Hi, everyone, I want to welcome you to today's webinar, Emergency Medical Treatment and Active Labor Act, MTALA, and the Patient Who Experienced Sexual Assault. So this webinar is going to be brought to you through the International Association of Forensic Nurses, the Technical Assistance Project, and we're grateful to be able to host Susan Chaston for today's webinar. My name is Tammy Scarlett, and I am a forensic nursing specialist with the IFN, and I'll be hosting. And first off, I'd like to share a few housekeeping items for us as well before we begin. Now, today's webinar is possible due to funding provided through the Office on Violence Against Women, and the presenters of today's webinar disclose no conflict of interest. Of course, if you have multiple people watching today's webinar with you, please send a list of all attendees that have not formally registered to SafeTA. Oh, thank you. To safeTA at forensicnurses.org, and share the evaluation link with them. I'll put that email in the chat in just a little bit as well. Now, members of IFN are eligible to receive 1.5 contact hours for this continuing education activity. IFN is an approved provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. But for members to obtain CE for this activity, they are asked to attend the webinar in full and complete the post-activity webinar evaluation in order to obtain a certificate documenting the contact hour for this activity. For non-members, with the completion of the post-activity webinar evaluation, you will receive a certificate of attendance. This webinar is being recorded today and will be available on the SafeTA website for viewing at a later date as well. Now, all registered attendees will receive an announcement when that is available for viewing. I would like to introduce today's presenter. We have with us Susan Chaston. Susan is the statewide sexual assault nurse examiner, program manager, the Utah Coalition Against Sexual Assault. For more than 25 years, she's helped hospitals and communities create programs for providing healthcare to victims of violence in Utah. She's a sexual assault nurse examiner at the Utah County Children's Justice Center. Working closely with the International Association of Forensic Nurses and the American College of Emergency Physicians, and of course, many other content experts, Susan was the lead consultant on the OVC TTAC SANE Program Development and Operation Guide. We are very grateful to have her here today presenting, and we look forward to hearing what she has to say. Susan, I'll turn it over to you to get started. Thank you, Tammy, and thank you, Mary Kate, for all of the technical assistance, which is so important when we do these. Just to give you a little bit more of an introduction, Tammy reminded me that I didn't say anything in my introduction about being an attorney. I am a graduate of Brigham Young University Law School. I am an inactive member of the Utah Bar, and I did teach health law for several years, but I've never practiced as an attorney. And therefore, I'm gonna give this disclaimer. The information that we're gonna go over today is for education purposes only. When you talk about the law, it is always very case-specific and situation-specific, so please do not consider anything that we talk about today to be considered to be legal advice. If you have specific legal concerns, it's very important to reach out to whoever provides that information for you in your agency or your hospital, whether it be legal counsel or risk management. And it's important to have an attorney who understands this aspect of the law. Unfortunately, a lot of times, SANEs reach out to prosecutors, and prosecutors know as much about health care law and EMTALA as labor and delivery nurses know about cardiac care. So just realize lawyers specialize just like nurses do, and when you're seeking a legal opinion, you should get it from an attorney who understands both your state law and the specific area of law that you need help with. So our learning outcomes today will be, hopefully, you'll get a little bit of the history and purpose of EMTALA, and some of the key concepts will be defined, but ultimately, we're gonna try and have a discussion here about how EMTALA impacts the medical forensic exam and SANE practice. So we're gonna start with a few poll questions, mainly because I like to know who I'm talking to. So Mary-Kate's gonna put a poll up, and if you could just take a minute to answer it. And if you're not SANE law enforcement or an advocate, could you just write in the chat? And I'm curious to see if there are any attorneys on the presentation today. So if you can just mark in the chat just mark in the chat if you're an attorney or anyone else that's participating today or watching today. And we'll just give you one more second here to answer. It looks like the majority of participants today are SANEs. Don't see any other attorneys on the presentation today, but that would be fine. And then a few advocates. All right, do you wanna end the poll and go to the next poll or do we wait? Okay. And then our next question is, it's not letting me advance. Oh, here we go. If you're a SANE, what setting do you work in? Are you in a hospital, community-based, mobile team or an other? And again, you can write that in the chat. And the main reason why I wanna know this question is, EMTALA really only applies to the hospital-based programs as far as enforcement of the law. If you're other, I'd be curious to know, we are part of the hospital, but have offices outside of the hospital. So yeah, so you are still pretty much Alice in a hospital-based setting. Again, hospital-based ambulatory clinic. If you are on the hospital campus, EMTALA is gonna probably apply to you. Tell a SANE, you know, yeah. Again, depends on who you're providing that for. So Louise, you're community-based, but you provide care in the ED, but you are not an employee of the hospital, would be my understanding of that. Okay. Let's go ahead and end the poll. And if you're hospital-based, last but not... How many of your programs are able to provide 24-7, 365 coverage? And it looks like a little bit more than, just waiting for a few more people to chime in. Looks like a little more than 50%. And again, that's one of the reasons why we need to talk today about MTALA, because certainly if you're not able to provide that 24-7, 365 coverage, you may need to have some plans in place in order to be compliant with MTALA. Okay, if you wanna close the polls, we'll get going here. So- You will have to close the polls, the panelists, but they're closed. Okay, they're closed. Okay, so I have to close it off the thing. There, now it's out of my sight. All right, so I would like to start with a little history of MTALA for two reasons. One, so that many of you I'm sure have not practiced in a time when MTALA did not exist. And to give you an idea of what life was like before MTALA and why MTALA was put in place. It wasn't just there to make emergency room doctors crazy. It was actually put there with a purpose. And so it was enacted in 1986 as a result of multiple reports of patient dumping. And what patient dumping means is a patient would come to the hospital and be refused care based on the fact typically that they were uninsured. And again, when you think back to 1986, the majority of the people who were insured in this country were insured because they were employed. So if you were unemployed, you probably did not have health insurance, but also it was used to screen minorities out and not provide them care. And the best example was Cook County Hospital in Chicago, which was a public hospital. And they received 80% of their transfers from private hospitals were due to a patient not having insurance. And of those 24% were probably too unstable to actually transfer. So they were actually placing the patient at risk by transferring them to Cook County Hospital. I worked in a community, I worked at a university burn center. In the early 1980s, we did not own the only helicopter in town that was owned by a private hospital. And we used to joke that the private hospital helicopter would go to the scene of an accident or go to pick up a patient. And the first thing that they would do would be a pocket book biopsy to determine whether or not the hospital had it, whether the patient had insurance. If the patient had insurance, they would take them back to the private hospital. If they did not, they were immediately sent to our burn unit. We're talking specifically about burn patients. But the other thing that caused Congress to pass this law were stories or anecdotes. And I think as saints who are out there advocating for healthcare policy changes on a regular basis, it's important to understand the power