EMTALA Policies

Three EMTALA policies have recently been reviewed by our Medical Executive Committee and approved by the Board of Trustees:

These policies apply to all patients and visitors and establish that we are responsible to provide a medical screening exam and stabilize. It is important to note that on page 8 of the Medical Screening policy, EC-EMTALA Medical Screening-002, there is a specific reference to Behavioral health patients that states the Emergency Department provider is the primary physician until the patient is physically on the Behavioral health unit. Policy EC-EMTALA Transfer-001 speaks to the transferring of patients. Please note that nursing supervisors are always available to help facilitate if you need assistance transferring. When accepting transfers, please utilize the Transfer Center and ensure that there is approval from the Administrator on Call (AOC) or nursing supervisor before accepting. The policy LL-EM-001-EMTALA Definitions-MEC is a company-wide policy; it is important to note physicians “on call” obligations on page 13. Page 14 of this policy also references the Transfer Center. Note that the center will not make the decision on behalf of the hospital to accept incoming/outgoing transfers; that decision will be made by the Administrator on Call, who will speak with the physician(s) and other parties involved to determine what is needed for the best patient care. If you have urgent legal questions, please contact the AOC as well.


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