Medical Legal Considerations in IFT, CCT, and SCT Mobile Intensive Care Paramedic Series
Focus Statement <ul><li>Focus Statement: This Module will introduce the participant to EMTALA, COBRA, medical direction, a...
Presentation Information <ul><li>Last revised 04/23/08 </li></ul><ul><li>For more information contact the education depart...
Striking a balance…
Laws/Regulation Affecting Critical Care <ul><li>Most are familiar from paramedic practice </li></ul><ul><ul><li>Mandatory ...
4 Basic Concerns To Most Legal And Ethical Dilemmas <ul><li>Beneficence  is the principle of doing good for the patient. <...
Scope of Practice? <ul><li>“What makes you think you can do this?” </li></ul><ul><li>Currently, no national standard defin...
State Law <ul><li>States define scope of critical care paramedic’s practice </li></ul><ul><ul><li>EMS regulations </li></u...
Medical Director <ul><li>Critical care paramedic only permitted to provide care under auspices of physician medical direct...
COBRA and EMTALA <ul><li>COBRA passed in 1986 and updated periodically since. EMTALA is a sub-part of COBRA </li></ul><ul>...
EMTALA: “Coming to the Emergency Department” <ul><li>Key concept to EMTALA is when a patient “Presents to the Emergency De...
EMTALA and Medical Control <ul><li>Normally, a patient in a non-hospital ambulance does not constitute coming to the ED </...
EMTALA and “Appropriate Transfer” <ul><li>An &quot;appropriate transfer&quot; (a transfer before stabilization which is le...
Principals of EMTALA  <ul><li>A patient may not be transferred to another facility if they are at risk to deteriorate from...
Principals of EMTALA <ul><li>The patient may not be transferred if they are unstable and remain at risk of deterioration  ...
EMTLA and Qualified Personnel <ul><li>EMTALA places the responsibility on the  transferring  hospital to ensure that the s...
EMTALA and OB transfers <ul><li>Most risky part of EMTALA covered transfers </li></ul><ul><li>Requires a medical screening...
What do I need for the Transfer?  <ul><li>Required paperwork includes: </li></ul><ul><ul><li>Statement that risks of trans...
EMTALA and “Diversion” <ul><li>DIVERSION is unstable ground.  </li></ul><ul><li>Generally speaking, in IFT, a hospital whi...
EMTALA and “parking” <ul><li>Patient parking occurs when  EMS  arrives with a  patient, but the hospital does not immediat...
Advanced Directives <ul><li>POST trumps all.  </li></ul><ul><li>Written Physician orders </li></ul><ul><li>Living Wills ha...
ADA Issues <ul><li>Occasionally we must deal with ADA recognized disability. When ity is safe and possible, we should (and...
<ul><li>The single most important question a paramedic has to answer when faced with an ethical, legal, or moral challenge...
Go out there and do  GREAT  Things…..
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MICP - Medico-legal aspects fo CCT, IFT, and SCT

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Focus Statement: This Module will introduce the participant to EMTALA, COBRA, medical direction, advance directives, and scope of practice issues particular to the transport environment.

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  • MICP - Medico-legal aspects fo CCT, IFT, and SCT

    1. 1. Medical Legal Considerations in IFT, CCT, and SCT Mobile Intensive Care Paramedic Series
    2. 2. Focus Statement <ul><li>Focus Statement: This Module will introduce the participant to EMTALA, COBRA, medical direction, advance directives, and scope of practice issues particular to the transport environment. </li></ul><ul><li>This lecture meets Section 2 of the Idaho EMS Critical Care Curricula Guide </li></ul>
    3. 3. Presentation Information <ul><li>Last revised 04/23/08 </li></ul><ul><li>For more information contact the education department </li></ul><ul><ul><li>208-287-2972 </li></ul></ul><ul><ul><li>[email_address] </li></ul></ul>
    4. 4. Striking a balance…
    5. 5. Laws/Regulation Affecting Critical Care <ul><li>Most are familiar from paramedic practice </li></ul><ul><ul><li>Mandatory reporting requirements </li></ul></ul><ul><ul><li>Negligence and medical liability </li></ul></ul><ul><ul><li>Confidentiality </li></ul></ul><ul><ul><li>Health Insurance Portability and Accountability Act (HIPAA) law </li></ul></ul><ul><ul><li>Defamation of character </li></ul></ul><ul><ul><li>Obtaining patient consent </li></ul></ul><ul><ul><li>Patient withdrawal of consent (refusal of care) </li></ul></ul><ul><ul><li>Advanced directives </li></ul></ul><ul><ul><li>Potential crime and/or accident scenes </li></ul></ul>
    6. 6. 4 Basic Concerns To Most Legal And Ethical Dilemmas <ul><li>Beneficence is the principle of doing good for the patient. </li></ul><ul><li>Nonmaleficence is the obligation not to harm the patient. </li></ul><ul><li>Autonomy is a competent adult patient’s right to determine what happens to his or her own body. </li></ul><ul><li>Justice refers to the obligation to treat all patients fairly. </li></ul>
