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Dr. Looney's recommendation to presume that EMTALA still applies to "scheduled patients" is sound advice.  In 2003, CMS issued new EMTALA regulations that addressed a number of related issues such as:  which acute care facilities qualify as "dedicated emergency departments" under EMTALA; what are the EMTALA screening requirements for patients who present with non-emergency conditions; and how do screening requirements differ when the patient presents to the ED rather than elsewhere on the hospital campus.  These regulations are reviewed in:  Clearing the Fog (A Bit):  The 2003 EMTALA Regulations and Their Implications for Pediatric Emergency Departments.  Pediatr Emerg Care 2004;20(8):536-539.

William M. McDonnell, MD, JD
Division of Pediatric Emergency Medicine
Adjunct Professor of Law
University of Utah
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-----Original Message-----
From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Darrell Looney
Sent: Monday, November 07, 2011 8:42 AM
To: [log in to unmask]
Subject: Re: Appointments in the ED

Whether or not patients are "scheduled" to arrive at your acute care facility (Clinic, Office, Surgicenter, etc.), I believe EMTALA would still apply. Prudent administrations would operate under the assumption this is the case.
My personal concern is one much broader in scope. That is, with society's trend towards "doing more with less", I have sincere reservations about "ED Appointments" because they represent a further erosion of the practice of Emergency Medicine. The focus of the Emergentologist is the treatment and stabilization of urgent and Emergent conditions. Currently, that role has been redefined by society to be one of a glorified 24 hour clinic but with the benefit of Critical/Trauma Care capabilities attached. The next step in the evolutionary process must span the obvious gap created by patients expecting to be seen at a specific time, juxtapositioned against nonurgent, urgent and Emergent patient presentations - who gets seen first? How will acuity affect that decision process? Each appointment then becomes a liability and an impediment to the flow of delivered care in the ED. An untenable situation at best without significant numbers of additional staff at hand. 
DGLooney, MD, FACEP, FAAEM

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> Date: Mon, 7 Nov 2011 03:10:29 -0600
> From: [log in to unmask]
> Subject: Re: Appointments in the ED
> To: [log in to unmask]
> 
> Out hospital system has just announced that this service will be offered.
> 
> In addition to the concerns expressed by Ernie, I have these additional
> concerns:
> 
> 1) Approximately 55% of our patients are ESI Level 4 and 5. This means that
> if we could figure out a way to implement this, we would have to make
> available "appointments" to more than 25,000 patient visits/year.
> 
> 2) Our population is approximately 70% Medicaid/Medicaid HMO. I am
> concerned that "scheduling appointments" will give the states just the
> excuse they need to decrease reimbursements to Hospitals for ED visits.  In
> other words, why should insurance companies pay ED fees for non-emergent
> patients who have "scheduled" appointments?
> 
> I would appreciate hearing your thoughts regarding the scheduling
> "appointments" for pediatric patients in Emergency Departments.
> 
> Thanks,
> 
> Bob Flood
> Division Director, Cardinal Glennon Children's Medical Center
> St. Louis, MO
> 
> On Tue, Sep 20, 2011 at 7:46 AM, Ernest Bertha <[log in to unmask]>wrote:
> 
> > Just a thought as I am reviewing some CME.... If patients make an
> > appointment in the ED, is the hospital and the ED doc still responsible
> > under EMTALA?  Obviously, if it is an appointment, no emergency medical
> > condition exists and therefore a MSE isn't required.  Just wondering how
> > this might/will affect this type of care in the ED?
> >
> > Ernie
> >
> > Ernest G. Bertha, MD, MBA, CPE, FAAP
> > Chief Medical Officer, Pediatric Services
> > Sheridan Healthcare Services, Inc.
> > 1613 North Harrison Parkway
> > Suite 200, SH-10
> > Sunrise, Florida 33323
> > 954-838-2746 (Direct & Voice Mail)
> > 954-858-0100 (FAX)
> > [log in to unmask]<mailto:[log in to unmask]>
> >
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