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EMTALAEMTALAEmergency Medical Treatment and Emergency Medical Treatment and

Active Labor ActActive Labor Act

William F. JourdainWilliam F. JourdainMinor, Bell & NealMinor, Bell & Neal


EMTALA BASICSEMTALA BASICS

!! Federal law enacted in 1986Federal law enacted in 1986!! Where a person comes to the dedicated Where a person comes to the dedicated

emergency department (DED) or hospital emergency department (DED) or hospital property and request is made for (or property and request is made for (or symptoms require) examination or symptoms require) examination or treatment, MUST:treatment, MUST:!! Provide appropriate medical screeningProvide appropriate medical screening!! Provide necessary stabilizing treatmentProvide necessary stabilizing treatment!! Provide appropriate transferProvide appropriate transfer


What is DED or Hospital Property?What is DED or Hospital Property?

!! DED if licensed by the state as ED or ER;DED if licensed by the state as ED or ER;!! Held out to the public as a ED or ER;Held out to the public as a ED or ER;!! During preceding calendar year provided During preceding calendar year provided

at least one third of outpatient care to at least one third of outpatient care to treatment of emergency medical treatment of emergency medical conditions on urgent basis without conditions on urgent basis without appointment.appointment.



!! Hospital property is the entire main Hospital property is the entire main campus of the hospital including parking campus of the hospital including parking lots, sidewalks, and driveways.lots, sidewalks, and driveways.

!! Does NOT include other areas or Does NOT include other areas or structures of hospitalstructures of hospital!!s main building such s main building such as physician offices, skilled nursing as physician offices, skilled nursing facilities, shops, restaurants or other nonfacilities, shops, restaurants or other non--medical facilities. medical facilities.



!! ""CampusCampus## has been defined as has been defined as ""The The physical areas immediately adjacent to the physical areas immediately adjacent to the providerprovider!!s main buildings, other areas and s main buildings, other areas and structures that are not strictly contiguous structures that are not strictly contiguous to the main buildings but are located to the main buildings but are located within 250 yards of the main buildings, within 250 yards of the main buildings, and any other areas determined on an and any other areas determined on an individual case by case basis, by CMS individual case by case basis, by CMS regional office to be part of the providerregional office to be part of the provider!!s s campuscampus##



!! In certain situations, can also apply to:In certain situations, can also apply to:

!! In hospital owned ambulance;In hospital owned ambulance;

!! In nonIn non--hospital owned ambulance on hospital hospital owned ambulance on hospital property.property.


!!Comes to the EDComes to the ED""

!! Not already an inpatientNot already an inpatient!! At DED and requests examination or At DED and requests examination or

treatment for a medical condition, request treatment for a medical condition, request is made on their behalf, or is made on their behalf, or ""a prudent a prudent layperson observer would believe, based layperson observer would believe, based upon individualupon individual!!s appearance or behavior s appearance or behavior that the individual needs emergency that the individual needs emergency examination or treatmentexamination or treatment##..


!!Comes to the EDComes to the ED""

!! At hospital property other than DED and At hospital property other than DED and requests examination or treatment for WHAT requests examination or treatment for WHAT MAY BE AN EMERGENCY MEDICAL CONDITION, MAY BE AN EMERGENCY MEDICAL CONDITION, request is made on their behalf, or request is made on their behalf, or ""a prudent a prudent layperson observer would believe, based upon layperson observer would believe, based upon individualindividual!!s appearance or behavior that the s appearance or behavior that the individual needs emergency examination or individual needs emergency examination or treatmenttreatment##..


!!Emergency Medical ConditionEmergency Medical Condition""

!! ""A medical condition manifesting itself by acute A medical condition manifesting itself by acute symptoms of sufficient severity (including severe symptoms of sufficient severity (including severe pain, psychiatric disturbances and/or symptoms pain, psychiatric disturbances and/or symptoms of substance abuse) such that the absence of of substance abuse) such that the absence of immediate medical attention could be immediate medical attention could be reasonably expected to result in:reasonably expected to result in:!! Serious impairment of bodily functions;Serious impairment of bodily functions;!! Placing the health of person (or woman and unborn Placing the health of person (or woman and unborn

child) in serious jeopardy;child) in serious jeopardy;!! Serious dysfunction of any bodily organ or part.Serious dysfunction of any bodily organ or part.##


!!Emergency Medical ConditionEmergency Medical Condition""

!! In case of pregnant woman having contractions, In case of pregnant woman having contractions, ""emergency medical conditionemergency medical condition## if there is if there is inadequate time to effect a safe transfer to inadequate time to effect a safe transfer to another hospital before delivery of the child; or another hospital before delivery of the child; or that the transfer may pose a threat to the health that the transfer may pose a threat to the health and safety of the woman or unborn child.and safety of the woman or unborn child.


