Patients have well established rights when it comes to receiving healthcare. A Patient’s Bill of Rights was drafted with the expectation that it will contribute to more effective patient care and be supported by the hospital on behalf of the institution, its medical staff, employees, and patients. The American Hospital Association (AHA) encourages health care institutions to tailor this bill of rights to their patient community by translating and/or simplifying the language of this bill of rights as may be necessary to ensure that patients and their families understand their rights and responsibilities. Those rights are centered on the following (for the sake of brevity, these are purposefully generalized and non-exhaustive):
The right to emergency treatment
The right to respect
The right of informed consent
The right to refuse treatment
The right to choose providers
The right to privacy
The right to appeal
These rights can be exercised on the patient’s behalf by a designated surrogate or proxy decision-maker if the patient lacks decision-making capacity, is legally incompetent, or is a minor.
Additionally, the patient has some amount of responsibility as well and this includes being an active participant in their own care, timely completion of their financial obligations, and respectful interactions with medical staff members. For the most successful outcomes, it is always a two-way street.
For this blog we will just focus on the right to emergency treatment and how EMTALA plays a vital role in the patient rights arena. Emergency medicine is a unique endeavor. You're in EMS so I think you realize that things may operate a little differently when every second matters between life and death. Think about your last primary care visit - before you proceeded with the doctor, a transaction of insurance and potentially a co-payment had to happen first. But, emergency departments are unique—anyone who has an emergency must be treated or stabilized, regardless of their insurance status or ability to pay. The patient protection that makes this possible is a federal law known as the Emergency Medical Treatment and Labor Act (EMTALA).
A patient has the right to a physician screening in an emergent setting regardless of their ability to pay. When they arrive "on the property" - which could include the parking lot, or an adjacent sidewalk, a medical screening from a qualified provider has to be a part of the equation. If this doesnt happen, the healthcare institution violates EMTALA and consequences including sizeable fines could happen thereafter. In short, the emergency department has an ethical responsibility for the provision of emergency care.
Source: Orlando Health
Facts and frequent areas of non-complilance to be aware of when it comes to EMTALA:
EMTALA technically applies only to hospitals that accept Medicare or Medicaid and have emergency departments. This ends up being most hospitals, but not all of them. VA and military hospitals are exempt, and EMTALA does not apply to urgent care centers unless they are affiliated with a hospital.
The rule extends to 250 yards off the hosptial property - even if the patient doesn't self present to the physical ED location.
Qualified providers can include physician extenders or advance practice providers (APRN, PA) Nurses never qualify!
At times transfers to a more capable facility are appropriate and warranted. A patient with an emergency medical condition may only be transferred after screening and the provision of stabilizing treatment. Four requirements must be met: • The transferring hospital minimizes the medical risks (and in the case of a woman in labor, the medical risks of the fetus as well). • The receiving medical facility has available space and agrees to accept the transfer. • The transferring hospital sends all medical records related to the emergency condition that are available at the time of the transfer and any other records not yet available as soon as practicable. • The patient is transferred using EMS and medically appropriate life support measures during the transfer.
Common Areas of Non-Compliance + Reasons:
Financial Pressures - hospitals may look for ways to avoid Medicaid or uninsured patients as reimbursement rates are low or non-existent.
Ignoring the Rules/Lack of Knowledge - they may know the basics, but many are unfamiliar with the details and finer print when it comes to speciality patients (psychiatric cases).
Receiving Hospital Burdens - transferring sick patients to already over burdened hospitals has its share of consequences on "the system"
Inter-hospital relationships - Hospitals may not wish to file an EMTALA complaint due to reluctance to damage the relationship with the referring facility or lose them as a transfer partner. This is especially true if they are part of the same hospital network.
Differing priorities - Hospitals may prioritize EMTALA issues higher than physicians. Their priorities may not be aligned. The doctors may be more concerned with things like malpractice. Physicians may beleive that EMTALA is a hospital liability issue and may be unaware that they could be also subject to EMTALA related fines.
EMTALA can be complex, but I don't beleive its going anywhere. Countless lives have been saved since its inception several decades ago. Know that at times the act can indirectly affect us in EMS - especially around inter-facility transfers and the dreaded ED Diversions. In the future, I predict more physician related training around EMTALA (its overall purpse and non-compliance consequences). I also beleive additional revisions will continue to be made (as was true during the COVID pandemic).
In short, Know your rights - Know the patient's rights - Know that you can safely transfer care and you don't have to babysit your patient hours of end for fear of abandoning them in the ED.
December 18, 2023
Author: Joshua Ishmael, MBA, MLS(ASCP)CM, NRP
Pass with PASS, LLC.