of anecdotes and having a good story to be able to tell why you want to change policy or change practice or enact legislation. But I think it's important that when you do that, when you use that as a very valid technique, that you make sure the information that you share is correct. And just to let you know, one of the instances that actually was testified to in Congress was the case of Mr. Takewell. He was a diabetic who was not, as we would say, not very compliant with his care. And he was brought to the hospital and admitted to the hospital. And the story that was told to Congress was that the hospital administrator, because he had been to this hospital several times, did not pay his bill, walked into the room, lifted him out of the bed, carried him across the street to the other side of the, across the street from the hospital property where friends eventually found him, picked him up, and he died the next day. Now that's what was testified to in Congress. The reality of the story was that during the two years prior, Mr. Takewell had been treated at this hospital numerous times. He did not have insurance and he owed approximately $95,000, which in today's standards is not $9,500. In today's standards, that's not a lot of money, but back in the 80s, that was a significant hospital bill. And what the hospital administrator wanted him to do was to sign paperwork that would allow them to put him on charity care and therefore write this off as medical debt. And he had some mental health problems and was refusing to sign the papers. On the day of the actual incident, and they basically discharged, treated him, discharged, and said, you can always come to the hospital for emergency care, but if you are coming for non-emergent care, you're either gonna have to sign these papers or not come to this hospital again, was what he had been informed. What happened on the day of the actual event is he was sick at home. They called an ambulance. They did not take him to the hospital. They did not think he was that sick. They took him to a clinic where a doctor evaluated and said, yeah, his blood sugar's a little high. It's 250. He's hyperventilating a little bit. I don't think he has diabetic ketoacidosis, but let's go ahead and admit him to the hospital for further testing. He was sent directly to the hospital and did not go to the emergency room, was admitted to the hospital. The administrator came and asked him to sign the papers again. And the patient basically got mad and left and walked out of the house or walked out of the hospital and sat on the side of the road until a friend took him home. So two completely different stories, but of course we like to use the really bad story to get things changed. So if you're gonna use anecdote to change healthcare policy, just make sure that what you're using is accurate. So EMTALA was never meant to be and is not a federal malpractice statute. So for those of you who are not familiar with malpractice law, malpractice is a state claim. You cannot sue for malpractice at the federal level unless it's a federal facility that provided the bad care, right? So I can't sue for malpractice under the federal government if it's not care provided by a federal facility. And Congress didn't want EMTALA to be used instead of malpractice. Also, they did not want to create a national standard of care. Again, if you're familiar with medical malpractice, you have to meet several standards before you can sue for malpractice. And one of them is that there is a standard of care and that standard of care was breached by the provider and that by breaching that standard of care, harm was caused. So they did not wanna use EMTALA to say, this is how an emergency room should treat patients. The other thing that courts wanted to do was to avoid forum shopping. And again, forum shopping is where you look for a court that's favorable to what you wanna do. And I'll just, in Utah, we are not known in our state courts for giving very high medical malpractice awards. We tend to be kind of skeptical of people suing for malpractice. And so you have to have something really egregious and there may be an advantage instead of claiming malpractice to claim an EMTALA violation in Utah because then that gets you into federal court. The other thing is, and people use forum shopping for all sorts of reasons. One set of courts may have a higher backlog than others, state versus federal, and you may have judges that you feel are gonna be more likely to support your cause depending on where you are. And we'll talk about that just a little bit later. Suing under EMTALA does though have some advantages and patients cannot sue doctors under EMTALA because again, it's not malpractice, it's EMTALA. And so you can only sue hospitals, but when you do that, you don't have to prove negligence. And again, when you go to prove negligence, you have to show there was a standard of care, that standard of care was breached. And typically to do that in a malpractice case, you have to hire an expert to come in and educate the jury about what that standard of care is. And as we know, that can be very expensive. Experts charge anything these days between, I would say 200 to $500 an hour or more. And the other advantage, many state courts have limited damages under malpractice. And so they've limited the amount you can be awarded for pain and suffering, but there is no such cap under EMTALA. So that's one of the reasons why people, if they can bring charges or can bring a case under EMTALA would like to take that into federal court. So the Emergency Medical Treatment and Active Labor Act, first of all, it applies to hospitals who have an emergency department and accept Medicare. And that's basically 90%, 98% of all hospitals. Now, having said that, there may be some specialty hospitals who still have an EMTALA obligation, not to accept patients in an emergency room setting if they don't have an emergency room, but if they are the source of orthopedic specialty care in the community or other types of specialty care, they may have an EMTALA obligation. It applies to critical access hospitals with a dedicated emergency room. And it's now going to apply as of January 1st of this year to rural emergency hospitals. These are a new type of hospital that are popping up throughout the United States to provide emergency care in rural communities. They are only emergency rooms. They are not usually attached with inpatient hospital stays. And so they are now coming under EMTALA. And I know we have one of those in Utah now, but these are trying to meet the needs with hospital closures of just providing emergency care in rural communities. So what are the components of EMTALA? And hopefully if you work in a hospital emergency room, you are familiar with these. I see Andrew says he can remember wallet biopsies also. Yeah, that means you're old, Andrew, like me. So what are the components of EMTALA? The first thing is that you have to provide a medical screening exam by a qualified medical provider. And we're going to talk specifically about whether or not a SANE nurse can be a qualified medical provider. But pretty much if you come to the emergency room, you need to get that medical screening exam. That medical screening exam should be designed to identify an emergency medical condition. If you identify an emergency medical condition, you then have an obligation to stabilize that emergency medical condition. And if you cannot stabilize, and to give you a perfect example is the 90% burn, that you may not have the capabilities to stabilize and treat that patient long-term, then you are okay to transfer. And we're going to talk about specifically what is required to do a transfer. And the important thing is care must be given regardless of ability to pay. Now that doesn't mean that the hospital still can't bill the patient. What that means is that you can't delay care. You can't determine whether or not you're going to give care based on whether or not the patient can pay. And you need to be very careful when you make those decisions about and base them on whether or not the patient can pay. So how is a patient defined? So if I come to your emergency room tonight, the definition is basically has three parts to it. First of all, I am coming to the ER, I am saying I have an emergency medical condition I want you to treat, or I'm being brought to the ER by a family member or somebody is with me and says I need to be treated for a medical emergency condition, or it's obvious that the reasonable person would recognize that I am in an emergency. I'm sitting here clutching my heart and I'm not breathing. A reasonable person would recognize that I have an emergency condition. So, and this is presenting to, or, and you need to present to the