r/Paramedics • u/Dowcastle-medic Paramedic • Jun 25 '25
US EMTALA and bypassing a hospital
So I had a pt today totally stable but she has an injury I know the local type 4 community hospital (20min) is not going to be able to fix. It was suggested by the clinic staff where I picked her up to go to the type 3, 1.5 hours away. But one of the ER drs for the community hospital happened to be there and looked at the injury and said no just take her to our hospital.
She said the type 3 couldn’t deal with that either and she would need to go to One 3.5 hours away so go and get her c spine cleared…
So we did and then I get chewed out by the ER drs on call saying I can NEVER bypass them based on EMTALA. I always have to stop and let them stabilize the pt and cat scan and such…
That’s not true is it?
44
u/Topper-Harly Jun 25 '25
You can absolutely bypass a hospital to go to another hospital without violating EMTALA.
In fact, unless you work for a hospital-based system, you can do whatever you want without violating EMTALA.
-1
u/Robot-Tom Jun 25 '25
Depends on the state. Ours is hospital based, but hospital and pre hospital are two very different things according to my state board.
7
u/Topper-Harly Jun 25 '25
Depends on the state. Ours is hospital based, but hospital and pre hospital are two very different things according to my state board.
State-to-state differences would be governed by other regulations not EMTALA, as EMTALA is federal.
1
u/Robot-Tom Jun 25 '25
My bad I don't get too caught up in EMTALA because I know it doesn't affect me.
5
u/FullCriticism9095 Jun 25 '25
If you work for a hospital owned or operated EMS service, there are scenarios where EMTALA can apply to you.
Say for instance you respond to a call for someone who burned themselves on the stove. The house is not in great condition, and you might suspect that the family is not particularly well off. You ask the patient which hospital they want to go to, and they say “I think I want to go to your hospital.” Even though your hospital is not on a sanctioned divert status, you say “I don’t know, it’s pretty busy there tonight, you should probably go to the other hospital across town because who knows how long it’ll take you to be seen at my hospital.”
If you do that, the patient could argue that you formed an impression that they might not be able to pay, so you steered them away from your hospital to avoid having to provide requires stabilizing assessment and treatment that your hospital wouldn’t get paid for. That would be an EMTALA violation. Depending on the details, it may or may not really end up being a violation, but there would probably be enough there for the patient to file a complaint and trigger an investigation.
If you work for a hospital-based ambulance service, you should get training on these kinds of issues.
1
u/Robot-Tom Jun 25 '25
That scenario yes there is grey which I had not considered, my apologies. Mine is the only critical access hospital within 30 - 45 minutes any direction so it's either there or the pts choice if it's one of the other two (both different directions).
1
1
24
u/No_Helicopter_9826 Jun 25 '25
EMTALA has absolutely nothing to do with your decision-making process when choosing a destination for your patient. It's not at all relevant. EMTALA also does not in any way make a hospital responsible for patients who DON'T present to that hospital for treatment. If you don't go there, that patient simply doesn't exist to them. Whoever told you this is not just wrong, but wrong in a confusingly bizarre way.
3
u/finis08 Jun 25 '25
By “bizarre way” you mean not giving a shit about pt care and only caring about the missed financial opportunity because their hospital was bypassed. Generally speaking, every time I hear a hospital complain about a potential EMTALA violation it is because they just wanted the ability to bill the patient or they think I have zero understanding of EMTALA. They are wrong on both accounts. Regardless, I will be taking my patients to the most appropriate place given the situation at hand.
1
u/Robot-Tom Jun 25 '25
Trust me it's more common than you think especially with people who should know.
15
u/Squirelm0 Jun 25 '25
EMTALA has very little to do with ambulances. It only regulates hospital units. And at that, they cannot bypass an appropriate facility to go to their home facility. Dr's at a clinic/facility, regardless of who they are affiliated with, have no say in where you transport a patient based on need and YOUR assessment. If that's the case they can use an IFT unit and do as they see fit when the companies scheduling allows.
