SPECIAL TOPICS
CHAPTER 59 |
| EMTALA AND OTHER PRINCIPLES AFFECTING THE ACUTE CARE SURGEON |
The physician engaged in trauma management, emergency surgery, acute care surgery, or surgical critical care is intricately involved with patients with immediate life-threatening emergency conditions. Issues and decisions regarding receiving such patients, evaluation, management, consultation, and even transfer are all governed by the patient’s clinical condition. These issues and decision nodes have been the subject of the many chapters of this book and will not be repeated here, although some of the regulations will be reviewed in this chapter to formulate rules, misperceptions, and policies regarding patients with critical conditions.
No profession in the world is more regulated than that of physicians in the United States. Surgeons are more regulated than other medical specialists, and an “acute care surgeon” who may or may not participate in trauma and surgical critical care is subject to more regulations than any other surgeon. The Emergency Medical Treatment and Active Labor Act (EMTALA) is both the epitome and a surrogate for a long list of regulations, rules, practice guidelines, policies, and outside manipulation as to how an acute care surgeon must function. The regulations were initially designed to protect persons interacting in health care, beginning with the patient in need. Others who need regulatory protection include surgeons, hospitals, custodians of medical records, hospital administrators, nurses, and many others.
The initial EMTALA was signed into law in 1986. Minor amendments were made almost every year, with a major revision in 2003, clarifying the roles of hospitals and physicians. Unfortunately, with revisions come new areas of confusion and new areas to allow manipulations at both the sending and receiving facilities. For all EMTALA regulations, it is the hospital that bears the responsibility for complying with the law, with the physicians as representatives of the hospital care. Surgeons voluntarily accept their responsibility as “agents of the hospital” when they accept call or referred patients, as well as when they transfer patients out or refuse transfer or referral for care.
EMTALA rules were developed to ensure that a patient with an immediate life-threatening emergency in an original location, which did not have the physical and personal resources to manage that emergency condition, would be transferred to a region that possessed a facility with the capacity of diagnosing and managing that emergency. The EMTALA never intended these rules to be used as an economic screen. Nor was there any intent that a patient without financial resources for medical payment would automatically be sent to a facility with a higher level of care, especially when patients with payment resources with that same immediate life-threatening emergency were often kept at the original sending institution. Likewise EMTALA was never intended to be a required referral source for specialized hospitals nor a mechanism for a hospital to refuse to receive a patient in referral for an emergency merely because that patient did not have financial resources or was outside the usual payment system or program of the hospital.
DEFINITIONS WITH EMTALA RAMIFICATIONS
A number of terms or phrases have direct bearing on EMTALA and the responsibilities and interpretations by hospitals, patients, doctors, families, and governmental agencies.
“Emergency” is a word with multiple meanings; its interpretation depends on the person using the word, the situation, the venue, and combinations of these and many other variables. An emergency may be modified by ethereal politics, ethics, economics, regulations, interpretations, past experience, gender, age, culture, and ethnicity. The same person may not meet an emergency with the same response however identical the situations might be. Two persons may anticipate or define the same situation as being either an urgent emergency or a nonemergency to be handled entirely at a discretionary time.
The motivation to seek assistance during an emergency is likewise variable. Such motivations may be time limited, economic limited, culturally limited, or influenced by a previous condition, either in ones memory of another, by previous education, or by past direct experience.
Modern Western culture has imprinted on society that everything is urgent, immediate, and therefore an emergency, which must be investigated and “taken care of” that very second. Very few conditions either in personal life, politics, religion, business, or even in health care are truly “emergencies” that require an immediate response.
Most misinformation regarding the emergency nature of a medical condition is secondary to funding and payment for services issues. With regard to a medical emergency, a patient or even a payer of medical services might attempt to make a case that a condition is an emergency, either to achieve an immediate evaluation and treatment or to alter the payment source or amount. Thus the attempt to define the emergency condition might be in the mind of the patient or personnel working for a funding agency, not the physician who is evaluating and treating the patient.
“Immediate life-threatening emergency” is a condition recognized to result in the death of a patient within a reasonably short period of time, usually perceived as being within 24 hours, or in some instances 1–3 days. Such conditions have recognizable staging and classification schemes that allow a reviewer to place such a patient in an immediate life-threatening emergency. Many “highest level of code” trauma conditions, and many acute care surgery conditions, such as a perforated viscus, necrotizing infection, acute occlusion of a major blood vessel, and similar conditions are indeed universally recognized as immediately life threatening. Many acute, subacute, and chronic medical, surgical, and mental health conditions will eventually result in the disability and death of a patient, but their mere presence is not an immediate life-threatening condition. Many conditions such as neoplasia, degenerative diseases, many infections, and most vascular conditions do not require an immediate hospitalization, or even a visit to an emergency center, unless that disease process has an immediate life-threatening complication that makes it such an emergency. The immediate life-threatening emergency should be defined by the medical community as being a condition that would be readily agreed upon to be such, not just a perception on the part of a patient.
“Hospital emergency department” is a location or locations, on or off the hospital main campus, which is licensed to provide emergency services; and up to one-third of the outpatient visits to that location are seen on an urgent basis. In such instances, the hospital advertises or appears to the public as a location providing emergency medical services.
“Acute surgical emergency” is a subset of immediate life-threatening emergencies that will require a surgical or procedural approach to reversing that emergency. Such an acute surgical emergency might require surgical, nonprocedural interventions, such as might be achieved by a surgical intensivist in a surgical intensive care unit.
“Trauma” is a subset of an acute surgical emergency, requiring a specialized trauma center immediately and available 24 hours a day. Trauma conditions can be categorized by both anatomic and physiologic derangement, and sometimes by the mechanism of injury. For each body area injured classification mechanisms have been developed by the American Association for the Surgery of Trauma and are readily available on the Eastern Association for the Surgery of Trauma (EAST) website (http://www.east.org/portal/) for immediate review. The mere presence of an injury does not require the presence of a trauma center. More than 90% of injuries are of a sufficiently minor nature that it has been recommended by the Advanced Trauma Life Support course of the American College of Surgeons that only <10% of patients with major trauma be taken to a designated trauma center.
“Dumping” is a term often used to designate a transfer to a regional health facility (with or without the prior knowledge and agreement of the receiving facility) for the purpose of moving an “undesirable” patient from a sending health facility. The reason for the undesirability may be financial, complexity of conditions, unfavorable diagnosis, or a long list of other excuses.
“Reversed Dumping” is a term referring to a receiving hospital using maneuvers to prevent a sending hospital from transferring an appropriate patient with an immediate life-threatening emergency to the appropriate regional facility, when that facility clearly has a duty to accept that patient in transfer. A patient without financial means of payment for an emergency service that can be rendered at the local hospital is not a reason in itself to send the patient to a higher level of care.
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