    7. 7. Scope of Practice? <ul><li>“What makes you think you can do this?” </li></ul><ul><li>Currently, no national standard defining scope of Critical Care Scope </li></ul><ul><li>Paramedic scope normally defined by state </li></ul><ul><li>Modified by medical director </li></ul><ul><ul><li>More variability in CCT/SCT </li></ul></ul><ul><li>Concerns when crossed with Nursing Practice Acts </li></ul>
    8. 8. State Law <ul><li>States define scope of critical care paramedic’s practice </li></ul><ul><ul><li>EMS regulations </li></ul></ul><ul><ul><li>Medical Practice Act </li></ul></ul><ul><ul><ul><li>Governs the critical care paramedic’s practice of medicine </li></ul></ul></ul><ul><ul><ul><li>May also govern extent to which physician may delegate additional authority to the critical care paramedic </li></ul></ul></ul><ul><ul><li>Standards regarding certification/licensure </li></ul></ul><ul><ul><ul><li>Mechanism by which state regulates health care practice </li></ul></ul></ul><ul><ul><ul><li>Critical care paramedic is responsible for understanding limits of certification/licensure </li></ul></ul></ul>
    9. 9. Medical Director <ul><li>Critical care paramedic only permitted to provide care under auspices of physician medical director </li></ul><ul><ul><li>Methods </li></ul></ul><ul><ul><ul><li>Direct physician oversight via on line and off line medical control </li></ul></ul></ul><ul><li>Some systems put operational and clinical direction under the “nurse”, but this does not change scope. </li></ul><ul><li>Some systems do not differentiate. </li></ul>
    10. 10. COBRA and EMTALA <ul><li>COBRA passed in 1986 and updated periodically since. EMTALA is a sub-part of COBRA </li></ul><ul><li>Congress passed EMTALA to prevent hospitals from refusing to treat uninsured emergency patients or transferring them to another facility when they are medically unstable -- a practice known as patient dumping. </li></ul><ul><ul><li>This pertains to EMS because EMS was often used to provide the transportation during the “dumping”. </li></ul></ul><ul><ul><li>EMTALA violations happen every day </li></ul></ul><ul><li>Has grown into a complex, difficult to navigate, and sometimes poorly thought out regulations with big penalties. </li></ul>
    11. 11. EMTALA: “Coming to the Emergency Department” <ul><li>Key concept to EMTALA is when a patient “Presents to the Emergency Department/Hospital” </li></ul><ul><li>Pertains to EMS/SCT/CCT </li></ul><ul><ul><li>Parking Lot Calls </li></ul></ul><ul><ul><li>Helipads located on hospital property </li></ul></ul><ul><ul><li>Hospital Owned Ambulances </li></ul></ul><ul><ul><li>Medical Control Calls (discussed later) </li></ul></ul><ul><li>250 yard rule </li></ul><ul><li>Includes Stand alone ERs and clinics as well. </li></ul>
    12. 12. EMTALA and Medical Control <ul><li>Normally, a patient in a non-hospital ambulance does not constitute coming to the ED </li></ul><ul><ul><li>Exception for “hospital Based” ambulances, unless “integrated into the EMS system”. </li></ul></ul><ul><li>A 9 th Circuit Court decision in 2001 extends EMTALA to ambulances that are not hospital owned, when the ambulance makes contact via phone or radio for the purposes of speaking with a physician. . </li></ul><ul><ul><li>Counts as “presenting to the hospital” </li></ul></ul><ul><ul><li>Therefore involving a third party physician other than the transporting or receiving facilities increases the legal complexity exponentially. </li></ul></ul><ul><ul><li>Also calling a medical control for “CYA” regarding hospital destination may have unintended consequences. </li></ul></ul><ul><li>This is OPINION only and is somewhat contradictory to other regulations. </li></ul><ul><li>RECOMMENDATION: Only use physicians at accepting facilities except in unusual circumstances. </li></ul>
    13. 13. EMTALA and “Appropriate Transfer” <ul><li>An &quot;appropriate transfer&quot; (a transfer before stabilization which is legal under EMTALA) is one in which all of the following occur: </li></ul><ul><ul><li>Risk Benefit Assessment: </li></ul></ul><ul><ul><ul><li>The patient has been treated at the transferring hospital, and stabilized as far as possible within the limits of its capabilities; </li></ul></ul></ul><ul><ul><ul><li>The patient needs treatment at the receiving facility, and the medical risks of transferring him are outweighed by the medical benefits of the transfer; </li></ul></ul></ul><ul><ul><ul><li>This is certified in writing by a physician (Signature required); </li></ul></ul></ul><ul><ul><li>Continuity of Care </li></ul></ul><ul><ul><ul><li>The receiving hospital has been contacted and agrees to accept the transfer, and has the facilities to provide the necessary treatment to him; </li></ul></ul></ul><ul><ul><ul><li>The patient is accompanied by copies of his medical records from the transferring hospital; </li></ul></ul></ul><ul><ul><ul><li>The transfer is effected with the use of qualified personnel and transportation equipment, as required by the circumstances, including the use of necessary and medically appropriate life support measures during the transfer. </li></ul></ul></ul><ul><ul><ul><li>Any tests or other paperwork that becomes available after transport is begun must be forwarded to the receiving hospital. </li></ul></ul></ul>
