Portal de Periódicos da CAPES

CMS Warns EDs

2006; Lippincott Williams & Wilkins; Volume: 28; Issue: 12 Linguagem: Inglês

10.1097/01.eem.0000288893.89044.96

1552-3624

Ruth SoRelle,

Economic, financial, and policy analysis

The federal Centers for Medicare & Medicaid Services has warned the nation's hospitals that parking ambulance patients is “not a solution” to the crowding plaguing emergency departments and warned that leaving patients on EMS stretchers for long periods could violate the Emergency Medical Treatment and Labor Act (EMTALA). In a letter issued July 13, 2006, Thomas E. Hamilton, the director of the CMS Survey and Certification Group, told State Survey Agency Directors that parking patients transported by ambulance adversely affects the ability of EMS personnel to provide care to the rest of the community. He added that hospitals which routinely prevent EMS staff from transferring patients from ambulance stretchers to hospital beds mistakenly believe the hospital is not obligated to care for the patient until the staff takes responsibility by formalizing the transfer. Not only does this possibly violate EMTALA, Mr. Hamilton said, it also may violate a regulation for hospital participation in emergency services. He noted that the hospital's EMTALA obligation begins when the patient arrives at the emergency department or on hospital property and a request is made that the patient receive treatment for an emergency condition. Parking patients, refusing to release EMS equipment, and expecting EMS personnel to supervise care for the patient in the ED “jeopardizes patient health,” he wrote. Frederick Blum, MD, the president of the American College of Emergency Physicians, said CMS was engaging in “a bit of magical thinking.” “They want you to quickly offload patients,” he said. “What if you have no beds? No beds sometimes means no beds. If you don't have a gurney to put someone on, what do you do?Figure“Many times we don't have a bed to put people in, and we may put a bed in the hallway. That's a way to get around that issue. But sometimes we physically don't have a bed at all. It's an easy directive to make. It's a harder directive to follow if you don't have the resources to follow it or the people to do it,” Dr. Blum said. While he acknowledged EMS's perspective, he said he “can't make a bed, a room, or a nurse materialize if I don't have them.” Capacity Concerns He said the parking issue is a reflection of what emergency medicine has been “screaming” about for years — capacity. “To me, it [this letter] is akin to telling the American public not to get sick. There's a problem with too many sick people in the ED, so don't get sick. There's a space problem in the ED, so the ambulance stretchers can't be unloaded. So unload them anyway. Where are we going to put them? Certainly, in most emergency departments, people don't let ambulance patients lie on stretchers if there is no way around it,” Dr. Blum said. This is not the first time this problem has surfaced, said Robert Bass, MD, the president of the National Association of EMS Physicians and the executive director of the Maryland Institute of EMS Systems. Two regional CMS directors previously issued directives about patient parking, and he said it is a major concern in Maryland and around the country. Like Dr. Blum, he sees it as a part of chain reaction stemming from a capacity problem. “The hospital gets full, and then the patient in the ED who needs admission is boarded there. EMS comes in with a patient, and there is no place to unload that patient and no hospital staff because they are taking care of patients who need to be in the ICU. The problem this causes for EMS is that EMS then has to wait until they can unload the patient. That can take two to two and a half hours at times in our state.” The city's health commissioner recently convened a forum to examine the issue in Baltimore, said Dr. Bass. “Their ambulances were so tied up that they were running out of ambulances to respond,” he said. “We … set up a reverse alert system. When EMS starts to get short of units, we let hospitals know so they can do their best to free up units.” Comments about this article? Write to EMN at [email protected].