EMTALA compliance and emergency room crowding in hospital operations

EMTALA

EMERGENCY MEDICAL TREATMENT and ACTIVE LABOR ACT (EMTALA) COMPREHENSIVE PLAN

FOR a HOSPITAL EMERGENCY ROOM

The objective of this work is to develop a comprehensive plan for the hospital that addresses relevant current issues in the emergency room and specifically the problem of crowding. The focus of this work will be EMTALA rules and regulations in relation to the hospital emergency room to include corporate culture. A SWOT model for situational analysis will be performed in the attempt to understand the political, legal, economic, social, cultural, technological and competitive situations faced by organizations leaders.

In 1986 a Federal law was passed referred to as the "Emergency Medical Treatment and Active Labor Act" (EMTALA) which makes it a requirement for hospitals to provide specific services to individuals who come to the emergency room of the hospital regardless of their ability to pay for these services. Minimal treatment requirements are for:

Screening;

2) Stabilization; and 3) Transfer to another facility if necessary. (Pedor and Perez, 2001)

In terms of the need for the EMTALA, the Ethics Resource Center expresses that there was a definite need for EMTALA due to the "rise of health insurance plans, with fixed, cost-based reimbursement schedules, which made cost-shifting difficult and the emergency rooms had been noted to turn away the patients who were not able to pay. (Ethics Resource Center, AMA, 2006)

Prior to the EMTALA only hospitals that were constructed under the Hill-Burton Act of 1946 were required to treat emergency patients who were not able to pay but when the EMTALA was enacted in 198 that obligations was extended to all hospitals that are participants in the Medicare Programs. (Ethics Resource Center, AMA, 2006) the screening examination is for the purpose of making a determination as to whether the individual is in an emergency medical condition and if this is established to be the case then requirements exist for the provision of stabilizing treatment. Furthermore, there is a requirement that restricts transfer of the patient until the patient has been stabilized. The transfer may not be conducted unless the individual requests a transfer or the transfer is deemed to be an appropriate transfer.

Appropriate transfers include conditions that the hospital makes provision of medical treatment that minimizes the risks to the patient or the unborn child of the patient. Secondly, the facility that intends to receive the patient must have space available and personnel that are qualified for treating the individual and then the facility must accept the transfer of the individual. All medical records must be sent to the receiving facility as well as informed consent and certification as well as any address of any physician who has refused to provide stabilizing treatment. These are only some of the requirements and do not constitute an exhaustive list of all requirements of transfer under the EMTALA.

Strengths

Strengths of the hospital emergency room include proper training of staff in adherence to EMTALA requirements as well as efficient scheduling and coordination of staff in terms of the work environment and scheduling of work hours.

Weaknesses

Weaknesses and threats are much the same in that failure or emergency room staff to adhere to requirements of the EMTALA. It is reported in a recent survey conducted by the American College of Emergency Physicians states findings that two-thirds of emergency room departments lack appropriate on-call specialty physician coverage. Further stated in the findings is that as the volume of patients increase for emergency rooms each year the likelihood of the increase of the shortage of specialty physicians will increase as well. The effects that are related to be likely due to on-call staff shortages include:

Delayed or improper treatment for patients in need of specialty care;

EMTALA violations; and Patient dissatisfaction and complaints that damage the reputation of the institution. (Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas, 2006)

Opportunities

Opportunities for the hospital emergency room include coordination and collaboration with other nearby institutions in scheduling of specialty care physicians. In the situation where two emergency rooms are located in the same area the initiative of the institutions in coordinating the scheduling of specialty physicians would greatly assist each of the hospital emergency departments in avoidance of EMTALA violations.

Threats

Stated, as 'common pitfalls' to avoid under the regulations of the EMTALA are the following:

1) Failure to document that the transferring hospital accepted a patient for transfer;

2) Failure to establish physician compliance with on-call responsibilities;

3) Failure to ensure compensation for on-call;

4) Failure to appropriately maintain the central/on-call logs;

5) Failure to appropriately sequence registration/insurance questions to avoid delaying the medical screening exam;

6) Failure to post the appropriate signage to alert patients to their rights under EMTALA; and 7) Failure to implement procedures that clarify who can conduct the medical screening exam. (Hospital Auditing and Monitoring: Sample Programs for Key Risk Areas, nd) recent survey by the American College of Emergency Physicians reports that two-thirds of emergency departments lack on-call coverage in specialty areas of care. In addition, with emergency department patient volume increasing every year, it is likely that shortages will occur even more frequently.

III. STRATEGY FORMULATION

The strategy set out is one in which physicians are paid to stay on-call in order that uninsured emergency department patients are provided care in the emergency room of the hospital. This plan is to be evaluated and implemented in the near future.

IV. IMPLEMENTATION STRATEGIES

The work entitled: "Call-Coverage Pay on Rise but Remains Minority Policy" reports that two recent reports by major data organizations state that "a rising percentage of medical groups are paying physicians expressly for taking call duty, but that such compensation remains a minority policy." (2003) Methods of calculating the compensation are inclusive of:

Flat fees per shift

Dividing 20% of the annual practice profit among all the units of call taken by each physician;

Differentiation between weeknight and weekend calls with the weekend calls paying a higher rate

Subtraction of a set amount from a physicians in semi-retirement for a physician's refusal to take a call; and Differentiation of pay levels between specialties and subspecialties.(Physician Compensation Duties, 2003)

Another method report for use in physician compensation is one in which a 1-physician Utah Valley Pediatrics group "adds each of its owners' billings for the previous 12 months and at the end of each quarter the percentage of each is calculated. While this cannot be expected to work in the larger emergency department, in small institutions this method might prove productive. The pay is further calculated by units according to duties perfumed while the physician is on-call. (Physician Compensation Duties, 2001)

V. EVALUATION of STRATEGIES

The strategies reviewed in this work include on-call pay for emergency room physicians as well as punitive reduction of pay for refusal to take calls. The primary factor supporting call-duty compensation is the fact that the physicians are busier than ever before and this is particularly true of those who are specialty physicians who "simply don't have time to accept such duty unless paid additionally for it." (Physician Compensation Report, 2003) While many hospital emergency departments expect their physicians to be on-call without receiving extra compensation, this is not a reasonable view for the busy emergency room department management. Appropriate compensation for on-call physicians will motivate these physician's in adherence to EMTALA requirements and will support the institution in delivery of proper EMTALA aligned healthcare.