Summary of final changes to EMTALA regulations

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted in 1986. Its purpose was to ensure that all individuals receive necessary emergency services from hospitals and not be denied care (i.e., "patient dumping") because of their economic status or lack of insurance. In its application, EMTALA has reduced "patient dumping," but at great cost to hospitals and physicians as an unfunded mandate. Despite 17 years of experience with the law, providers have been uncertain as to where and when, and to whom, the EMTALA obligations apply. The law has also proven to be burdensome and has been interpreted as extending far beyond the hospital emergency room. After reviewing the law for some time, the Centers for Medicare and Medicaid Services (CMS) released its final rules redefining the scope of EMTALA, reaffirming certain guidelines and modifying or clarifying others. The new regulations attempt to restate the parameters of the law as it applies to the emergency department and the hospital, as well as to inpatients and outpatients. The new rules clarify on-call obligations for physicians, confirming guidance issued by CMS in June 2002. This article summarizes the salient features of these new regulations.     

Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions

The Emergency Medical Treatment and Labor Act (EMTALA), which requires Medicare‐participating hospitals to provide emergency care to patients regardless of their ability to pay, plays an important role in protecting the uninsured. Yet many hospitals do not comply. This study examines the reasons for noncompliance and proposes solutions. We conducted 11 semistructured key informant interviews with hospitals, hospital associations, and patient safety organizations in the Centers for Medicare and Medicaid Services region with the highest number of EMTALA complaints filed. Respondents identified 5 main causes of noncompliance: financial incentives to avoid unprofitable patients, ignorance of EMTALA's requirements, high referral burden at hospitals receiving EMTALA transfer patients, reluctance to jeopardize relationships with transfer partners by reporting borderline EMTALA violations, and opposing priorities of hospitals and physicians. Respondents suggested 5 methods to improve compliance, including educating subspecialists about EMTALA, informally educating hospitals about borderline violations, and incorporating EMTALA‐compliant processes into hospital operations such as by routing transfer requests through the emergency department. To improve compliance we suggest (1) more closely aligning Medicaid/Medicare payment policies with EMTALA, ( 2) amending the Act to permit informal mediation between hospitals about borderline violations, (3) increasing the hospital's role in ensuring EMTALA compliance, and (4) expanding the role of hospital associations.     

EMTALA obligations for psychiatric patients

The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 and governs the obligations of licensed hospitals that participate in the Medicare program with respect to patients with emergency medical conditions. Psychiatric units and facilities often believe that it does not apply to them, or they are cavalier in their efforts to comply with it. If the entity is a licensed hospital, or operates within a licensed hospital, that participates in Medicare, the Act is fully applicable to them. Such entities disregard EMTALA at their peril.     

Learning the developments in EMTALA jurisprudence through the lens of John West's “case law update”

This article covers three recurring issues concerning the federal law known as the Emergency Medical Treatment and Labor Act (EMTALA) that keep popping up in John West's Case Law Update case updates, and consistently bedevil hospital risk managers. First, what exactly constitutes an “appropriate” medical screening examination; second, when is a patient actually “stabilized’ under EMTALA; and third, does the EMTALA obligation really “disappear” when a patient is admitted to the hospital? The editors wanted to analyze topics that challenge the courts to “get it right” on the law and that drive risk managers crazy. EMTALA is the “poster child” for such a topic.     

BANKRUPTCY,MEDICAL INSURANCE,AND A LAW WITH UNINTENDED CONSEQUENCES

Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986, guaranteeing a standard of medical care to anyone who entered an emergency room. This guarantee made default a more reliable substitute for medical insurance. I construct a tractable structural model of the medical insurance market and find that repealing EMTALA would increase the fraction of the population with insurance while decreasing its price. Copyright © 2013 John Wiley & Sons, Ltd.     

Fixing EMTALA: what's wrong with the Patient Transfer Act

Congress primarily enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) in 1986 to prevent the denial of care to uninsured patients in emergency departments. The final version of EMTALA lacks specific protection for indigent patients and saddles hospitals and physicians with more liability than Congress initially intended. Loopholes in the law allow denial of care to patients when temporarily stabilized. Congress should ameliorate these problems through amendment of the law.     

