01.06 EMTALA & Transfers

So what is EMTALA. It is the Emergency Medical Treatment and Active Labor Act. It was created in 1986 because we discovered that there were EDs all over the country that were refusing to treat patients. The biggest factor was money. Doctors and facilities were not only refusing to treat patients because they couldn't pay, but were transferring them out if they found out this info later. 

Currently EMTALA is the law for any facility that accepts Medicare payment but it seems that it has become the standard of care for all emergency departments. 

The way EMTALA works is that it requires that certain things must be done for any patient who comes through our doors. The first is a medical screening exam. This means that a patient cannot be denied evaluation due to financial reasons. Ever wonder why the registrars come around after the patient has already been through triage in is being cared for. This is why. Many facilities have decided that asking a patient about payment before they even get seen, gives the impression we might refuse it. While that is no longer the case, we have found its best to get the patient in front of a nurse or doctor before a cashier. 

EMTALA also says that a patient has the right to stabilization regardless of payment. We can't start coding someone and then stop because we don't take his insurance. If for some reason we need to transfer, and there are definitive guidelines for this, we need to stabilize the patient to the best of our abilities before we ship them out. 

When it comes to transfers, we always have to weigh the risks vs the benefits. Take the 82 year old trauma patient with the open compound femur fracture and lacerated femoral artery. Your facility does not have ortho or vascular specialists on call but the tertiary center 30 minutes away does. If he stays,. he is risk for hemorrhage, sepsis, fat emboli. A transfer would get him the higher level of care he needs, But there is a chance he could code on the way. Risk vs benefit. 

When we make the call to transfer, we have to meet all the requirements. The hospitals have to have a transfer agreement between them. Basically a document that says, yea, we will take your patients. We need written informed consent, if possible. We can't just take an alert and oriented patient and load them into an ambulance against their will. We need, in writing, the accepting facility actually can take the patient, and that they have a doc who will accept his care. We also need an appropriate transfer method. The back of a pick up truck may not be the best way to transfer a person. On the other end of the spectrum, the MediVac Chopper may be a bit of overkill for our stable trauma patient with the minor head bleed. 

On top of all of this, when we transfer, we have to make sure that all of the paperwork travels with the patient. Make copies of everything and have a set of those copies ready for the transport team.

So what is the nurses job here. Well first thing first, take care of the patient. Work with the team to get them as stable as possible for transport. Once you can step away, start putting the paperwork together. I highly recommend you get your unit clerk on your good side because they are pure gold in these situations. You are going to have to give report twice. Once to the receiving facility, usually a nurse on the other end, and again to the transport team. Do not assume those two will speak to each other, make sure they both get a thorough report. If you are delegated, speak to the family. Let them know when the transfer team gets there and where they are going. One recommendation i will make. Do not let the family leave before the patient does. The last thing you want is the family to be at the receiving facility waiting for their loved one who coded two minutes into the ride and was brought right back to your ED for further stabilization. I know they want to beat the ambulance there but trust me on this one. 

Communication is key in these situations. With the patients, with family, your team and the members of the receiving facility. With a transfer you might talk to 10 different people just to get the job done. 

Know the EMTALA laws as well as the transfer regulations in your state and your facility.

Remember, the patient always is the most important aspect of this case, always make sure we are providing for their safety during the transfer process.