Detailed EMTALA Guidelines and Scenarios

Med mal suits often allege EMTALA violations.
EMTALA does not permit claims against physicians for EMTALA violations; claims can only be made against hospitals.
Hot complaint areas include:
- Inadequate stabilization of emergency medical conditions (EMCs).
- Delays in providing definitive care for transfers.
- Inadequate documentation of the transfer process.
Courts have consistently rejected EMTALA as the basis for a federal malpractice standard.

Referencing 42 USCS §1395dd, in the case of a hospital that has a hospital emergency department.
If any individual comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination.
This examination should be within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department.
The purpose is to determine whether or not an emergency medical condition exists.

Scenario 1: A Medicaid patient leaves after a two-hour wait. This may be an EMTALA violation if CMS considers two hours inappropriate.
Scenario 2: EMS brings a patient to a swamped ED with no open beds. Instructing EMTs to wait in the hallway may violate EMTALA if CMS determines the patient was inappropriately "parked."
Scenario 3: Trauma victim arriving via helicopter. EMTALA applies if a request is made for examination or treatment for a medical condition.
Absence of 'emergency': Note the absence of “emergency” before “medical condition” in the phrasing of the law.
Scenario 4: Medic requests help with airway management.
Scenario 5: A man has a syncopal episode while visiting a friend. EMTALA may apply.
Scenario 6: A teenager asks for help for a friend shot nearby. Consider if the ED has a policy about this.
Scenario 7: A nurse from a nearby doctor’s office reports a patient fall. EMTALA considerations apply.
Scenario 8: A patient in the hospital’s endoscopy suite complains of chest pain. EMTALA may apply.
Training: Train all hospital staff about their responsibility in the EMTALA process.

Symptoms of sufficient severity that the health is placed in serious jeopardy.
Serious impairment of bodily functions.
Serious dysfunction of a bodily organ or part.
Significant pain.
Pregnant woman having contractions, where there is inadequate time to effect a safe transfer before delivery, or the transfer itself may pose a threat.

A 'process standard': hospital must provide an equivalent MSE, without delay.
Regardless of financial status, race, or gender.
Using “all appropriate resources within the capability of the ED”, which may include involvement of a physician or specialist.
Triage is not equivalent to an MSE.
Triage physician screening is not equivalent to an MSE.

On-call specialist must come to the ER to evaluate and help stabilize the EMC.
The statute gives you the power to enforce this.
Must notify the receiving facility if the on-call specialist refuses or the system 'fails'.

Scenario 1: Unstable MVA victim needing surgery but no surgeon available. Transfer may violate EMTALA if the patient is unstable.
Scenario 2: ED on diversion; ambulance arrives anyway. EMTALA applies.
Scenario 3: Patient's PMD requests transfer to a specific orthopedist. What should you do?
Scenario 4: Ophthalmologist instructs you to send a patient with a corneal ulcer to his office.
Scenario 5: Tertiary hospital refuses transfer of patient with a hand injury. What if the patient shows up at the tertiary hospital's ED by private car? EMTALA applies.

If EMC is not stabilized, must not transfer unless it is to a higher level of care where the benefits outweigh the risks.
If the receiving hospital has capability and capacity, it must accept transfer, even if a specialty hospital without an ED.
If no acceptance, do not send.
The level of transport care must be appropriate.

Note the benefits expected from care at the receiving facility & the risks of transfer.
State if it is for health insurance/continuity of care reasons.
Patients cannot be transferred for health insurance reasons alone.

Scenario 1: Orthopedist demands to know financial status before responding to a shoulder dislocation case.
Scenario 2: Orthopedist refuses to treat patient with Pacific Mutual of Omaha (PMO) insurance.

ED must have a list available (“in accordance with hospital’s resources”).
Bylaws, policies & procedures must define the responsibility of on-call physicians.
If an inadequate number of specialists are on staff, call lists may be incomplete.
Hospital policy must address what to do if a specialty is not available.
On-call response should be within a “reasonable period of time”.
Cannot refer a patient to the on-call physician’s office for exam & treatment, except for definitive care (e.g., ophthalmologist).
Community Call Plan: allows for regional coverage with a written monitored plan.
May schedule elective surgery with backup.
On-call list must specify doctor – not group.
Report refusal of the on-call physician on the transfer form.

Scenario: Transfer to Hospital A is requested by the patient, but Hospital A redirects to Hospital B. What should you do?
Scenario: Internist sends a chest pain patient for direct admission, but no telemetry beds are available, and the patient is sent to the ED to be boarded. Is a screening exam required?

Collecting co-pays and deductibles while patients are still in the ED may violate EMTALA if it causes a delay in care.
Requesting insurance information is permissible if it causes no delay in providing medical care.