Court decisions side with continued treatment of medically futile cases

Confusion reigns in the care of two medically futile cases as one state's supreme court requires hospitals to ask the local state attorney's office to arbitrate conflicts between "acceptable medical treatment and the patient's wishes," and another court applies the federal Emergency Medical Treatment and Active Labor Act (EMTALA) to require a hospital to stabilize an anencephalic child's respiratory distress.     

Cops and docs: The challenges for ED physicians balancing the police,state laws,and EMTALA

State laws are awash with discord concerning whether a police officer's request or court order necessarily obligates physicians to perform a body fluid analysis of an arrested, conscious, nonconsenting suspect. Police typically bring arrestees directly to the emergency department (ED), and federal courts have begun to wrestle with the implications of the Emergency Medical Treatment and Labor Act (EMTALA), which requires that anyone presenting to the ED be screened for treatment. Some state laws require health care providers to comply with any police request for lab analysis, while other states offer more leeway to physicians. Recent trends in federal case law interpreting EMTALA suggest that a medical screening exam is not required for patients brought by police specifically for a blood or urine sample unless either the arrestee requests medical care or a prudent observer would believe medical care was indicated. This article answers two questions: What happens when a police officer presents to the ED requesting service on behalf of an arrestee? What does EMTLA require of physicians in response? We survey current state statutes, review recent state and federal case law, describe example policies from various hospitals, and conclude with recommendations for hospital risk managers.     

The Emergency Medical Treatment and Labor Act (EMTALA)

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted to prevent patient dumping. It provides patients a considerable amount of protection and leverage in obtaining care under emergency situations. The reimbursement strictures imposed by managed care organizations have compounded the problems. This article summarizes the Act's definition of role and duties of hospitals and physicians and the regulations to which these parties must adhere or face significant penalties.     

Hospital location as a determinant of emergency room utilization patterns.

The use of the emergency rooms of three private, acute care, nonprofit hospitals was investigated in relation to each hospital''s location. The emergency room of the hospital located in an urban poverty area served as the "poor man''s doctor," whereas the emergency rooms of the two hospitals in more affluent areas served more traditional emergency room patients. Investigation showed that even when patient populations were similar in demographic characteristics, the hospitals'' locations influenced emergency room utilization patterns. Thus, one emergency room is not the same as another, and one standard model for dealing with emergency room issues will not work in every facility.     

Adverse reactions and other drug-related problems in an emergency service department

BACKGROUND: Adverse Drug Reactions (ADR) and Drug-Related Problems (DRP's) are a frequency cause of hospital emergency room visits and require better assessment. METHOD: An analysis was made of 1097 consecutive admission to the emergency room at the Nuestra Senora de los Volcanes, Hospital (currently the General Hospital of Lanzarote) in Arrecife de Lanzarote (Canary Islands) over a three-month period in order to detect any possible DAR or any other drug-related problems. RESULTS: Nineteen (19) of the 1097 admissions were due to Adverse Drug Reactions (ADR) (1.73%; 95% IC:0.96%-2.5%). Some of the most outstanding of the other "Drug-Related Problems" (DRP's) were medication overdose, which was diagnosed in 5 (0.45%) of the patients; the worsening of the symptoms due to ceasing to take the medication was involved in 8 (0.72%), and incorrect treatments which involved medical care at the emergency room totaled 11 (1.0%). The number of drug-related problems (DRP's) in the sample totaled 43 (3.9%). The drug-related problems (DRP's) led to hospitalization in 1.9% of the cases seen in the emergency room and led to hospitalization in 9.6% of all of hospital admission through the emergency room for the period of time under study. The ADR led to 4.1% of the hospital admissions. CONCLUSIONS: Drug-related problems are a frequent, major problem which has not been well-analyzed in the emergency rooms. Additionally, emergency rooms can function as the first point of detection of a ADR among an outpatient population.     

