the Hospital’s
Medical Staff Bylaws, Rules and Regulations and approved by the Hospital’s Governing Board to
perform the initial medical screening examinations for those individuals who come to the emergency
department and request examination or treatment.

Signage refers to the hospital’s requirement to post signs conspicuously in any emergency department
or in a place or places likely to be noticed by all individuals entering the emergency department as
well as those individuals waiting for examination and treatment in areas other than the traditional
emergency department, (e.g., labor and delivery, waiting room, admitting area, entrance and treatment
areas) informing the patients of their rights under federal law with respect to examination and
treatment for emergency medical conditions and women in labor. The sign must also state whether or
not the hospital participates in the State’s Medicaid program.
DEPARTMENT: Risk & Insurance                           POLICY DESCRIPTION: EMTALA –
                                                       Medical Screening
PAGE: 5 of 10                                          REPLACES POLICY DATED:
APPROVED: November 12, 1998                            RETIRED:
EFFECTIVE DATE: January 1, 1999                        REFERENCE NUMBER: RI.001


Stabilized with respect to an emergency medical condition means that no material deterioration of the
condition is likely within reasonable medical probability, to result from or occur during the transfer of
the individual from the facility or in the case of a woman in labor, that the woman delivered the child
and the placenta. A patient will be deemed stabilized if the treating physician of the individual with
an emergency medical condition has determined, within reasonable clinical confidence, that the
emergency medical condition has been resolved.

To Stabilize with respect to an emergency medical condition means to provide such medical
treatment of the condition necessary to assure, within reasonable medical probability, that no material
deterioration of the condition is likely to result from or occur during the transfer of the individual
from a facility or in the case of a woman in labor, that the woman has delivered the child and the
placenta.

Stable for Discharge: A patient is stable for discharge, when within reasonable clinical confidence, it
is determined that the patient has reached the point where his/her continued care, including diagnostic
work-up and/or treatment, could reasonably be performed as an outpatient or later as an inpatient,
provided the patient is given a plan for appropriate follow-up care with the discharge instructions. In
the case of a patient who is suffering from psychiatric condition(s), the patient is considered to be
stable for discharge when he/she is no longer considered to be a threat to himself/herself or to others.

Stable for Transfer: A patient is stable for transfer if the treating physician attending to the patient has
determined, within reasonable clinical confidence, that the patient is expected to leave the hospital
and be received at the second facility, with no material deterioration in his/her medical condition; and
the treating physician reasonably believes the receiving facility has the capability to manage the
patient’s medical condition and any reasonably foreseeable complication of that condition. In the case
of a patient who is suffering from psychiatric condition(s), the patient is considered to be stable for
transfer when he/she is protected and prevented from injuring himself/herself or others.

Transfer means the movement (including the discharge) of an individual outside a hospital’s facilities
at the direction of any person employed by (or affiliated or associated, directly or indirectly, with) the
hospital, but does not include such a movement of an individual who has been declared dead or who
leaves the facility against medical advice or without being seen.
Triage is a sorting process to determine the order in which patients will be provided a medical
screening examination by a physician or qualified medical person. Triage is not the equivalent of a
medical screening examination and does not determine the presence or absence of an emergency
medical condition.

II. Facility Policies
DEPARTMENT: Risk & Insurance                        POLICY DESCRIPTION: EMTALA –
                                                    Medical Screening
PAGE: 6 of 10                                       REPLACES POLICY DATED:
APPROVED: November 12, 1998                         RETIRED:
EFFECTIVE DATE: January 1, 1999                     REFERENCE NUMBER: RI.001

Each hospital that provides emergency medical services must develop policies and procedures to
insure compliance with EMTALA requirements relating to the medical screening process. Such
policies should contain the following provisions:

A. General Requirements.
   In general, when an individual comes by him or herself or with another person to the emergency
   department of the hospital, and a request is made on the individual’s behalf for a medical
   examination or treatment, the hospital must provide for an appropriate Medical Screening
   Examination within the capability of the hospital’s emergency department, including ancillary
   services routinely available to the emergency department, to determine whether an emergency
   medical condition exists, or with respect to a pregnant woman having contractions, whether the
   woman is in labor.

B. When a Medical Screening Examination is Required.
   1.   If an individual arrives at the hospital and is not technically in the emergency department,
        but on Hospital Property or Premises (as defined under this policy) and requests
        emergency care, he or she must receive a Medical Screening Examination within the
        capabilities of the facility or, if necessary, execute an appropriate transfer according to the
        guidelines of EMTALA and these policies. However, common sense and individual
        judgment should prevail. In exercising such judgment, the following factors should be
        taken into account but are not necessarily determinative in all situations:

           a) Whether the hospital emergency department has the personnel and resources necessary
              to render adequate medical treatment to all existing patients in the emergency
              department and to adequately respond to new patient emergencies that could arrive at
              any moment,
           b) Whether responding to the emergency could send hospital personnel into harm’s way
              or unreasonably endanger or jeopardize the lives or health of such personnel, and
           c) Whether non-hospital paramedics, emergency medical technicians, or other qualified
              personnel are present to respond.

