The Mouse, the Code and EMTALA

By Al Anthony Mercado, Esq., and Tammie Smeltz

The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law enacted in 1986 by Congress to address the issue of “patient dumping.” More specifically, it is intended to address situations where:

  • hospitals failed to screen or appropriately transfer patients;
  • hospitals refused to treat; and
  • uninsured patients were transferred, solely for financial reasons, from private to public hospitals without consideration of medical condition or stability for transfer. 

EMTALA applies to Medicare-participating hospitals with dedicated emergency departments for the treatment of emergency medical conditions and Critical Access Hospitals that operate dedicated emergency departments. However, EMTALA does not apply to hospital-based clinics not equipped to handle medical emergencies. 

Under EMTALA, a hospital must perform a medical screening exam on any person who comes to the emergency department and requests care to determine whether an emergency medical condition exists or if the patient is in active labor regardless of their ability to pay, insurance status or ethnicity. The request for emergency care can come from the patient or the patient’s representative. 

The purpose of a medical screening exam is to determine whether an emergency medical condition exists. An emergency medical condition is defined as acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could result in placing the health of a person or unborn child in serious jeopardy, serious impairment to bodily function and serious dysfunction of part of the body. The medical screening exam should be a documented ongoing evaluation that continues until the patient is stabilized, transferred or discharged. A medical screening exam cannot be delayed to inquire about the ability to pay or insurance status. 

If the medical screening exam shows that no medical emergency exists, there are no EMTALA duties. However, if an emergency medical condition or active labor is found to exist, treatment must be provided until the emergency medical condition is resolved or stabilized. Whether a patient is stable is a medical determination. A patient is “stable” when there is no material deterioration of the patient’s condition likely to result from or occur during a transfer or discharge. A pregnant patient can be stable if she has delivered (including the placenta). A mental health patient can be stable if they are not in danger of injuring themself or others.

If the hospital does not have the capability to treat an emergency medical condition, the hospital must institute treatment or stabilize the emergency medical condition to the extent of the hospital’s ability and arrange an appropriate transfer to another (higher level) hospital. “Stable for Transfer” means there has been a medical determination that the patient will arrive at a receiving facility with no material deterioration in his/her condition and a reasonable belief that the receiving facility has the capacity to manage the condition and any reasonably foreseeable complication.

“Stable for discharge” means when continued care, including diagnostic work-up or treatment, could reasonably be performed as an outpatient or later as an inpatient. There must be an appropriate discharge plan provided to the patient and discharge vital signs documented in the medical record.  A final resolution is not required.

Rural hospitals and Critical Access Hospitals have EMTALA obligations, but those obligations are limited by the hospital’s capacity.

The penalties for an EMTALA violation include exclusion from Medicare, civil monetary penalties of up to $104,826 per violation ($25,000 if the hospital is under one hundred beds), civil monetary penalties for physicians of up to $50,000 per violation for physicians arising from examination, treatment or transfer, and civil actions for both EMTALA violations and medical malpractice.

To manage the risk of an EMTALA violation or a malpractice claim where the requirements of EMTALA are at issue, there should be strong documentation of all aspects of EMTALA, including the timing of when the patient received a medical screening exam and what was included as part of that exam.

Documentation is important in managing the risk of both an EMTALA violation and a medical malpractice action.

Complete and accurate documentation is imperative when documenting the following: 

  • the timing of when the patient received a medical screening exam and what was included as part of that exam;
  • whether an emergency medical condition was diagnosed and what that condition was;
  • what treatment and stabilization procedures were provided to the patient, referencing ancillary services if appropriate, as well as the extent of the hospital’s capability;
  • whether an appropriate transfer was arranged or refused by the patient; and 
  • whether the patient was admitted, discharged, or transferred.

Case Study

The patient in this case was 43 years old at the time of the incident. Her past medical history was significant for diabetes, high blood pressure, renal failure and colon cancer. Her past surgical history was significant for a renal transplant and colostomy. Due to her medical history, she was disabled from work. 

Despite all her chronic medical conditions, the patient did not have a primary care physician. Instead, she used the emergency room as her physician’s office. She was well-known to the hospital and healthcare providers in this case study.

The patient was visiting her mother and noticed a mouse running through her mother’s kitchen. She became very upset, vomited and started to experience chest pain. She drove herself to the hospital and presented to the emergency department at 7:27 p.m.  She reported experiencing radiating chest pain, 6/10, down her left arm. However, on her way to the hospital the chest pain dissipated. She was triaged at 7:35 p.m., at which time she had no complaints of chest pain, shortness of breath, diaphoresis, nausea or vomiting. Her blood pressure was 94/61 and her pulse was 61. The remainder of her vital signs were normal.

The hospital was a small community-based facility. The emergency department was at capacity that evening. As a result, the patient was placed in a pediatric treatment room because there were no adult treatment rooms available. The triage nurse left the pediatric treatment room for a few minutes to obtain an EKG monitor. When he returned, he found the patient unresponsive with gurgling respirations and a faint pulse. She was placed on a monitor and moved to the trauma room immediately. However, she went into cardiac arrest at 7:48 p.m. A code was called, and CPR was initiated. Despite extensive resuscitative measures, the patient was pronounced dead at 9:04 p.m.

