BILL ANALYSIS                                                                                                                                                                                                    Ó



                                                                SB 630
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        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        
         
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        |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 








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             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.









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         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 








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        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.









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        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