The relationship between hospital capacity characteristics and emergency department volumes in Korea

OBJECTIVE: To describe the level of emergency department (ED) volumes according to the hospital characteristics and to identify the relationship between hospital capacity characteristics and ED volumes in Korea. METHOD: A survey was conducted to acquire information on the ED, its' hospital (facility, personnel, equipment), and the number of ED patients, as part of the National Emergency Medical Centers Assessment Program. Data from 106 nation-wide LEMCs were used. Multiple regression analysis was performed to determine the hospital capacity characteristics related with ED volumes. RESULTS: The number of ED patients differed according to bed size, nurse staffing, residency training program, and the availability of emergency care-related equipment of the hospital. In the multiple regression analysis, the significant factors which explained the ED volumes were nurse staffing, inpatients per bed, and the population in the area where hospitals are located. The hospitals that were nurse staffing level 2, with more inpatients per bed and larger population of the service area, had more ED patients. CONCLUSIONS: With the service area population, the ED volumes significantly related with nurse staffing and inpatients per bed. These could be used as one of criteria to designate a LEMC.     

Absent proof of HIV exposure, fear is deemed unreasonable

A New York appeals court has ruled that a plaintiff stuck by a sharp object has no basis for a fear-of-AIDS claim if the plaintiff cannot identify the object or prove that the object is contaminated. Phyllis Bishop was leaving Mount Sinai Medical Center when she was struck by a plastic bag of trash that fell off a loading dock. Something sharp in the bag cut her hand. The hospital offered to test Bishop and give her prophylactic AZT, but she declined. Her HIV test results a year later were negative. Bishop sued for negligent infliction of emotional distress. The hospital presented evidence that the garbage came from the kitchen, making it unlikely that she would be exposed to HIV from it. The court ruled that Bishop's negative test results and testimony that the trash was not contaminated indicated Bishop's fear was unreasonable, stating that the plaintiff does not have a legally compensable claim.     

Mississippi retreats from its strict view of actual exposure

The Mississippi Supreme Court changed direction and allowed Jimmie N. Pickering to proceed with a fear-of-AIDS lawsuit against South Central Regional Medical Center. Pickering, a diabetic, was being taught by a nurse how to use a lancet to monitor her blood sugar levels. The nurse used lancets that had been used previously by other patients. When the nurse realized the error, she notified Pickering and threw away the lancets. The lancets were never tested for HIV contamination. Most courts have generally ruled that the patient must demonstrate actual exposure to allow fear-of-AIDS cases to proceed. However, in this case, the defendant destroyed the evidence by discarding the lancets allowing the plaintiff to gain a rebuttable presumption of actual exposure. Pickering's attorney expects a settlement.     

Uncompensated emergency care in hospital markets in Los Angeles County.

A survey of hospital emergency rooms in Los Angeles County was conducted in March 1987. Analysis of the distribution of uninsured emergency care patients revealed that private hospitals play a significant frontline role in terms of entry into the hospital system for patients who are unable to pay--almost one-half of such patients were treated in the emergency rooms of private hospitals. Hospitals serving markets in which a higher proportion of residents had incomes below the poverty level provided a greater share of uncompensated emergency room services.     

Sudden cardiac death in Hispanic Americans and African Americans.

OBJECTIVES: The goal of this study was to estimate rates of sudden cardiac death in US Hispanics and African Americans. METHODS: Data on coronary deaths occurring outside of the hospital or in emergency rooms were examined for 1992. RESULTS: In 1992, 53% (8194) of coronary heart disease deaths among Hispanic Americans 25 years of age and older occurred outside of the hospital or in emergency rooms. The percentage was lower among Hispanics than among non-Hispanic Whites and Blacks. Age-adjusted rates per 100,000 were lower in Hispanics than in non-Hispanic Whites or Blacks (Hispanic men, 75; White men, 166; Black men, 209; Hispanic women, 35; White women, 74; Black women, 108). The percentages dying outside of the hospital or in emergency rooms were higher in young persons, those living in nonurban areas, and those who were single. CONCLUSIONS: The percentage and rate of coronary deaths occurring outside of the hospital or in emergency rooms were lower in Hispanics than in non-Hispanics; African Americans had the highest rates. Further research is needed on sudden coronary death in Hispanic Americans and African Americans.     

