✯✯✯ EMTALA Ethical

Tuesday, August 31, 2021 4:01:57 PM

EMTALA Ethical

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This is a Federal law that places restrictions on medical care from hospitals that receive Medicare money. As with all legislation of this type, a majority of the written law addresses how it is to be enforced. This is definitely not breakfast table reading. If you are up to the task, visit the Health and Human Services web page to read the whole thing. I did, and I still don't understand some of it. General Information. EMTALA requires hospitals with emergency departments to provide a medical screening examination to any individual who comes to the emergency department and requests such an examination, and prohibits hospitals with emergency departments from refusing to examine or treat individuals with an emergency medical condition.

It is important to develop a formal scope of services that specifically describes the types of patients for whom the psychiatric unit can provide care. This should be based on a realistic appraisal of the training and experience of the staff, the numbers and types of staff members available and the physical configuration of the unit. The hospital that has been asked to accept the patient in transfer must have the capacity to accept the patient and must accept the transfer. If the transferring facility feels that the transfer was wrongly rejected, it is required to report the same within 72 hours. Patients have the right to refuse to consent to a transfer. If this happens, the facility must discuss the risks of remaining and the benefits of being transferred to another facility.

It is only in the case of a transfer for a voluntary admission that a patient has the right to refuse. As noted above, there is a very real scarcity of psychiatric inpatient beds relative to the demand for them. Since a behavioral patient in an ordinary ED is not receiving care in a safe environment, it is critical to transfer the patient to an appropriate level of care as quickly as possible. It is critical that the receiving facility base its decision to accept or deny the transfer from another facility on its capacity to care for the patient.

This is, again, where a formal scope of services can be enormously beneficial. If the facility has made an objective assessment of its capabilities and determined that it cannot safely care for a particular category of patient, it is within its rights to deny the transfer. A participating hospital will be in violation of EMTALA if it refuses the transfer of a patient that it had the capacity to treat. Transfers need to be accomplished using qualified personnel and appropriate equipment. An appropriate transfer of a behavioral patient may be accomplished by ambulance, but, more often it is accomplished by law enforcement personnel. Liability may attach for failure to use appropriate equipment and staff to effect the transfer. It is not always clear when EDs should implement safety precautions for behavioral patients e.

This writer is of the opinion that precautions should be implemented as soon as the staff members have a reasonable suspicion that the patient may be a danger to self or others. It would certainly be preferable to defend a claim for false imprisonment rather than wrongful death. As soon as it is felt that the patient may be a danger to self or others, the patient should be searched for sharps and drugs, and shoelaces and belts should be removed. Ideally, the patient should be placed in a gown, although some facilities allow them to wear scrubs. It must be remembered that patients may be able to hang themselves using their pants.

The search and removal of clothing and personal items should be done as soon as possible after a determination of a threat to self is made to avoid allowing the patient to secrete hazardous materials somewhere in the room or above the ceiling. Whenever a patient needs to use the bathroom, the bathroom should first be checked for contraband razors, mouthwash, etc.

If a facility has a high volume of behavioral patients that it is boarding at all times, it may be practical to move them out of the ED altogether. A bed in the ED is a valuable piece of real estate and it should turn over rapidly in order to keep the ED functioning properly. It is possible to set up an observation unit where behavioral patients can be housed pending a transfer. It is important to designate this as an observation unit.

If it is technically a part of the ED and patients have not been admitted, it is not a behavioral health unit. If the unit is set up as a safe environment, [26] the unit can have lower staffing levels than would be possible using sitters in the ED. It is typically the case that sitters cannot effectively attend to more than 2 or 3 behavioral patients in the ED. In a behavioral observation unit, the facility may be able to operate effectively with a much higher staff to patient ratio. It also allows the facility to hire nurses with a background in behavioral health or to train current nurses more extensively in behavioral health. Although there is certainly an expense involved in setting up a unit to be a safe unit, there may be savings in the long term if the volume of behavioral patients remains high.

If the observation unit is secured or has other features that would impede egress in an emergency e. An alternative to setting up a behavioral observation unit is to establish safe rooms in the ED in which to provide care for behavioral patients. If safe rooms are developed, it may be possible to allow sitters to watch more patients than would be possible in a non-safe environment. Some ideas for making a room safe would be to include as many of the following features as possible:. Again, as with the behavioral observation unit, many of these features in a safe room should be approved by the fire marshal. It is certainly possible to render an ordinary examination room safe when a safe room is required.

If the facility chooses this route, it should try to implement as many of the above safety features as possible into the convertible safe room. Safe rooms can reduce the number of sitters necessary to watch behavioral patients, but they do not obviate the need for sitters. Sitters should still provide an appropriate level of supervision for behavioral patients. It is preferable to have someone, such as a sitter, whose job it is to watch the patient to ensure that he or she does not try to leave or to injure himself or herself.

It is best to assign this responsibility to someone. Sitters may be required in any environment, although the higher the level of safety, the lower the number of sitters for a given number of patients. Sitters can be nurses, CNAs or security officers. Although security officers are used in many EDs, it is preferable to use people with some clinical background to function as sitters. It is probably not appropriate to use volunteers or non-clinical staff other than security officers to function as sitters.

If security officers are used as sitters, they need to understand that CMS forbids the use of tazers or other non-lethal devices as a method to control patient behavior. The function of the sitter is, simply, to watch the patient. The number of patients that one sitter can watch may be variable. If the patients are asleep at night and the patients are in adjacent rooms, one sitter may be able to watch 3 patients. If all of the patients are in safe rooms, the number of patients that a sitter could watch could be higher. Whoever is used as a sitter, sitters need to be carefully trained on how to perform their function. They must understand that the patient must always be within the zone of observation and supervision e.

This includes when the patient is in the bathroom. The bathroom should also be safe no sharps, plastic trash can liners or hazardous liquids and have nothing that would allow the weight of a human body to be suspended from it e. Many of these items can be obtained commercially, [29] including grab bars around which nothing can be tied. It may be acceptable to allow the sitter to stand or sit outside the bathroom door with the door ajar. If the patient is allowed to smoke, the sitter should accompany him or her outside and have control of smoking paraphernalia cigarettes, lighters and matches at all times. The patient should never be left to smoke unattended outside the ED, even if it is in an enclosed courtyard. If the sitter is engaged in an activity involving a patient that takes him or her away from other patients he or she is supposed to be watching, someone should be required to fill in for the sitter.

Sitters also need to be aware that they need to devote their attention to the patient. Sitters should not read magazines or newspapers, or check their e-mail on their phones. Sitters should not be asked to do other work while performing the duties of a sitter. One of the primary obligations of a sitter is to be the eyes and ears of the ED medical and nursing staff. EMTALA requires that the transferring hospital provide stabilizing care within its capabilities prior to transfer. Thus, a boarding hospital could use telepsychiatric resources for an assessment or begin a medication regimen to try to stabilize the patient.

This must be done in accordance with the psychiatric facility that will ultimately receive the patient to ensure that the expectations of both entities are synchronized. A detailed discussion of the use of restraints in an ED is beyond the scope of this posting. Staff members need to be aware of the rules regarding restraints to avoid liability or patient injury. Both hospitals and physicians can be liable for penalties under the Act. Hospitals, but not physicians, can be liable for civil damages to the injured patient if the injury was caused by the violation of the statute.

CMS also may exclude a physician from further participation in Medicare and Medicaid as punishment for a violation of certain aspects of the statute.

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