1. EMTALA Emergency Medical Treatment and Active Labor Act
As part of our annual education, it is highly recommended that you print the handouts associated with this presentation and take notes along the way. As you will see at the conclusion of this lesson, it is extremely important that you understand what EMTALA is and the role that you play in the compliance of this law. Handouts can be found in the digital library , click on the folder icon in the lower left hand corner of your screen.
For those working on the frontline.

2. What is EMTALA?
The Emergency Medical Treatment and Active Labor Act is a FEDERAL statute which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he/she is in an unstable medical condition.
EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as "the COBRA law". In fact, a number of different laws come under that general name. Another very familiar provision, also referred to under the COBRA name, is the statute governing continuation of medical insurance benefits after termination of employment.
EMTALA applies only to hospitals that participate in the Medicare Program.
Let’s begin by discussing, What is EMTALA? The Emergency Medical Treatment and Active Labor Act is a FEDERAL statute which governs when and how a patient may be (1) refused treatment or (2) transferred from one hospital to another when he/she is in an unstable medical condition.
EMTALA was passed as part of the Consolidated Omnibus Budget Reconciliation Act of 1986, and it is sometimes referred to as "the COBRA law". In fact, a number of different laws come under that general name. Another very familiar provision, also referred to under the COBRA name, is the statute governing continuation of medical insurance benefits after termination of employment.
EMTALA applies only to hospitals that participate in the Medicare Program.

3. So What Does All of That Mean to You?
Simply put, it means that any and all patients who present to the Emergency Department (or on hospital grounds) and that request assistance for a possible emergency medical condition, must at a minimum, receive a medical screening by a qualified medical professional and, if needed, receive medical stabilization and an appropriate transfer if necessary.
Simply put, it means that any and all patients who present to the Emergency Department (or on hospital grounds) and that request assistance for a possible emergency medical condition, must at a minimum, receive a medical screening by a qualified medical professional and, if needed, receive medical stabilization and an appropriate transfer if necessary.

4. Who is a Qualified Medical Professional?
EMTALA allows for individual hospitals to identify, in their hospital bylaws, who the qualified medical professionals are.
Putnam General Hospital procedures state that medical screenings may be done a qualified member of the medical staff.
Let’s define a Qualified Medical Professional. EMTALA allows for individual hospitals to identify, in their hospital bylaws, who the qualified medical professionals are. The screening must be performed by a qualified member of the medical staff.

5. What is an Emergency Medical Condition?
The definition provided under the statute is:
"A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in -- placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, or
"With respect to a pregnant woman who is having contractions -- that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or her unborn child."
So what is an Emergency Medical Condition? It is a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy, serious impairment to bodily functions, or serious dysfunction of any bodily organ or part, or
"With respect to a pregnant woman who is having contractions --that there is inadequate time to effect a safe transfer to another hospital before delivery, or that the transfer may pose a threat to the health or safety of the woman or her unborn child."

6. Caution!! According to CMS Interpretive Guidelines
Some intoxicated individuals may meet the definition of “emergency medical condition” because the absence of medical treatment may place their health in serious jeopardy or result in serious dysfunction of a bodily organ. Further, it is not unusual for intoxicated individuals to have unrecognized trauma.
According to CMS Interpretive Guidelines, some intoxicated individuals may meet the definition of “emergency medical condition” because the absence of medical treatment may place their health in serious jeopardy or result in serious dysfunction of a bodily organ. Further, it is not unusual for intoxicated individuals to have unrecognized trauma.

7. Caution!! According to CMS Interpretive Guidelines
Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would be considered an “emergency medical condition.”
Likewise, an individual expressing suicidal or homicidal thoughts or gestures, if determined dangerous to self or others, would be considered an “emergency medical condition.”