hospital property. And so that's will affect those same programs who are in the ambulatory setting, that they still may have EMTALA obligations under this part that you've presented on the hospital property. And I request exam for a medical treatment that could be considered an emergency condition. So EMTALA requires that screening exam, stabilization, appropriate transfer, and you can't delay treatment to inquire about insurance or payment. Many years ago, my father was really sick and in the hospital where he worked. And my mother showed up to the front door and was denied entrance to go visit him. And she basically said, you want to bet? And went around to the back door and got in to go see him. And when she asked what was going on, they had a bomb threat and they pretty much related to a family where a family had come in for hospital care and he had died while trying to give his insurance information while he sat there answering a thousand questions. This was actually in the seventies. So this was way before EMTALA. And you have to obtain or attempt to obtain informed refusal for an exam or care or transfer. So if a patient is declining to be transferred, then you have to make sure that you have gotten some sort of written refusal for that or attempt to do so and document that the patient declined to do that. So let's talk about the medical screening exam for a purpose, for a minute here. So is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. And it's not an isolated event. It is ongoing. And I am not an emergency room provider. I loved working in family practice because patients could come to me with a problem and I could say, hmm, let me go look at the research. Let me look at this and let me get back to you in a couple of days. And we know that when you're in the emergency room you have to make that determination a lot more quickly. And you typically don't send patients home until you decide that they're not gonna die. If you send them home. So again, I think it's really helpful to explain to patients that one of the reasons people spend so much time in the emergency room is they're kind of waiting to see what happens to make sure that things aren't gonna get significantly worse that would require them to either be hospitalized or that they're not gonna get worse and therefore they can go home. It's important to understand the difference between triage and a medical screening exam. Triage is what happens to determine that when you have a waiting room full of 20 people who needs to be seen first. Triage is not the medical screening exam that happens after the patient gets back in there because triage is typically done by a triage nurse and that medical screening exam needs to be done by a qualified medical provider. So again, it's to set the priority of who is gonna be seen by that QMP. And it's important to make sure that you don't think triage is happening when that patient first walks, that a medical screening exam is not happening when that patient first walks into the emergency room. So an emergency medical condition defined. And I think it's important to look at this definition because there has been debate back and forth in the courts about whether sane care is an emergency medical condition. I think there's some courts who've said yes and some who've said no. And so that's why it's important to kind of understand what is the law said in your jurisdiction. So an emergency medical condition is a condition manifesting itself by acute symptoms of sufficient severity, including severe pain. So again, the majority of the patients I see for sexual assault exams are typically not in severe pain. So they're not gonna meet that qualification, but it's such that the absence of immediate medical attention could reasonably be expected to result in placing the individual's health or the health of an unborn child. Because remember EMTALA not only refers to emergency room care, but also to patients presenting to labor and delivery. In serious jeopardy, serious impairment of bodily functions or serious dysfunction of bodily organs. So again, whether you get evidence collected or not, whether you get the forensic part of that medical forensic exam, which typically requires a trained provider, I'm not sure that that rises to the level of an emergency medical condition. So that may be able to get you out of that. That doesn't mean that you don't have to provide these patients with some sort of care. So when there is an emergency medical condition, you must treat until the condition is resolved or stabilized. So once you've identified that emergency medical condition, and whether it's someone having an acute asthma attack, someone having a severe migraine, because again, if you come in with a migraine that's 10 out of 10 pain score, I think that qualifies as emergency medical condition. We don't think of it as being life-threatening, but pain obviously qualifies under that definition. First, you have to stabilize them until it is resolved or until you can then transfer them if you need to. So it's important to understand under minors in EMTALA, a lot of times hospitals and clinics will not treat minors for medical conditions. I know many states have exceptions for reproductive care and they've used that to allow minors to consent for their medical forensic exam. But EMTALA is looking specifically at those emergency medical conditions. And you cannot delay care on a minor until a parent or a guardian is contacted. You can go ahead and start that care because otherwise that would be a EMTALA violation. So once you determine there is no medical, emergency medical condition, then the staff can wait for parental consent. But you have to do that medical screening exam and start the process of providing emergency care. And Susan, just to, sorry, jump in. Anthea had asked a question about, I didn't know if you're gonna be able to get to that soon or if that applied to one of the last- Yeah, let me look at these questions in the chat. Okay, so if a patient presents to a hospital but due to injuries is unable to be discharged to a standalone center for forensic medical exam and they have no SANE, can a transfer take place to a hospital nearby where a SANE who is credentialed from the sexual assault center can go? So again, we're gonna get to that. It's gonna talk, you need policies in place and you're going to need not only policies in place but you're gonna need permission from the patient to be transferred. So I think there's a lot to that that we'll talk to you about some of the details later. The other thing is, we know now that you can do evidence collection up to four or five days. Is there a reason to not delay that forensic medical exam and talk to the nursing staff about things they can do to make sure that they're not destroying evidence and to make sure that the medical needs of that patient are taken care of until a SANE can come there? And I know hospitals can give emergency permission for people to come in and provide care. So again, always that's hard to work out in the moment. So those are the things that probably need to be worked out by protocol and procedure ahead of time. And then does EMTALA usually apply to urgent cares? It probably does not apply to an urgent care unless it is on the campus of the hospital. So my hospital has an urgent care on the campus. Yes, it's gonna apply to them. Is an MOU with hospitals adequate along with policies to do that? And I would say that is up to your hospital legal counsel or your agency legal counsel determine whether that's gonna be sufficient. And to be honest, there is no relationship between what insurance companies are gonna do and what EMTALA says. So we have a freestanding urgent care emergency department. Does EMTALA apply? And it would depend on where you are, I think. And if you are calling yourself an emergency department, I think there's a good chance, and you accept Medicare patients, there's a good chance that EMTALA applies. But again, that's something you would wanna talk to a legal counsel about. Okay, so can the SANE perform a medical screening exam? And the bottom line answer is yes, but you have to follow specific procedures. And that means if the, so EMTALA was not, you don't do the same medical screening exam for every patient. So if I come in complaining of a UTI, you're not gonna do an EKG on me, right? You're gonna base your medical screening exam on my presenting symptoms. So a SANE, and again, labor and delivery nurses do the medical screening exam to determine whether someone is in active labor. In many hospitals, they are, that's routinely part of what they do as part of their job. If your emergency room is going to have you, the SANE, who is a hospital employee, be the medical, be the qualified medical