Appropriate Medical ScreeningAppropriate Medical Screening

!! ""Process required to reach with reasonable Process required to reach with reasonable clinical confidence, the point at which it clinical confidence, the point at which it can be determined whether a medical can be determined whether a medical emergency does or does not existemergency does or does not exist##

!! If hospital applies in a nondiscriminatory If hospital applies in a nondiscriminatory manner a screening process that is manner a screening process that is reasonably calculated to determine if a reasonably calculated to determine if a EMC exists, it has met its EMTALA EMC exists, it has met its EMTALA obligations.obligations.


Appropriate Medical ScreeningAppropriate Medical Screening!! Ongoing process Ongoing process -- not isolated eventnot isolated event!! Elements:Elements:

!! Log entry with dispositionLog entry with disposition!! Triage recordTriage record!! Ongoing recording of vitalsOngoing recording of vitals!! Oral historyOral history!! Physical examinationPhysical examination!! Use of all available testing resourcesUse of all available testing resources!! Use of onUse of on--call physician as neededcall physician as needed!! Discharge or transfer vital signsDischarge or transfer vital signs! Adequate documentation of all of the above



!! Poor outcome not indicative of Poor outcome not indicative of inappropriate screening.inappropriate screening.

!! Incorrect diagnosis not indicative of Incorrect diagnosis not indicative of inappropriate screening.inappropriate screening.

!! Follow above guidelines and document Follow above guidelines and document what was done to comply with EMTALAwhat was done to comply with EMTALA

!! SCREENING MUST BE SCREENING MUST BE UNIFORMUNIFORM AND AND REASONABLEREASONABLE!! Same for every patient with similar conditionSame for every patient with similar condition



!! Clinical Guidelines of Hospital can be used Clinical Guidelines of Hospital can be used to judge appropriateness of screening.to judge appropriateness of screening.!! Failure to follow could be construed a failure Failure to follow could be construed a failure

to comply with EMTALAto comply with EMTALA

!! If no Clinical Guidelines, will likely be If no Clinical Guidelines, will likely be judged by the standard of care applicable judged by the standard of care applicable to like and surrounding circumstances.to like and surrounding circumstances.



!! Who performs the medical screening?Who performs the medical screening?!! The examining physician or other qualified The examining physician or other qualified

medical personnel (QMP).medical personnel (QMP).!! QMP must be established by hospital rules or QMP must be established by hospital rules or

byby--laws approved by the governing body.laws approved by the governing body.!! Cannot be an informal delegation by the Cannot be an informal delegation by the

physician or ER director.physician or ER director.


Appropriate Medical ScreeningAppropriate Medical Screening!! Registration of Patient?Registration of Patient?

!! May not delay appropriate medical screening exam to May not delay appropriate medical screening exam to inquire about method of payment or insurance status.inquire about method of payment or insurance status.

!! May follow reasonable registration processes May follow reasonable registration processes including obtaining insurance information as long as including obtaining insurance information as long as inquiry does not delay screening or treatment.inquiry does not delay screening or treatment.

!! Registration process may not discourage individual Registration process may not discourage individual from remaining for further evaluation.from remaining for further evaluation.

!! ""The registration process permitted in the dedicated The registration process permitted in the dedicated ED typically consists of collecting demographic ED typically consists of collecting demographic information, insurance information, whom to contact information, insurance information, whom to contact in an emergency and other relevant information.in an emergency and other relevant information.##


Stabilizing TreatmentStabilizing Treatment

!! What if patient refuses?What if patient refuses?!! Medical record MUST contain a description of Medical record MUST contain a description of

the examination and/or treatment refused;the examination and/or treatment refused;!! MUST attempt to obtain written informed MUST attempt to obtain written informed

refusal of examination/treatment;refusal of examination/treatment;!! MUST document that person was informed of MUST document that person was informed of

risks and benefits of examination/treatment;risks and benefits of examination/treatment;!! MUST document the reason for the refusal MUST document the reason for the refusal

and steps taken to try to get written refusal if and steps taken to try to get written refusal if it was not obtained.it was not obtained.



!! Parental Consent?Parental Consent?!! Must screen even if no parental consent.Must screen even if no parental consent.!! If no emergency medical condition requiring If no emergency medical condition requiring

stabilizing treatment, can wait for parental stabilizing treatment, can wait for parental consent.consent.

!! If EMC, must initiate stabilizing treatment If EMC, must initiate stabilizing treatment even if no parental consent.even if no parental consent.

!! Should document any and all attempts to Should document any and all attempts to obtain consent from parents if obtain consent from parents if screening/treatment without consent.screening/treatment without consent.


Stabilizing TreatmentStabilizing Treatment!! ""StabilizedStabilized##

!! ""No material deterioration of the condition is likely, No material deterioration of the condition is likely, within reasonable medical probability, to result or within reasonable medical probability, to result or occur during the transfer of the individual from a occur during the transfer of the individual from a facility.facility.##

!! When determined with clinical confidence that When determined with clinical confidence that emergency medical condition has been resolved.emergency medical condition has been resolved.

!! After a pregnant woman has delivered the child and After a pregnant woman has delivered the child and the placenta.the placenta.

