EMTALA

Presented by The Office of

Corporate Compliance and The
Office of Risk Management

For those working on the frontline.

What is EMTALA?
The Emergency Medical Treatment and Active Labor Act is a
FEDERAL statute which governs when and how a patient may
be (1) refused treatment or (2) transferred from one hospital to
another when he/she is in an unstable medical condition.
EMTALA was passed as part of the Consolidated Omnibus
Budget Reconciliation Act of 1986, and it is sometimes referred
to as "the COBRA law". In fact, a number of different laws come
under that general name. Another very familiar provision, also
referred to under the COBRA name, is the statute governing
continuation of medical insurance benefits after termination of
employment.
EMTALA applies only to hospitals that participate in the
Medicare Program.

So What Does All of

That Mean to You?
Simply put, it means that any and all patients
who present to the Emergency Department
(or on hospital grounds) and that request
assistance for a possible emergency medical
condition, must at a minimum, receive a
medical screening by a qualified medical
professional and, if needed, receive medical
stabilization and an appropriate transfer if
necessary.

Who is a Qualified
Medical Professional?
EMTALA allows for individual hospitals to
identify, in their hospital bylaws, who the
qualified medical professionals are.
The University Hospital bylaws state that
medical screenings may be done by a
physician, advanced practice professional or
by a registered nurse acting under medically
approved protocols.

What is an Emergency
Medical Condition?
The definition provided under the statute is:
"A medical condition manifesting itself by acute symptoms of
sufficient severity (including severe pain) such that the absence of
immediate medical attention could reasonably be expected to
result in -placing the health of the individual (or, with respect to a pregnant
woman, the health of the woman or her unborn child) in serious
jeopardy, serious impairment to bodily functions, or
serious dysfunction of any bodily organ or part, or
"With respect to a pregnant woman who is having contractions -that there is inadequate time to effect a safe transfer to another
hospital before delivery, or
that the transfer may pose a threat to the health or safety of the
woman or her unborn child."

Caution!!
According to CMS Interpretive
Guidelines

Some intoxicated individuals may meet

the definition of emergency medical
conditionbecause the absence of
medical treatment may place their
health in serious jeopardy or result in
serious dysfunction of a bodily organ.
Further, it is not unusual for intoxicated
individuals to have unrecognized
trauma.

Caution!!
According to CMS Interpretive
Guidelines

Likewise, an individual expressing

suicidal or homicidal thoughts or
gestures, if determined dangerous to
self or others, would be considered an
emergency medical condition.

What is an Acceptable
Medical Screening?
CMS Interpretive Guidelines state the following;
Individuals coming to the emergency room
must be provided a medical screening beyond
initial triage.
The medical screening must be the same
medical screening that the hospital would
perform on any individual coming to the
hospitals emergency room with those signs
and symptoms, regardless ..to pay.

What is an Acceptable
Medical Screening?
A medical screening examination is the
process required to reach with reasonable
clinical confidence, the point at which it can
be determined whether a medical emergency
does or does not exist.
Depending upon the patient, this process will
vary from only a brief H&P to a complex
process involving ancillary studies and
specialty consultations.

What is an Acceptable
Medical Screening?
A medical screening is not an isolated event.
It is an ongoing process.
Hospital and Department medical staff
should address, through policy and medical
standards, how best to provide the screening.
Medical Screenings are required to be
documented.
If it isnt written down, it never happened!!

Medical Screening
Documentation
Need to document why the patient is now
stable enough to be transferred.
Is patient hemodynamically stable to the best of
our capabilities?
Has psychiatric condition been evaluated and
treated to the best of our capabilities?
Have any abnormal test (EKGs) been repeated
if the first one was abnormal and the patient
has been in our care for a lengthy period of
time?

Caution!!
Regardless of a positive or negative patient
outcome, a hospital will be in violation of the
anti-dumping statute if it fails to meet any of
the medical screening requirements.
If a misdiagnosis occurs, but the hospital
utilized all of its resources, a violation of the
screening requirement does not occur.

Transfers
Documentation
Must show that the transfer was initiated by
either a written request by the patient (or
his/her representative) or a physicians
certification.
Must state the reason for the transfer.
The receiving facility and the accepting
physician. Recommendation: Include a brief
statement that the patients full condition was
discussed with the accepting physician.
The risk and benefits of the transfer.

Transfers
Documentation
Risk & Benefits!!
Need to be realistic and pertinent to the case.
MVA is not usually a true risk of the transfer
that needs to be documented in most cases.
Worsening of condition, lack of medical
equipment, increase of pain, increase
exposure to infection and no physician for
intervention are some examples of true risk.

Sounds Simple But.

EMTALA sounds
simple but
incidences happen
everyday that could
potentially cost a
hospital thousands
of dollars.

CAUTION!!!!!!
Case history has not been kind to
hospitals who utilized non-physician
medical screeners even though by law,
it is allowed.
TRAIGE IS NOT CONSIDERED TO BE
A MEDICAL SCREENING!!!!!

Dont Our Bylaws Make

us a Target?
Answer:
NO.
Not as long as we

understand our
responsibilities and our
liabilities.
There is less liability for
those patients without
an emergency
condition.