provider, they're going to have to go to the medical staff and have that written specifically into their bylaws with protocols. So it can be done, but you have to have that in written protocol, and it has to be approved by the medical staff. So just know that you can do it, but you have to jump through all the hoops. And it has to be within your scope of practice to do that medical screening exam. So many times there's an argument constantly out there, and I'm just gonna tell you my personal bias. I do not believe that there is a medical part and a forensic part to the medical forensic exam. It is something in its entirety that has ongoing medical and forensic implications throughout the exam. And so frequently people are looking for ways to minimize the medical part of the medical forensic exam or to separate those out. And my personal bias is that you can't do that. Having said that, is there a forensic exam exception to EMTALA? And so when you read the code section, it says use of a dedicated emergency department for non-emergency services. If an individual comes to a hospital's dedicated emergency department and a request is made for treatment, but the nature of the request makes it clear that the medical condition is not of an emergency nature. So again, we have patients who come to small emergency rooms for routine blood pressure screening. And as long as their blood pressure is normal, they're probably fine doing that, or they can come in for immunizations. There are lots of things that because primary care providers are not available 24 seven, they may send their patients to the emergency room. There may be an agreement to send them for something that is non-emergent care. And so they have made this exception to allow for things like evidence for criminal cases, which would include sexual assault and blood alcohol test. But before you use this exception to try to get out of your EMTALA obligations, I would be very careful and look at these two things. First of all, even for blood alcohol testing. So if law enforcement brings someone in who's been involved in a motor vehicle accident and wants blood alcohol testing, the question is if they're having any signs or symptoms of intoxication, you have an obligation, I think, to do a medical screening exam because are they truly intoxicated or do they have a blood sugar of 20? They're a diabetic. So if you have a situation where a commercial truck driver is in an accident, there's no signs or symptoms of injury. He's not abundant, but by state law, you have to test all commercial drivers if they're involved in an accident for their blood alcohol level, that probably would be fine because you're just bringing this person in to determine their blood alcohol level. They're not being treated for any kind of condition. But other than that, you're probably not gonna be able to get around just doing blood alcohol testing and not doing that medical screening exam. For the medical forensic exam, where it might work is for a suspect exam because depending on how you talk about suspect exams to the patient, and we educate our nurses to say that I am doing this as a nurse, but the patient-nurse relationship is limited to just collecting this evidence. If you have any medical concerns, then we need to have you checked in with the emergency room doctor, but I am not seeing you for medical. I'm just seeing you for evidence. That might work. But for the typical sexual assault patient, you're doing so much more than evidence collection for law enforcement. You are evaluating their mental health. You're evaluating them for suicide risk. You're doing a safety assessment. You're doing STI possibly testing and prophylaxis. You're doing emergency contraception. All of that goes way beyond just evidence collection. So I would not try to use this and if you are using this, then basically you're gonna lose your, if you use this exception, you are potentially going to lose your ability to give medical provider hearsay exception testimony because now you're making your role just one of a CSI technician and not a nurse. So I would stay away from using the forensic exception. And Betsy has asked if there are gonna be slides available and I'm assuming they will be available after the presentation. You wanna? As far as I'm aware of right now, it'll just be posted to the safety website when it's uploaded there, which you all will get a reminder. But Betsy, I will double check and follow up with you if that is a different case. Thanks, Susan. Okay, so let's talk about some recent case law. So SRAM versus Montage Health. This was a woman who came to a hospital where she was known and it's hard to tell from the facts of the case because she was reluctant to go to the hospital after being sexually assaulted. And it's hard to tell whether she didn't want a medical forensic exam initially and her friends and family kind of forced her to go or whether she didn't wanna go to this hospital because she had been there before and treated badly. She was known by the hospital to have bipolar disorder and they basically refused to do a medical forensic exam because they basically thought she was there for a mental health problem and they refused to do medical screening. I mean, they did a medical screening exam but they refused to deal with the fact that she had been sexually assaulted. They originally filed these as an EMTALA. She actually filed multiple complaints in federal court. She filed under the ADA Act. She filed under the Rehabilitation Act but she also filed under EMTALA. And they originally, the trial court originally discharged it basically saying that because she was admitted to the hospital. So she came in, she's well-known there, she's bipolar and they went ahead and admitted her. They just didn't do her medical forensic exam. And they wouldn't let her leave to go to a hospital where she could have this done. They basically said that the original trial court dismissed the case based on the fact, well, they admitted her. And once you admit somebody to the hospital then EMTALA no longer applies. Well, she appealed this to a higher court and what the higher court said is just by admitting does not avoid your EMTALA obligations and that she might really have a case here for inadequate screening because they did not identify the fact that she had this need for a medical forensic exam and that she could go forward on her EMTALA claim. But why? And that basically she received inappropriate screening and she described it as diagnostic overshadowing. So, and this can happen that we, especially with patients that we're familiar with, we know that they're there for their chronic migraine and we are not necessarily stopping to make sure they don't have chest pain, right? So it's called diagnostic overshadowing that their primary problem that we know about tends to take over and we ignore everything else. That was what her complaint was. The case has been allowed to go up, to go back and be looked at under EMTALA. But where I want you to think about this are the patients that we see for multiple sexual assault exams. We know these patients, they come in on a frequent basis with recurrent complaints and they're very difficult patients to take care of. And there are two problems with these patients. First of all, they may be patients who have had a real history of trauma who are getting triggered and are having basically flashbacks and reliving that trauma. Or the fact that they're patients with mental illness make them very vulnerable to being victims of sexual assault. So I think when you look at this problem, you need to think about EMTALA as being a potential problem here based on this case and that you need to have protocols in place. And that even though you may not do a full medical forensic exam because you've already done two of them on this patient this month, or whatever your policy is, that you probably still need to go ahead and give them that medical care. And whether that's emergency contraception or STI prophylaxis, you can't assume that because they have a mental health problem, you don't have to provide them care. And so again, that's something I think all facilities need to have some sort of policy in place for patients that have multiple reports of sexual assault so that you're following your hospital policies and that they've been approved by your hospital legal staff and that you have some EMTALA considerations when you look at these specific patients. So we see pediatric patients that are outside of the EC protocol. The same does their... All right, so we see pediatric patients that are outside of the EC protocol. Is that emergency contraception? I'm not sure what EC protocol you're talking about. The same does their evaluation history is documented. It's