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Policies,Clinical,UW Health Clinical,Emergency Response/Management

Emergency Assessment at UW Health Facilities (5.1.1)

Emergency Assessment at UW Health Facilities (5.1.1) - Policies, Clinical, UW Health Clinical, Emergency Response/Management

5.1.1


UW HEALTH CLINICAL POLICY 1
Policy Title: Emergency Assessment at UW Health Facilities
Policy Number: 5.1.1
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: October 19, 2015

I. PURPOSE

To assure that patients requesting services for emergency medical conditions at UW Health locations,
including: University Hospital (600 Highland Avenue), American Family Children’s Hospital (AFCH) and The
American Center (TAC) receive appropriate medical screening examinations or appraisals and referrals for
emergency medical services as required.

II. DEFINITIONS

A. An "emergency medical condition" is defined in EMTALA (Emergency Medical Treatment and Active Labor
Act) as a medical condition manifesting itself by acute symptoms of suff icient severity (including severe pain,
psychiatric disturbances and/or symptoms of substance abuse) such that absence of immediate medical
attention could reasonably be expected to result in:
i. Placing the patient's health (or, w ith respect to a pregnant w oman, the health of the w oman or her
unborn child) in serious jeopardy.
ii. Serious impairment to bodily functions.
iii. Serious dysfunction of any body organ or parts.
iv. An "emergency medical condition" w ith respect to a pregnant w oman w ho is having contractions
means:
a. That there is inadequate time to effect a safe transfer to another hospital before delivery;
or
b. That transfer may pose a threat to the health or safety of the w oman or the unborn child.
B. "Stabilized" means, w ith respect to an emergency medical condition, that no material deterioration of the
condition is likely (w ithin reasonable medical probability) to result from or during the transfer.
C. "Medical Screening Examiner" is a Physician or a Physician Assistant, Nurse Practitioner or Registered
Nurse w ho has received training in the performance of a medical screening exam.
D. "Transport" is the movement of a patient from a UW Health facility to a UW Health Emergency Department
(ED) or another facility that provides emergency medical services.
E. An "appropriate transfer" is one in w hich:
i. The transferring hospital provides medical treatment w ithin its capacity that minimizes the risks to
the individual's health, and, in the case of a w oman in labor, the health of the unborn child;
ii. The receiving facility:
a. Has available space and qualif ied personnel for the patient's treatment; and
b. Has agreed to accept the patient transfer and to provide appropriate medical treatment.
iii. The transferring hospital sends to the receiving facility all medical records (or copies thereof)
related to the emergency condition w hich the individual has presented that are available at the time
of the transfer, including available history, records related to the individual's emergency medical
condition, observations of signs or symptoms, preliminary diagnosis, results of diagnostic studies or
telephone reports of the studies, treatment provided, results of any tests and the informed w ritten
consent or certif ication (or copy thereof), if required, and the name and address of any on-call
physician w ho has refused or failed to appear w ithin a reasonable time to provide necessary
stabilizing treatment. Other relevant records not available at the time of transfer must be sent as
soon as practicable after transfer; and
iv. The transfer is effected through qualif ied personnel and transportation equipment, including the use
of necessary and medically appropriate life support measures during the transfer. The term
"transfer" does not include the movement of a patient w ho has been declared dead or w ho leaves
UW Health w ithout the permission of any employee or of persons aff iliated or associated w ith UW
Health. When a patient leaves w ithout permission, staff should seek to obtain the patient's
signature on the "Left Without Being Seen or Against Medical Advice" forms (# UWH 335). When a
patient leaves w ithout signing the form, the circumstances should be documented in the patient's
record.

III. POLICY ELEMENTS




UW HEALTH CLINICAL POLICY 2
Policy Title: Emergency Assessment at UW Health Facilities
Policy Number: 5.1.1

A. PATIENT REQUESTS EMERGENCY MEDICAL TREATMENT AT UW HEALTH EMERGENCY
DEPARTMENT OR AT SITES IN EMERGENCY RESPONSE ZONES 1 OR 2 AS DETAILED ON THE
ATTACHED MAP.
i. If a patient presents to a UW Health Emergency Department; either at the University Hospital,
American Family Children’s Hospital (AFCH)) or at the American Center (TAC) or to any location
w ithin Zones 1 or 2 on the tw o attached maps, staff must:
a. Provide an appropriate medical screening examination or arrange to provide an
appropriate medical screening examination by calling 911 to transport the patient to a UW
Health emergency department; and either:
1. Provide necessary stabilizing treatment if it is determined from the medical
screening examination that an emergency exists; or
2. Provide for an "appropriate transfer" to another facility
b. The above also applies if an individual requests services on behalf of another individual,
or if an individual presents, is unable to communicate, but a layperson w ould believe or
assume that the individual needed emergency medical attention.
ii. Staff w ill not delay a required medical screening examination or required stabilizing treatment to
inquire about the person's method of payment or insurance status.
iii. The screening and stabilizing or transfer requirements do not apply to:
a. Individuals seen in University Hospital and TAC outpatient clinics for regularly scheduled
visits if their treatment encounter has begun.
b. Inpatients.
iv. The stabilization and transfer requirements do not apply:
a. If it is documented that there is not an emergency medical condition.
b. If the patient is admitted to the hospital.
v. The transfer requirements do not apply during a national emergency.
B. UW HEALTH FACILITIES NOT IN ZONES 1 OR 2.
If a patient requests services for an emergency medical condition at UW Health facilities not in Zones 1 or 2,
staff is required to appraise w hether a patient needs emergency services and call 911 as appropriate. The
above also applies if an individual requests services on behalf of another individual, or if an individual
presents, is unable to communicate, but a lay person w ould believe or assume that the individual needed
emergency medical attention.
C. FACILITIES THAT ARE NOT OWNED OR OPERATED BY UW HEALTH are not subject to this policy.
Examples of this category include all Clinical Joint Ventures.

