Paramedic Interfacility Transfer MEDICAL-LEGAL Module

1. New Hampshire Department of Safety, Division of Fire Standards and Training & Emergency Medical Service Paramedic Interfacility Transfer  MEDICAL-LEGAL Module

2. Terminal Objective At the completion of this section the student will understand the basic principals of the medical-legal considerations for an interfacility transfer

3. Enabling Objectives At the conclusion of this section the student will be able to: Differentiate responsibilities between interfacility transfer (IFT) & 911 calls. Define the federal legal principal guiding IFTs Describe the principals of EMTALA Describe a legally appropriate transfer Define the State Laws and Rules guiding IFTs

4. Objectives Psychomotor None identified Affective Advocate for the patient for the appropriate level of care during transfer Given a scenario, defend the need to accept or deny a transfer request

5. Interfacility Transfer (IFT) Defined for the PIFT The act of transferring the medical care of a patient from one facility (hospital) to another facility (hospital) that can provide an equal or higher level of medical care.

6. A 911 call is not an IFT! In the Street, a patient is the responsibility of the paramedic and any problems or challenges are the paramedic�s to solve. In a Hospital, a patient is the responsibility of the physician, and any problems or challenges are the physician�s to solve.

7. A 911 call is not an IFT! 911 calls: implied legal �Duty to Act� for EMS Providers who respond Meaning, you are asked to respond, and must provide appropriate evaluation, treatment and transport to consenting patients

8. A 911 call is not an IFT! IFTs: NO legal �Duty to Act� for EMS Providers Meaning-you can say �No Thanks� to a patient that is beyond your scope-of-practice or clinical comfort level The patient is already in a hospital, under a physician�s care An EMS Service may have a contractual obligation with a hospital to transport a patient, but� As a provider, you still have a right to decline to transport a patient that is beyond your scope-of-practice and clinical comfort level

9. IFTs: Not a problem for EMS An IFT is NOT an EMS problem, but a problem that is legally and clinically the responsibility of the patient's physician and hospital to solve. EMS is called upon to help solve their problem by physically moving the patient and maintaining appropriate medical care during the transport.

10. Critical Thinking Check� You get called to a hospital ED to transfer a cardiac patient to the nearest cardiac center. The hospital told dispatch the patient was stable on heparin and nitroglycerin drips. You arrive to find a pale, cool, diaphoretic patient with 10/10 C/P, SOB, decreasing mental status, hypotensive with frequent PVCs� Can you legally decline to transport this patient as a PIFT provider?

11. Two legal layers regarding IFTs Primary Layer: The Key Federal Law Directly effects hospitals Effects EMS through Hospital rules Secondary Layer: State Laws and Rules Directly effects EMS Includes EMS Protocols

12. The Key Federal Legal Principal� The federal law applies to all patients who come to an ED and requires that : Everyone who comes to an ED must be examined and stabilized. Transfers are only allowed under certain circumstances. If patients are transferred, appropriate medical care must continue.

13. Ever seen this sign in an ED?

14. WHAT IS �THE LAW�? EMTALA Emergency Medical Treatment and Active Labor Act (Section 1867(a) of the Social Security Act) Sometimes known as the Anti-Dumping law Passed to prevent hospitals from refusing to treat indigent persons or transferring them inappropriately to other facilities-specifically including women in labor Hospitals can�t discriminate or delay exam and treatment based on insurance or ability to pay

15. EMTALA Requires� Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives.

16. A patient comes to a hospital if they arrive �on the hospital campus�

17. Except if�

18. When Can a Patient be Transferred? When a patient requests a transfer to another institution (and meets certain guidelines), or When the patient is not actually experiencing an �emergency medical condition�, or When a patient has been examined and �stabilized� within the capabilities of the hospital and meets �appropriate transfer� guidelines.

19. EMTALA requires an �Appropriate Transfer� to include all of the following: The patient has been treated and stabilized at the transferring hospital within the limit of it�s capabilities, Patient needs treatment at the receiving facility, and the benefits of transfer outweigh the risks of the transport, A physician certifies, in writing, that the benefits outweigh the risks, and the patient or family consent to the transfer, A receiving physician/facility agrees to accept the patient, and has the facilities to provide the treatment to the patient, The patients medical records go with them to the receiving hospital, AND......

20. EMS and �Appropriate Transfers� �..�the transfer is effected with the use of qualified personnel and transportation equipment, as required by circumstances, including the use of necessary and medically appropriate life support measures during transfer.�

21. So how does all this legal jargon apply to EMS ?

22. Scope of EMTALA and EMS An ambulance service may not be charged with an EMTALA violation unless it is a hospital-owned service. BUT�

23. Scope of EMTALA for EMS An ambulance service may still be sued by either the sending hospital or the patient for negligence or misrepresentation if it fails to provide the appropriate personnel and equipment requested by the sending facility.