STI testing and possible treatment. The doctor does not see these patients. Oh, Evans collection. Okay, sorry, too many abbreviations. Doctor does not see these patients because it is not an emergent thing. Is this breaking EMTALA? So you're in an emergency room. Who is doing that medical screening exam? So if they're coming to the emergency room, and again, they may be outside of evidence collection, but you still have to do that. In my opinion, you still have to do a medical screening exam. And in reality, the only emergency may be that the parents feel it's an emergency, but you still have to do some sort of basic screening and a qualified medical provider should be doing that. Now, whether the doctor actually has to see the patient to do that, again, that's going back to your hospital legal counsel, but I think you should have a policy in place that says when a patient comes in for a pediatric child sexual abuse exam. And again, you don't wanna be missing that there could be physical abuse involved, which might make it then an emergency medical condition. So I think you either need policy and protocol in place, but if they're coming to the emergency department, that needs to have, if you're reading EMTALA, it needs to have a medical screening exam, and that has to be done by a qualified medical provider. Does that help? You know, this is like years ago, we had a phone-in service called Ask-A-Nurse, and we nicknamed it call your doctor because eventually every time you called into the Ask-A-Nurse the nurse would say, call your doctor. And I'm just gonna tell you, today's presentation is gonna be call your lawyer because your state laws may impact this and your hospital policy and procedure and the specific facts. So I would say, make sure that you have policies in place, but that you also talk to hospital legal counsel. The other case is CM versus Tomball, and this was a 15-year-old who came to an emergency room for a medical forensic exam. She had been assaulted 48 hours prior and she had bathed. And the emergency room nurse basically did her medical screening exam in the waiting room where there were approximately 20 other patients sitting. So, needless to say, this should never have happened the way it did, and the family was extremely upset. And they basically told her that because she had bathed she could not have a medical forensic exam. So there were so many things wrong with this case, but they did then make an EMTALA request under this. And what their EMTALA came back, so EMTALA is not there to say that there was a violation of privacy because that again is privacy laws in the state. But again, maybe if the emergency room did it, was she a qualified medical provider to do that? Because she didn't do anything except talk to the patient. So there was probably inadequate medical screening exam. And so this could go forward on an EMTALA violation, but hopefully nobody is working in a facility where the medical screening exam is happening in the waiting room by an RN, and that patients are refused care because they were not bathed. So lots of things here, but a lot of potential violations. And the one thing they didn't talk about was reporting this nurse to the board of nursing, because depending on the nurse practice act in this state, I can see several violations that may have occurred in this situation. And if this nurse was in Utah and this did not happen in Utah, I could see at least three different violations of my nurse practice act for not treating a patient with dignity and respect and for violation of confidentiality. So again, there are lots of ways that state law can impact the care you give and you can't operate in isolation with EMTALA. Okay, let me go back to some of the questions. So the qualified medical person can be an F&E, but it has, because nurses can be the QMP, but it has to be spelled out in medical staff regulations. You can't just say nurses are gonna start to do this. There is a process for doing that. We have a waiver for a medical screening exam that patients have to sign when they present to the ED and state they only want to see the same, not the ED provider. DR is always supposed to ensure that the patient is educated, that they are allowed to see the ER provider, but they are informed of what the medical forensic exam is. And if the patient reiterates that all they want is they do not want any care provided by the ED itself, only the same, then they will have to sign, then they have to sign the waiver as well. And let me get to one of my future slides where it talks about getting consent for transfer and pressure being put on the patient. I think if you've cleared this with your hospital legal staff and they're okay with this, I'm not gonna say you can't do it. Does it break him tall if a hospital refuses to perform medical forensic evidence collection and post-exposure treatment if a patient does not want to wait for a SANE to be available? So if the patient leaves, that's different. We're gonna talk about transfer and discharging of patients in a second. The question with mine on consent is if we want the patient to sign consent for this procedure, but if they're having a psychiatric crisis where they are not in their right mind, it makes it not able to give consent. So again, that's a totally different issue and not EMTALA related. So you've done, the question comes down to is you, the patient's coming in there, are they coming in for the medical forensic exam? Are they coming in for a psychiatric crisis? Are you identifying their emergency medical conditions and are you stabilizing those? And again, consent is a completely different issue about whether or not a patient can give consent. We have patients who are psychotic who give consents to their medical forensic exam because being psychotic is their normal state of functioning. And that doesn't, and they are their own legal guardian and they consent for all sorts of care, even though they are hallucinating on a regular basis and having thoughts that are not based in reality. So it really is gonna be patient specific. And again, I would talk to your mental health staff about how they consent for care in those situations. Okay, so let's keep going here. So this is a little bit off topic, but it goes to two concepts. One, it goes to forum shopping about where we're seeing laws pop up. And one of the places we see a lot of conservative law popping up is in the state of Texas. They were the state that basically blocked the Affordable Care Act's ability to require hospitals to give care to transgender and non-binary people. Gay and lesbian patients to not discriminate against those patients. But the most recent place where they have popped up is the president of the United States created a memorandum saying that to not provide emergency care for abortion is a violation of EMTALA. And so this was brought up in federal court in Texas. And basically under the Texas court reading, health and human services may not enforce the following interpretations contained in the CMS guidance. So health and human services may not enforce the guidance and letters interpretation that Texas abortion laws are preempted by EMTALA. So preemption is a very specific legal term. Preemption says that federal law outstrips all state law. And EMTALA does not have a preemption clause. It does not state anywhere that it preempts state law. And so there are basically two ways a federal statute can preempt state law. One is if it specifically states that. The best example is ERISA, which is the Employee Retirement Insurance Security Act. And it basically says we are gonna be supreme over all state insurance law. The only other place where federal law preempts and basically takes precedent over state law is something where the federal government is the only person doing this. And so the best example of that is nuclear power. The federal government pretty much controls all nuclear power plants and nuclear power and radiation, that kind of stuff. Or, and so it's assumed that they, what they say about this takes precedent over state law. So having said that and giving you a small lesson in preemption, what the Texas law said is that since EMTALA does not specifically have a preemption clause, they cannot force us to change our abortion law. Interesting enough though, Idaho, the federal courts in Idaho have taken the same exact issue and ruled on the opposite, that the EMTALA has to be enforced in the emergency room when it comes to an emergency medical condition that would result in an abortion. So it has yet to be finally decided, but just to give you an example of what the courts are looking at when they look at EMTALA enforcement. So as I've said already multiple times, when you are creating policies for your