Texas Administrative Code
Title 25 - HEALTH SERVICES
Part 1 - DEPARTMENT OF STATE HEALTH SERVICES
Chapter 133 - HOSPITAL LICENSING
Subchapter C - OPERATIONAL REQUIREMENTS
Section 133.44 - Hospital Patient Transfer Policy
Universal Citation: 25 TX Admin Code ยง 133.44
Current through Reg. 49, No. 38; September 20, 2024
(a) Definitions.
(1) Designated provider--A
provider of health care services, selected by a health maintenance
organization, a self-insured business corporation, a beneficial society, the
Veterans Administration, CHAMPUS, a business corporation, an employee
organization, a county, a public hospital, a hospital district, or any other
entity to provide health care services to a patient with whom the entity has a
contractual, statutory, or regulatory relationship that creates an obligation
for the entity to provide the services to the patient.
(2) Mandated provider--A person who provides
health care services, is selected by a county, public hospital, or hospital
district, and agrees to provide health care services to eligible
residents.
(b) General.
(1) The governing body of each hospital shall
adopt, implement, and enforce a policy relating to patient transfers that is
consistent with this section and contains each of the requirements in
subsection (c) of this section. The policies shall identify hospital staff who
have the authority to represent the hospital and the physician with regard to
the transfer from or receipt of patients into the hospital.
(2) The transfer policy shall be adopted by
the governing body of the hospital after consultation with the medical staff
and shall apply to transfers between hospitals licensed under the Health and
Safety Code, Chapters 241 and 577, as well as transfers to hospitals which are
exempt from licensing.
(3) The
policy shall govern transfers not covered by a transfer agreement.
(4) The movement of a stable patient from a
hospital to another hospital is not considered to be a transfer under this
section if it is the understanding and intent of both hospitals that the
patient is going to the second hospital only for tests, the patient will not
remain overnight at the second hospital, and the patient will return to the
first hospital. This paragraph applies only when a patient remains stable
during transport to and from hospitals and during testing.
(5) The hospital's transfer policy shall
include a written operational plan to provide for patient transfer
transportation services if the hospital does not provide its own patient
transfer transportation services.
(6) If possible, each governing body, after
consultation with the medical staff, shall implement its transfer policy by
adopting transfer agreements with other hospitals in accordance with §
133.61
of this title (relating to Hospital Patient Transfer Agreements).
(7) A public hospital or a hospital district
shall accept the transfer of its eligible residents if the public hospital or
hospital district has appropriate facilities, services, and staff available for
providing care to the patient.
(8)
The hospital's policy shall recognize and comply with the requirements of the
Indigent Health Care and Treatment Act, Health and Safety Code (HSC),
§§61.030 - 61.032 and §§61.057 - 61.059 (Mandated
Providers) since those requirements may apply to a patient.
(9) The hospital's policy shall acknowledge
contractual obligations and comply with statutory or regulatory obligations
which may exist concerning a patient and a designated provider.
(10) The hospital's policy shall require that
all reasonable steps are taken to secure the written informed consent of a
patient, or of a person acting on a patient's behalf, when refusing a transfer
or related examination and treatment. Reasonable steps include:
(A) a factual explanation of the increased
medical risks to the patient reasonably expected from not being transferred,
examined, or treated at the transferring hospital;
(B) a factual explanation of any increased
risks to the patient from not effecting the transfer; and
(C) a factual explanation of the medical
benefits reasonably expected from the provision of appropriate treatment at
another hospital.
(D) The informed
refusal of a patient, or of a person acting on a patient's behalf, to
examination, evaluation or transfer shall be documented and signed if possible
by the patient or by a person acting on the patient's behalf, dated and
witnessed by the attending physician or hospital employee, and placed in the
patient's medical record.
(11) The hospital's policy shall recognize
the right of an individual to request a transfer into the care of a physician
and a hospital of the individual's own choosing.
(12) Transfer of patients may occur routinely
or as part of a regionalized plan for obtaining optimal care for patients at a
more appropriate or specialized facility.
(c) Requirements for transfer of patients between hospitals.
(1) Discrimination. Except
as is specifically provided in subsection (b)(8) and (9) of this section,
relating, respectively, to mandated providers and designated providers, the
hospital policy shall provide that the transfer of a patient may not be
predicated upon arbitrary, capricious, or unreasonable discrimination based
upon race, religion, national origin, age, sex, physical condition, economic
status, insurance status or ability to pay.
(2) Disclosure. The hospital's policy shall
recognize the right of an individual to request transfer into the care of a
physician and a hospital of his own choosing; however, if a patient requests or
consents to transfer for economic reasons and the patient's choice is
predicated upon or influenced by representations made by the transferring
physician or hospital administration regarding the availability of medical care
and hospital services at a reduced cost or no cost to the patient, the
physician or hospital administration shall fully disclose to the patient the
eligibility requirements established by the patient's chosen physician or
hospital.
