EMTALA Prepared by: Sarah Axler, MD University of Connecticut

Emergency Medical Treatment & Active Labor Act Introduction Emergency Medical Treatment & Active Labor Act Federally-mandated requirement Patient anti-dumping law

Objectives EMTALA: When? What? Whom? EMTALA requirements EMTALA exceptions Violations

Individual comes to E.D. & requests treatment When does EMTALA apply? Individual comes to E.D. & requests treatment Regardless of ability to pay, insurance status, citizenship, ethnicity, … ‘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 Hospital property: Main campus, parking lots, driveway within 250-yards

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 Shriners' Hospital for Crippled Children & many military hospitals do not participate in Medicare and are therefore excluded. Photo Courtesy of U.S. Army

EMTALA Requirements A hospital must perform a medical screening exam to any person coming to ED seeking care A hospital must treat any patient with an emergency medical condition until stable, or must transfer the patient 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 Photo by Pearson Scott Foresman, donated to the Wikimedia Foundation

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

QMP must certify that the patient is in false labor Pregnancy Pregnant women with contractions are considered to be medically unstable (active labor) QMP must certify that the patient is in false labor QMP = Qualified medical person

US Air Force / 445th Airlift Wing Stabilization Definition: Medical treatment of an EMC within the capabilities of the facility & staff After stabilization, there are no further EMTALA obligations EMC = Emergency medical condition Regarding labor, stabilization is defined as delivery of baby and placenta. Regarding a psychiatric patient, stabilization is achieved when a suicidal or homicidal patient is no longer a threat to self or others. US Air Force / 445th Airlift Wing Maj. Ted Theopolos

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 MSE = Medical screening exam Document: Type of exam or treatment refused and explanation of risks

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: Appropriate care is not available at the current facility Patient requests transfer Hospital discharge is considered a ‘transfer’ Picture: Ed Edahl, Federal Emergency Management Agency

Before Transfer … Treat & stabilize patient as far as possible Patient must sign certification / informed consent for transfer Contact receiving hospital Receiving hospital must accept transfer Send copies of medical records & test results 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 MSE = Medical screening exam Inappropriate transfers – Transfer of an unstable patient, etc

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

Maximum fine per violation: $50,000 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! EMTALA violations are completely separate from any malpractice litigation, and may not be covered under malpractice policy.

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