BILL ANALYSIS Ó SB 630 Page 1 SENATE THIRD READING SB 630 (Alquist) As Amended January 18, 2012 2/3 vote. Urgency SENATE VOTE : 36-0 HEALTH 19-0 APPROPRIATIONS 17-0 ----------------------------------------------------------------- |Ayes:|Monning, Logue, Ammiano, |Ayes:|Fuentes, Harkey, | | |Atkins, Bonilla, Eng, | |Blumenfield, Bradford, | | |Garrick, Gordon, Hayashi, | |Charles Calderon, Campos, | | |Roger Hernández, | |Davis, Donnelly, Gatto, | | |Bonnie Lowenthal, | |Hall, Hill, Lara, | | |Mansoor, Mitchell, | |Mitchell, Nielsen, Norby, | | |Nestande, Pan, | |Solorio, Wagner | | |V. Manuel Pérez, Silva, | | | | |Smyth, Williams | | | | | | | | ----------------------------------------------------------------- SUMMARY : Permits Stanford Hospital and Clinics (SHC) and Lucile Packard Children's Hospital at Stanford (LPCH), for the purposes of providing emergency services and care to patients with conditions related to active labor presenting in the emergency department (ED) of SHC, to be treated as a single licensed facility if the two hospitals have entered into a specified agreement. Specifically, this bill : 1)Permits, SHC and LPCH to be treated as a single licensed facility for purposes of providing emergency services and care to patients with conditions related to active labor presenting to the ED at SHC if all of the following conditions are met: a) The two hospitals have entered into an agreement in which LPCH accepts and provides emergency services and care to all patients who are in active labor presenting to the ED at SHC, without regard to insurance status, financial status, or other nonclincal factors; b) A physician and surgeon, qualified ED registered nurse, or other appropriately licensed personnel under the supervision of a physician and surgeon determines, prior to the transfer, that the patient has signs or symptoms, or both, suggestive of active labor, the patient can be safely transferred from the ED SB 630 Page 2 at SHC to the Labor and Delivery unit of LPCH, and the patient does not have a condition, illness, or injury more appropriately treated in the ED; c) The patient has the right to refuse the transfer; and, d) Each hospital has a prepared plan to promptly transport the patient with an employee escort who has specialized training in transporting women in labor. 2)Makes findings and declarations regarding the unique circumstances of SHC and LPCH and the justification regarding the need for a special law. 3)Contains an urgency clause that will make this bill effective immediately upon enactment. EXISTING LAW : 1)Provides for the licensure of health facilities, including general acute care hospitals, by the Department of Public Health (DPH). 2)Establishes the federal Emergency Medical Treatment and Active Labor Act (EMTALA), which governs when and how a patient may be refused treatment or transferred from one hospital to another when the patient is in an unstable medical condition. 3)Prohibits the transfer of a person needing emergency services and care from one hospital to another for any nonmedical reason, unless specified conditions are met, including that the person is examined and evaluated by a physician. 4)Defines "emergency services and care" as requiring screening, examination, and evaluation by a physician to determine if active labor exists, and if it does, the care, treatment, and surgery by a physician necessary to relieve or eliminate the emergency medical condition. 5)Defines "active labor" to mean labor in which there is either inadequate time to safely transfer to another hospital prior to delivery or a transfer may pose a threat to the health and safety of the patient or the unborn child. SB 630 Page 3 FISCAL EFFECT : According to the Assembly Appropriations Committee, negligible state costs. COMMENTS : According to the author, this bill is a narrowly tailored patient safety bill to help expectant mothers obtain optimal care when they arrive in active labor at SHC's ED. SHC, which is physically connected via an interior hallway to LPCH, has an ED but does not have a Labor and Delivery unit, so it uses LPCH's Labor and Delivery unit, which is approximately 600 feet away. The author maintains that, unfortunately, existing law, while well intended, requires an expectant mother who arrives at SHC's ED to be subjected to a full medical screening by a physician before she can be transferred to the dedicated Labor and Delivery unit at LPCH. This screening and coordination of SHC and LPCH physicians can delay optimal care for the expectant mother and child by up to 90 minutes. This bill, the author argues, will improve the safety of patient's in active labor who arrive at SHC's ED by speeding up the transfer process for patients from SHC's ED to LPCH. According to SHC, SHC and LPCH are separately licensed and accredited acute care hospitals located in Palo Alto, California on the campus of Stanford University. The main