UTMB HANDBOOK OF OPERATING PROCEDURES

Section 9 Clinical Policies Subject 9.1 Admissions, Transfers, and Discharges Policy 9.1.21 Examination and Treatment for Emergency Medical Conditions and Women in Labor

08/01/92 -Originated 12/13/06 - Reviewed w/ changes - Reviewed w/o changes Admitting Department - Author

Examination and Treatment for Emergency Medical Conditions and Women in Labor

Definitions

Campus: the physical area immediately adjacent to the UTMB’s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case basis, by the CMS regional office, to be part of the provider’s campus. Emergency Medical Condition: (A) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could reasonably be expected to result in: (i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, (ii) serious impairment to bodily functions, or (iii) serious dysfunction of any bodily organ or part; or (B) with respect to a pregnant woman who is having contractions-- (i) that there is inadequate time to effect a safe transfer to another hospital before delivery, or (ii) that transfer may pose a threat to the health or safety of the woman or the unborn child. Medical screening exam: The process required to reach, with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist. It is an ongoing process and must reflect continued monitoring according to the patient's needs and must continue until he/she is stabilized or appropriately transferred. The exam will include information about the chief complaint, the patient's vital signs, mental status assessment, general appearance, and a focused physical exam related to the patient's complaint. Note: Triage is not the equivalent of a medical screening examination. The medical screening exam must be the same that UTMB would perform on any individual coming to the ER with those signs and symptoms regardless of the individual's ability to pay for medical care. Qualified Medical Personnel (QMP): An MD, RN, Advanced Practice Nurse, PA, or LVN at an off-site clinic who has been educated on the process for medical screening and trained in the appropriate handling of emergency situations within the scope of their education and experience.

Definitions, continued

Stabilize: The provision of such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility, or, with respect to a pregnant woman in labor, that the woman has delivered (including the placenta).

Policy

Healthcare workers in the Emergency and Nursing Service departments and Off Site Clinics will ensure that all individuals who come to the UTMB Emergency Department (ED), or on UTMB property, for an examination or treatment for a medical condition will be screened to determine whether an emergency medical condition exists. When a woman presents in labor, the OB/Gyn resident on-call will be paged immediately. For purposes of this section, ‘‘property’’ means the entire main hospital campus, including the parking lot, sidewalk, and driveway, as well as any facility or organization that is located off the main hospital campus but has been determined to be a department of the hospital. All individuals who present to a provider-based clinic either on or off campus for emergency medical care will be screened to determine whether a medical emergency does or does not exist. At least one individual on duty during the clinics regular hours of operation must be a designated qualified medical person (QMP). Clinics that are not routinely staffed with MD’s, RN’s, PA’s or LVN’s must have a written protocol to provide guidance as to what actions to take. These can include contacting the UTMB Emergency Department for guidance. If it is determined that a medical emergency does exist and EMS is called and the patient transported to UTMB or another hospital, the UTMB Emergency Department must be notified of the individual’s arrival to the clinic and the handling of the case, which will be noted in the hospital’s emergency department central log. Neither initial medical screening nor treatment will be impeded by inquiries about the individual's method of payment or insurance status. If an individual is determined to have an emergency medical condition and consent is obtained, UTMB must provide either (1) further medical examination and such treatment as may be required to stabilize the medical condition, or (2) transfer of the individual to another medical facility in accordance with the Transferring of Stabilized Individuals section below. All appropriate transfers of persons with emergency medical conditions will be accepted subject to UTMB's specialized capabilities and capacity to provide treatment.

Policy, continued

Transfer records will be maintained on all patients (emergency and non-emergency) receiving examination and treatment for a period of no less than five (5) years.