program, EMTALA is only part of the picture. So you need to know what is VAWA required for payment and law enforcement cooperation. You need to know who qualifies for your crime victims reparations, what are your sexual assault kit tracking laws, and what are any state SANE requirements for care. So as you create a policy, it's hard to do just an EMTALA policy. You need to be aware of all of these laws and how they impact when you create a policy for how you're going to provide care to sexual assault patients. To give you some examples of states that are regulating SANE practice. So the Texas Health and Safety Code, you must notify a patient if you are not a safe ready hospital. And there are specific requirements for being a safe ready hospital. You can offer transfer to a safe ready facility. So state law is giving you the ability to do that. And all ER nurses must have evidence collection training at a minimum of two hours. So again, if you're in the state of Texas, you need to know what your law requires and how that works with EMTALA. Illinois has a forensic services or transfer services must be available. So if you're an Illinois hospital, you either have to be able to provide those on site or be able to provide a transfer. You have to have submitted a plan to the state about how you're going to handle sexual assault patients. And you can't just say, well, I'm going the hospital down the road has SANE services. I'm going to just transfer to them. There has to be an agreement with that hospital. And right now, Pennsylvania Senate Bill 414 is in the proposal stages. And what they are requiring is a hospital website will have to list the capabilities of whether or not there's a SANE available. So applying EMTALA. So let's, and you can kind of answer this in the chat. You're in a community where you have four hospitals, three have SANE programs, no one has 24-7 coverage. So first of all, if you're one of those four hospitals, does EMTALA apply? And you can just put it in the chat if you want to chime in or wait and we'll discuss it. Yes, yes, you're right. EMTALA is going to apply because you are an emergency room department with, and you take Medicare patients. So those would be the things. If you don't take Medicare patients and you don't have an emergency room available to patients, then it doesn't apply. So I'm local law enforcement and I have a patient who needs a SANE exam and I'm calling your hospital to find out if you have a SANE on call and you tell me no. Is that an EMTALA violation? Right. Because you've not done anything that EMTALA triggers, that is triggering EMTALA. The patient's not at the hospital. Law enforcement is not an ambulance service. If the ambulance calls and says they're bringing a patient to your hospital and you don't have a SANE there, can you refuse that patient? No. And you're right. You cannot refuse the patient. You're going to have to figure out what to do with them once they get there. And what if a patient comes to the orthopedic clinic for a cast removal and says, oh, by the way, I was sexually assaulted two days ago. Has this now triggered an emergency medical condition? Would this be recognized as emergency medical condition? Are they asking for emergency medical care? It's going to depend, yeah, if it has a hospital in the process. So there's a lot we're going to kind of talk about these details. So these are the rules for ambulance. If your ambulance is owned by the hospital and they're bringing it to you, you have an EMTALA obligation to see that patient. You can't turn them away. If it's not owned by the hospital, but it still shows up on your doorstep, you have an obligation to treat that patient, to provide them with a medical screening exam, and to go through your process that you would do to provide that patient with care. If it is owned, your hospital owns the ambulance, but you have community-wide EMS protocols and the hospital goes to the closest facility, which is not you, that does not trigger an EMTALA obligation on your part because you own the ambulance. And if it's not owned by the hospital and the hospital is on diversion, but it has to be an official, we are on diversion, whatever your process is for announcing that, then you do not have an obligation. If you're on diversion and you've announced that because of capacity, and again, with COVID, I'm sure this happened quite a bit, and I'm sure there were diversions based on same patients not being able to be seen because of COVID. That does not trigger an EMTALA violation. So again, it goes back to seeking care versus emergency care. So if you have presented to a hospital's dedicated emergency department, and again, whether you are asking for medical care, someone is, or in the absence of such a request or by or on behalf of the individual, a prudent lay person observer would believe based on the individual's appearance or behavior that the individual needs examination or treatment for a medical condition. And I think when it comes to the medical forensic exam, typically our patients are sitting there calmly. They may be crying. They may look sad. They may have their head down, but there may not be anything obvious in their appearance or behavior that would lead to believe that they have an emergency medical condition. And again, these are the things that are going to get debated in the courts on a case by case depending on what happens next. And then when presenting to hospital services, so you've presented to the property as defined in this section other than the dedicated emergency department, and again, are you asking for care for an emergency condition? And going back to the person with the cast removal, are they asking for care as a result of their sexual assault? Are they just saying, you know, two days ago I was assaulted? That's, I think, you know, and my arm got twisted in the process. So when you check my cast, be aware of that. I think it's really going to be very fact specific there. Are they asking for that emergency medical care or not? And would the person, would a lay person believe based on the individual's appearance or behavior that the individual needs emergency examination or treatment? My favorite example was one of my patients came to see me and went up to the desk and then, why are you here today? And they said, I'm having chest pain. And they said, well, go wait. Susan will be ready to see you in about 30 minutes. And I'm like, fortunately, I found out in less than 30 minutes that they were complaining of acute chest pain. And we immediately called EMS to get them to the hospital. So sometimes, meanwhile, they're sitting there looking very calm and collected, but they're having acute chest pain in MI. So again, I think you need to make sure your policies are in place to protect you no matter what the circumstances. So options to deal with this. And I work with a lot of rural hospitals in Utah. And we just had an incident where four different hospitals were called and there was no SANE available. So we are looking as part of our new state funding initiative to have a regional call schedule so that law enforcement's going to know and have access to schedules for all of those hospitals and know where a SANE is available so that they're not having to call five different hospitals. The other thing is, just because a SANE's not available does not mean you shouldn't offer advocacy services. So again, this goes back to taking care of that whole patient. Do you work with a community-based advocacy team? Do they have 24-7 response? If they don't, is there a hotline or a helpline that you can call and make sure that patient's emotional needs are taken care of? Is it reasonable to have the patient return for the medical forensic exam within a reasonable timeframe? And I know a lot of rural hospitals are going to that saying, listen, I know it's a pain, but don't bathe and we'll have you come back tomorrow morning at nine o'clock or we'll have you come back in three hours when a SANE can be available. And I'm not sure that that's such a bad option, but the patient needs to agree to that. And that's the whole thing. If you don't have a SANE available, you need to be able to you need to be able to provide the patient with options. And again, hopefully you're not going to delay things like every emergency room in my state is mandated to provide emergency contraception if a patient presents who has been sexually assaulted. So hopefully that's not going to get delayed to the next day. And if there's risk of HIV and a need for HIV prophylaxis, hopefully your emergency room staff can take care of that emergency need for the patient so that those aren't delayed, that the evidence can potentially wait. Yes, something may be lost, but that's not the emergency consideration. HIV