8. What is an Acceptable Medical Screening?
CMS Interpretive Guidelines state the following;
Individuals coming to the emergency room must be provided a medical screening beyond initial triage.
The medical screening must be the same medical screening that the hospital would perform on any individual coming to the hospital’s emergency room with those signs and symptoms, regardless of their ability to pay.
Medical Screenings. What is acceptable? CMS Interpretive Guidelines state the following:
Individuals coming to the emergency room must be provided a medical screening beyond initial triage. The medical screening must be the same medical screening that the hospital would perform on any individual coming to the hospital’s emergency room with those signs and symptoms, regardless *of their ability* to pay.

9. A Note about Financial and Registration Inquiries
With regard to requesting financial information from a patient, first, a facility (or its agents) may not contact an individual’s insurance company until after the medical screening has been completed.
The facility may provide a reasonable registration, which may include asking if the individual has insurance, provided there is no delay for the individual to be screened.
**It is important to note here clarify what a facility may and may not do with regard to requesting financial information from a patient. First, a facility (or its agents) may not contact an individual’s insurance company until after the medical screening has been completed. If at that point no emergency condition is found to exist, the facility may find out insurance and financial information from the patient. If an emergency condition is found to exist, the facility must begin stabilizing treatment prior to requesting insurance or financial inquiries. A facility may not delay treatment in order to receive authorization from the individual’s insurance. Once the stabilization begins and the facility is allowed to contact the individual’s insurance company, the facility must continue to stabilize whether or not the insurance authorizes the treatment. While an emergency department physician or non-physician practitioner may contact an individual’s primary physician at any time, this may not inappropriately delay services to such individual.
However, when an individual presents at the emergency department, the facility may provide a reasonable registration, which may include asking if the individual has insurance, provided there is no delay for the individual to be screened. Staff members should be available to explain that the facility will provide screening and stabilization if necessary regardless of the individual’s ability to pay, and should encourage individuals to discuss further financial responsibilities after screening. If the medical screening reveals an emergency medical condition and the individual leaves on his or her own accord prior to receiving stabilizing treatment, the facility will not be considered to have dumped the patient as long as no staff member suggested that the individual leave and/or the facility was operating beyond its capacity and did not attempt to transfer the individual to another facility.

10. What is an Acceptable Medical Screening?
A medical screening examination is the 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.
Depending upon the patient, this process will vary from only a brief H&P to a complex process involving ancillary studies and specialty consultations.
A medical screening examination is the 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.
Depending upon the patient, this process will vary from only a brief H&P to a complex process involving ancillary studies and specialty consultations.

11. What is an Acceptable Medical Screening?
A medical screening is not an isolated event. It is an ongoing process.
Hospital and Department medical staff should address, through policy and medical standards, how best to provide the screening.
Medical Screenings are required to be documented.
If it isn’t written down, it never happened!!
A medical screening is not an isolated event. It is an ongoing process.
Hospital and Department medical staff should address, through policy and medical standards, how best to provide the screening.
Medical Screenings are required to be documented.
If it isn’t written down, it never happened!!

12. Medical Screening Documentation
Need to document why the patient is now stable enough to be transferred.
Is patient hemodynamically stable to the best of our capabilities?
Has psychiatric condition been evaluated and treated to the best of our capabilities?
Have any abnormal test (EKGs) been repeated if the first one was abnormal and the patient has been in our care for a lengthy period of time?
Medical Screening Documentation. You need to document why the patient is now stable enough to be transferred.
Is patient hemodynamically stable to the best of our capabilities?
Has psychiatric condition been evaluated and treated to the best of our capabilities?
Have any abnormal test (EKGs) been repeated if the first one was abnormal and the patient has been in our care for a lengthy period of time?

13. Caution!!
Regardless of a positive or negative patient outcome, a hospital will be in violation of the anti-dumping statute if it fails to meet any of the medical screening requirements.
If a misdiagnosis occurs, but the hospital utilized all of its resources, a violation of the screening requirement does not occur.
Regardless of a positive or negative patient outcome, a hospital will be in violation of the anti-dumping statute if it fails to meet any of the medical screening requirements.
If a misdiagnosis occurs, but the hospital utilized all of its resources, a violation of the screening requirement does not occur.