EMTALA only applies to hospitals once a patient is on their campus grounds. They must be given a medical screening and stabilization if needed regardless of insurance. Then they can be transferred to another facility.
6
u/howawsm Jun 25 '25
We always take to the most appropriate hospital for the patient, but also the transit time difference from our community-ish ER to our level 1 or 2 is just 45 minutes more with a few intermediate ERs that are like higher level stroke and cardiac centers. I’ve passed plenty of hospitals on the way to the one that is going to produce the best patient experience for their condition/disease/injury
4
u/grav0p1 Jun 25 '25
Do you not have protocols for this?
3
u/Dowcastle-medic Paramedic Jun 25 '25
No, not really. Used to be a volunteer service now a fairly new ALS service and the only protocols are the statewide ones. For the most part. And they only talk about when to call air ambulance…
5
u/Anonymous_Chipmunk Critical Care Paramedic Jun 25 '25
This is not an EMTALA issue, it's a protocol issue. Only you can look at your protocols and find the answer. But no, this isn't an EMTALA issue.
2
u/Advanced-Day-9856 Jun 26 '25
If your service is not owned by a hospital, EMTALA doesn’t apply to you at all. It regulates hospitals, not ambulances (so long as they’re not owned by the hospital). You are bound by your protocols so if your protocols don’t allow bypass, that’s another issue. If this was a 911 call pretty substantial distance versus going to the closest hospital. It’s hard to believe that any ER would be unable to run routine CT scans — fixing the issue that they may find is another story. Then again in rural areas, they might not be 24-7 CT coverage.
There could also be reimbursement issues, insurance wants to pay to get to the closest hospital, and after that they may not pay for additional mileage. Anytime a hospital complains about receiving a patient. It’s because they’re just being lazy and don’t want to deal with it. THEIR EMTALA obligation is to take care of patients when you bring them.
4
u/tacmed85 FP-C Jun 25 '25
As others have said EMTALA doesn't apply to us. That said dropping a 911 unit from a system for 3+hrs especially in what I presume is a pretty rural area without a lot of resources is a big decision and shouldn't be made lightly. In the vast majority of cases in that scenario I'm going to the local ER and letting them sort things out from there.
1
u/Dweide_Schrude Jun 26 '25
This is always challenging in a resource limited system. We are “rural” with a 10k population in our district. Fortunately we have two Level 1 (1 of those is peds Level 1 as well) and three Level II all within 30min of the farthest point of our district.
Most of the overrides I do are for PCI/Comprehensive stroke patients.
As long as documentation is in place and you justify it in the narrative it should be fine.
1
u/tacmed85 FP-C Jun 26 '25
As long as documentation is in place and you justify it in the narrative it should be fine.
It's not a matter of "being fine" it's a matter of doing what's right for the system. In a resource limited area like it or not every call and decision is a triage decision. 30 min like in your example isn't as big a deal, but OP is talking about dropping system resources for 3-7 hours. That's a ton of time where a lot can happen and people with serious issues could be left with a severely delayed response depending on resource location and quantity. The first agency I worked for in rural Utah had a similar problem in that we had one ER with pretty limited capabilities, but our closest trauma or specialty center was over 2 hours away. There was only one ambulance staffed by full time employees for the entire county so if we weren't available they'd have to page out our volunteers who responded from home to the station to pick up an ambulance and finally to the call creating a massive delay and lower level of care(usually ILS). Our closest potential mutual aid was 45+ minutes away so that really wasn't an option either. The policy there was everyone gets transported to the local ER and then they can fly them out or whatever they need to do. It sucks on the patient's side if the complaint isn't that time sensitive and they're getting a flight bill now, but it was realistically the only viable way to do it. Sure it's only about 10K people in the county, but that's still plenty for more than one to need help while the primary unit is tied up especially if we were taking 4 hours to run a single call.