    14. 14. Principals of EMTALA <ul><li>A patient may not be transferred to another facility if they are at risk to deteriorate from or during transfer </li></ul><ul><ul><li>Unless the current hospital cannot meet the needs of the patient. </li></ul></ul>
    15. 15. Principals of EMTALA <ul><li>The patient may not be transferred if they are unstable and remain at risk of deterioration unless the sending physician certifies in writing that the benefits to be obtained at the receiving hospital justify the risks of transfer . </li></ul>
    16. 16. EMTLA and Qualified Personnel <ul><li>EMTALA places the responsibility on the transferring hospital to ensure that the statute's requirements are met. </li></ul><ul><li>The statute requires that the patient be accompanied by &quot;qualified personnel and transportation equipment&quot; [Section 1395dd(c)(2)(D)] </li></ul><ul><ul><li>In some cases, this may be construed to mean that it must send its own personnel with the patient. </li></ul></ul><ul><ul><li>In other cases, simply meeting state licensing requirements is sufficient. </li></ul></ul><ul><ul><li>CCT training may meet the definition of qualification. </li></ul></ul><ul><ul><li>Appropriate equipment is also key. </li></ul></ul><ul><li>This is where SCT/CCT comes in to play. </li></ul>
    17. 17. EMTALA and OB transfers <ul><li>Most risky part of EMTALA covered transfers </li></ul><ul><li>Requires a medical screening and determination of “safe transfer”. </li></ul>
    18. 18. What do I need for the Transfer? <ul><li>Required paperwork includes: </li></ul><ul><ul><li>Statement that risks of transport do not outweigh anticipated benefits </li></ul></ul><ul><ul><ul><li>Signed by physician or Designee </li></ul></ul></ul><ul><ul><ul><li>The regulations add a requirement that the written certification contain an express summary of the risks and benefits upon which it is based [42 CFR 489.24(e)(1)(ii)(C)] </li></ul></ul></ul><ul><ul><ul><li>The statute provides that, if a physician is not physically present in the emergency room, the written certification in support of transfer may be signed by a &quot;qualified medical person&quot; in consultation with the physician, provided that the physician agrees with the certification and subsequently countersigns it. [42 USC 1395dd(c)(1)(iii)] </li></ul></ul></ul><ul><ul><li>Written request for transport by patient? </li></ul></ul><ul><ul><ul><li>No duress </li></ul></ul></ul><ul><ul><ul><li>Signed patient consent for transfer </li></ul></ul></ul><ul><ul><li>Documented acceptance by receiving facility </li></ul></ul><ul><ul><li>Patient medical Records and Diagnostic Images (X-Rays, CT, etc) </li></ul></ul><ul><ul><li>Medical orders documented for transporting team </li></ul></ul>
    19. 19. EMTALA and “Diversion” <ul><li>DIVERSION is unstable ground. </li></ul><ul><li>Generally speaking, in IFT, a hospital which has accepted a patient must continue to accept the patient even if it has since gone on diversion status. </li></ul><ul><li>Exception, physical hazard (such an on-site shooting or fire) </li></ul>
    20. 20. EMTALA and “parking” <ul><li>Patient parking occurs when EMS arrives with a patient, but the hospital does not immediately accept care. </li></ul><ul><ul><li>“ … Patient parking “may result in a violation of the Emergency Medical Treatment and Labor Act ( EMTALA ) and raises serious concerns for patient care and the provision of emergency services in a community.” </li></ul></ul><ul><ul><ul><ul><li>» Center for Medicare and Medicaid Services, Letter of July 2006 </li></ul></ul></ul></ul>
    21. 21. Advanced Directives <ul><li>POST trumps all. </li></ul><ul><li>Written Physician orders </li></ul><ul><li>Living Wills have more validity on IFT than pre-hospital, but still shaky. </li></ul><ul><li>Beware of unsigned “boxes” </li></ul>
    22. 22. ADA Issues <ul><li>Occasionally we must deal with ADA recognized disability. When ity is safe and possible, we should (and are legally obligated to) make reasonable accommodations. Examples include </li></ul><ul><ul><li>Hearing impaired </li></ul></ul><ul><ul><li>Vision Impaired </li></ul></ul><ul><ul><li>Developmentally Impaired </li></ul></ul><ul><ul><li>Many others…. </li></ul></ul>
    23. 23. <ul><li>The single most important question a paramedic has to answer when faced with an ethical, legal, or moral challenge is: </li></ul>WHAT IS IN THE PATIENT’S BEST INTEREST?
    24. 24. Go out there and do GREAT Things…..

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