In June 2010, a Chicago hospital paid penalties of $50,000 for allegations of failure to perform a medical screening exam or stabilizing treatment. Mr. D came to the ED via ambulance and was left unattended in the waiting room for 3 hours without receiving a screening exam. He was never logged into the hospital's system. After a family member approached the ED staff with concerns that Mr. D hadn't been seen, the triage nurse went to see the patient and found him unresponsive. Mr. D was taken to an exam room and pronounced dead. The nursing staff had a duty to evaluate the patient to ensure he was properly screened, prioritized, and monitored, but according to the Emergency Medical Treatment and Active Labor Act (EMTALA), they didn't provide these services.
When a patient enters your hospital, do you know what your obligations are under EMTALA?
Enacted in 1986, EMTALA applies to hospitals receiving Medicare dollars.1 Lawmakers felt it was needed to protect patients who don't have insurance from being either turned away from the ED or sent to another hospital via ambulance even if the transferring hospital had the resources needed to treat the patient—a circumstance sometimes called "patient dumping." This article discusses what EMTALA requires and how it applies to nursing practice.
Defining the act
EMTALA requires that any patient who comes to a hospital's dedicated ED with what the patient believes to be an emergency medical condition must be given a medical screening exam by a qualified healthcare provider to determine if a medical emergency exists. EMTALA defines an emergency medical condition as one where a patient presents with acute symptoms (including pain) of sufficient severity that in the absence of immediate medical attention could reasonably be expected to seriously jeopardize the patient's health or body functions, or cause serious dysfunction of any body organ or part. It also covers women coming to the ED in active labor.1
Many states have statutes that define what an emergency medical condition is. Both the federal and individual state laws usually incorporate a layperson standard to the definition. You'll want to check your state statute to determine if it's any more restrictive than the federal statute, which might place additional obligations on the hospital.
According to Centers for Medicare and Medicaid Services (CMS), patient triage on arrival to the ED isn't considered a medical screening exam.2 CMS recognizes that medical screening exams could be performed by a physician or another healthcare provider, such as a nurse. If the exam is performed by a nonphysician, the hospital's medical staff bylaws must set out the classification of medical personnel permitted to perform the medical screening exam. Even if the bylaws permit nonphysician professionals such as RNs to conduct the medical screening exam, the exam must be consistent with the professional's scope of practice under state laws. A written protocol must exist defining the medical functions the nonphysician provider may perform.
The medical exam must reasonably determine whether an emergency medical condition exists, and includes all necessary testing and on-call services within the capability of the hospital to reach a diagnosis that excludes the presence of an emergency medical condition.
After the enactment of EMTALA, the CMS issued a "final rule," effective November 10, 2003, clarifying EMTALA regulations to help clear up confusion in the interpretation of the law.3 For example, the CMS clarified that a hospital ED is considered "dedicated" if it meets one of three criteria:
- It has state licensure as an ED.
- The hospital holds it out to the public (by a means such as the name, signage, or advertising) as a place where a patient can go without an appointment to receive urgent care for an emergency medical condition.
- Based on visits from the prior year, at least one-third of all outpatient visits to the ED needed treatment for emergency medical conditions on an urgent basis.1
Additional guidelines to determine if a hospital department is a dedicated ED can be found at www.cms.gov/manuals/downloads/som107ap_v_emerg.pdf.4
At times, EMTALA comes into play even when the patient doesn't arrive at a dedicated ED. For example, if a patient arrives on a hospital campus requesting emergency services, the 250-yard rule for hospital campuses applies if a reasonably prudent person could conclude the person needs emergency treatment. This rule applies to an emergency within a 250-yard proximity to the hospital, with some exceptions.
The 250-yard rule excludes nonmedical entities such as restaurants and gift shops, as well as healthcare providers' offices and other separate medical entities on the hospital campus. However, it does apply to parking lots and sidewalks that are on the hospital campus. That means hospital personnel must render care to patients who may be unable to make it into the ED but are within 250 yards of the hospital campus. EMTALA doesn't apply to off-campus facilities unless they independently qualify as dedicated EDs.5
When an emergency medical condition is identified, the hospital has the obligation to treat the patient within the "capability and capacity" of the hospital's resources, regardless of the patient's ability to pay. Capability means that the hospital has the appropriate resources to meet the patient's specific treatment needs. Capacity means that a hospital having capability also has the needed resources available when the patient requires them. When a hospital lacks either capability or capacity to care for a patient, the hospital is required to stabilize the patient's condition and transfer the patient to an appropriate facility that has the capability and capacity to meet the patient's needs.