3
u/Arconomach Paramedic Jun 25 '25
EMTALA is a hospital only thing. Our job is, at the minimum, closest appropriate facility.
Tell your med control, and ask him to talk to the ED doc. Also ask that your med control follow up with you about the incident.
3
u/HiGround8108 Paramedic Jun 26 '25 edited Jun 26 '25
Yeah. No. EMTALA? None of our business. That is a hospital problem.
3
u/Paramedickhead CCP Jun 26 '25
Except in some very specific situations EMTALA doesn’t apply to EMS whatsoever.
And no hospital has an EMTALA obligation until the patient presents at their hospital WITH the intention of being seen or receiving care at that hospital.
You can park in a hospital bay, walk through their ER, and go up to a rooftop helipad to meet a flight crew and it’s still not an EMTALA violation.
2
2
u/Difficult_Sweet_6904 Jun 26 '25
EMTALA starts at hospital property. Not in the ambulance. You go to the closest most appropriate facility. Or if patient is requesting bypassing the closest most appropriate facility, you make sure they have decisional making capacity and get informed consent and a signature. 99% of ER docs have no clue about anything EMS unless they used to be in it, or are a medical director tor EMS.
2
2
u/Zrobb44 Paramedic Jun 27 '25
Unless you’re employed by that specific hospital, and already have the patient checked in while AT the location- it’s your job and the patients choice to decide where to go. ER doc doesn’t know what they’re talking about.
5
u/SubstantialDonut1 Jun 25 '25
The doctors are wrong and probably also violating anti kickback laws by telling you that
1
u/emergentologist Jun 27 '25
They are wrong about it violating EMTALA, but they definitely aren't violating anti-kickback laws
1
u/SubstantialDonut1 Jun 28 '25
YKW I did a google search, and I definitely misunderstood a case I read about years back. You right you right
2
u/jawood1989 Jun 25 '25
EMTALA doesn't affect prehospital EMS whatsoever. It was created to force hospitals into treating and stabilizing patients instead of dumping them on the curb of the poor man's hospital.
1
u/No_Occasion_4658 Jun 25 '25
Most protocols state “closest APPROPRIATE facility” I’m not stopping at my local critical access hospital with something I know needs higher care unless they’re totally unstable.
2
u/Mediocre_Daikon6935 Jun 25 '25
I’m also not taking an EMS unit out of service for 3 hours to go to the big boy hospital.
They’re going local, and they’ll get them transferred out.
My state is pretty clear that 45 minutes is the maximum acceptable transportation tune to get to a speciality hospital.
And that the ability to get back in service to cover your primary response area is a priority consideration.
If hospital A is 30 minutes away, and hospital B is 35, but I came from the direction of hospital B, they’re going to B because I need to be able to respond when someone calls 911, and that isn’t ideal from 50 minutes away.
Obviously there would be exceptions l&d, stroke center, etc) but that’s about it.
1
u/bleach_tastes_bad Jun 25 '25
you must live in a small state, or one with a lot of hospitals everywhere, because there’s a very large portion of the country where you need to drive 45+ minutes to even get to a hospital at all, let alone a specialty center
2
u/Mediocre_Daikon6935 Jun 25 '25
Oh….I didn’t say the transport was going to be only 45 minutes.
But you’re not going past the closest critical access hospital if it is.
1
1
u/FullCriticism9095 Jun 25 '25
What kind do agency do you work for? Is it owned or operated by a hospital?
1
u/Robot-Tom Jun 25 '25
Even then, at least my state that doesn't matter, the hospital and pre hospital are two different animals. I know because I work for a hospital service, my state even says transfer are the hospitals problem not the EMS services.
With that said being owned and operated by the hospital you do have to follow the policies and procedures they approve, but as for as your medical license at least in my state they only care that we run the 911 calls and are doing things by the (pre hospital) book while the pt is in your care.
