EMTALA

Prepared by:Sarah Axler, MD

University of Connecticut

Introduction

• Emergency Medical Treatment & Active Labor Act

• Federally-mandated requirement

• Patient anti-dumping law

Objectives

• EMTALA: When? What? Whom?

• EMTALA requirements

• EMTALA exceptions

• Violations

When does EMTALA apply?

1. Individual comes to E.D. & requests treatment

– Regardless of ability to pay, insurance status, citizenship, ethnicity, …

2. ‘Prudent Layperson’ Standard: Individual’s appearance or behavior would cause a prudent layperson to believe that examination or treatment is needed

What constitutes an ‘E.D.’?

• Dedicated emergency department

• Hospital property

• Ambulances

Photo Courtesy of U.S. Army

To whom does EMTALA apply?

• All Medicare-participating hospitals

• Any physician responsible for examination, treatment, or transfer of patient in an ED– Including physician-on-call

EMTALA Requirements

1. A hospital must perform a medical screening exam to any person coming to ED seeking care

2. A hospital must treat any patient with an emergency medical condition until stable, or must transfer the patient

3. A hospital may not transfer an unstable patient

MSE: Medical Screening Exam

• Performed by a ‘qualified medical person’ (QMP)– MD, DO, PA, NP, midwife– Anyone defined by hospital privileges as QMP

• MSE cannot be delayed to inquire about payment or insurance status

• Triage ≠ MSE

EMC: Emergency Medical Condition

• Definition: When absence of immediate medical attention could result in:– Placing health of a person or unborn child in

serious jeopardy– Serious impairment to bodily function– Serious dysfunction of part of the body– Severe pain

• No EMC found?– Hospital has no further legal obligation to treat

Pregnancy

• Pregnant women with contractions are considered to be medically unstable (active labor)

• QMP must certify that the patient is in false labor

US Air Force / 445th Airlift Wing Maj. Ted Theopolos

Stabilization

• Definition: Medical treatment of an EMC within the capabilities of the facility & staff

• After stabilization, there are no further EMTALA obligations

Patient Refusal of MSE or Treatment

• Inform patient of risks of refusal

• Document this conversation in the medical record

• Attempt to obtain patient’s written refusal

On-call Physicians

• Must respond within ‘a reasonable amount of time’ when requested

• Hospital must have policy in place for back-up or transfer if on-call physician cannot respond

Picture: Ed Edahl, Federal Emergency Management Agency

Transfer

• Reasons for transfer:1. Appropriate care is not available at the

current facility

2. Patient requests transfer

• Hospital discharge is considered a ‘transfer’

Before Transfer …

1. Treat & stabilize patient as far as possible

2. Patient must sign certification / informed consent for transfer

3. Contact receiving hospital

4. Receiving hospital must accept transfer

5. Send copies of medical records & test results

6. Arrange necessary personnel & equipment for transfer

Transfer: Receiving Hospital

• Must accept transfer if hospital’s capabilities to treat the patient exceeds risks of transfer

• Not obligated to conduct another MSE

• Snitch Rule: Receiving hospital must report cases of inappropriate transfers

Patient Refusing Transfer

• Inform patient of risks & benefits of transfer– Document conversation in medical record

• Attempt to obtain patient’s written refusal of transfer & reason for refusal

• Continue to treat patient until stable

EMTALA Sign

• Must be posted in all public entrances, registration areas & ED waiting areas

Enforcement

• Maximum fine per violation: $50,000 – $25,000 for hospitals with <100 beds

• Gross violations can lead to termination of Medicare funding

• Individual doctors CAN be fined!

Take Home Points: EMTALA

• Every patient presenting to any ED must have a medical screening exam

• Every patient with an emergency medical condition must be stabilized and/or transferred

• Before hospital transfer, a patient must be stabilized as far as possible

• EMTALA is enforced with hefty fines

Conclusion

• Treat EVERY patient that comes to the ED to the best of your ability without regard to their ability to pay