IV. PROCEDURE

A. PATIENT PRESENTS TO UW HEALTH EMERGENCY DEPARTMENT
i. General
a. All patients presenting to a UW Health Emergency Department requesting emergency
medical treatment or w ho are in active labor, or w ho evidence signs of needing
emergency medical treatment w ill receive a medical screening examination. The
emergency medical screening examination in the ED w ill be completed by a physician
unless the senior attending physician in the ED or the administrator on call determines
that under the circumstances other medical screening examiners may be used.
b. If it is documented that there is no emergency medical condition, then this policy shall not
further apply to the case.
c. If the emergency screening examination determines that there is an emergency medical
condition, UW Health w ill provide, w ith the staff and facilities available at UW Health, such
further medical examination and treatment as may be required to stabilize the medical
condition.
ii. Obstetrical Cases
Since UW Health does not have an obstetric delivery unit, patients in active labor w ill usually need
to be transferred to another facility for treatment. These patients are usually transferred to Meriter
Hospital or St. Marys Hospital. Such transfer may occur only after the patient has received an
appropriate medical screening at UW Health to determine w hether or not an emergency medical
condition exists, the receiving hospital has agreed to accept the transfer, and the appropriate
documentation and arrangements for transfer have been completed (see II.E.).
a. A pregnant w oman w ho is having contractions is defined to have an emergency medical



UW HEALTH CLINICAL POLICY 3
Policy Title: Emergency Assessment at UW Health Facilities
Policy Number: 5.1.1

condition w hen there is inadequate time to effect a safe transfer to another hospital before
delivery or that transfer may pose a threat to the health or safety of the w oman or the
unborn child.
b. When obstetrical patients seek transfer to a facility other than Meriter Hospital or St.
Marys Hospital, arrangements for such a transfer can be made w hen either:
1. A UW Health physician determines the patient does not have an emergency
medical condition as defined above, or
2. The patient signs the "Patient's Request/Refusal/Consent to Transfer" form.
Arrangements for such transfers must include all of the items listed under II.E.
except for medical treatment that had been refused by the patient.
iii. Transfers
a. If a transfer is required, it w ill occur only after the procedures required for an appropriate
transfer (see section II.E.) have been completed.
b. If a patient is transported to the ED to be evaluated, the patient w ill be transferred to
another hospital only after the patient has received appropriate medical screening at UW
Health and has been (a) determined not to have an emergency medical condition or (b)
stabilized (unless one of the exceptions to the requirement of stabilization in the next
sentence applies). Transfer may take place before the patient is stabilized if the patient
requests in w riting transfer to a non-UW Health facility (after being informed of the
hospital's obligation under EMTALA and the risks of such transfer) or a physician certif ies
that the medical benefits of the transfer outw eigh the risks.
c. If the patient (w ho has decisional capacity), patient’s guardian or a responsible family
member/healthcare pow er of attorney (POA) acting on the patient's behalf (if patient does
not have capacity), requests transfer prior to medical stabilization of the patient's
condition, an attempt should be made to persuade the patient or family member to w ait for
transfer until stabilization has occurred. If he or she refuses to w ait, an appropriate
transfer as defined in section II.E. may occur, but only after authorization by an ED
physician and after risks to the patient have been explained by the physicians to the
patient or responsible family member and appropriate forms are completed and signed.
d. If (a) the transfer request is by someone other than a patient w ith decisional capacity and
(b) carrying out the request appears to constitute abuse or neglect of the patient or is
contrary to the know n prior instructions of the patient w hile w ith decisional capacity, the
physician may disregard the instructions and provide immediate emergency care for the
patient under the emergency doctrine. When time permits consistent w ith preserving the
life of the patient and minimizing the risk of permanent injury, the physician may consult
the attorney-on-call through the paging operator for assistance in determining w hether
legal steps are w arranted. If not consulted at the time of treatment, the General Counsel's
Office (or attorney on call) should be notif ied by the next day w henever a transfer request
has been disregarded.
e. Any other patient w ho in the judgment of the ED physician cannot receive necessary care
at UW Health, or w ho requests (or w hose responsible family member requests) transfer,
may be transferred to another appropriate institution only after all the risks have been
explained to the patient or responsible family member.
iv. Charges
a. Persons w ho receive medical care in the ED or clinic and are subsequently transferred or
transported should receive UW Health customary charges.
B. PATIENT PRESENTS IN ZONES 1 OR 2 (OTHER THAN IN THE EMERGENCY DEPARTMENT).
i. Patients presenting in Zones 1 or 2, requesting or requiring emergency treatment, or appearing to
need emergency services, w ill be transported to a UW Health Emergency Department either by
internal movement or by calling 911 and the procedures under IV.A. w ill be follow ed. A UW Health
staff member must stay w ith the patient until EMS arrives. If applicable, w hen the patient is
inappropriate to move, the appropriate emergency response team (e.g., Code Blue, Stroke Code,
etc.) may be called to the location. When the area w here the request arises has a physician w ho
w ill provide the emergency medical screening, the physician may do so. Typically if an emergency
medical condition is found, the patient w ill then be transported to the ED. How ever, a physician
may make the determination that the patient needs to be sent directly to another location in the
hospital for services (e.g., operating room, radiology).
ii. Transfers to other facilities should be made only in consultation w ith the ED to assure that all of the



