QUESTION: Is the sample scoring tool and policy on this site a mandated EMTALA compliance form? Our Obstetricians don’t like some of the provisions.
COMMENT: CLICK HERE FOR REFERENCED FORM)
ANSWER:
The OB scale was created using scales in use at several hospitals at the time and published standards. Originally it was assembled by my staff and consulting physicians and various hospital OB staffs in response to EMTALA violations. Over the past 20 years this scale and variations have been accepted by CMS in plans of correction in all regions of the US. The scale was created because CMS could not — or would not — specify what it wanted in order for OB nurses to be able to provide OB assessments that would allow physicians some assurance that they did not have to come in on each and every OB presentation.
OB presentations prior to the creation of the scale often resulted in citations for OBs not coming to assess all patients personally. The scale has served its purpose by creating a clear and objective standard that met all of the observation factors required by CMS and assuring that physicians only had to come in when the patient exceeded the scoring scale or when the nurse felt that a factor required physician attention. It also addressed the CMS expectation that the OB as an on-call physician must respond promptly and without exception when the patient is deemed to need a physician exam by the score or nurse request.
The current version of the scale represents the best of the combined opinions of the OB staffs of multiple hospitals that have implemented the system and applied their own judgment to the scores, and it chooses to resolve any question on the side of patient safety and avoiding EMTALA citations.
The scoring system itself is not mandatory — it was developed as a self-defense tool for EMTALA compliance. The requirement to have protocols that meet CMS expectations for QMP (non-physician) screening and the rule that on-call physicians must respond promptly to provide a medical screening exam if patient needs exceed the level of QMP qualifications are mandatory.
The elements of the score correspond to those elements that CMS has deemed required when citing violations and those set forth in various private advisory letters from CMS. Additional elements may be added. Condition scores, score thresholds for physician exam, and issues appropriate to the actual level of staffing in the unit can all be adjusted to reflect the status of the individual hospital. Raising score thresholds to reduce physician responses automatically increases the risk of citation, but adjusting scores to reflect actual current medical risks with appropriate documentation would not necessarily increase risks.
OB patients were the primary reason for EMTALA. A huge percentage of EMTALA citations have been issued for OB situations. Of the non-transfer citations, most have to do with not receiving a timely evaluation by the OB and typically involve a failure to appreciate the EMTALA obligation to OB patients. This protocol and a variety of others have resulted in a significant reduction in OB citations, but citations still occur over issues of OB reluctance to see patients.
You can do away with this scoring system entirely. But please understand that CMS expects SOME system that assures that no patient falls through the cracks and that all presenting OB patients receive a prompt physician exam unless an acceptable protocol for non-physician screening exists. Strict adherence to hospital policies and protocols is expected and enforced. This protocol was developed to protect the physician, the nurse, the patient, and the hospital and not as a ball and chain.
You should also be aware that CMS has made it clear in recent warnings that Obamacare does not reduce or eliminate EMTALA standards and that they will be aggressively enforcing EMTALA. More than 250 citations have been issued for EMTALA violations have been issued over the past 3 years and EMTALA lawsuits for OB cases continue to be successful. See the EMTALA categories link on this site.
It is appropriate to review all policies and procedures on a regular basis, including this one. I simply recommend patient safety and regulatory compliance should be the driving forces for any changes, not any attempt to avoid prudent provisions that are personally inconvenient.