In the early 1980s it was not unusual for transfers to be motivated by not only the need for a higher level of care, but also for financial reasons. Hospitals might arrange a transfer of a patient with less ability to pay simply to avoid expending the resources when compensation was not likely. These hospitals may have had the resources to handle the patient's medical needs, but recommended transfer for purely economic reasons. This practice was often referred to as “dumping” and was obviously not in the best interests of the patient's medical needs in most cases.
In response to accumulating evidence of this economically driven denial of care throughout the country, in 1985 Congress enacted a law that was intended to prevent this unethical practice. The Emergency Medical Treatment and Active Labor Act (EMTALA) was a part of the Consolidated Omnibus Budget Reconciliation Act (COBRA), and while it has been amended a number of times it remains the most significant regulation ever enacted related to the emergency care and transfer of patients in the United States. It was the first law that provided a right to emergency medical care for every citizen.
The law defines a hospital's responsibility to provide emergency care to anyone presenting with a request for help. It details the obligations of the hospital with regard to initial evaluation and management as well as with regard to transfer arrangements. Hospitals are obligated to obey these guidelines under penalty of hefty fines.
Shortly after this law was enacted that mandated the emergency care of any patient requesting such, a new problem emerged. The original language of EMTALA mandated the care that must be provided at the hospital to which the patient presents but did not address the responsibilities of higher level centers to which patients might be transferred. When hospitals attempted to transfer patients they felt were in need of care at another facility, they encountered difficulty in getting acceptance of these patients. This problem also appeared to have financial motivation in some cases. This is sometimes referred to as “reverse dumping” and is just as big an ethical issue as the original problem.
In 1989, EMTALA was amended to include language that required higher level hospitals to accept patients in transfer when they had the ability to manage the patients' condition. The details of the many amendments of these laws are rather confusing; therefore, interpretive guidelines have been issued over the years clarifying hospitals' responsibilities under the law.7
SENDING HOSPITAL OBLIGATIONS
The law requires that every hospital provide an appropriate screening examination to any patient who requests examination or treatment. This screening cannot be delayed for financially motivated reasons. If the screening examination reveals an emergency medical condition, the hospital is obligated to stabilize the patient, or if this is not possible, transfer the patient to a hospital that can. The interpretive guidelines issued over the years are extensive and have clarified many of the details regarding these responsibilities.
Affect an Appropriate Transfer
There are a number of requirements for sending hospitals when arranging the transfer of an unstable patient. First is the certification of medically necessity. The documentation of this may take many forms but must include a definition of the medical benefits expected from transfer as well as the risks that can reasonably be expected by the transfer. The sending facility must certify that the expected benefits outweigh the potential risks of the transfer.
Consent for transfer must always be obtained, whether directly from the patient or family member or implied under the emergency doctrine. This consent must be in writing and is often included as a part of the certification of risks and benefits.
The sending hospital has an obligation of arrange an “appropriate” transfer. There are five components to this outlined in the law:
The hospital must provide treatment within their capacity to minimize the risks of transfer. This might range anywhere from initiating IV access to intubation or chest tube placement if it is felt that these interventions would reduce the risk of the transfer.
Arrangements must be made for another hospital to accept the patient in transfer. Simply transferring a patient without having another hospital identified that it is willing and able to accept the patient would constitute a violation of the law.
It is a legal obligation for the sending facility to ensure that relevant data be sent with the patient for use by the receiving staff in continuation of care. This includes documentation of care and radiographic studies performed.
The transfer must be affected through qualified personnel and transportation equipment. It is important to recognize that the needs of the patient are not just what the patient needs at the time of the transfer, but has to include potential needs if the situation changes during the move. This must be based on the treating physician's best estimate of what the patient may need during transfer. For example, if a patient with an acute coronary syndrome is being transferred, there is a good possibility that they may experience an arrhythmia during transport. The team chosen to complete that transfer must be qualified and have the equipment necessary (ie, medications and defibrillator) to effectively manage arrhythmias. Similarly, a patient with an acute stroke may deteriorate and require intubation during transport. The team accompanying the patient should be qualified and have appropriate equipment to offer this intervention if needed.
The vehicle utilized should be that which is determined to be most appropriate for the patient's condition at the judgment of the sending physician.
It is also crucial to consider that the sending facility is legally responsible for the patient until care is assumed by the receiving facility. This includes the care provided by the transport agency. It seems imperative for the sending facility to have a proper understanding of the capabilities of the transport team. There should be prior communication and preplanning between hospitals and transport agencies in order to facilitate safe transport of these patients.
It is important to remember that the EMTALA regulations regarding transfers relate to unstable patients, those whose conditions have not been stabilized. Once a patient has been stabilized, these regulations do not apply and transfers can be arranged for economic reasons if desired. EMTALA defines “stabilized” as when it is determined that a patient will not likely deteriorate during transfer. An appropriate level of care for the patient's current needs is obviously still required.
RECEIVING HOSPITAL OBLIGATIONS
Hospitals that offer specialized services have an obligation under EMTALA to accept patients in transfer if they have the ability and capacity to manage that patient's condition at that time. This must be done without any consideration of the patient's ability to pay for such care. Refusal to accept transfers is one of the largest areas of EMTALA violation investigations. This has led to very complicated algorithms in some hospitals to determine the hospital's capacity at any given time for managing any given condition. If a hospital determines that it does not have the ability or capacity to manage a patient for whom transfer is requested, they can refuse without being in violation of the law. This would seem to be very reasonable, as it would not be safe to bring an unstable patient to a hospital that did not have the ability to safely manage their condition. In today's age of hospital overcrowding, overfull emergency departments and lack of hospital beds may result in interfacility transfers that bypass one or more institutions that would have otherwise been able to manage a patient's condition. This translates into what may be very long transport times for the IFT team.
TRANSPORT PROVIDER OBLIGATIONS
While the practice of an EMS provider during interfacility transfer is not directly detailed in this regulation, it is helpful to understand the background behind the details of the transfer process. It is clear that there are legal obligations for the transport agency and providers to affect a medically appropriate patient transport in the safest manner possible; however, they are not detailed under EMTALA. These regulations may differ from state to state and the EMS physician involved with a transport team should be familiar with the relevant local regulation.
It certainly makes sense for a transport service to meet with local hospitals for purposes of preplanning regarding IFT needs. The transport service should educate the hospital regarding the capabilities of the transport team and equipment. This knowledge will enable the facility to make appropriate decisions regarding staffing during a transfer. There may be times when it is necessary for hospital staff to accompany a patient during transfer. It is helpful to have some sort of collaborative training prior to this occurrence that enables the hospital staff to function safely in the transport vehicle. Clarification of the roles and responsibilities of each of the providers staffing the transport in this case is helpful.