!! A patient can be critical, but stabilized.A patient can be critical, but stabilized.!! Psychiatric: When patient is protected and prevented Psychiatric: When patient is protected and prevented

from injuring himself or others.from injuring himself or others.


Stabilizing TreatmentStabilizing Treatment!! Physician must determine whether patient is Physician must determine whether patient is

stabilized.stabilized.

!! Physician must sign EMTALA transfer certificate Physician must sign EMTALA transfer certificate that patient is stable for transfer.that patient is stable for transfer.



!! On call physician must come to ED if requested by On call physician must come to ED if requested by attending ED physician to provide stabilizing treatment in attending ED physician to provide stabilizing treatment in subspecialty of on call physician.subspecialty of on call physician.

!! Duty of hospital to maintain on call list and coverage.Duty of hospital to maintain on call list and coverage.

!! Hospital has discretion to maintain on call list Hospital has discretion to maintain on call list ""in a in a manner that best meets the needs of its patientsmanner that best meets the needs of its patients##..


Transfer of PatientTransfer of Patient!! Away from DED and hospital property at Away from DED and hospital property at

direction of employee or representative of the direction of employee or representative of the hospital.hospital.

!! Requirements:Requirements:!! Must be Must be ""appropriateappropriate##;;!! Person requests the transfer in writing after being Person requests the transfer in writing after being

informed of risks and benefits of transfer;informed of risks and benefits of transfer;!! Written certification of physician that benefits of Written certification of physician that benefits of

transfer outweigh risks of transfer and risks and transfer outweigh risks of transfer and risks and benefits must be listed on certificate.benefits must be listed on certificate.


Transfer of PatientTransfer of Patient!! ""Appropriate TransferAppropriate Transfer##!! Requirements:Requirements:

!! Transferring hospital provides medical treatment within its Transferring hospital provides medical treatment within its capacity that minimizes risk to health of person;capacity that minimizes risk to health of person;

!! Receiving facilityReceiving facility!! Has available space and qualified personnel;Has available space and qualified personnel;!! Has agreed to accept the transfer;Has agreed to accept the transfer;

!! Medical records regarding EMC sent with patient;Medical records regarding EMC sent with patient;

!! Transfer effected through qualified personnel and transportationTransfer effected through qualified personnel and transportationequipment (including life support equipment).equipment (including life support equipment).


Transfer of PatientTransfer of Patient!! Hospital with specialized capabilities (burn units, Hospital with specialized capabilities (burn units,

shockshock--trauma units, neonatal intensive care, trauma units, neonatal intensive care, etc.) may not refuse transfer if person requires etc.) may not refuse transfer if person requires the specialized care and if the facility has the the specialized care and if the facility has the capacity to treat the person.capacity to treat the person.


EMTALA SummaryEMTALA Summary

!! Where a person comes to the dedicated Where a person comes to the dedicated emergency department (DED) or hospital emergency department (DED) or hospital property and request is made for (or property and request is made for (or symptoms require) examination or symptoms require) examination or treatment, MUST:treatment, MUST:!! Provide appropriate medical screeningProvide appropriate medical screening!! Provide necessary stabilizing treatmentProvide necessary stabilizing treatment!! Provide appropriate transferProvide appropriate transfer


Violations of EMTALAViolations of EMTALA!! CMS investigates EMTALA violations and OIG CMS investigates EMTALA violations and OIG

enforces through Justice Department.enforces through Justice Department.!! Civil Monetary Penalties:Civil Monetary Penalties:

!! $50,000 per violation for hospital that negligently $50,000 per violation for hospital that negligently violates EMTALA ($25,000 if under 100 beds);violates EMTALA ($25,000 if under 100 beds);

!! Physician who negligently violates EMTALA subject to Physician who negligently violates EMTALA subject to penalty of not more than $50,000 per violation.penalty of not more than $50,000 per violation.

!! Private individuals may sue hospital and doctors Private individuals may sue hospital and doctors under EMTALA (can also make general medical under EMTALA (can also make general medical malpractice claims);malpractice claims);

!! Two year statute of limitation to bring claim/suit.Two year statute of limitation to bring claim/suit.


Violations of EMTALAViolations of EMTALA!! Between 1986 and 1996, government collected Between 1986 and 1996, government collected

approximately $1.45 million for EMTALA violations.approximately $1.45 million for EMTALA violations.

!! During 1997 and 1998, it collected greater than $2 million.During 1997 and 1998, it collected greater than $2 million.

!! Between 2002 and 2005, approximately 100 enforcement Between 2002 and 2005, approximately 100 enforcement actions by the government resulted in over $2 million in actions by the government resulted in over $2 million in penalties paid.penalties paid.

!! In 2006, government collected $680,000 for EMTALA In 2006, government collected $680,000 for EMTALA violations.violations.

!! This does not include any private EMTALA related medical This does not include any private EMTALA related medical malpractice verdicts/settlements during these time frames.malpractice verdicts/settlements during these time frames.


EMTALAEMTALA

QUESTIONSQUESTIONS

William F. JourdainWilliam F. JourdainMinor, Bell & NealMinor, Bell & Neal

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