prophylaxis, which is very Toms sensitive and emergency contraception should always be offered if possible. And again, as long as a transferring hospital accepts, yes. As long as a transferring hospital accepts, yes. So if you have it set up so that we're not able to do this and the transferring hospital accepts, that is perfectly okay. So we're going to talk a little bit, which is a great segue to talk about transfer under EMTALA. Sexual assault patient arrives at your hospital and you're only saying cannot come in for seven hours. Does this patient need a medical screening exam? And hopefully everyone is out there saying yes, yes, yes, yes. Can you discharge and have the patient go to another hospital? So that becomes the question is if you transfer, there is some language in EMTALA that may indicate that you have to do it via ambulance, which is a huge cost. So the reality is, are we talking about a transfer, which may require an ambulance, or can you discharge them? You've met their emergency, you've done your medical screening exam. They don't have an emergency medical condition. You may have already gone ahead and done emergency contraception and started them on their HIV prophylaxis. At that point, can you discharge them and then have them go to another hospital? Hopefully you will call that other hospital and made sure that they have a soft landing when they get there, but that is certainly an option. Can a patient refuse to be transferred to another hospital? Yes. And can another hospital refuse to take the patient? The only exception to that is the only time another hospital can't refuse to take a patient is if they are a specialty provider. So for example, if they are the regional burn center and you have a burn patient, I don't think this applies to sexual assault patients, but for other specialty services that are very high cost specific care, if you're the regional burn center, you cannot refuse a transfer unless you absolutely do not have beds. That's the only time a hospital cannot refuse a transfer. So you can't delay your medical forensic, your medical screening exam until the SANE arrives. And, and we know this used to happen. We know that these patients used to get put in rooms and sit there for hours waiting for someone to be free to come in and talk to them. They still have to, you still have to meet your basic Intala obligation. You can discharge a patient, but first you have to be treated for all medical emergency medical needs. And a patient that can refuse to be transferred, but should be prepared to have a patient signed and informed refusal. So you need to be able to say to the patient, we cannot do your medical forensic exam. We would like to transfer you to this hospital that can, and they're saying, I don't want to do this. Then you protection sake, you should probably have some sort of informed refusal and hospitals can refuse transfer if they do not have capacity. So here's some more transfer requirements under the statute. Is it an Intala violation if the patient is discharged from hospital X and told to go to hospital Y, but hospital X does not. Well, if they're discharged, it's not an Intala violation. Is it poor patient care? Yes. I mean, if you've done your medical screening exam, if you have met all their emergency medical needs, then what you're saying is that that medical forensic exam is not emergency care and I'm discharging them. But I think, again, you have an obligation under other aspects of your nurse practice act and other kinds of care to make sure that you're sending that patient to a soft landing. And that they are going someplace where they will get the care they need. I think that's an ethical obligation more than Intala obligation, if you can. But again, you may be in a jurisdiction where they've said the medical forensic exam is emergency care and that you can't discharge, you have to transfer and that transfer has to be accepted. So medical screening exam, medical care, what does a transfer require? Again, you're going to get sick of hearing this, but you need the MSE, you need medical care within your capabilities to stabilize the patient, care to reduce the risk of transfer if you're unable to care for that patient's needs, and physician certification that the risk of the transfer are outweighed by the benefits of care reasonably expected at the destination hospital that cannot be provided at your hospital. Or, as in the case of the second lawsuit, the woman wanted to be transferred to another hospital where she could get a medical forensic exam. But again, and this goes back to the comment I meant about your waiver, it should not be influenced by the hospital or anyone affiliated directly or indirectly with the hospital. And that's for patient requested transfer. I think you need to make sure that if you're using a waiver, and this is just my opinion, it's not a legal opinion, that it's very clearly spilled out the risk and benefits. And I think it sounds like you've done that. But again, it should be approved by your hospital legal counsel who also understands if there's any state law implications. So again, it requires, when you're transferring, it requires advanced acceptance from a hospital that is capable of providing the assessment or care that's not available at your hospital. So transferring them down to the road to another hospital that doesn't have the same nurse is not going to be acceptable. Okay, so our hospital is SANE certified. Are you in Texas? Philip? Oh, you're in New York. So and I haven't looked at your laws. Our hospital is SANE certified, but never has SANE available, wants ED nurse to do it. I feel this is inappropriate. Not trained transfer here would be appropriate. So here the issue becomes, is this a malpractice issue? Because it's not an EMTALA issue. Again, it goes back to the fact that EMTALA is not a federal malpractice statute. So just because they're going to get a less than adequate medical forensic exam does not trigger EMTALA. That triggers a malpractice issue. And so it comes down to whether your hospital wants to set themselves up for liability for being sued for malpractice if they do a lousy job with a medical forensic exam. Unfortunately, our patients are incredibly vulnerable, and I don't see them suing or having the knowledge to know that they got a bad medical forensic exam, except when things are obvious like being told in the waiting room you don't qualify in front of everybody. So transfer is not appropriate here because they're saying we can give the care. So it doesn't become an EMTALA issue. Okay, Lisa wants to know, is it acceptable to document in the medical record the patient does not want to have a forensic examination at this time rather than a signed refusal? Well, the informed refusal is not for care, it's for transfer. So it's absolutely fine to not provide care if a patient doesn't want it, right? The patients always have the right to say no to care. So it's not an EMTALA issue. It's a basically I don't want this care to happen. Oh no, you're in Arkansas. Okay, so again. All right, so what does a transfer require? Patient signed consent for transfer, list of risk and benefits, transferred by appropriate medical vehicle with appropriate personnel equipment. So this is why you may want to look at discharging patients instead of transferring them, because I think EMTALA is pretty much saying if you're transferring, you might have to use an ambulance. And again, this is something you need to discuss with your hospital legal counsel. And that at that point, you need to send copies of your medical records and the visit and testing and imaging so that the hospital gets there and knows that you've already given emergency contraception or HIV prophylaxis. So best practices. Do not delay the medical screening exam until saying can come to the hospital. The health care of the patient should always come first and forensic evidence collection should not be the priority. And I always like to quote the great Kim Day in every presentation I give, it is not about the box what we do. And when we make it about the box, we're not doing it. It is not about the box what we do. And when we make it about the box, we're not necessarily giving the best patient care. If you must transfer a patient to get a medical forensic exam, assess and stabilize. Physician certification, advanced acceptance, meaning they have to be willing to take the patient and get signed consent from the patient. And discharge may be the best option. You got to document that you did a medical screening exam, testing, testing and consults. Note that no emergency medical condition was identified or if it was identified, it was resolved. You need a policy. If you want to avoid EMTALA accusations, you need a policy