           No hospital may establish, maintain or enforce a policy that prohibits personnel from
           leaving the hospital to examine and/or treat an individual in need of emergency services in
           the immediate vicinity of the hospital.

           An individual in a hospital-owned or operated ambulance is considered to be on Hospital
           Property or Premises even if the ambulance is not on hospital grounds.

       2. An individual in a non-hospital-owned ambulance which is on hospital property is
DEPARTMENT: Risk & Insurance                          POLICY DESCRIPTION: EMTALA –
                                                      Medical Screening
PAGE: 7 of 10                                         REPLACES POLICY DATED:
APPROVED: November 12, 1998                           RETIRED:
EFFECTIVE DATE: January 1, 1999                       REFERENCE NUMBER: RI.001

           considered to have come to the hospital’s emergency department. An individual in a non-
           hospital-owned ambulance not on the hospital’s property is not considered to have come
           to the hospital’s emergency department when the ambulance personnel contact the
           hospital by telephone or telemetry communications. A hospital may deny access to
           patients when it is in “diversionary” status because it does not have the staff or facilities to
           accept any additional emergency patients at that time. However, if the ambulance
           disregards the hospital’s instructions and brings the individual on to hospital grounds, the
           individual has come to the hospital, and the hospital cannot deny the individual access to
           hospital services.

           Should a hospital which is not in diversionary status fail to accept a telephone or radio
           request for transfer or admission, the refusal could represent a violation of other Federal or
           State requirements.

C. The Location in Which the Medical Screening Examination Should Be Performed.
      1. The Medical Screening Examination and other emergency services need not be provided
         in a location specifically identified as an emergency room or any emergency department.
         If an individual arrives at a facility and is not technically in the emergency department, but
         is on the premises of the hospital and requests emergency care, he or she is entitled to a
         medical screening examination. For example, all pregnant women may be directed to the
         labor and delivery area of the hospital. The hospital may use areas to deliver emergency
         services which are also used for other in-patient or out-patient services. Medical
         Screening Examinations or stabilization may require ancillary services available only in
         areas or facilities of the hospital outside of the emergency department.

       2. Patients may be directed to other hospital-owned facilities which are contiguous (i.e., any
          area within the hospital or a hospital-owned facility on land that touches land where a
          hospital emergency department sits) or is part of the hospital’s “campus” and is owned by
          the hospital, and is operated under the hospital’s provider number. Physicians’ offices
          may be defined as such a facility, provided they are located in a hospital-owned building
          which is contiguous or located in a hospital-owned building which is “on campus.”
          However, the hospital should not move the patient to a non-contiguous or off-campus
          facility for the Medical Screening Examination or other emergency services.

           In order for the patient to be directed to the hospital-owned contiguous or on-campus
           facility, three conditions must be met:

           a) All persons with the same medical condition are moved to this location regardless of
              their ability to pay for treatment,
DEPARTMENT: Risk & Insurance                        POLICY DESCRIPTION: EMTALA –
                                                    Medical Screening
PAGE: 8 of 10                                       REPLACES POLICY DATED:
APPROVED: November 12, 1998                         RETIRED:
EFFECTIVE DATE: January 1, 1999                     REFERENCE NUMBER: RI.001

           b) There is a bona fide medical reason to move the patient, and
           c) Qualified medical personnel accompany the patient.

D. How to Provide the Medical Screening Examination.
   1. Hospitals are obligated to perform the Medical Screening Examination to determine if an
      emergency medical condition exists. It is not appropriate to merely “log in” a patient and not
      provide a Medical Screening Examination.

   2. Medicare participating hospitals that provide emergency services must provide a Medical
      Screening Examination to any individual regardless of diagnosis (e.g., labor, AIDS), financial
      status (e.g., uninsured, Medicaid), race, color, national origin, handicapped, etc.

   3. Individuals coming to the emergency department must be provided a Medical Screening
      Examination beyond initial triage. Triage is not equivalent to a Medical Screening
      Examination. Triage merely determines the “order” in which patients will be seen, not the
      presence or absence of an emergency medical condition.

   4. The Medical Screening Examination includes both a generalized assessment and a focused
      assessment based on the patient’s chief complaint, with the intent to determine the presence or
      absence of an emergency medical condition.

   5. A hospital, regardless of size or patient mix, must provide screening and stabilizing treatment
      within the scope of its abilities, as needed, to the individuals with emergency medical
      conditions who come to the hospital for examination and treatment.