Hospitals are required to maintain an on-call list of physicians on staff in various specialty areas for which the hospital treats its patient population. There may be times when specialized care is needed but the appropriate physician isn't available for legitimate reasons. But if a patient must be transferred because the physician doesn't meet his or her obligation to see the patient when summoned by the ED physician and no other physician with the appropriate expertise is available, the name and address of the on-call physician who failed to respond must be documented in the patient's transfer record. Failure to include this information could result in the hospital, the ED physician, and the on-call physician being cited and fined by the CMS.6,7
When a transfer is required because the patient needs a higher level of care, hospitals with a higher level of care than the transferring hospital are expected to accept the patient.8,9 An appropriate transfer under EMTALA occurs for medical necessity, not physician convenience. When determining if a transfer is appropriate, the following factors must be considered: The patient is stabilized as far as possible within the capability and capacity of the transferring hospital, the receiving hospital is capable of providing the treatment needed by the patient, and the risk of transferring the patient to the receiving hospital are outweighed by the benefits of the transfer.
A patient can always request to be transferred to another facility. Such a request needs to be made in writing after the patient is advised of the risk of transfer.
A receiving hospital can decline to accept a patient only if the patient can be cared for adequately at the originating facility or if the receiving hospital lacks the capability or capacity to treat the patient. The receiving hospital can't accept or reject the transfer of a patient based on the patient's ability to pay. However, hospital personnel can ask about insurance coverage after the patient has been accepted for transfer.
Under CMS guidelines, when patients are cleared for transfer to another hospital, their vital signs and a discharge summary must be documented.10 Make sure the patient's medical record and discharge summary document the information that the CMS requires.
The transfer documentation must also clearly state the time of the transfer and specify that the risks of the transfer are less than the anticipated benefits for the transfer.11 The physician is required to certify this. If a physician isn't physically present, the written certification in support of the transfer may be signed by a qualified medical person consulting with the physician. In this situation, the physician must agree with the certification and subsequently countersign it.12 The ED nurse will want to make sure that all documentation required for the transport is included: copies of the medical record, the transfer certification, copies of X-rays and lab reports, and so on.
The appropriate means of transport are then determined by the referring healthcare provider, along with the personnel, equipment, and supplies needed to safely transport the patient. You may be asked to give report to the receiving hospital and to the transport personnel. Make sure copies of the patient's medical records, including results of diagnostic studies performed at the transferring hospital, are sent with the patient unless waiting for the reports would jeopardize the patient's condition. Once the records are available, the transferring hospital must get them to the receiving hospital as soon as possible.
If transport personnel request medical assistance to manage the patient, the hospital is obligated to provide assistance within its capabilities.
The receiving hospital's obligation under EMTALA is to report possible violations within 72 hours.13 (See When things go wrong for some examples of EMTALA violations.) The failure to report carries significant sanctions, including civil monetary penalties and even potential exclusion from Medicare. The CMS learns of potential violations through mandatory reporting, direct complaints from patients, transport personnel, physicians, nurses, and so on. Make sure you know your hospital's process for reporting an EMTALA concern.
Not every patient who comes into an ED is covered by EMTALA. A medical screening exam under EMTALA isn't required for:
- patients admitted directly into the hospital, bypassing the ED.
- patients who experience problems after a scheduled outpatient procedure begins (but if that patient is transported to an ED for care, EMTALA would apply).
- patients coming to the ED for interventions such as a suture removal or routine immunization such as an annual influenza vaccine offered in the ED, or to attend a health fair.
- patients arriving for scheduled outpatient clinic visits.
- patients being transported by ambulance who are on hospital property solely for the purpose of being transported to another hospital via fixed wing or rotary wing aircraft.1
Know your obligations
To avoid penalties, hospitals must ensure that patients are appropriately screened, prioritized, monitored, and prepared for transfer if appropriate. Potential violations of EMTALA can result in fines and malpractice suits. Make sure you know the details of EMTALA to keep you, your staff, and your patients safe.
When things go wrong
Here are a few examples of real-life EMTALA violations.
- A California hospital was cited in 2010 for allegations of failing to perform a medical screening exam and stabilizing treatment to a patient who came to the ED. Mr. S arrived at the ED complaining of chest pain, but he left the hospital after sitting in the waiting room for over 3 hours. After leaving the hospital, he collapsed outside of the building. The ED staff was unable to resuscitate him and he was pronounced dead. Civil monetary penalties of $25,000 were awarded to Mr. S's family.14
- In June 2009, a Florida hospital paid $40,000 in civil monetary penalties for allegations that it failed to provide an appropriate medical screening exam and stabilizing treatment or secure an appropriate transfer. Ms. L was in active labor, but rather than secure ambulance transport or deliver the baby, Ms. L was driven via car by a friend to another facility where she delivered her baby minutes after arrival. The hospital was fined even though neither the mother nor the infant was seriously harmed.15
- An on-call physician failed to respond to a request to come to the ED. The patient was subsequently transferred to another facility and underwent emergency surgery. In a civil court settlement, the physician agreed to pay $35,000 in penalties.15