Introduction

The Emergency Medical Treatment and Labor Act (EMTALA) is a United States Congressional Act passed as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1986. It is commonly referred to as a federal “anti-dumping law” that prevents hospitals from denying or limiting treatment to patients based on their insurance status or ability to pay and transfer them to other facilities. Since the law was passed, it has had other far-reaching influences on various aspects of the healthcare system, including emergency medical services (EMS).[1] 

Failure of hospitals and EMS systems to comply with EMTALA mandates can result in stiff penalties imposed by federal agencies, including the Office of the Inspector General (OIG) and Centers for Medicare and Medicaid Services (CMS). These penalties can be in the form of monetary fines, exclusion from Medicare reimbursement, and federal prosecution.[2]

Issues of Concern

EMTALA regulations can be broken down into three important provisions that are important to hospitals and EMS systems. These provisions are as follows:  

Patients who present to a hospital emergency department (ED) (which includes a hospital-based EMS system) must undergo an "appropriate" medical screening examination by a physician or qualified medical person to determine whether they have an "emergency medical condition."[3]

• The ambiguous use of the term "appropriate" medical screening examination has been the topic of debate within both the judicial and medical systems. At the time of this writing, the general understanding of an "appropriate" medical screening examination involves an exam that can be reasonably expected to identify critical emergency medical conditions in a patient who presents to the ED for evaluation.[2]
• Concerning the term "emergency medical condition," this is defined according to EMTALA legislation as follows [see Federal statute 42 USCS § 1395dd section e(1)(A)]:
• "A medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain).  The lack of immediate medical attention could reasonably be expected to result in placing the health of the patient, or (in case of pregnancy, the unborn child) in serious jeopardy, the significant impairment to bodily functions, or serious dysfunction of any bodily organ or part." 
• Concerning a pregnant woman who is having contractions, EMTALA defines an "emergency medical condition" to be when [see Federal statute 42 USCS § 1395dd section e(1)(B)]:
• "There is inadequate time to effect a safe transfer to another hospital, or that transfer may pose a threat to the health or safety of the woman or the unborn child."

Patients who are found to have an "emergency medical condition" must be "stabilized" and treated within the capabilities of the facility. If definitive treatment cannot be provided, after stabilization, an "appropriate" transfer may take place to another facility with adequate capabilities.

According to the language used in the EMTALA legislation, stabilization of a patient involves providing [see Federal statute 42 USCS § 1395dd section e(3)(A)]:

"Such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility."

For a pregnant woman with contractions, the term "stabilization" refers to the delivery of the fetus and the placenta.[2]

The "transfer" of a patient to another facility refers to the physical movement of the patient. An "appropriate" transfer is one in which the patient receives adequate stabilization to minimize risk during transfer, and the receiving hospital accepts the transfer of the patient. Furthermore, the receiving hospital must have the necessary resources (i.e., beds, equipment, etc.) and personnel to treat the patient. An "appropriate" transfer also necessitates the transportation of pertinent medical records and diagnostic findings (i.e., laboratory values, radiographs, CT scans, etc.). Furthermore, the patient must be transported with qualified personnel and transportation equipment. According to EMTALA, the term "transfer" can also refer to the discharge of the patient from the ED once their emergency medical condition has been stabilized and treated. If the patient is transferred before appropriate stabilization, then the hospital and EMS system transporting the patient can be penalized for violating EMTALA regulations.

If the patient is determined to be "stable" and "not in active labor," then the hospital has no further obligations under EMTALA law.  

If an individual has an emergency medical condition and has not been stabilized, the patient cannot be transferred unless a physician or "qualified medical person" deem the benefits of treatment at another facility outweighs the risk of transfer.[4]

EMTALA regulations mandate that "unstable" patients who are being transferred (or an individual legally acting on their behalf) consent to being transferred and are aware of the risks and benefits associated with being transferred. Furthermore, there must be documentation provided by a physician or "qualified medical person" that explicitly confirms that the benefit of definitive treatment at the outside facility outweighs the risk of further decompensation during transport by EMS.[2] An example would be a trauma patient with an intracranial hemorrhage who presents to a hospital that does not have neurosurgical services.[4]

Physicians or "qualified medical persons" who transfer unstable patients under EMTALA provisions must still demonstrate that the transfer is "appropriate" as outlined in the EMTALA regulation described above.

Important Caveats

EMTALA is triggered whenever a patient presents to the hospital campus, not just the physical space of the ED, that is, within 250 yards of the hospital.

Patients who present to a hospital parking lot, sidewalks, and adjacent medical buildings are mandated to undergo EMTALA screening and stabilization. Typically, outpatient physician offices that do not have resources to stabilize critically ill patients are not required to perform a medical screening examination or stabilization before transferring the patient to an ED. In other words, patients who are a part of an outpatient encounter are exempt from these EMTALA regulations.[2]

Hospital-owned or operated ambulances have an EMTALA obligation to provide medical screening examination and stabilization.

Patients who present off hospital grounds and are transported by a hospital-owned or operated ambulance are considered to have presented to the hospital's emergency department and must undergo routine medical screening examination and stabilization as outlined by EMTALA regulations. Before 2003, EMS systems that were owned and operated by a hospital were required under EMTALA laws to transport all patients to their specific hospital to discourage the practice of only carrying insured patients to that hospital. However, given the possibility that the hospital tied with the hospital-based EMS system may not have specialty services that may be required to stabilize and treat the patient, an EMTALA revision was implemented that allowed hospital-based EMS systems to transport a patient to a different hospital if the area protocols require transport to another hospital. Indications for transport to a different hospital include the following [see CMS.gov Emergency Medical Treatment and Labor Act (EMTALA) Interim Guidance, 2003]:

The patient is experiencing a time-critical condition that the specific hospital does not provide service for (i.e., no cardiac catheterization capabilities for STEMI)

If the patient is stable but requires particular subspecialty care that is not present at the hospital tied with the hospital-based EMS system, the patient may be transported to the "closest most appropriate facility" (i.e., the patient has a pregnancy-related issue, and the specific hospital does not have obstetrics services)

The patient requests to be transported to a different area hospital.

Specialized hospitals cannot refuse to accept transfers from other facilities if they have specialized capabilities and sufficient capacity (i.e., beds).

What is known as the "reverse-dumping" EMTALA clause, this provision primarily prevents receiving hospitals from refusing to accept a patient based on their insurance status or ability to pay. If a specialized hospital or "higher-level of care" facility can accommodate a patient and has the required services, the facility must accept the patient.[5]

Before transferring the patient, the sending facility must request the most appropriate EMS level of care. 

Per EMTALA regulations, the transferring facility must anticipate the patient's needs during transport if clinical deterioration occurs. For example, if the patient will require cardiac monitoring, intravenous infusion of medications, or advanced airway management, the transferring hospital must specifically request an Advanced Life Support (ALS) service to transport the patient. This matter becomes significantly more complicated when deciding when to use specialty transport services such as pediatric transport teams or air medical transport.

Clinical Significance

EMTALA regulations are often open to interpretation because of the language used in the initial legislation, which can often lead to significant confusion for healthcare providers and hospital administrators. Failure to follow EMTALA regulations can result in substantial financial and legal consequences for hospitals and EMS systems.[6]