14. Transfers Documentation
Must show that the transfer was initiated by either a written request by the patient (or his/her representative) or a physician’s certification.
Must state the reason for the transfer.
The receiving facility and the accepting physician. Recommendation: Include a brief statement that the patient’s full condition was discussed with the accepting physician.
The risk and benefits of the transfer.
*Transfer documentation*:
Must show that the transfer was initiated by either a written request by the patient (or his/her representative) or a physician’s certification.
Must state the reason for the transfer.
*Must indicate* the receiving facility and the accepting physician. *It is recommended to* Include a brief statement that the patient’s full condition was discussed with the accepting physician.
*Must include* the risk and benefits of the transfer

15. Transfers Documentation
Risk & Benefits!!
Need to be realistic and pertinent to the case.
MVA is not usually a true risk of the transfer that needs to be documented in most cases.
Worsening of condition, lack of medical equipment, increase of pain, increase exposure to infection and no physician for intervention are some examples of true risk.
**Continuing with the last bullet from the previous slide, risks and benefits:**
Need to be realistic and pertinent to the case.
MVA is not usually a true risk of the transfer that needs to be documented in most cases.
Worsening of condition, lack of medical equipment, increase of pain, increase exposure to infection and no physician for intervention are some examples of true risk.

16. Sounds Simple But…….
EMTALA sounds simple but incidences happen everyday that could potentially cost a hospital thousands of dollars.
EMTALA sounds simple but incidences happen everyday that could potentially cost a hospital thousands of dollars.

17. CAUTION!!!!!!
Case history has not been kind to hospitals who utilized non-physician medical screeners even though by law, it is allowed.
TRAIGE IS NOT CONSIDERED TO BE A MEDICAL SCREENING!!!!!
Case history has not been kind to hospitals who utilized non-physician medical screeners even though by law, it is allowed.
TRAIGE IS NOT CONSIDERED TO BE A MEDICAL SCREENING!!!!!

18. The Simple Rules
Never turn a patient who is requesting treatment away from the facility once they are on hospital property.
Always perform a medical screening if the patient is requesting services.
Document Everything!!
Make Sure You Document Everything!!
The Simple Rules:
Never turn a patient who is requesting treatment away from the facility once they are on hospital property.
Always perform a medical screening if the patient is requesting services.
Document Everything!! and
Make Sure You Document Everything!!

19. Items of Interest
Diversions, (Arrington vs. Wong) Case study says that you cannot redirect an ambulance unless a compelling reason exists. (ex: lack of staff or resources.)
Do not pick and choose patients when on diversion.
Items of Interest #1:
Diversions, (Arrington vs. Wong) Case study says that you cannot redirect an ambulance unless a compelling reason exists. (for example: lack of staff or resources.) Do not pick and choose patients when on diversion.

20. Items of Interest
Specialized Hospitals do not have the EMTALA obligation to accept the transfer of patients who have already been admitted to another hospital, even if the unstable emergency medical condition present at original admission still remains.
Items of Interest #2:
Under the final rule, if an individual with an unstable emergency medical condition presents to a hospital and is admitted, the admitting hospital has satisfied its EMTALA obligation towards that individual even if the unstable emergency medical condition continues AND
If the patient is subsequently transferred to a hospital with capabilities for specialized care, that hospital does not have an EMTALA obligation to accept the individual.

21. Items of Interest New regulations do not pertain to inpatients.
Caution: Carey’s Opinion; be cautious about refusing an inpatient transfer from another hospital that has recently developed an emergency condition that is beyond the resources of the referring hospital.)
Items of interest #3:
New regulations do not pertain to inpatients. (Caution: Carey’s Opinion; be cautious about refusing an inpatient transfer from another hospital that has recently developed an emergency condition that is beyond the resources of the referring hospital.)

