impact of EMTALA on the interfacility transport populations Williams offers an excellent in-depth publication describing EMTALA This act places clear duties on both the referring and receiving hospitals The referring clinicians must everything within their capabilities to stabilize the patient’s medical condition before transport and may not transfer a patient against his or her will unless the facility cannot provide the appropriate level of care Furthermore, the referring physician must obtain informed consent for transfer and, as part of this process, must advise the patient or the guardians of a minor about the risks and benefits associated with transfer Of course, when consent is not practical/possible (absent guardians), and the child’s condition is critical, the transport should not be delayed Under EMTALA rules, emergent transport decision making should not include the financial ramifications of the decision It may seem prudent to disclose that a refusal of transfer may potentially leave the patient/family responsible for a hospital bill, however, under EMTALA rules, such information, though well intentioned, may be construed as financial coercion to enable the transfer Instead, if the patient’s medical acuity does not preclude it, the parents of the patient may be told to contact their insurance representatives, or the hospital financial personnel to discuss these issues The referring team is also responsible for selecting an appropriate means of transport Obviously, the more critical the need for medical care and expertise, the more sophisticated the transport capabilities required This is an important point for the referral physician to remember The desire to transfer a child to a more appropriate medical facility as soon as possible is understandable, but if the method chosen places the child in a medical environment that does not offer at least the level of care at the referral center, that center and physician may be liable for any untoward effects that can be construed as having occurred because of the choice of transport Finally, EMTALA requires the receiving hospital to accept the patient in transfer if the appropriate type and level of care are available Again, the ability of the patient to pay for medical care cannot be considered by either the referring or the receiving facility In addition to the EMTALA, there are often local regulations that direct transport services For example, some cities have regulations designating certain agencies as official providers of prehospital services Such statutes must be considered when offering transport services It is important to note, that guidelines, such as trauma center transfer protocols, not negate or supersede EMTALA guidelines Also, as EMTALA does not apply to inpatients, temporarily admitting a patient to the hospital to attempt to circumvent the ED-focused EMTALA requirements is not allowable Any law that contradicts or conflicts with EMTALA is considered preempted by EMTALA The HIPAA of 1996 also impacts the traditional transport system Limitations are placed on information dispersion that could be potentially linked to a specific patient Although this should not impact patient information flow between primary providers or the assessment of services by an established CQI system, the generic follow-up letters that many systems used for feedback and as marketing tools are no longer permitted Legal advice should be sought on how to replace this time-honored, but now outdated, method of generic communications As noted, traditional tort law also applies to the transport team Most of these issues are similar to those encountered in other healthcare venues However, one potential source of medical–legal risk is unique to the transport team As stated earlier, the transport team gradually becomes more and more involved in the care of the patient At first, this involvement is limited to giving advice and management suggestions It is the referring physician’s responsibility to consider these suggestions as he or she deems appropriate At this stage in the transport process, transport personnel should try to gain the clearest possible picture of the patient’s condition so the most appropriate suggestions may be given Furthermore, advice may be best prefaced with general phrases such as “Most patients with this condition” or “We often manage this problem by …” The transport team should clearly document any advice given, in writing or recorded conversations, in case disagreements regarding what advice was given arise later The next stage of involvement occurs when the transport team arrives at the referral facility and begins to care for the patient, often along with one or more members of the referring hospital’s staff At this point, the greatest medical–legal risks are conflicts over management and difficulties in determining who gave or carried out medical orders Written consent and permission for disseminating medical-related information should be obtained, and if the patient/guardian is unable to provide it, alternative means of approving the transport should be considered ( Figs 11.12 and 11.13 ) When management conflicts arise, the medical control physician should be contacted, and he or she should help resolve these conflicts by speaking directly with the referring physician In these situations, the referring provider is ultimately in charge of the patient, and the transport providers are considered onsite consultants The medical record should clearly reflect who gave and who carried out each order The transport team assumes total responsibility for the care of the patient when they leave the referral center Consequently, the team should assure that the patient is as stable as possible before leaving If an unstable patient is transported, the team must document why it was in the patient’s best interest to undertake transport at that time In some cases, transfer agreements exist between hospitals Typically, such agreements stipulate that the receiving hospital will accept all transfers from the referring hospital In the past, transfer agreements served to decrease the time needed to accept the patient by eliminating or shortening the approval process More recently, transfer agreements have become less important for two reasons First, the EMTALA places a duty on the receiving hospital to accept the patient as long as there is an appropriate bed location available Second, for patients who have undergone an EMTALA-mandated “Medical Screening Exam” by a “Qualified Medical Person,” and are determined to not have an “Emergent Medical Condition,” managed care organizations or insurance plans may stipulate certain receiving facilities In such cases, the transfer agreement may exist between the managed care organization and the receiving facility However, as above, the laws of EMTALA override these agreements for patients deemed to still have an Emergency Medical Condition There are important legal ramifications to transport teams who operate under specific guidelines or protocols Therefore, it is imperative that all guidelines represent the current standard of care Furthermore, guidelines should be designed to ensure that providers not exceed their scopes of practice as defined by state, local, and institutional regulations Routine review of existing protocols and guidelines is warranted New guidelines should be developed in conjunction with recognized authorities, and should be reviewed by risk-management specialists before implementation Use of protocols/guidelines is not a medical–legal shield regarding lawsuits, although adherence to evidence-based guidelines can help demonstrate state of the art and thoughtful care FIGURE 11.13 A consent for admission should also be completed for patients This form may contain other information, including intrainstitutional transfer information, photography verbiage, etc (Used with permission, © The Children’s Hospital of Philadelphia, Philadelphia, PA.) ... However, as above, the laws of EMTALA override these agreements for patients deemed to still have an Emergency Medical Condition There are important legal ramifications to transport teams who operate