UW HEALTH CLINICAL POLICY 4
Policy Title: Emergency Assessment at UW Health Facilities
Policy Number: 5.1.1

required arrangements have been met.
iii. When it is documented that there is no emergency medical condition or that the patient has been
stabilized, then this policy shall not further apply to the case.
iv. UW Health Outpatient request for medical services/hand-off communication tool (# UWHC
4005825) must be used to document services rendered if an individual requests emergency
medical services or appears to need emergency medical services at these sites.
C. PATIENT PRESENTS TO UW HEALTH FACILITIES THAT ARE OUTSIDE ZONES 1 OR 2.
UW Health is not required to provide a medical screening examination and stabilizing treatment to patients
w ho present at UW Health ow ned or controlled facilities more than 250 yards from the University Hospital,
AFCH, or TAC. How ever, UW Health staff in those facilities must, at minimum, be able to appraise w hether
a patient needs emergency medical services and call 911. The follow ing should be implemented in those
offsite facilities:
i. Making appraisal of and referral for emergency medical services. Staff responding to requests for
emergency treatment (or w hen it appears that an individual needs emergency treatment) at an
offsite facility must provide any basic health care they may be trained to provide and call 911 to
arrange transportation to a facility that provides emergency medical services. Staff must stay w ith
the individual until EMS arrives.
ii. Making determination that the individual does not need emergency medical services. Only
physicians, nurse practitioners, physician assistants, certif ied nurse midw ives (CNM), and
registered nurses are permitted to make a determination that a patient does not need emergency
medical services. In all other cases, transportation to a facility that provides emergency services
should be made unless the patient refuses transportation.
iii. Patient refuses transportation to a facility that provides emergency medical services. Staff must
document in a Health Link encounter if a patient w ho requests or appears to need emergency
medical services, refuses transportation to a facility that provides emergency medical services.
iv. All requests and responses for emergency services or incidents in w hich a patient appears to need
emergency medical services at an offsite UW Health facility must be documented in Health Link. If
Health Link is not available, an approved hand off communication tool can be used (UWHC form
#4005825).
v. Communication from off site facilities to receiving facilities must follow the approved hand-off
communication process (refer to UW Health policy #3.3.1 Hand-Off Communication) as soon as
possible prior to or after transport.

V. FORMS

-Patient's Request/Refusal/Consent to Transfer # UWH 4002775
-Physical Assessment and Certif ication # UWH 4002776
-Outpatient request for medical services/hand-off communication tool # UWHC 4005825
-Discharge Against Advice # UWH 335


VI. COORDINATION

Author(s): Director, HVT; Director, Risk Management
Senior Management Sponsor: SVP, Patient Care Services and CNO
Review ers: Director, Compliance
Approval committees: Resuscitation Review Committee; UW Health Clinical Policy Committee; Medical
Board
UW Health Clinical Policy Committee Approval: August 17, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.

VII. APPROVAL




UW HEALTH CLINICAL POLICY 5
Policy Title: Emergency Assessment at UW Health Facilities
Policy Number: 5.1.1

Peter New comer, MD
UW Health Chief Medical Officer

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

VIII. REFERENCES

-42 U.S.C. s 1395dd (COBRA-EMTALA anti-dumping requirements)
-UW Health Clinical Policy #3.3.1, Hand-Off Communication

IX. REVIEW DETAILS
Version: Revision
Next Revision Due: February 19, 2018
Formerly Know n as: Hospital Administrative policy #7.12