24. Example A sending facility requests an ALS equipped ambulance staffed by an ACLS certified paramedic to transfer a cardiac patient to another hospital. The service provides only a BLS ambulance with an EMT and fails to mention this to the sending hospital. If the patient requires ALS treatment during transport and suffers damages, the EMS service may be liable.

25. State Laws and Rules The State Statutes are the �big picture� Laws. The specific NH Statute for EMS is under: Title XII, Public Safety and Welfare, Chapter 153-A Emergency Medical And Trauma Services

26. State Laws and Rules The State Administrative Rules define more specifically how we are supposed to do things within the Statutes. The specific Rules for EMS are under: Chapter Saf-5900, Emergency Medical Services Rules

27. Statutes Supporting a PIFT The NH Statute Sections: 153-A:2 XVI-a: �Prerequisite� (protocols) and 153-A:2 XVII: �Protocol� Authorizes the NH EMS Medical Control Board to set and approve EMS Patient Care protocols and prerequisite requirements

28. How and Where is a PIFT Defined? NH Administrative Rules Saf-C 5922.01 �Patient Care Protocols� NH EMS Patient Care Protocols Protocol 7.0 �Interfacility Transfers�

29. What the PIFT does for you� Teach paramedics to think critically in the IFT setting, and understand when they should and shouldn�t be helping to solve someone else�s problem by accepting a transfer. Define the upper limits of the PIFT scope-of-practice to keep physicians, hospitals and services from pressuring a PIFT paramedic to accept a transfer that may put the PIFT Crew in a situation that is beyond their appropriate patient care abilities.

30. An Appropriate PIFT Transport� You have directly evaluated the patient and determined they are clinically appropriate for a PIFT transport You have all of the equipment, medications and additional staff that you need for the transport

31. Appropriate PIFT Transports You have a written physician order for the transport that details treatments and medications You have reviewed all medications and therapies for the current patient with the sending staff and/or published resources as appropriate, and understand dosing, side effects, interactions and complications of the sending physician�s treatment orders and patient condition

32. Appropriate PIFT Transports You have applied critical thinking to the situation, considering: your skills, the patient condition, potential for deterioration, other complications that could occur during transport remembered that you don�t know what you don�t know, and that could kill your patient, AND

33. You still feel comfortable doing the transport� Then you have an appropriate PIFT transport.

34. Checks and Balances All PIFT services must meet certain criteria to be approved to do PIFT transports, including: Having an active QA/QI program Receiving periodic audits by the BEMS to insure: Transports are appropriate for PIFT level �Black Market� Critical Care transports are not occurring

35. Checks and Balances Failure to maintain PIFT criteria, or transporting inappropriate patients may lead to an EMS Provider or Service losing their approval for PIFT transports

36. Critical Yes/No Decisions� Can you decline a PIFT transport of a patient that is beyond your scope-of-practice or clinical comfort level when a physician tells you the �Patient is going to die if you don�t take them right now�?

37. Patient is going to die� Answer: Yes You can decline this patient transport. Remember: IFTs are actually a physician and hospital problem that you have been asked to help solve. Don�t let a physician try and guilt you into solving their problem

38. Critical Yes/No Decisions� Can you decline a PIFT transport of a patient that is beyond your scope-of-practice or clinical comfort level when your EMS service manager tells you that you must �take this transport�?

39. Manager says: �Take it�� Answer: Yes You can decline this patient transport, as you are ultimately the EMS provider who will be responsible for patient care between facilities, and services are required to meet PIFT requirements to maintain their approval to perform these transports

40. Critical Yes/No Decisions� Can you decline a PIFT transport of a patient that is an appropriate PIFT transport, is NOT beyond your scope-of-practice or clinical comfort level, but you go off shift soon and you don�t feel like doing the transport?

41. Don�t feel like it� Answer: NO This would be negligent and unprofessional and the PIFT prerequisites are intended as protection for the PFT provider, not an excuse for poor and unprofessional behavior

42. Critical Yes/No Decisions� Can you decline a PIFT transport of a patient that is an appropriate PIFT transport, is NOT beyond your scope-of-practice, BUT: there is a nasty Nor�easter blizzard occurring right now and your transport time is normally 90 minutes to the receiving facility?

43. Nor�easter� Answer: Yes You can decline this patient transport. Keeping in mind several factors that can influence the clinical and operational situation: This is an IFT, and you don�t have a duty to act, unlike a 911 call; The patient is currently in a stable, safe environment with many resources and can wait out a storm; Patients inherently become more unstable during transport, regardless of how stable they were in the hospital; Transport times can easily double or triple during inclimate weather travel, The risk of significant injury to all passengers are much higher in an ambulance crash; Everyone�s goal is to go home safe at the end of the shift!