Presentation for ISU PARM 2223 Paramedic Course

1. Special
Considerations in
Emergent
Interfacility
transports

2. Objectives
• Define Inter-facility transport, Specialty Care Transport, and
levels of acuity
• Discuss the Emergency Medical Treatment & Active Labor
Act(EMTALA)
• Discuss medical control considerations

3. September 21, 2003
https://www.ems1.com/ems-management/articles/886650-Lessons-to-learn-from-Fla-10M-birth-lawsuit-outlined-
at-EMS-Expo/

4. The Medics…
• Conducted an Emergency Transfer of a
pregnant patient
• Physician ordered, certified as
stable
• 26 weeks gestation, c/o labor pains
• Followed policy. 15 minutes into transfer:
Water Broke
• Baby delivered (26 week premie).
• Medic did an resuscitated baby
• Baby lived, but diagnosed with
Cerebral Palsy (CP), possibly from
anoxia.

5. Found Liable

6. What is an interfacility transfer?
• “The transfer of patients from one medical facility to another has
become a national issue for Emergency Medical Services (EMS).
Patient transfers between facilities or between facilities and a
specialty care resource have increased as a result of regionalization,
specialization, and facility designation by payers. The emergence of
specialty systems (e.g., cardiac centers, stroke centers) often
determines the ultimate destination of patients rather than proximity
of facility.”
• NHTS “Guide For Interfacility Patient Transfer”

7. Keep this in mind
• Inter-/Intra- facility transports carry many of the same challenges.
• Even routine Interfacility transfers involve some level of risk.
• The mere act of transferring the patient is physiologically stressful on
the patient.
• Transfers from hospitals to other facilities, particularly emergency and
specialty transfers, have additional legal considerations not present in
the 911 realm.

8. Definitions
• Interfacility Transfer — Any transfer, after initial assessment and
stabilization, from and to a health care facility. Examples would
include:
• hospital to hospital;
• clinic to hospital;
• hospital to rehabilitation; and
• hospital to long-term care.

9. Levels of Acuity
• Stable with no risk for deterioration
• Oxygen, monitoring of vital signs, saline lock, (basic emergency medical care).
• Preferred level: BLS+
• Stable with low risk of deterioration
• Running IV, some IV medications including pain medications, pulse oximetry, increased need for assessment and
interpretation skills (advanced care).
• Preferred level: AEMT/ALS?
• Stable with medium risk of deterioration
• 3-lead EKG monitoring, basic cardiac medications, e.g., heparin or nitroglycerine
• Preferred level: ALS
• Stable with high risk of deterioration
• Patients requiring advanced airway but secured, intubated, on ventilator, patients on multiple vasoactive medication drips
(advanced care +), patients whose condition has been initially stabilized, but has likelihood of deterioration, based on
assessment or knowledge of provider regarding specific illness/injury.
• Preferred level: ALS
• Unstable
• Any patient who cannot be stabilized at the transferring facility, who is deteriorating or likely to deteriorate, such as patients
who require invasive monitoring, balloon pump, who are post-resuscitation, or who have sustained multiple trauma
• Preferred level: critical care or available crew with time considerations.

10. Specialty Care Transport
• As defined by the Centers for Medicare & Medicaid Services (CMS):
• IFT of a critically injured or ill beneficiary by a ground ambulance vehicle
including the provision of medically necessary supplies and services, at a
level of service beyond the scope of the EMT-Paramedic.
• SCT is necessary when a beneficiary’s condition requires ongoing care
that must be furnished by one or more health professionals in an
appropriate specialty area, for example, emergency or critical care
nursing, emergency medicine, respiratory care, cardiovascular care, or
a paramedic with additional training.
• Question: What is reality for many agencies?

11. This is not even an option…

12. EMTALA/COBRA

13. Disclaimer
• We are going to
focus on EMTALA
in the context of
emergency
transports.
• There is a lot
more to EMTALA.

14. COBRA and EMTALA
• COBRA passed in 1986 and updated periodically since. EMTALA is a sub-part of
COBRA
• Congress passed EMTALA to prevent hospitals from refusing to treat uninsured
emergency patients or transferring them to another facility when they are
medically unstable -- a practice known as patient dumping.
• This pertains to EMS because EMS was often used to provide the transportation during the
“dumping”.
• EMTALA violations happen every day
• Has grown into a complex, difficult to navigate, and sometimes poorly thought
out regulations with big penalties.

15. EMTALA was written to address
• Patient dumping of
• Un-insured
• Under-insured
• Indigent
• Pregnant patients
• Minorities
• Mandates requirements to:
• Screen for emergency conditions or labor
• Provide stabilizing treatment
• Make an appropriate transfer

16. To whom does
EMTALA apply?
• All Medicare-participating
hospitals
• All patients, not just
Medicare patients.
• Any physician responsible
for examination,
treatment, or transfer of
patient in an ED
• “Screening Exam”
Photo Courtesy of U.S. Army

17. EMTALA: “Coming to the Emergency
Department”
• Key concept to EMTALA is when a
patient “Presents to the
Emergency Department/Hospital”
• Pertains to EMS/SCT/CCT
• Parking Lot Calls
• Helipads located on hospital
property
• Hospital Owned Ambulances
• Medical Control Calls
(discussed later)
• 250 yard rule
• Includes Stand alone ERs and
clinics as well.