in place. And you need to especially have this if you are not providing 24-7, 365 care. And you want to work with your SART to make sure they know how to access care for survivors. So, again, if you think of your role as the same, one of the important aspects of your role is being part of a multidisciplinary team. It is not fair to make your team members guess whether you can do a medical forensic exam at your facility or not. So, this is why it is so important to be involved in a SART and to let them know what your capability is. And again, I work with a team that provides, I recently retired from a team that provides 24-7 call for four counties. And they are pretty much responding within an hour. Those patients don't have anything to worry about as far as access to care. But I work with very rural communities where they have a total of maybe six trained SANEs in an area where the driving time is one to three hours. They just don't have the capacity to do 24-7. So, we're really going to try and make them have a call schedule available so we know when those nurses are in the ER and so that patients can have access to care. So, I think you've been asking questions all along. But any final follow-up questions before we end this today? Or comments? Or things that you disagree with which you're totally entitled to disagree with? So, Anthea, how do you provide call 24-7 for 10 counties? And has this been a long-term commitment or a short-term commitment? Because, again, we need to look at solutions for your community to change that. So, I'll put my email in the chat. You're always welcome. If I can remember my email. I'm always willing to chat with people about community solutions, things you can do to improve access. I did want to show you the references and the article there, Lies, Damn Lives, and Narrative. I was able to Google it and get it offline. It's an old article, but it's fascinating to read about how MTALA came to be through narrative. We're very rural. Two hours to the next hospital with an exam team. And that's the reality of rural hospitals. So, I think it's perfectly okay. And maybe you, again, whenever you do this kind of policy, you need to talk about, and I'm going to quit sharing my screen here. Oh, Susan, keep that up, just because I'll do the next couple slides. Okay. Oh, I'm sorry. No, fine. I'll move to the next slide. I keep forgetting you get to end this. I think you need to always have the input of your crime lab, your police, and your prosecutor. So, for example, could you put together a protocol where every emergency room nurse can at least do a mouth swab and collect urine for toxicology and somehow store that forensically so that it's maintained until the same nurse can come in? I mean, those are the two things that would allow your patient to eat and to continue to void with instructions. But, again, your crime lab may not want two separate evidence people collecting evidence. They may want all evidence collected at the same time by the same provider. So there are lots of things that have to be talked out with your other team members before you create a protocol that would allow patients to come in, get their emergency needs met, preserve a minimal amount of evidence, and then allow for the complete medical forensic exam to happen. Susan, I guess maybe that even goes along with a question that Jacqueline asked right above where you put your email. If we don't have it available, is it good to discharge it and inform the patient to return in the morning? I think if you have a procedure in place and you have to come up with instructions for the patient, and the patient has to be okay with it. But, again, because we also know, and this is one of the reasons why our big program in Utah goes to the hospital, we know that if we send patients to another location, half the time they're not going to show up. And we know that chances are, if you send this patient home, that they may not return in the morning. So I think you need to realize that that can potentially happen. So you don't want to send them out the door without their emergency contraception and their STI prophylaxis. Susan, I think this was so informative. This answered a lot of questions I think I've always had kind of just in my head of, was this how it went or was this not? And especially, you know, the delineation between urgent cares and ED. So that was a really awesome. Thank you so much. There's one more question in the chat. We serve a large community and we aren't able to provide 24 seven, which is the reality for the majority of the United States. We almost do, that's great. And that is what we do if a SANE isn't available. Every once in a while, we can refer them to a neighboring jurisdiction. Yeah, I think you need, you don't want to make that decision at two in the morning. You want to have a plan in place before that patient shows up. And that's true for the patient with the mental health problem. That's true for, I mean, you need to be able to think outside of the box. What could we potentially see? And that's why SART is also so important is to have these discussions ahead of time so that all your team members know what you're going to be doing. And I think I'm giving you back a couple of minutes to your day today. Yeah. Susan, I think another point to that is always, who do you call in the middle of the night? Who's your contact person to ask that question? Is that like the nursing supervisor? Is that your admin on call? Do you have legal that you can talk to? So that's a really good point. That being said, thank you everybody so much for attending. As a reminder, if you have multiple people watching, I am putting that email in the chat for you to send that list of those who did watch it, but did not technically register. So again, our webinar today is being supported through IFN's Technical Assistance Grant. Through that grant, IFN has the Safe TA website. This houses various educational opportunities, resources, and the national guiding documents. Now you can contact IFN with your request for technical assistance by calling the TA line at 1-877-879-7278, which is listed at the top of the webpage. But you can also visit the webpage at safety.org to submit a request form online. To do so, click on the request TA button on the Safe TA webpage. I know a lot of thoughts probably came up through this presentation. So if you have ongoing questions or anything else and you're unable to reach out to Susan, this is a perfect place to put those questions and we can help you with that. And I'll just warn you, if you send me an email and I don't respond within 48 hours, send it again because it means you're now 200 down in the pile. And I may have looked at your email and said, I can't answer that right this minute. It's gonna take me a minute. So don't be afraid to harass me. And then on that note too, you can also continue the learning with upcoming webinars. So visit www.safeta.org forward slash events to learn more and register today. There's a bunch that are upcoming. And then, thank you again, Susan, for being with us today. And thank you all for joining us. Please remember to complete the webinar post evaluation that Mary Kate put in the chat and you will receive it via email shortly after this webinar concludes. We're looking forward to connecting with you all in the near future and hope you have a wonderful day. Thank you all very, very much. And again, Susan, thank you. Thank you for all your help. Do you see the question about showing up at the Online Learning Center? It won't show up in the Online Learning Center. These don't show up in the Online Learning Center for CEs because they're done through SafeTA, right? No, you can, and you can receive it. It's just free to access. So just reach out to us if you do need that. Yeah. My question is, can they watch it later? Will this be posted in the Learning Center for later watch? Yes, it will. Okay. And you'll actually get an email with that. If you don't see it come across eventually, just bear with us till it gets there. Reach out to SafeTA and ask, especially. That is a good question. Not really sure how long until it shows up. Just depends on how it gets approved in that process. All right, are we good to close? Also, Philip, you can fill out that eval that Mary-Kate posted earlier, just like a couple back, and you can fill that out now, since you've already watched it today. Perfect, yeah, Mary-Kate re-posted it. Otherwise, we're good to close. Thank you all so much. Please reach out with any questions at safetyaid.org. Bye.

EMTALA regulations

medical care

sexual assault

medical screening exams

case law

obligation of hospitals

SANE nurses

protocols

recurrent sexual assault

legal guidance

pediatric patients

collaboration