EMTALA

Prepared by: Sarah Axler, MD University of Connecticut

Introduction •

E

mergency

M

edical

T

reatment &

A

ctive

L

abor

A

ct • Federally-mandated requirement • Patient anti-dumping law

Objectives • EMTALA: When? What? Whom?

• EMTALA requirements • EMTALA exceptions • Violations

When does EMTALA apply?

1.

– Individual comes to E.D. & requests treatment Regardless of ability to pay, insurance status, citizenship, ethnicity, … 2.

‘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

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 Photo Courtesy of U.S. Army

EMTALA Requirements 1.

A hospital must perform a

medical screening exam

to any person coming to ED seeking care 2.

A hospital must treat any patient with an

emergency medical condition

until stable, or must transfer the patient 3.

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

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

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

Stabilization • Definition: Medical treatment of an EMC within the capabilities of the facility & staff • After stabilization, there are no further EMTALA obligations 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

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

Transfer • 1.

2.

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 … 1.

Treat & stabilize patient as far as possible 2.

Patient must sign certification / informed consent for transfer 3.

Contact receiving hospital 4.

Receiving hospital must accept transfer 5.

Send copies of medical records & test results 6.

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

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

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!

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