The relationship between hospital capacity characteristics and emergency department volumes in Korea

ObjectiveTo describe the level of emergency department (ED) volumes according to the hospital characteristics and to identify the relationship between hospital capacity characteristics and ED volumes in Korea.MethodA survey was conducted to acquire information on the ED, its’ hospital (facility, personnel, equipment), and the number of ED patients, as part of the National Emergency Medical Centers Assessment Program. Data from 106 nation-wide LEMCs were used. Multiple regression analysis was performed to determine the hospital capacity characteristics related with ED volumes.ResultsThe number of ED patients differed according to bed size, nurse staffing, residency training program, and the availability of emergency care-related equipment of the hospital. In the multiple regression analysis, the significant factors which explained the ED volumes were nurse staffing, inpatients per bed, and the population in the area where hospitals are located. The hospitals that were nurse staffing level 2, with more inpatients per bed and larger population of the service area, had more ED patients.ConclusionsWith the service area population, the ED volumes significantly related with nurse staffing and inpatients per bed. These could be used as one of criteria to designate a LEMC.     

Emergency response planning in hospitals, United States: 2003-2004

OBJECTIVE: This study presents baseline data to determine which hospital characteristics are associated with preparedness for terrorism and natural disaster in the areas of emergency response planning and availability of equipment and specialized care units. METHODS: Information from the Bioterrorism and Mass Casualty Preparedness Supplements to the 2003 and 2004 National Hospital Ambulatory Medical Care Surveys was used to provide national estimates of variations in hospital emergency response plans and resources by residency and medical school affiliation, hospital size, ownership, metropolitan statistical area status, and Joint Commission accreditation. Of 874 sampled hospitals with emergency or outpatient departments, 739 responded for an 84.6 percent response rate. Estimates are presented with 95 percent confidence intervals. RESULTS: About 92 percent of hospitals had revised their emergency response plans since September 11, 2001, but only about 63 percent had addressed natural disasters and biological, chemical, radiological, and explosive terrorism in those plans. Only about 9 percent of hospitals had provided for all 10 of the response plan components studied. Hospitals had a mean of about 14 personal protective suits, 21 critical care beds, 12 mechanical ventilators, 7 negative pressure isolation rooms, and 2 decontamination showers each. Hospital bed capacity was the factor most consistently associated with emergency response planning and availability of resources.     

Occupational injury and illness among migrant and seasonal farmworkers in New York State and Pennsylvania, 1997-1999: pilot study of a new surveillance method

BACKGROUND: Traditional worksite injury surveillance methods are often ineffective for Northeastern farms employing seasonal harvest labor. Many are small farms, exempt from mandatory injury reporting. The high proportion of foreign workers and the temporary nature of the work further discourages reporting. Therefore, an alternative migrant health center-based occupational injury and illness surveillance system was piloted during 1997-1999. METHODS: Anonymous medical chart data from nine migrant health centers and four regional hospital emergency rooms was collected during 1997-1999. RESULTS: There were 516 injury/illness cases over two seasons. Joint/muscle straining (31%), falling (18%), poison ivy contact (10%), and object strikes (8%) were most common injurious events. The participation rate of health care was 75%; 130 cases were reported by hospital emergency rooms; and optimal health center participation was associated with: being a farmworker-dedicated program, and including the chart reviewer in the health center's decision to participate. CONCLUSIONS: Further development of a medical records-based surveillance system should include hospital emergency rooms and focus on identified health center performance factors.     

Interpersonal violence-related injuries in an African-American community in Philadelphia

Violence has been recognized as a significant health problem. This study describes fatal and nonfatal interpersonal violence-related injury events over 1 year in an indigent African-American community in Philadelphia. Information on injuries was collected from emergency rooms, the Office of the Medical Examiner, and death certificate files. For persons aged 15 through 49 years, violence-related injury rates surpassed any other injury type. The overall violence-related injury rate was 28.7 per thousand population. Interpersonal violence-related injuries were important for the 0- to 4-year age group (9.19 injuries per 1000 population), and continued as a major cause of morbidity through age 59 (12.08 injuries per 1000 population). For more than half of the events, information from the emergency room chart was sufficient only to categorize the incident as a "fight" or that it was intentional; no further classification was possible.