18. “Emergency
Department”
• Up until recently did not apply to:
• Rehab hospitals
• Nursing facilities
• Urgent care
• Clinics
• Recent legal opinion may cast this in
doubt:
• Friedrich v. South County Hospital
Healthcare, et al., US District Court
Rhode Island CA No 14-353 (2017).
• http://epmonthly.com/article/emtala
-apply-semantics-emergency-care/

19. EMTALA Requirements
• A hospital must perform a
medical screening exam for an
Emergency Medical Condition
to any person coming
(“presenting”) to ED seeking
care.
• ‘Prudent Layperson’
Standard
• A hospital must treat any
patient with an emergency
medical condition until stable,
or must transfer the patient
• A hospital may not transfer an
unstable patient
• After stabilization, there
are no further EMTALA
obligations

21. Special Considerations:
Pregnancy
• EMTALA protections of the pregnant patient
and the unborn child are at the core of the
legislation.
• Pregnant women with contractions are
considered to be medically unstable (active
labor) by default
• QMP must certify that the patient is in false
labor
• Note: After infant and placenta are delivered,
the mother may be considered “stable”.

22. Principals of EMTALA
The patient may not be transferred if they are
unstable and remain at risk of deterioration
unless the sending physician certifies in
writing that:
• the current hospital cannot meet the
needs of the patient.
• the benefits to be obtained at the
receiving hospital justify the risks of
transfer.

23. EMTALA and “Appropriate Transfer” (Part 1)
• An "appropriate transfer" (a transfer before stabilization
which is legal under EMTALA) is one in which all of the
following occur:
• Risk Benefit Assessment:
• The patient has been treated at the transferring hospital, and stabilized as
far as possible within the limits of its capabilities;
• The patient needs treatment at the receiving facility, and the medical risks
of transferring him are outweighed by the medical benefits of the
transfer;
• This is certified in writing by a physician (Signature required);

24. EMTALA and “Appropriate Transfer” (Part 2)
• An "appropriate transfer" (a transfer before stabilization
which is legal under EMTALA) is one in which all of the
following occur:
• Continuity of Care
• The receiving hospital has been contacted and agrees to accept the
transfer, and has the facilities to provide the necessary treatment to him;
• The patient is accompanied by copies of his medical records from the
transferring hospital;
• The transfer is effected with the use of qualified personnel and
transportation equipment, as required by the circumstances, including the
use of necessary and medically appropriate life support measures during
the transfer.
• Any tests or other paperwork that becomes available after transport is
begun must be forwarded to the receiving hospital.

25. “The transfer is effected with the use of qualified
personnel and transportation equipment, as
required by the circumstances, including the use of
necessary and medically appropriate life support
measures during the transfer.”

26. EMTLA and Qualified Personnel
• EMTALA places the responsibility on the transferring hospital to ensure that the
statute's requirements are met.
• The statute requires that the patient be accompanied by "qualified personnel and
transportation equipment" [Section 1395dd(c)(2)(D)]
• In some cases, this may be construed to mean that it must send its own personnel with the
patient.
• In other cases, simply meeting state licensing requirements is sufficient.
• CCT training may (or may not) meet the definition of qualification.
• Appropriate equipment is also key.
• This is where SCT/CCT comes in to play.

27. Big difference between the skill required, yet both are “critical care”…

28. But what if
there is no
SCT/CT
available?
I hate my job
right now….

29. Just grab a nurse???? Not so fast….

30. Idaho – Ambulance Based Clinicians Debate

31. What do I need for the Transfer?
• Required paperwork includes:
• Statement that risks of transport do not outweigh anticipated benefits
• Signed by physician or Designee
• The regulations add a requirement that the written certification contain an express summary of the risks and
benefits upon which it is based [42 CFR 489.24(e)(1)(ii)(C)]
• The statute provides that, if a physician is not physically present in the emergency room, the written
certification in support of transfer may be signed by a "qualified medical person" in consultation with the
physician, provided that the physician agrees with the certification and subsequently countersigns it. [42 USC
1395dd(c)(1)(iii)]
• Written request for transport by patient?
• No duress
• Signed patient consent for transfer
• Documented acceptance by receiving facility
• Patient medical Records and Diagnostic Images (X-Rays, CT, etc)
• Medical orders documented for transporting team

32. Medical Control Considerations
• Agency Medical Director:
• Protocols
• “The medical director is ultimately responsible for the care provided by the IFT
service.”
• Sending Physicians
• “Written orders from the transferring facility may suffice for the stable patient
during most transfers, but on-line medical direction should be available at all
times, in case unforeseen situations arise during transport.”
• As per the Emergency Medical Treatment and Labor Act (EMTALA), the sending
physician is responsible for the patient being transferred from one facility to
another, until the patient arrives at the receiving facility.”
• Receiving Physicians
• The receiving physical may be the most qualified to give direction for the patient.
• This is why you always get a name and phone number to receiving facility

33. Who you
going to call?

34. Let’s look at that $10,000,000 Ambulance call
• Did not question stability (EMTALA)
• Did not request additional help (EMTALA)
• Did not call supervisor or medical control
• Did not have right equipment for worst case scenario (birth of a preemie)
(EMTALA)
• Did not have right personnel for worst case scenario (birth of a preemie)
(EMTALA)
• Did not contact medical control when things started to go south
• Did not have a “oh crap” plan and got lost.
• Did not have a plan for when things went south

35. Aftermath

36. If this happened in your community, what
would you have done?

37. The single most important question a paramedic has
to answer when faced with an ethical, legal, or
moral challenge is:
WHAT IS IN THE PATIENT’S
BEST INTEREST?

38. Hi. I am a rural ER doctor sending you on a stable transport 2 hours to the “big city”. What is
the worst that could happen?