Outside the Emergency Department ambulances are jammed into lines waiting to deliver their emergency patients. Patients in need of life-saving care sit 150 feet from the doctors they need to save their lives, and they cannot reach them. Inside the ED doors, EMS crews stand over their patients and vainly attempt to get nurses to take their patients so they can return to the street to respond to the next call. Delays to unload of 45 minutes to an hour are reported by EMS crews, with similar times inside the hospital awaiting a nurse or other hospital employee to assume charge of the patient.
Is this some major disaster? A plane crash, tornado, or terrorist attack? No, its a typical day at some of the country’s busiest hospitals — busy and not adequately staffed or equipped with enough beds to handle a typical day’s presenting patients.
But it is LEGAL to leave patients, EMS personnel and ambulances stacked up like cord wood?
This condition is known by various terms. It used to be known as “parking” until CMS regulations made it clear that “parking” patients with EMS personnel did not delay the official “presentation” of the patient and the duty of the hospital to assume responsibility under EMTALA with prompt triage and access to a Medical Screening Exam.
Now, it appears that by calling it something else — “wall time” referring to standing along the wall waiting for someone to assess the patient and assume care — hospitals are hoping to avoid a confrontation between EMTALA and staffing and equipment levels.
What does CMS require?
CMS site review guidelines make it clear that the duty to provide a prompt triage, on-going monitoring, medical screening examination, and stabilizing care starts at the moment that the patient “presents”. For patients arriving by ambulance, the patient legally presents when the in-bound ambulance crosses the outer boundaries of the hospital property and the hospital becomes aware of the patient. An in-bound radio report once the ambulance crosses onto the property triggers the hospital’s legal obligations to the patient under EMTALA.
“Hospitals that deliberately delay moving an individual from an EMS stretcher do not thereby delay the point in time at which their EMTALA obligation begins.”
What can the hospital do?
CMS guidelines on “parking” seem to indicate a about hospital delays while acknowledging that in some cases they are unavoidable and without any fault of the hospital.
“Furthermore, such a practice of “parking” individuals arriving via EMS, refusing to release EMS personnel or equipment, can potentially jeopardize the health and safety of the transferred individual and other individuals in the community who may need EMS services at that time. On the other hand, this does not mean that a hospital will necessarily have violated EMTALA and/or the hospital CoPs if it does not, in every instance, immediately assume from the EMS provider all responsibility for the individual, regardless of any other circumstances in the hospital.
“So, if the EMS provider brought an individual to the dedicated ED at a time when ED staff was occupied dealing with multiple major trauma cases, it could under those circumstances be reasonable for the hospital to ask the EMS provider to stay with the individual until such time as there were ED staff available to provide care to that individual.
“However, even if a hospital cannot immediately complete an appropriate MSE, it must still assess the individual’s condition upon arrival to ensure that the individual is appropriately prioritized, based on his/her presenting signs and symptoms, to be seen by a physician or other QMP for completion of the MSE. The hospital should also assess whether the EMS provider can appropriately monitor the individual’s condition.
Cutting through the “layer-speak”, CMS looks at the circumstances of each case to determine whether the delay is justified in terms of the circumstances at the time and whether or not the hospital is facing an unexpected overload or has failed to staff to meet “community need” by providing enough staff and equipment to handle foreseeable ED presentations.
At the least, CMS expects that the hospital in periods of high ED EMS demand will promptly triage patients upon presentation to determine the patient’s condition. In cases of unusual high utilization levels, the hospital would be required to determine whether EMS personnel would be appropriate to care for the patient for the anticipated delay times, and, if appropriate, to request EMS personnel to remain with the patient. If it is not an unusual level of demand, hospitals will not be able to rely on EMS personnel as surrogate staff for ED operations.
Why isn’t CMS doing something about it?
From the number of complaints I am getting from EMS, it appears that “parking” is becoming a bigger issue that may reflect a conscious failure to address adequate staffing in the ED. So, why is it allowed to happen?
CMS actually took rather prompt and dramatic — for them — action in putting the site review guidelines on “parking” into place. Several hospitals have been cited for violations around “parking” incidents, but are cited for delay of triage or medical screening rather than using the terms “parking” or “wall time”.
The real key, however, is that CMS does not conduct random investigations or seek out violations on its own. Put simply, they only investigate complaints, so if there are no complaints, there are no investigations.