EMTALA for Dummies

What is EMTALA?

EMTALA stands for “Emergency Medical Treatment & Labor Act.” It is a federal law enacted by Congress in 1986 to prevent hospitals from sending away patients based on insurance status, race, gender, national origin, preexisting medical conditions, etc. It was developed in response to public outrage about reported cases of private hospitals refusing to treat uninsured patients in the 1980s, sometimes even transferring them to public hospitals while they were medically unstable. The goal of EMTALA is to ensure that any person with any emergency medical condition will receive reasonable evaluation and stabilization in any emergency room in the country before they are transferred. While the law is tied to Medicare reimbursements, it applies to ALL patients seeking medical care in emergency rooms, not just Medicare beneficiaries.

Why Should I Care?

Violation of EMTALA is extremely serious. It can result in large fines to physicians that medical malpractice insurance does not cover. Every EMTALA violation triggers a federal investigation that can result in hospitals losing their Medicare reimbursement. This would effectively shut down most hospitals. 

While EMTALA seems straightforward in principle, it can be surprisingly tricky to apply in practice. Well-meaning physicians can violate EMTALA by making decisions that seem perfectly reasonable, such as sending sick patients away to bigger and better-equipped facilities, redirecting young healthy patients to urgent care, delegating the Medical Screening Exam (MSE) to residents or PAs, or simply honoring patient requests. The following is a step-by-step guide on how to comply with EMTALA as an ED resident, including how to avoid surprising pitfalls (did you know that a healthy woman in active labor can be considered “medically unstable?”) and deal with tricky scenarios (what if a perfectly healthy person comes to the ED for a sandwich?).    

Please note that this is a very basic summary of EMTALA written by a resident for residents, and is superseded by formal CME education, institutional training, hospital bylaws, and the sophisticated and nuanced language of EMTALA itself.  

How Do I Comply with EMTALA on Shift?

1. Make sure all ED patients are registered. This seems obvious, but it also includes any patient with any emergency medical condition (including those brought in by family or EMS who have no specific medical complaint) and unaccompanied patients without capacity (a 5 year old girl who shows up alone). Doing this helps demonstrate that you have not actively tried to turn patients away.
2. Make sure a “licensed independent practitioner” performs a Medical Screening Exam (MSE). A licensed independent practitioner can be a physician with a medical license or a nurse practitioner. Some hospitals, via their bylaws, allow physician assistants to preform MSEs. Note that this does not include interns, unlicensed residents, or non-NP nurses. Some hospitals go a step further and only allow attending physicians to perform the MSE, so check with your department leadership to be safe. The content of the MSE is not defined, so the licensed independent practitioner can use his or her own “reasonable standard of care.” Finally, be careful about triage nurses that turn patients away. The brief screening exam performed at triage is not the same thing as a MSE performed by a licensed MD or NP.
3. Make sure the Medical Screening Exam (MSE) is performed on hospital grounds. This also seems obvious, but be careful about sending patients to nearby PMD offices or affiliated hospitals, even if this is more convenient or the patient/staff makes this request during very busy shifts. That being said, the MSE does not always need to be performed in the ED, even if the patient initially presents there.
   • For instance, if a woman in active labor presents to the ED, it is perfectly acceptable to send her immediately to the Labor & Delivery floor to receive the MSE if you are reasonably certain that she will not have a dangerous delivery en route (i.e., on the elevator).
   • Likewise, if a visitor suddenly develops chest pain in Labor & Delivery, it is perfectly acceptable to immediately send him or her to the ED to receive the MSE.
   • In other words, you can send ED patients to any other licensed independent practitioners inside the hospital, so long as the patient doesn’t leave the hospital before receiving their MSE. If this becomes confusing because your hospital facilities are spread across many buildings or floors (as they often are), always ask an attending before sending patients away.
4. Before initiating ANY patient transfer, make sure you have made a reasonable attempt to stabilize the patient using the full extent of your hospital’s capabilities, regardless of the condition in which the patient presented. This is a crucial requirement that can be difficult to fulfill, but it is the main point of EMTALA. According to EMTALA, “unstable” means there is “a reasonable expectation of deterioration en route.”
   • For example, if a patient is hemodynamically unstable due to an aortic dissection and your hospital has the resources to repair that dissection, you are obligated to keep the patient.
   • If you are at a hospital without surgeons who can perform this operation, you STILL need to make a reasonable attempt to stabilize the patient in the ED using every resource at your disposal, including placing a central line, starting pressors, intubating, or whatever else to reduce the chances of decompensation during the transfer.
   • For a patient in active labor, “unstable” means you have a reasonable expectation that the patient will deliver either the fetus or the placenta en route. A common example would be a multigravida patient who is crowning in the ED. Even if this is a healthy woman and fetus in normal labor, the patient is considered “unstable for transfer” because the delivery is imminent, and the patient therefore CANNOT be sent away without treatment first.