The Simple Rules

Never turn a patient who is requesting

treatment away from the facility once

they are on hospital property.
Always perform a medical screening if
the patient is requesting services.
Document Everything!!
Make Sure You Document Everything!!

Items of Interest
Diversions, (Arrington vs Wong) Case
study says that you cannot redirect an
ambulance unless a compelling reason
exists. (ex: lack of staff or resources.)
Do not pick and choose patients when
on diversion.

Items of Interest
New regulations do not pertain to
inpatients. (Caution: Careys Opinion;
be cautious about refusing an inpatient
transfer from another hospital that has
recently developed an emergency
condition that is beyond the resources
of the referring hospital.

EMTALA Facts
Since 10/1/99, there have been 154 EMTALA
investigations done by CMS involving
Missouri hospitals.
Since November 1998, the University hospital
has been investigated four times.
The University Hospital has been cited 2 out
of the 4 times it has been investigated.

Practical Case Study

Lets Discuss

Practical Lessons
Case #1
The ER attending physician receives a call
from a small rural hospital wanting to
transport a 50 y/o male with chest pain to
your facility. The rural hospital has done an
EKG and performed blood work. Your ER
attending denies the transport suggesting that
the patient be admitted to the rural hospital
for observation. The rural hospital does not
have a cardiologist on staff.

Is this an EMTALA
violation?
YES!!
Why??
Under EMTALA, if a hospital does not have
the staff or the resources to treat and stabilize
a patient with an emergency medical
condition, a tertiary care center (or any
hospital) who does have the resources, has
to accept the patient if requested.

Case #2
A local law enforcement agency
presents to the ER with a subject whom
they have arrested. They request a
psychiatric evaluation on the subject.
The hospital is on psychiatric diversion
due to no beds. The triage nurse
advises the law officers of this and they
voluntarily take the subject to another
hospital.

EMTALA Violation?
Answer
YES
Why: The patient was present on hospital
grounds and a request for services was made.
At a minimum, the patient should have had a
medical screening completed and
documented. If the law officers voluntarily
decide to leave without a medical screening, it
should be documented with the appropriate
details that the patient left without being seen.

Use Caution when

Dealing With Psych
Patients
ED physicians and staff should appropriately
document any symptoms on which the determination
that an emergency medical condition exists is based.
Items to screen for: Does the patient have a history of
violence to himself or others? Has the patient made a
suicide attempt or voiced suicidal ideations? Is the
patient a potential danger to others through violent
actions or threats? Is substance abuse present that
could impair their judgment or are they showing signs
of confusion for which a reason cannot be
determined?

Case #3
A 23 y/o female presents to the ER
requesting a suture removal. The wound
appears to be healing appropriately and
appears to be free from infection. The patient
is evaluated and appears not to be suffering
from any emergency medical condition. Due
to the high volume of patients in the ER, the
patient is referred to her primary care
physician for suture removal.

EMTALA Violation?
Answer
NO!!
Once the patient received a medical
screening from a qualified medical
professional and it was found that an
emergency medical condition did not exist,
EMTALA is no longer applicable. The medical
screening should, however be documented.

Case #4
A middle aged male approaches the
registration area and states that he
would like to go to Mid-Mo. You give
him directions to Mid-MO and he leaves
without any further conversation.

EMTALA Violation?
Answer:
NO!!
Why: Because the subject did not ask for any
medical services, only directions.
NOTE: If this person had displayed behavior
that would lead even a prudent layperson to
believe that a emergency medical condition
did exist, you would have to offer a medical
screening.

CASE #5
The helicopter has just landed with a
patient who is supposed to be a direct
admit to the V.A. Hospital. The patient
was stabilized at the referring hospital
and has remained stable throughout the
flight. The patient is brought through
the ER enroute to the tunnel. Should
the ER perform a medical screening?

Case # 5 Review
Answer
NO!!
Why? Unless the patient requests (or a
representative requests) a medical
service, or the patients condition is
such that immediate care is needed,
EMTALA does not kick in.
Discussion:

Case # 6
Your UHC ambulance responds to a
minor MVA. The patient is from out of
town and requests to be taken to the
closest hospital for evaluation. Your
partner examines the patient and tells
the patient that he doesnt need to be
transported by ambulance. You and
your partner return to service.

Case #6, EMTALA

Violation?
YOU BET!!
If this patient is later found to have an
emergency medical condition, EMTALA
has been violated. A hospital based
ambulance is an extension of the
hospital. In addition, EMT-B and EMTParamedics are not recognized in the
hospital bylaws as QMPs.

Case #7
A 21 y/o female is brought by an outside
ambulance to the ER. The patient is
complaining of intermittent back pain.
The patient is 38 weeks gestation with
her first child. No radio report had been
given and the patient arrived
unexpectedly. The EMTs say the
patient is to be admitted to OB. You
direct the ambulance crew to CRH.

Case #7
EMTALA Violation?
Answer: Yes
Why?: The patient may be in active labor.
Without knowing any prior history, there is a
potential danger of redirecting this patient
without performing a medical screen.
Rule of thumb for active labor: It is active
labor until observation for an acceptable
period of time can prove otherwise.

Questions
and
Answers
What scenarios would you like to
talk about?