An autopsy was performed, and the cause of death was arteriosclerotic cardiovascular and hypertensive disease. 

The patient’s son commenced a lawsuit against the hospital, two emergency room physicians and the entity that had a contract for emergency medicine services with the hospital. MLMIC represented the hospital and one of the emergency medicine physicians. The allegations were wrongful death, failure to diagnose a myocardial infarction and a violation of EMTALA (42 USC 1395 dd(a). The decedent’s son arrived at the hospital shortly after his mother and claimed that his mother was not seen by any medical provider for 45 minutes.

MLMIC retained an emergency medicine expert to review this case. He felt the standard of care was met. The expert opined that according to the American College of Cardiologists and the American Heart Association, “active” chest pain requires an EKG to be performed within ten minutes of arrival at the hospital. However, this patient was not in active chest pain. She reported her pain resolved before arriving at the hospital. In fact, the medical record indicated her chest pain was 0/10 on presentation. It was his opinion that all the ACLS protocols were followed and that both physicians, as well as the nurses at the hospital, acted within the standard of care. The patient was treated in a timely manner. 

Additionally, he opined that a small rural hospital’s EMTALA obligations are limited by its capacity. Regarding EMTALA, it was his opinion that the purpose of EMTALA is not to guarantee that emergency personnel will correctly formulate an accurate diagnosis during the initial screening. Rather, it only requires an appropriate medical screening to determine whether an emergency medical condition exists. 

The MLMIC-appointed defense attorney served a motion for summary judgment, together with an expert affidavit upon completion of depositions. The plaintiff opposed the motion and provided an expert affidavit. The co-defendant also served a motion for summary judgment. The motion was argued, and the judge denied MLMIC’s motion for summary judgment relative to the malpractice claim, as well as the EMTALA violation. He also denied the plaintiff’s motion but did grant the co-defendant’s motion. As a result, the case proceeded to trial. The MLMIC-insured hospital and emergency room physician were the only defendants remaining in this action.

A jury was selected, and the case proceeded to trial. As we often see in the courtroom, it was a battle of the experts. It was clear the plaintiff’s expert was essentially a “hired gun.” He testified he reviewed malpractice cases in 13 states and had testified in the courtroom on more than 200 occasions. He was not credible and argumentative. Alternatively, the emergency room expert who testified on behalf of the MLMIC defendants was engaging. The jury was extremely attentive as he educated them on the medicine, as well as EMTALA. 

Once trial testimony was complete, the defense attorney made a motion to dismiss both the EMTALA, as well as the medical malpractice claim. The judge dismissed the EMTALA claim, and the case was sent to the jury for deliberations regarding the medical malpractice claim.

During closing arguments, the plaintiff outlined the damages as follows: $108,000 for loss of guidance, $94,500 for loss of future guidance and $15,000 for pain and suffering. 

The jury deliberated the case for less than an hour and returned with a defense verdict.

Legal Analysis

There were two key elements leading to the dismissal of the alleged EMTALA violation. First, the case involved a rural hospital that was at capacity. EMTALA did apply, but the hospital’s obligations were limited by its capacity and made the placement of the patient in the pediatric room acceptable. Second, the medical screening examination showed that the patient reported that her pain resolved before arriving at the hospital. In fact, the medical record indicated her chest pain was 0/10 on presentation.  This meant that she did not have an emergency medical condition triggering EMTALA. 

The court did not grant summary judgment on the EMTALA allegation because a fact issue requiring trial was found on the EMTALA violation. However, upon the close of the plaintiff’s case the court could make a determination that there was no EMTALA violation.

Takeaways

EMTALA does not take the place of or limit malpractice actions under state law. That being said, the same circumstances may support both a medical malpractice action and an EMTALA violation. Also, actions may differ in jurisdiction, damages and elements.

There are many aspects of EMTALA in addition to the alleged violation in this case study. MLMIC suggests keeping the following in mind when treating patients at a rural or critical access hospital:

  • Rural and critical access hospitals have EMTALA obligations, but those obligations are limited by the hospital’s capacity.
  • Documentation is important in managing the risk of both an EMTALA violation and a medical malpractice action.
  • Complete and accurate documentation is imperative when documenting the following: 
    • The timing of when the patient received a medical screening exam and what was included as part of that exam
    • Whether an emergency medical condition was diagnosed and what that condition was
    • What treatment and stabilization procedures were provided to the patient, referencing ancillary services if appropriate, as well as the extent of the hospital’s capability
    • Whether an appropriate transfer was arranged or refused by the patient 
    • Whether the patient was admitted, discharged, or transferred

MLMIC policyholders can reach our 24/7 emergency support services for questions regarding EMTALA by calling (844) MMS-LAW1. You can also submit a specific question by sending an email request here

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