22. Items of Interest
An on call list must be maintained “in accordance with resources available to hospital, including availability of on-call physicians.”
But written policies and procedures must provide that emergency services are available to meet the needs of patients with emergency conditions and respond to situations in which a particular specialty is not available or on-call physician is unable to respond.
Items of interest #4:
Before the 2009 Final Rule Change, EMTALA required the ED call panel to maintain an on-call list in a manner that “best meets the needs of hospital’s emergency patients In accordance with resources available to hospital, including availability of on-call physicians.” CMS dropped the language “in a manner that best meets the needs of the hospital’s patients” from this requirement. CMS made this change because the previous language had caused provider confusing regarding what the standard was. CMS noted that the existing language stating that an on-call list must be maintained “in accordance with the resources available to the hospital” provides sufficient guidance that a hospital is obligated to provide on-call services based on the resources it actually has available at the time, including the availability of specialists. 
Of note, the failure to maintain an on-call list is no longer an EMTALA violation, but instead a violation of regulations governing provider agreements.

23. Items of Interest Community Call Plan
Hospital A
Items of interest #5:
The 2009 IPPS Final Rule adds the community call plan option to provide additional flexibility to hospitals to participate in a formal Community Call Plan to share on-call responsibilities. A community call plan must be a formal agreement, but does not require preapproval from CMS. Participation in a community call plan is strictly voluntary.
Hospital C

24. Items of Interest Community Call Plan Requirements
Clear delineation of on-call coverage responsibilities
Description of the specific geographic area covered
Written agreement signed by all hospitals
Assurances that any local and regional EMS system protocol formally includes information on “community on-call” arrangements;
Must specify that even if an individual arrives at a hospital that is not designated as the on-call hospital, that hospital still has an EMTALA obligation to provide a medical screening examination and stabilizing treatment within its capability, and perform EMTALA compliant transfers
Annual reassessment of the Call Plan by participating hospitals
Items of interest #6:
These are the minimum requirements, and CMS notes in the preamble, a plan may take different forms. CMS is trying to give hospitals more flexibility.
This does not take away from the hospital’s other EMTALA requirements. Hospitals are still required to perform medical screening examinations and provide for a transfer when appropriate. Additionally, hospitals participating in a community call plan must have written policies and procedures to ensure the availability of emergency medical services for individuals in need of emergency care.
Community Call Plans can pose some anti-trust and HIPAA concerns, so it is advisable to seek legal assistance when structuring this type of plan.

25. Items of Interest EMTALA WAIVERS
Sanctions for potential EMTALA violations may be waived for:
The inappropriate transfer of an individual who has not been stabilized where the inappropriate transfer arises out of the circumstances of the emergency; or
The direction or relocation of an individual to receive a medical screening examination at an alternate location pursuant to an appropriate State emergency preparedness plan or state pandemic preparedness plan.
Items of interest #6:
Prior to the amendment, the EMTALA regulations specified that sanctions for inappropriate transfers during a national emergency do not apply to a hospital with a dedicated emergency department located in an emergency area.
The IPPS final rule clarifies that the waiver of sanctions includes those for:
The waiver of sanctions applies to hospitals with dedicated emergency departments located in an emergency area during an emergency period. The regulations were also revised to specify a 72-hour duration of the waiver from EMTALA enforcement. The 72-hour period would begin with the implementation of a hospital disaster protocol. In the case of an infectious pandemic disease, however, the waiver would continue past the 72 hours and remain in effect until termination of the declaration of a public health emergency.
The Act further defines an emergency area as a geographical area in which there exists:
An emergency or disaster declared by the President pursuant to the National Emergencies Act or the Robert T. Stafford Disaster Relief and Emergency Assistance Act;
AND
A public health emergency declared by the Secretary.

26. Practical Case Study Let’s Discuss
Let’s discuss some practical case studies.
Let’s Discuss

27. Practical Lessons Case #1
The ER attending physician receives a call from a small rural hospital wanting to transport a 50 y/o male with chest pain to your facility. The rural hospital has done an EKG and performed blood work. Your ER attending denies the transport suggesting that the patient be admitted to the rural hospital for observation. The rural hospital does not have a cardiologist on staff.
Practical Lesson 1:
The ER attending physician receives a call from a small rural hospital wanting to transport a 50 y/o male with chest pain to your facility. The rural hospital has done an EKG and performed blood work. Your ER attending denies the transport suggesting that the patient be admitted to the rural hospital for observation. The rural hospital does not have a cardiologist on staff.