2
u/FullCriticism9095 Jun 25 '25
The question is about EMTALA, which is a federal law. This has nothing to do with your state or your license.
If you don’t work for an agency that is owned or operated by a hospital with emergency services, there is no question that EMTALA does not apply. There isn’t even anything to discuss.
If the ambulance service is owned or operated by a hospital, EMTALA considerations can come into play. There are potential scenarios where it actually can be a violation for a hospital-owned ambulance service to take a patient to another hospital. State protocols provide some protection, and it’s highly unlikely that EMTALA was violated in the OP’s case, but you can’t just wave your hand and say “EMTALA doesn’t matter at all” like you can when the ambulance service is not owned or operated by a hospital.
1
1
Jun 25 '25
It’s not. Neither is requesting an air ambulance and meeting them at the hospitals helipad. You aren’t feeling treatment at that hospital just using their real estate. I will say document the reasons why you bypassed a hospital/facility thoroughly not only for yourself but for any bill g questions for that patient down the line. “X services are not available at referring facility and only available at ____, which is one hour away”
1
u/Difficult_Sweet_6904 Jun 26 '25
This does get tricky though. Particularly when walking through the ER to get to the elevator at places with rooftop helipads. If a doc interacts with that patient it can become a EMTALA violation pretty quickly
1
u/Immediate-Coconut700 Jun 25 '25
I came here to ask a similar question to y’all today just on the opposite side of things. Urgent care clinic thinks patient who is asymptomatic and feels totally fine — who just happened to take her BP today — needs to go to high acuity ED an hour away because her cardiologist “is there.” Recently taken off BP meds. Does have cardiac history but nothing suggesting anything happening right now aside from needing to be back on BP meds. Thought it was definitely good to go to ED based on history, but no need to go to an hour away and wait for six hours. Apparently clinic had to redo the EMTALA and was angry I even did an assessment because I was delaying care? What the hell
3
u/emergentologist Jun 27 '25
Thought it was definitely good to go to ED based on history
Nah, that patient doesn't even need to go to the ED based on the scenario given. Absolutely ridiculous of the quick care staff to not only send them to the ED, not only by ambulance, but also wanting to send them an hour away. Fucking hell what an epic waste of a lot of resources.
1
u/Immediate-Coconut700 Jun 27 '25
I appreciate you! I actually had to look at this twice to make sure it wasn’t my own comment because it sounds like me so much 😂
1
u/ImJustRoscoe Jun 25 '25
Even in rural ND, our critical access hospitals can page imaging after hours to clear spinal. If there's a problem the ER arranges EMTALA compliant transport to higher level care. Sometimes thats flight, oftentimes that's us. 2-4 hours by ground depending on specialty and bed availability ...
-1
u/Dangerous_Ad6580 Jun 27 '25
So your ER docs can't read a C-Spine CAT scan?
1
u/ImJustRoscoe Jun 27 '25
Im sorry, Im not understanding the point of your question.... ER docs do a quick look/quick read and radiologists have the final say... is that not how it goes everywhere? What exactly are you asking. Talk to the tism when you clarify.
-2
1
1
u/Dangerous_Ad6580 Jun 27 '25
Bullshit
You get to make the decision, scope of practice says closest, most appropriate facility.
EMTALA doesn't attach until you are on hospital grounds or within 300 yards, look it up.
Always do what is best for your patient and screw political rules, you will be vindicated in the end.
2
u/twistedgam3r Jun 28 '25
Even if that physician told you to go one place, if you deem it necessary to go to another, it’s ultimately your decision. Once care is turned over to you, that’s your patient now.
0
u/Famous-Response5924 Jun 25 '25
Closest most appropriate facility for unstable patients. For stable patients you can transport them anywhere they ask to go as long as your service doesn’t care.
101
u/ggrnw27 FP-C Jun 25 '25
Nope. Assuming you don’t actually work for the hospital, EMTALA doesn’t apply to you at all