But what if the patient asks/demands to be transferred while they are medically unstable?  This is a very tricky situation and way above resident pay grade. Even attendings will likely call in administrative or legal resources to deal with this one. It can be done under certain and exceedingly well-documented circumstances, but it is not a resident level decision. 

Once the patient receives a Medical Screening Exam at the hands of a licensed independent practitioner AND a reasonable attempt has been made at stabilization, your EMTALA obligations are fulfilled.

Common EMTALA Pitfalls

• My patient would receive more definitive care at a different hospital, and I’m going to transfer him even though he’s unstable. This is tricky. EMTALA does not expressly forbid the transfer of unstable patients, but remember that you can only do so AFTER a reasonable attempt was made to stabilize. At a large tertiary care academic center, with all services available, there should NEVER be any reason to transfer an unstable patient. If the patient remains unstable despite your best efforts, then he or she should be admitted to your hospital rather than transferred elsewhere. At a smaller hospital with fewer resources, you may lack the capability to fully stabilize the patient, and may therefore be justified in transferring an unstable patient to a larger facility once your attempt at stabilization fails. Make sure you clearly document the MSE, your stabilization efforts, and the reason for transfer (what services/capacity does your facility lack that the other facility has?).

• EMTALA only applies when I’m transferring patients out of my own hospital, and not when I’m accepting transfers from other hospitals. Absolutely not! This is a common and dangerous mistake at large tertiary care academic centers. BOTH the transferring AND receiving hospitals are responsible for the Medical Screening Exam (MSE). This means that, if you pick up the phone to accept a transfer, it’s your responsibility to ask if the other hospital performed a proper MSE, attempted to stabilize the patient, and has a valid reason for the transfer. Here are two sneaky ways to commit an EMTALA violation as the receiving hospital:
  1.  Refusal to accept a perfectly valid transfer from another hospital
  2. Failing to report an invalid transfer by another hospital (ie., not reporting someone else’s EMTALA violation, which is itself a violation).

• EMTALA only applies to ED physicians, not consulting services. Wrong again! If a consult fails or refuses to perform an initial assessment of an ED patient within a reasonable amount of time, they have violated EMTALA. The amount of time is determined by hospital bylaws, but in general, it’s important to remind consults that they also have an obligation to see patients expediently in the ED.

• Remember that EMTALA stands for the Emergency Medical Treatment **AND LABOR** Act. This is to acknowledge that sometimes women in active labor need to be treated as if they were a “medical emergency,” even if they are undergoing a perfectly normal and healthy delivery. See below for more details about this tricky situation.

Tricky EMTALA Scenarios

• What if a medically STABLE patient in active labor presents to my ED? 

The triage nurse should register the patient in the ED, then send them to the Labor & Delivery floor for the medical screening exam. If your hospital does not have a Labor & Delivery floor, then have a licensed independent practitioner perform a Medical Screening Exam in the ED first, confirm that the patient is stable, THEN initiate a transfer to another facility that has Labor & Delivery.

• What if a medically UNSTABLE patient in active labor presents to my ED? 

If the patient may decompensate or deliver en route from the ED to the Labor & Delivery floor, the triage nurse should register the patient and give her a bed in the ED. You should see the patient, then consult an Ob/Gyn physician to come down to the ED immediately. If they fail to do so, this constitutes an EMTALA violation on their part.

• What if my ED is on diversion, but EMS still comes with a patient? 

EMTALA still applies. You must still register the patient and have an licensed independent practitioner perform a medical screening exam before you have EMS take the patient elsewhere. 

• What if the patient shows up to the ED, has no medical complaint or request whatsoever, is very well-appearing, and only wants a sandwich or a place to sleep? 

If a patient CLEARLY states that they have no emergency medical requests, and a reasonable layperson would agree with you that they don’t need medical attention, technically EMTALA does not apply. However, given how ambiguous this can become, you should always check with an attending first.

In summary, all patients who enter any ED in the country need:

1.  Medical Screening Exam at the hands of a licensed independent practitioner before leaving hospital grounds.
2. A reasonable attempt at stabilization using the full extent of your hospital’s capabilities before transfer. 

Here’s the full EMTALA law in all its glory, in case you’re curious. A huge thanks to Dr. Elaine Rabin, Dr. Peter Shearer, and Dr. Ben Azan for their edits and contributions.