28. Is this an EMTALA violation?
YES!!
Why??
Under EMTALA, if a hospital does not have the staff or the resources to treat and stabilize a patient with an emergency medical condition, a tertiary care center (or any hospital) who does have the resources, has to accept the patient if requested.
Is there an EMTALA violation?
YES!!
Why??
Under EMTALA, if a hospital does not have the staff or the resources to treat and stabilize a patient with an emergency medical condition, a tertiary care center (or any hospital) who does have the resources, has to accept the patient if requested.

29. Case #2
A local law enforcement agency presents to the ER with a subject whom they have arrested. They request a psychiatric evaluation on the subject. The hospital is on psychiatric diversion due to no beds. The triage nurse advises the law officers of this and they voluntarily take the subject to another hospital.
Practical Lesson #2:
A local law enforcement agency presents to the ER with a subject whom they have arrested. They request a psychiatric evaluation on the subject. The hospital is on psychiatric diversion due to no beds. The triage nurse advises the law officers of this and they voluntarily take the subject to another hospital.

30. EMTALA Violation? Answer YES
Why: The patient was present on hospital grounds and a request for services was made. At a minimum, the patient should have had a medical screening completed and documented. If the law officers voluntarily decide to leave without a medical screening, it should be documented with the appropriate details that the patient left without being seen.
Is there an EMTALA violation?
YES
Why: The patient was present on hospital grounds and a request for services was made. At a minimum, the patient should have had a medical screening completed and documented. If the law officers voluntarily decide to leave without a medical screening, it should be documented with the appropriate details that the patient left without being seen.

31. Dealing With Psych Patients
ED physicians and staff should appropriately document any symptoms on which the determination that an emergency medical condition exists is based. Items to screen for:
Does the patient have a history of violence to himself or others?
Has the patient made a suicide attempt or voiced suicidal ideations?
Is the patient a potential danger to others through violent actions or threats?
Is substance abuse present that could impair their judgment or are they showing signs of confusion for which a reason cannot be determined?
Caution should be exercised when dealing with Psych patients. ED physicians and staff should appropriately document any symptoms on which the determination that an emergency medical condition exists is based. Items to screen for: Does the patient have a history of violence to himself or others? Has the patient made a suicide attempt or voiced suicidal ideations? Is the patient a potential danger to others through violent actions or threats? Is substance abuse present that could impair their judgment or are they showing signs of confusion for which a reason cannot be determined?

32. Case #3
A 23 y/o female presents to the ER requesting a suture removal. The wound appears to be healing appropriately and appears to be free from infection. The patient is evaluated and appears not to be suffering from any emergency medical condition. Due to the high volume of patients in the ER, the patient is referred to her primary care physician for suture removal.
Practical Lesson #3:
A 23 y/o female presents to the ER requesting a suture removal. The wound appears to be healing appropriately and appears to be free from infection. The patient is evaluated and appears not to be suffering from any emergency medical condition. Due to the high volume of patients in the ER, the patient is referred to her primary care physician for suture removal.

33. EMTALA Violation? Answer NO!!
Once the patient received a medical screening from a qualified medical professional and it was found that an emergency medical condition did not exist, EMTALA is no longer applicable. The medical screening should, however be documented.
Is there an EMTALA violation?
NO!!
Once the patient received a medical screening from a qualified medical professional and it was found that an emergency medical condition did not exist, EMTALA is no longer applicable. The medical screening should, however be documented.

34. Case #4
A middle aged male approaches the registration area and states that he would like to go to *“XYZ” hospital*. You give him directions to “XYZ” and he leaves without any further conversation.
Practical Lesson #4:
A middle aged male approaches the registration area and states that he would like to go to *“XYZ” hospital. You give him directions to *“XYZ” and he leaves without any further conversation.