(3) Patient. A patient is
an individual:
(A) seeking medical treatment
who may or may not be under the immediate supervision of a personal attending
physician, has one or more undiagnosed or diagnosed medical conditions, and
who, within reasonable medical probability, requires immediate or continuing
hospital services and medical care; or
(B) admitted to the hospital as a
patient.
(4) Patient
evaluation. The hospital's policy shall provide that each patient who arrives
at the hospital is:
(A) evaluated by a
physician who is present in the hospital at the time the patient presents or is
presented or evaluated by a physician on-call who is:
(i) physically able to reach the patient
within 30 minutes after being informed that a patient is present at the
hospital who requires immediate medical attention; or
(ii) accessible by direct, telephone, or
radio communication within 30 minutes with a registered nurse, physician
assistant or other qualified medical personnel as established by the governing
body at the hospital under orders to assess and report the patient's condition
to the physician; and
(B) personally examined and evaluated by the
physician before an attempt to transfer is made; however:
(i) after receiving a report on the patient's
condition from the hospital's registered nurse, physician assistant or other
qualified medical personnel as established by the governing body by telephone
or radio, if the physician on-call determines that an immediate transfer of the
patient is medically appropriate and that the time required to conduct a
personal examination and evaluation of a patient will unnecessarily delay the
transfer to the detriment of the patient, the physician on-call may order the
transfer by telephone or radio; and
(ii) physician orders for the transfer of a
patient which are issued by telephone or radio shall be reduced to writing in
the patient's medical record, signed by the registered nurse, physician
assistant or other qualified medical personnel as established by the governing
body receiving the order, and countersigned by the physician authorizing the
transfer as soon as possible. The patient transfers resulting from physician
orders issued by telephone or radio shall be subject to automatic review by the
medical staff pursuant to paragraph (8) of this subsection.
(5) Hospital personnel,
written protocols, standing delegation orders, eligibility and payment
information. The policy of the transferring and receiving hospital shall
provide that licensed nurses and other qualified personnel are available and on
duty to assist with patient transfers and to provide accurate information
regarding eligibility and payment practices. The policy shall provide that
written protocols or standing delegation orders are in place to guide hospital
personnel when a patient requires transfer to another hospital.
(6) Special requirements related to the
transfer of patients who have emergency medical conditions.
(A) If a patient at a hospital has an
emergency medical condition which has not been stabilized or when stabilization
of the patient's vital signs is not possible because the hospital or emergency
treatment area does not have the appropriate equipment or personnel to correct
the underlying process (e.g. children's hospitals, thoracic surgeon on staff,
or cardiopulmonary bypass capability), evaluation and treatment shall be
performed and transfer shall be carried out as quickly as possible.
(B) The hospital's policy shall provide that
the hospital may not transfer a patient with an emergency medical condition
which has not been stabilized unless:
(i) the
individual (or a legally responsible person acting on the individual's behalf),
after being informed of the hospital's obligations under this section and of
the risk of transfer, requests the transfer, in writing and indicates the
reasons for the request, as well as that he or she is aware of the risks and
benefits of the transfer;
(ii) a
physician has signed a certification, which includes a summary of the risks and
benefits, that, based on the information available at the time of transfer, the
medical benefits reasonably expected from the provision of appropriate medical
treatment at another hospital outweigh the increased risks to the patient and,
in the case of labor, to the unborn child from effecting the transfer;
or
(iii) if the physician who made
the determination to transfer a patient with an emergency condition is not
physically present in the emergency treatment area at the time of transfer, a
qualified medical person may sign a certification described in clause (ii) of
this subparagraph after consultation with the physician. The physician shall
countersign the physician certification within a reasonable period of
time.
(C) Except as is
specifically provided in subsection (b)(8) and (9) of this section, the
hospital's policy shall provide that the transfer of patients who have
emergency medical conditions, as determined by a physician, shall be undertaken
for medical reasons only. The hospital must provide medical treatment within
its capacity that minimizes the risks to the individual's health and, in the
case of a woman in labor, the health of the unborn child.
(D) A hospital that has specialized
capabilities or facilities (including, but not limited to such facilities as
burn units, shock-trauma units, neonatal intensive care units, or, with respect
to rural areas, regional referral centers) may not refuse to accept from a
referring hospital an appropriate transfer of an individual who requires such
specialized capabilities or facilities if the receiving hospital has the
capacity to treat the individual. Except as expressly permitted in clauses (i)
and (ii) of this subparagraph, a hospital's policy shall provide for the
receipt of patients who have an emergency medical condition from other
hospitals so that upon notification from a transferring physician or a
transferring hospital prior to transfer, the receiving hospital shall respond
to the transferring hospital and transferring physician with the status of the
transfer request within 30 minutes and either accept or refuse the transfer.
The time period begins to run at the time a member of the staff of the
receiving hospital receives the call initiating the request to transfer.