   6. The Medical Screening Examination must be the same Medical Screening Examination that
      the hospital would perform on any individual coming to the hospital’s emergency department
      with those signs and symptoms, regardless of the individual’s ability to pay for medical care.
      If the Medical Screening Examination is appropriate, and does not reveal an emergency
      medical condition, the hospital has no further obligations under EMTALA or this policy.
   7. A Medical Screening Examination is the process required to reach with reasonable clinical
      confidence, the point at which it can be determined whether a medical emergency does or
      does not exist. The hospital must apply in a non-discriminatory manner (i.e., a different level
      of care must not exist based on payment status, race, national origin, etc.) a screening process
      that is reasonably calculated to determine whether an emergency medical condition exists.

   8. Depending on the patient’s presenting symptoms, the Medical Screening Examination
      represents 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 and
DEPARTMENT: Risk & Insurance                         POLICY DESCRIPTION: EMTALA –
                                                     Medical Screening
PAGE: 9 of 10                                        REPLACES POLICY DATED:
APPROVED: November 12, 1998                          RETIRED:
EFFECTIVE DATE: January 1, 1999                      REFERENCE NUMBER: RI.001

      procedures such as (but not limited to) lumbar punctures, clinical laboratory tests, CT scans
      and other diagnostic tests and procedures.

   9. A Medical Screening Examination is not an isolated event. It is an on-going process. The
      record must reflect continued monitoring according to the patient’s needs and must continue
      until he/she is stabilized or appropriately transferred. There should be evidence of this
      evaluation prior to discharge or transfer.

E. The Impact of Managed Care on the Medical Screening Examination.
   1. Every individual who comes to the hospital’s emergency department and requests a medical
      examination or treatment must be provided a Medical Screening Examination, which must not
      be delayed to inquire about the individual’s method or payment or insurance status.
   2. The Medical Screening Examination should be the same appropriate screening the hospital
      would perform on any individual coming to the hospital’s emergency department with those
      signs and symptoms, regardless of the individual’s ability to pay.

   3. A hospital may not refuse to screen an enrollee of a managed care plan because the plan
      refuses to authorize treatment or to pay for such screening and treatment.

   4. It is not appropriate for a hospital to request prior authorization before the patient has received
      a Medical Screening Examination to determine the presence or absence of an emergency
      medical condition or before an existing emergency medical condition has been stabilized.
      [See the Collection of Financial Information in the Emergency Department Policy,
      BOS.BILL.002, for further guidance on billing compliance issues.]

F. Who May Perform the Medical Screening Examination.
   1. Medical Screening Examinations must be performed by individuals who are:

       a) Determined qualified by hospital medical staff bylaws, rules and regulations which are
          approved by the hospital’s Board of Trustees or other governing body, and
       b) Functioning within the scope of their license and in compliance with State law and
          applicable State nurse and medical practice acts.

   2. When non-physician personnel perform Medical Screening Examinations, the hospital’s
      Board of Trustees and/or the appropriate medical staff committees, should approve specific
      screening protocols that outline the examination and/or diagnostic workup required to
      determine if an emergency medical condition exists. These protocols will normally be
      complaint specific and will be limited to those presenting complaints that lend themselves to
      screening by such non-physician personnel.
DEPARTMENT: Risk & Insurance                        POLICY DESCRIPTION: EMTALA –
                                                    Medical Screening
PAGE: 10 of 10                                      REPLACES POLICY DATED:
APPROVED: November 12, 1998                         RETIRED:
EFFECTIVE DATE: January 1, 1999                     REFERENCE NUMBER: RI.001


   3. The competencies for any non-physician personnel performing Medical Screening
      Examinations should be documented and validated by a qualified physician. There should
      also be an education plan for measuring and developing core competencies in medical
      screening.

   4. Facilities must establish a process to ensure that an emergency department physician examines
      all patients whose conditions or symptoms require physician examination.

       Facilities must establish processes to ensure that 1) an emergency department physician on
       duty is responsible for the general care of all patients presenting themselves to the emergency
       department; and 2) the responsibility remains with the emergency department physician until
       the patient’s private physician or an on-call specialist assumes that responsibility, or the
       patient is discharged.

REFERENCES:
Social Security Act, Section 1867, 42 U.S.C. 1395dd, Examination and Treatment for Emergency
Medical Conditions and Women In Labor
HCFA Site Review Guidelines, State Operations Manual
42 Federal Register 489.24(a) and 489.24(c), Special Responsibilities of Medicare Hospitals in
Emergency Case
EMTALA Stabilization Policy, RI.002
EMTALA Transfer Policy, RI.003
EMTALA Signage Policy, RI.004
EMTALA Central Log Policy, RI.005
EMTALA Duty to Accept Policy, RI.006
EMTALA Provision of On-Call Coverage Policy, RI.007

								
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