EMTALA Emergency Medical Treatment and Active Labor Act William F. Jourdain
EMTALA BASICS! Federal law enacted in 1986! Where a person comes to the dedicated emergency department (DED) or hospital property and request is made for (or symptoms require) examination or treatment, MUST:! Provide appropriate medical screening! Provide necessary stabilizing treatment! Provide appropriate transfer
What is DED or Hospital Property?! DED if licensed by the state as ED or ER;! Held out to the public as a ED or ER;! During preceding calendar year provided at least one third of outpatient care to treatment of emergency medical conditions on urgent basis without appointment.
What is DED or Hospital Property?! Hospital property is the entire main campus of the hospital including parking lots, sidewalks, and driveways.! Does NOT include other areas or structures of hospital!s s main building such as physician offices, skilled nursing facilities, shops, restaurants or other non- medical facilities.
What is DED or Hospital Property?! "Campus# has been defined as "The physical areas immediately adjacent to the provider!s s main buildings, other areas and structures that are not strictly contiguous to the main buildings but are located within 250 yards of the main buildings, and any other areas determined on an individual case by case basis, by CMS regional office to be part of the provider!s campus#
What is DED or Hospital Property?! In certain situations, can also apply to:! In hospital owned ambulance;! In non-hospital owned ambulance on hospital property.
!Comes to the ED"! Not already an inpatient! At DED and requests examination or treatment for a medical condition, request is made on their behalf, or "a a prudent layperson observer would believe, based upon individual!s s appearance or behavior that the individual needs emergency examination or treatment#.
!Comes to the ED"! At hospital property other than DED and requests examination or treatment for WHAT MAY BE AN EMERGENCY MEDICAL CONDITION, request is made on their behalf, or "a a prudent layperson observer would believe, based upon individual!s s appearance or behavior that the individual needs emergency examination or treatment#.
!Emergency Medical Condition"! "A A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of immediate medical attention could be reasonably expected to result in:! Serious impairment of bodily functions;! Placing the health of person (or woman and unborn child) in serious jeopardy;! Serious dysfunction of any bodily organ or part.#
!Emergency Medical Condition"! In case of pregnant woman having contractions, "emergency medical condition# if there is inadequate time to effect a safe transfer to another hospital before delivery of the child; or that the transfer may pose a threat to the health and safety of the woman or unborn child.
Appropriate Medical Screening! "Process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist#! If hospital applies in a nondiscriminatory manner a screening process that is reasonably calculated to determine if a EMC exists, it has met its EMTALA obligations.
Appropriate Medical Screening! Ongoing process - not isolated event! Elements:! Log entry with disposition! Triage record! Ongoing recording of vitals! Oral history! Physical examination! Use of all available testing resources! Use of on-call physician as needed! Discharge or transfer vital signs! Adequate documentation of all of the above
Appropriate Medical Screening! Poor outcome not indicative of inappropriate screening.! Incorrect diagnosis not indicative of inappropriate screening.! Follow above guidelines and document what was done to comply with EMTALA! SCREENING MUST BE UNIFORM AND REASONABLE! Same for every patient with similar condition
Appropriate Medical Screening! Clinical Guidelines of Hospital can be used to judge appropriateness of screening.! Failure to follow could be construed a failure to comply with EMTALA! If no Clinical Guidelines, will likely be judged by the standard of care applicable to like and surrounding circumstances.
Appropriate Medical Screening! Who performs the medical screening?! The examining physician or other qualified medical personnel (QMP).! QMP must be established by hospital rules or by-laws approved by the governing body.! Cannot be an informal delegation by the physician or ER director.
Appropriate Medical Screening! Registration of Patient?! May not delay appropriate medical screening exam to inquire about method of payment or insurance status.! May follow reasonable registration processes including obtaining insurance information as long as inquiry does not delay screening or treatment.! Registration process may not discourage individual from remaining for further evaluation.! "The registration process permitted in the dedicated ED typically consists of collecting demographic information, insurance information, whom to contact in an emergency and other relevant information.#
Stabilizing Treatment! What if patient refuses?! Medical record MUST contain a description of the examination and/or treatment refused;! MUST attempt to obtain written informed refusal of examination/treatment;! MUST document that person was informed of risks and benefits of examination/treatment;! MUST document the reason for the refusal and steps taken to try to get written refusal if it was not obtained.
Stabilizing Treatment! Parental Consent?! Must screen even if no parental consent.! If no emergency medical condition requiring stabilizing treatment, can wait for parental consent.! If EMC, must initiate stabilizing treatment even if no parental consent.! Should document any and all attempts to obtain consent from parents if screening/treatment without consent.
Stabilizing Treatment! "Stabilized#! "No material deterioration of the condition is likely, within reasonable medical probability, to result or occur during the transfer of the individual from a facility.#! When determined with clinical confidence that emergency medical condition has been resolved.! After a pregnant woman has delivered the child and the placenta.! A patient can be critical, but stabilized.! Psychiatric: When patient is protected and prevented from injuring himself or others.
Stabilizing Treatment! Physician must determine whether patient is stabilized.! Physician must sign EMTALA transfer certificate that patient is stable for transfer.
Stabilizing Treatment! On call physician must come to ED if requested by attending ED physician to provide stabilizing treatment in subspecialty of on call physician.! Duty of hospital to maintain on call list and coverage.! Hospital has discretion to maintain on call list "in a manner that best meets the needs of its patients#.
Transfer of Patient! Away from DED and hospital property at direction of employee or representative of the hospital.! Requirements:! Must be "appropriate#;! Person requests the transfer in writing after being informed of risks and benefits of transfer;! Written certification of physician that benefits of transfer outweigh risks of transfer and risks and benefits must be listed on certificate.
Transfer of Patient! "Appropriate Transfer#! Requirements:! Transferring hospital provides medical treatment within its capacity that minimizes risk to health of person;! Receiving facility! Has available space and qualified personnel;! Has agreed to accept the transfer;! Medical records regarding EMC sent with patient;! Transfer effected through qualified personnel and transportation equipment (including life support equipment).
Transfer of Patient! Hospital with specialized capabilities (burn units, shock-trauma units, neonatal intensive care, etc.) may not refuse transfer if person requires the specialized care and if the facility has the capacity to treat the person.
EMTALA Summary! Where a person comes to the dedicated emergency department (DED) or hospital property and request is made for (or symptoms require) examination or treatment, MUST:! Provide appropriate medical screening! Provide necessary stabilizing treatment! Provide appropriate transfer
Violations of EMTALA! CMS investigates EMTALA violations and OIG enforces through Justice Department.! Civil Monetary Penalties:! $50,000 per violation for hospital that negligently violates EMTALA ($25,000 if under 100 beds);! Physician who negligently violates EMTALA subject to penalty of not more than $50,000 per violation.! Private individuals may sue hospital and doctors under EMTALA (can also make general medical malpractice claims);! Two year statute of limitation to bring claim/suit.
Violations of EMTALA! Between 1986 and 1996, government collected approximately $1.45 million for EMTALA violations.! During 1997 and 1998, it collected greater than $2 million.! Between 2002 and 2005, approximately 100 enforcement actions by the government resulted in over $2 million in penalties paid.! In 2006, government collected $680,000 for EMTALA violations.! This does not include any private EMTALA related medical malpractice verdicts/settlements during these time frames.
EMTALA QUESTIONS William F. Jourdain