(i) The receiving hospital's policy may
permit response to the transferring hospital and transferring physician within
a period of time in excess of 30 minutes but no longer than one hour if there
are extenuating circumstances for the delay. If the transfer is accepted, the
reason for the delay shall be documented on the memorandum of
transfer.
(ii) The response time
may be extended before the expiration of the initial 30 minutes period by
agreement among the transferring hospital and transferring physician and the
receiving hospital and receiving physician. If the transfer is accepted, the
agreed extension shall be documented in the memorandum of transfer.
(7) Physician's duties
and standard of care.
(A) The policy shall
provide that the transferring physician shall determine and order life support
measures which are medically appropriate to stabilize the patient prior to
transfer and to sustain the patient during transfer.
(B) The policy shall provide that the
transferring physician shall determine and order the utilization of appropriate
personnel and equipment for the transfer.
(C) The policy shall provide that in
determining the use of medically appropriate life support measures, personnel,
and equipment, the transferring physician shall exercise that degree of care
which a reasonable and prudent physician exercising ordinary care in the same
or similar locality would use for the transfer.
(D) The policy shall provide that except as
allowed under paragraph (4)(B) of this subsection, prior to each patient
transfer, the physician who authorizes the transfer shall personally examine
and evaluate the patient to determine the patient's medical needs and to ensure
that the proper transfer procedures are used.
(E) The policy shall provide that prior to
transfer, the transferring physician shall ensure that a receiving hospital and
physician that are appropriate to the medical needs of the patient have
accepted responsibility for the patient's medical treatment and hospital
care.
(8) Record review
for standard of care. The hospital's policy shall provide that the hospital's
medical staff review appropriate records of patients transferred from the
hospital to determine that the appropriate standard of care has been
met.
(9) Medical record.
(A) The hospital's policy shall provide that
a copy of those portions of the patient's medical record which are available
and relevant to the transfer and to the continuing care of the patient be
forwarded to the receiving physician and receiving hospital with the patient.
If all necessary medical records for the continued care of the patient are not
available at the time the patient is transferred, the records shall be
forwarded to the receiving physician and hospital as soon as
possible.
(B) The medical record
shall contain at a minimum:
(i) a brief
description of the patient's medical history and physical
examination;
(ii) a working
diagnosis and recorded observations of physical assessment of the patient's
condition at the time of transfer;
(iii) the reason for the transfer;
(iv) the results of all diagnostic tests,
such as laboratory tests;
(v)
pertinent X-ray films and reports; and
(vi) any other pertinent
information.
(10) Memorandum of transfer.
(A) The hospital's policy shall provide that
a memorandum of transfer be completed for every patient who is
transferred.
(B) The memorandum
shall contain the following information:
(i)
the patient's full name, if known;
(ii) the patient's race, religion, national
origin, age, sex, physical handicap, if known;
(iii) the patient's address and next of kin,
address, and phone number if known;
(iv) the names, telephone numbers and
addresses of the transferring and receiving physicians;
(v) the names, addresses, and telephone
numbers of the transferring and receiving hospitals;
(vi) the time and date on which the patient
first presented or was presented to the transferring physician and transferring
hospital;
(vii) the time and date
on which the transferring physician secured a receiving physician;
(viii) the name, date, and time hospital
administration was contacted in the receiving hospital;
(ix) signature, time, and title of the
transferring hospital administration who contacted the receiving
hospital;
(x) the certification
required by paragraph (6)(B)(ii) of this subsection, if applicable (the
certification may be part of the memorandum of transfer form or may be on a
separate form attached to the memorandum of transfer form);
(xi) the time and date on which the receiving
physician assumed responsibility for the patient;
(xii) the time and date on which the patient
arrived at the receiving hospital;
(xiii) signature and date of receiving
hospital administration;
(xiv) type
of vehicle and company used;
(xv)
type of equipment and personnel needed in transfers;
(xvi) name and city of hospital to which
patient was transported;
(xvii)
diagnosis by transferring physician; and
(xviii) attachments by transferring
hospital.
(C) The
receipt of the memorandum of transfer shall be acknowledged in writing by the
receiving hospital administration and receiving physician.
(D) A copy of the memorandum of transfer
shall be retained by the transferring and receiving hospitals. The memorandum
shall be filed separately from the patient's medical record and in a manner
which will facilitate its inspection by the department. All memorandum of
transfer forms filed separately shall be retained for five years. A copy of the
memorandum of transfer may also be filed with the patient's medical
record.
(d) Violations. A hospital violates the Act and this section if:
(1) the hospital fails to comply with the
requirements of this section; or
(2) the governing body fails or refuses to:
(A) adopt a transfer policy which is
consistent with this section and contains each of the requirements in
subsection (c) of this section;
(B)
adopt a memorandum of transfer form which meets the minimum requirements for
content contained in this section; or
(C) enforce its transfer policy and the use
of the memorandum of transfer.
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