Personnel Authorized to Perform Medical Screening Exam

The following personnel are authorized to perform medical screening exams at UTMB: • Faculty physicians • Residents assigned to the ED • Physician's Assistants employed in the ED under the direct supervision of the Emergency Medicine Faculty • Advanced Nurse Practitioners • Staff designated in offsite clinics as Qualified Medical Personnel (QMP)

On-Call Physicians	UTMB shall maintain a documented system for providing physician on-call coverage and second-call coverage for all services offered by the facility. If, after an initial examination, a physician determines that the individual requires the services of a physician listed by the hospital on its list of on-call physicians and notifies the on-call physician and the on-call physician fails or refuses to appear within 60 minutes and the physician orders the transfer of the individual because the physician determines that without the services of the on-call physician the benefits of transfer outweigh the risks of transfer, the physician authorizing the transfer shall not be subject to a penalty under subparagraph (B). However, the previous sentence shall not apply to the hospital or to the on-call physician who failed or refused to appear.
Refusal to Consent to Treatment	If it is determined that the individual has an emergency medical condition, UTMB will offer the individual further medical treatment and inform the individual (or person acting on the individual's behalf) of the risks and benefits to the individual of such examination and treatment. If the individual (or person acting on the individual's behalf) refuses to consent to the examination and treatment, UTMB shall take all reasonable steps to secure the individual's (or person's) written informed consent to refuse such examination and treatment.
Transferring of Individuals	If an individual at UTMB has an emergency medical condition which has not been stabilized: A) UTMB may not transfer the individual unless-- (i) the individual (or a legally responsible person acting on the individual's behalf) in writing requests transfer to another medical facility and refuses treatment at UTMB after being informed of UTMB's

Transferring of Individuals, continued

obligations and of the risk of transfer. (ii) a physician has signed a certification that based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment atanother medical facility outweigh the increased risks to the individual and, in the case of labor, to the unborn child from effecting the transfer, or (iii) if a physician is not physically present in the emergency department at the time an individual is transferred, a qualified medical person has signed a certification (as described above) after a physician, in consultation with the person, has made the determination described in such clause, and subsequently countersigns the certification; and B) the transfer is an appropriate transfer in which: • UTMB provides the medical treatment within its capacity which minimizes the risks to the individual's health and, in the case of a woman in labor, the health of the unborn child • the receiving facility has available space and qualified personnel for the treatment of the individual and has agreed to accept transfer of the individual and to provide appropriate medical treatment • UTMB sends to the receiving facility copies of all medical records related to the individual's emergency medical condition for which the individual has presented, available at the time of the transfer, including records related to the individual's emergency medical condition, observations of signs or symptoms, preliminary diagnosis, treatment provided, copies of results of any tests and the informed written consent or certification and the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment • the transfer is effected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during the transfer; and which meets such other requirements found necessary in the interest of the health and safety of individuals transferred.

Refusal to Consent to Transfer

If UTMB offers to transfer the stabilized individual to another medical facility and informs the individual (or a person acting on the individual's behalf) of the risks and benefits to the individual of such transfer, but the individual (or a person acting on the individual's behalf) refuses to consent to the transfer, UTMB shall take all reasonable steps to secure the individual's (or person's) written informed consent to refuse such transfer.

Documentation

The screening of all individuals in the Emergency Department and in offsite clinics will include documentation of: • If the individual has an emergency medical condition. • Actions taken to make the determination. • Results of diagnostic tests. • Completion of Agreements, Authorizations, and Irrevocable Assignments, Disclosure and Consent for Medical and Surgical Procedures, and Against Medical Advice forms, if applicable. • Actions taken to stabilize and/or transfer the patient to UTMB’s Emergency Department, for those seen in the offsite clinics. In the event the patient refuses treatment, transfer, or a procedure, all reasonable effort to have the patient sign the appropriate form will be made. If the patient refuses to sign, a physician will document: • The patient’s refusal to sign. • The steps taken to procure the signature. • Any apparent reasons for refusal. • The date and time.

References

42 U.S.C, Section 1395dd 9.3.16, Refusal of Consent/Treatment