1. EMTALA
Prepared by:
Sarah Axler, MD
University of Connecticut

2. Emergency Medical Treatment & Active Labor Act
Introduction
Emergency Medical Treatment & Active Labor Act
Federally-mandated requirement
Patient anti-dumping law

3. Objectives
EMTALA: When? What? Whom?
EMTALA requirements
EMTALA exceptions
Violations

4. Individual comes to E.D. & requests treatment
When does EMTALA apply?
Individual comes to E.D. & requests treatment
Regardless of ability to pay, insurance status, citizenship, ethnicity, …
‘Prudent Layperson’ Standard: Individual’s appearance or behavior would cause a prudent layperson to believe that examination or treatment is needed

5. What constitutes an ‘E.D.’?
Dedicated emergency department
Hospital property
Ambulances
Hospital property: Main campus, parking lots, driveway within 250-yards

6. 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
Shriners' Hospital for Crippled Children & many military hospitals do not participate in Medicare and are therefore excluded.
Photo Courtesy of U.S. Army

7. EMTALA Requirements
A hospital must perform a medical screening exam to any person coming to ED seeking care
A hospital must treat any patient with an emergency medical condition until stable, or must transfer the patient
A hospital may not transfer an unstable patient

8. 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
Photo by Pearson Scott Foresman, donated to the Wikimedia Foundation

9. 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

10. QMP must certify that the patient is in false labor
Pregnancy
Pregnant women with contractions are considered to be medically unstable (active labor)
QMP must certify that the patient is in false labor
QMP = Qualified medical person

11. US Air Force / 445th Airlift Wing
Stabilization
Definition: Medical treatment of an EMC within the capabilities of the facility & staff
After stabilization, there are no further EMTALA obligations
EMC = Emergency medical condition
Regarding labor, stabilization is defined as delivery of baby and placenta.
Regarding a psychiatric patient, stabilization is achieved when a suicidal or homicidal patient is no longer a threat to self or others.
US Air Force / 445th Airlift Wing
Maj. Ted Theopolos

12. 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
MSE = Medical screening exam
Document: Type of exam or treatment refused and explanation of risks

13. 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

14. Picture: Ed Edahl, Federal Emergency Management Agency
Transfer
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

15. Before Transfer … Treat & stabilize patient as far as possible
Patient must sign certification / informed consent for transfer
Contact receiving hospital
Receiving hospital must accept transfer
Send copies of medical records & test results
Arrange necessary personnel & equipment for transfer

16. 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
MSE = Medical screening exam
Inappropriate transfers – Transfer of an unstable patient, etc

17. 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

18. EMTALA Sign
Must be posted in all public entrances, registration areas & ED waiting areas

19. Maximum fine per violation: $50,000
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!
EMTALA violations are completely separate from any malpractice litigation, and may not be covered under malpractice policy.

20. 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

21. Conclusion
Treat EVERY patient that comes to the ED to the best of your ability without regard to their ability to pay