Ambulances and Helicopters
CMS has clarified a number of issues for hospital and non-hospital-owned and -operated ambulances and helicopters. Hospital property includes ambulances owned and operated by the hospital even if the ambulance is not on the hospital campus.
Hospital-owned and -operated ambulances and helicopters may be diverted only if the diversion occurs pursuant to community-wide EMS protocols.Telephone or telemetry contact with ED personnel by non-hospital- owned and -operated ambulances and helicopters does not trigger that hospital’s EMTALA obligation. The hospital may divert the ambulance to another facility if the hospital is on “diversionary status’’ (insufficient staff or facilities to accept additional emergency patients). However, once the ambulance drives on to the hospital property, even if they were told to divert, the patient is considered to have come to the hospital’s ED and the hospital has an EMTALA obligation. Additionally, if a hospital that is not on diversionary status fails to accept a telephone or radio request for transfer or admission, the refusal could represent a violation of other federal or state requirements.
In Arrington v Wong, the US 9th Circuit Court of Appeals ruled that diverting an ambulance requesting access may result in EMTALA liability. In this case, it was alleged that a patient with severe breathing difficulties was diverted en route from an ED to a military hospital. The patient died on arrival at the military facility, and the family sued the hospital that did not accept the patient. The hospital was not on diversion status. The court ruled that the allegations were enough to force the matter to trial on potential EMTALA liability.
"Parking" Patients
A hospital’s EMTALA obligation begins as soon as a patient presents to the emergency department or other qualified area. There are certain occasions, such as when ED staff are occupied dealing with multiple major trauma cases and a patient has arrived via EMS and has been assessed and appropriately prioritized by the hospital, in which it may be reasonable for the hospital to ask an EMS provider to stay with that patient until ED staff are available.
It was reported, however, to the CMS that some patients were being routinely left on stretchers with EMS staff in attendance for an extended period of time with hospital staff believing that they had no obligations to provide care or accommodate the patient until they took “responsibility” for the patient. In July 2006, the CMS issued a letter strongly discouraging this practice as concerning for both patient care and the provision of emergency services to the community. The letter clarifies that the EMTALA obligation starts at the time of presentation, not when EMS personnel transfer responsibility. Additionally, hospitals are legally required to meet the emergency needs of patients in accordance with acceptable standards of practice (42 CFR 482.55, Conditions of Participation for Hospitals for Emergency Services). The CMS concludes that the practice of “parking” patients in hospitals is not an acceptable practice.Helipads
Under the helipad exemption, ambulances may bring patients onto hospital grounds without triggering the hospital’s EMTALA obligation, under certain circumstances:
• The use of a hospital’s helipad by local ambulance services or other hospitals for the transport of patients to tertiary hospitals located throughout the state does not trigger an EMTALA obligation as long as the sending hospital conducted the MSE before transporting the patient to the helipad. The sending hospital is responsible for conducting the MSE before transfer to determine whether an EMC exists and implementing stabilizing treatment or conducting an appropriate transfer. Therefore, if the helipad serves simply as a point of transit for patients who have received an MSE before transfer to the helipad, the hospital with the helipad is not obligated to perform another MSE before the patient’s continued travel to the recipient hospital. If, however, while at the helipad, the patient’s condition deteriorates, the hospital at which the helipad is located must provide another MSE and stabilizing treatment within its capacity if requested by medical personnel accompanying the patient.
• If as part of the EMS protocol, EMS activates helicopter evacuation of a patient with a potential EMC, the hospital that has the helipad does not have an EMTALA obligation if it is not the recipient hospital unless a request is made for the examination or treatment of an EMC by EMS personnel, the patient, or a legally responsible person acting on the behalf of the patient.
Therefore, the patient who had an MSE at Hospital A could be taken by ambulance to the helipad located on the grounds of Hospital B for transfer to Hospital C without triggering Hospital B’s EMTALA obligation, unless the patient’s condition deteriorated before loading on the helicopter. In addition, a patient picked up in the field who is brought to the helipad at Hospital X for transfer to Hospital Z under local EMS protocol would not launch Hospital X’s EMTALA obligation unless the EMS personnel (or patient) requested care before loading on the helicopter.