inpatient facilities of the two hospitals are located in the same hospital building. While each hospital has a dedicated main entrance, internal corridors in the building connect the two hospitals, allowing easy access by patients, visitors, and personnel at both facilities. According to SHC, SHC maintains an ED that meets the definition of a "dedicated ED" under federal EMTALA obligations. However, SHC does not provide labor and delivery, post-partum, newborn nursery, or neonatal intensive care services. Alternatively, LPCH does not maintain a basic ED, or hold out the provision of a "dedicated ED" for pediatric emergency services. Instead, SHC and LPCH have coordinated providing pediatric emergency services in the SHC ED. SHC and LPCH have developed a Memorandum of Understanding (MOU) that expresses the terms and conditions under which laboring patients that present to the SHC ED will be transferred to the LPCH Labor and Delivery unit. The MOU would apply to all pregnant patients estimated to be 20 weeks of gestation or greater and requires an initial triage assessment by a qualified ED registered nurse to determine if the patient: a) has signs and/or symptoms suggestive of active labor; b) can be safely transported from the ED to the Labor and Delivery unit; and, c) is not suffering from a condition, illness or injury more appropriately treated with the ED. The MOU states LPCH agrees to accept all pregnant patients without SB 630 Page 4 discriminating against any patient on the basis of payor type or other non-clinical factor. According to a letter dated April 27, 2011, from the federal Centers for Medicare and Medicaid Services (CMS), CMS has found the MOU between SHC and LPCH appear to pose no negative outcome to beneficiaries and no potential violation of EMTALA. The letter indicated, however, that SHC and LPCH were also licensed by DPH and DPH might have regulations which could conflict with the hospitals' proposed joint facility transfer procedure. The letter instructed that the hospitals contact DPH directly to assess compliance with state regulations. On June 29, 2011, DPH communicated to SHC that the department had reviewed the MOU and determined that it did not meet the requirements established under current state law. Specifically, DPH found that current law requires screening, examination, and evaluation by a physician prior to any transfer from the ED. The MOU agreement requires a triage assessment by a qualified ED registered nurse, but not a physician. EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986 and requires hospitals to provide care to anyone needing emergency health care treatment regardless of citizenship, legal status or ability to pay. Hospitals may only transfer or discharge patients needing emergency treatment under their own informed consent, after stabilization, or when their condition requires transfer to a hospital better equipped to administer the treatment. Congress passed EMTALA to combat the practice of "patient dumping," i.e., refusal to treat people because of inability to pay or insufficient insurance, or transferring or discharging emergency patients on the basis of high anticipated diagnosis and treatment costs. EMTALA allows an on-call physician, under hospital policies, the option of sending a representative, such as a non-physician practitioner or his or her representative to appear at the hospital and provide further assessment or stabilizing treatment to an individual. According to EMTALA, this determination should be based on the individual's medical need, the capacities of the hospital, the applicable state's scope of practice laws, and the hospital bylaws and rules and regulations. The designated on-call physician is ultimately responsible for providing the necessary services to the individual regardless of who makes the in-person appearance. SB 630 Page 5 SHC and LPCH both write in support that this bill will provide statutory language to allow SHC and LPCH to implement a MOU to enable the two hospitals to be treated as a single consolidated license solely for women presenting to the SHC ED with labor-related conditions. SHC maintains that from September 1, 2010, to August 31, 2011, an average of 23 women per month were delayed in the SHC's ED on average for 54 minutes before they could be transferred to LPCH's Labor and Deliver unit. The hospitals explain that they have cooperated to encourage women with labor-related conditions to go directly to LPCH, but many women present to the SHC ED. SHC asserts that in most hospitals that provide emergency and obstetric services, women presenting to the ED are re-directed to the Labor and Delivery unit for examination and labor-related services. This bill ensures that expectant mothers and their unborn children can receive prompt and appropriate care eliminating undesirable delays Analysis Prepared by : Tanya Robinson-Taylor / HEALTH / (916) 319-2097 FN: 0003750