35. EMTALA Violation? Answer: NO!!
Why: Because the subject did not ask for any medical services, only directions.
NOTE: If this person had displayed behavior that would lead even a prudent layperson to believe that a emergency medical condition did exist, you would have to offer a medical screening.
Is there an EMTALA violation?
NO!!
Why: Because the subject did not ask for any medical services, only directions.
NOTE: If this person had displayed behavior that would lead even a prudent layperson to believe that a emergency medical condition did exist, you would have to offer a medical screening.

36. CASE #5
The helicopter has just landed with a patient who is supposed to be a direct admit to the V.A. Hospital. The patient was stabilized at the referring hospital and has remained stable throughout the flight. The patient is brought through the ER enroute to the tunnel. Should the ER perform a medical screening?
Practical Lesson 5:
The helicopter has just landed with a patient who is supposed to be a direct admit to the V.A. Hospital. The patient was stabilized at the referring hospital and has remained stable throughout the flight. The patient is brought through the ER enroute to the tunnel. Should the ER perform a medical screening?

37. Case # 5 Review
Answer
NO!!
Why? Unless the patient requests (or a representative requests) a medical service, or the patient’s condition is such that immediate care is needed, EMTALA does not kick in.
Discussion:
Is there an EMTALA violation:
NO!!
Why?
Unless the patient requests (or a representative requests) a medical service, or the patient’s condition is such that immediate care is needed, EMTALA does not kick in.

38. Case # 6
Your UHC ambulance responds to a minor MVA. The patient is from out of town and requests to be taken to the closest hospital for evaluation. Your partner examines the patient and tells the patient that he doesn’t need to be transported by ambulance. You and your partner return to service.
Practical Lesson #6:
Your UHC ambulance responds to a minor MVA. The patient is from out of town and requests to be taken to the closest hospital for evaluation. Your partner examines the patient and tells the patient that he doesn’t need to be transported by ambulance. You and your partner return to service.

39. Case #6, EMTALA Violation?
YOU BET!!
If this patient is later found to have an emergency medical condition, EMTALA has been violated. A hospital based ambulance is an extension of the hospital. In addition, EMT-B and EMT-Paramedics are not recognized in the hospital bylaws as QMPs.
EMTALA Violation?
YOU BET!! Yes!
If this patient is later found to have an emergency medical condition, EMTALA has been violated. A hospital based ambulance is an extension of the hospital. In addition, EMT-B and EMT-Paramedics are not recognized in the hospital bylaws as Qualified Medical Professional.

40. Case #7
A 21 y/o female is brought by an outside ambulance to the ER. The patient is complaining of intermittent back pain. The patient is 38 weeks gestation with her first child. No radio report had been given and the patient arrived unexpectedly. The EMTs say the patient is to be admitted to OB. You direct the ambulance crew to *another hospital*.
Practical Lesson #7:
A 21 y/o female is brought by an outside ambulance to the ER. The patient is complaining of intermittent back pain. The patient is 38 weeks gestation with her first child. No radio report had been given and the patient arrived unexpectedly. The EMTs say the patient is to be admitted to OB. You direct the ambulance crew to another *hospital*.

41. Case #7 EMTALA Violation?
Answer: Yes
Why?: The patient may be in active labor. Without knowing any prior history, there is a potential danger of redirecting this patient without performing a medical screen.
Rule of thumb for active labor: It is active labor until observation for an acceptable period of time can prove otherwise.
Is there an EMTALA violation?
Answer: Yes
Why?: The patient may be in active labor. Without knowing any prior history, there is a potential danger of redirecting this patient without performing a medical screen.
Rule of thumb for active labor: It is active labor until observation for an acceptable period of time can prove otherwise.

42. Additional Resources Centers for Medicare and Medicaid Services
American Academy of Emergency Medicine
Emergency Nurses Association (ENA)
Please refer to these resources for further information or contact your compliance officer if you have questions about today’s presentation.
Centers for Medicare and Medicaid Services
American Academy of Emergency Medicine
Emergency Nurses Association