The Emergency Medical Treatment and Active Labor Act (EMTALA) enacted by congress in 1986, was put in place to ensure patient access to emergency care regardless of ability to pay. EMTALA was also intended to prevent “patient dumping”, which is the act of transferring an uninsured patient to another facility exclusively for financial reasons without regard to that patient’s medical condition. The information in this newsletter is a follow-up to the UPLNC blog from December 12, 2012.
The EMTALA law applies when a person goes into an emergency department (ED) or labor and delivery department, and asks to be examined or treated for an “emergency medical condition (EMC).” It also applies if someone else asks for care for that person on that person’s behalf.
How is an EMTALA violation identified?
First, we must have an understanding of what an “appropriate” medical screening exam actually is. A MSE should be considered an ongoing process as opposed to a triage assessment or a one-time meeting between patient and physician. The MSE includes the history and physical of the patient, focused assessment of the presenting complaint, and any tests needed for further evaluation and diagnosis, including lab work and radiological studies. The MSE may also include consults from medical specialists, for example a cardiologist or gastroenterologist. Unfortunately, there is no specific definition of an MSE in the EMTALA statute, so providers should follow the standards of care for the treatment of patients with the same or similar complaints. When assessing a case for an EMTALA violation, we first identify the standards of care; then determine if the treating providers followed those standards during the MSE; and finally we must decide if an emergency medical condition was correctly identified or ruled out. Failure to follow the standards of care results in a failure to provide an appropriate MSE.
If the screening exam results in an EMC, the patient must then be stabilized within the hospital’s “capabilities”, and/or arrangements made for transfer of the patient to a hospital that can appropriately stabilize and/or treat the patient. Stabilization means that treatment is rendered such that the doctors are reasonably sure that the patient’s condition would not deteriorate as a result of a transfer or discharge. A hospital that transfers a patient to a facility that delivers a higher level of care is not an EMTALA violation; as long as the patient is appropriately stable. When determining if a patient is stable for transport, the sending physician must also consider the effect on the patient if the services provided by the receiving hospital were delayed.
example of failure to stabilize: If an adult develops chest pain while in a pediatric hospital than the pediatric ED staff would then be obligated to stabilize the patient to best of their ability; as opposed to simply waiting for EMS to arrive. Treatment may include establishing IV access and administering oxygen. Failure to do so would be an EMTALA violation.
Once the decision is made to transfer a patient, the transferring doctor must identify and document the name of the receiving facility and receiving doctor. He or she also must send all documentation related to the care and treatment of the patient to the receiving facility. Conversely, the receiving facility, specifically a doctor, must accept the transfer as long as it has the capacity to do so. They are also obligated to report EMTALA violations by a transferring facility.
example of transfer violation: A patient comes to a hospital that does not accept the patient’s insurance type. The emergency department staff calls for an ambulance and directs the crew to take the patient to a nearby emergency department without contacting the receiving hospital and arranging for admission. Failure to arrange for a receiving physician to assume care of the patient is an EMTALA violation.
PLEASE NOTE: Sending a patient from one emergency department to another is not necessarily a violation of EMTALA. This occurs commonly when the receiving hospital is expecting a bed to open in the inpatient floors but there is a delay in making that bed available. The difference between a violation and an appropriate transfer is the communication between the sending physician and the receiving physician; and acceptance of care by the receiving physician.
In January of this year, Holmes Regional Medical Center in Florida agreed to pay $50,000 to settle its liability for allegedly failing to provide an appropriate MSE and stabilize a 30 year-old pregnant woman with chest pain who presented to their ED. The woman and her baby both died. These types of violations are happening all over the country. Last year, violations were documented in Michigan, Illinois, North Carolina, Massachusetts, and several other states. Summaries of these violations can be seen here at the site of the Office of the Inspector General.
Failure to adhere to the three duties required by EMTALA can result in serious patient injury or death. Obviously, this opens the door for civil litigation, many examples of which already exist.
Information for this newsletter was obtained from the following websites:
http://www.aaem.org/em-resources/regulatory-issues/emtala
https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp
http://emedicine.medscape.com/article/790053-overview#aw2aab6b2
http://www.medlaw.com/healthlaw/EMTALA/index.shtml
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1305897/
