EMTALA Warning

     I'm excited to be writing this column, which is directed toward EMS managers and administrators. EMS has two distinct sides: patient care and the business of running an ambulance service. There's a need for a place dedicated to the business side of the industry, and I hope you find that place here. In an effort to ensure that you do, we are asking that you be a part of this column. Please e-mail questions, comments or topics for discussion to nancy.perry@cygnusb2b.com.

     On July 13, 2006, the Centers for Medicare and Medicaid Services' Survey and Certification Group published a letter (#S&C-06-21) dealing with the issue of "parking" EMS patients in hospitals. CMS had learned that some hospitals try to circumvent caring for patients by refusing to accept, or "take responsibility" for, them, often literally refusing to allow EMS crews to transfer them from stretchers to hospital gurneys or beds. Apparently the hospital staff in these cases believe this practice leaves the patient in the "care" of the EMS crew and insulates the hospital from any responsibility for the patient.

     CMS seems to disagree. Its letter did not present a clear decision on this issue, but it did state that the "parking" of patients may result in a violation of both the Emergency Medical Treatment and Active Labor Act (EMTALA) and a hospital's Conditions of Participation for Hospitals for Emergency Services. Specifically, the letter pointed out that under EMTALA, hospitals have an obligation to assess the patient's condition once they "present" at a hospital's dedicated emergency department. Once a patient's condition is assessed, if there is a "medical emergency," then the hospital must provide the treatment necessary to stabilize the patient. Because the existence of an "emergency medical condition" is a subjective criteria, and because the duty to assess a patient is required to be done "within acceptable standards of care," there exists enough of a gray area that CMS's conclusion was merely that there "may" be a violation of the law. However, EMS crews should have the training necessary to understand whether the hospital staff is truly doing its best to get to the patients or whether it is merely using the crew as patient-sitters--or, worse, endangering a patient in need of immediate care.

     In concluding the letter, CMS stated that they "recognize the enormous strain and crowding many hospital emergency departments face...however, this practice ["parking"] is not a solution. 'Parking' patients in hospitals and refusing to release EMS equipment or personnel jeopardizes patient health and impacts the ability of the EMS personnel to provide emergency services to the rest of the community."

     And that is the most important point. Not only is "parking" patients potentially dangerous for patients who have already presented at hospitals, it is assuredly detrimental to the welfare of the community the EMS crew is there to protect, in that it will eventually affect response times. Affected communities will likely include members of these hospital staffs' families. So the next time your crew is being "parked" at the local ED, remind the staff that if their son/daughter/mother/spouse is in an automobile accident while you are patient-sitting, then there will be no one to respond to their needs. We all have jobs to do, and the hospital staff must understand that theirs are no more important than yours!

     It is also noteworthy that this issue came to the attention of CMS by way of EMS services' complaints. So it appears that sometimes, the squeaky wheel still does get the grease. This shows that addressing issues such as these through proper channels can produce positive results.

     I've heard many EMS professionals say EMTALA doesn't apply to ambulance services, and technically this is true. However, this letter provides a prime example of why we should be familiar with EMTALA regulations: because even if EMTALA does not apply to us, it affects our patients, and anything that affects our patients should be of concern to us.

     Let me leave you with this thought: If your EMTs are sitting in an ED waiting room with a patient, not only are they and their ambulance out of service, but if the patient suffers a negative outcome that's exacerbated by their slow access to treatment, they (or their family) will likely point not only at the hospital's failure to abide by EMTALA, but also at your staff's failure to assert its rights under EMTALA. Don't be on the short end of the finger-pointing--know your patients' legal rights and make sure you and your staff do everything possible to assert them if your patient is truly in an emergency condition.

     Per the letter, questions regarding this issue should be directed to Donna Smith, 410/786-3255, e-mail donna.smith@cms.hhs.gov. The full letter can be viewed at www.cms.hhs.gov.