The Emergency Medical Treatment and Active Labor Act 2006 42 USC 1395dd 42 CFR 489'24

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The Emergency Medical Treatment and Active Labor
Act 2006 42 USC 1395dd 42 CFR 489.24

• Jorge A. Martinez, MD, JD
• Clinical Professor of Medicine
• LSU School of Medicine

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EMTALA Basic Scheme 42 US 1395 dd
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Important Terms

• Individual comes to the ED
• ?
• Must perform MSE includes ancillary services
• ?
• Must determine if emergency medical condition
  exists ?
• If EMC exists must stabilize before
  transfer

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Comes to the ED42 CFR 489.24 (b)

• Has presented at hospitals dedicated ED and
  requests examination or treatment or request is
  made on his behalf, or a prudent layperson would
  believe that the individual needs an examination
• Has presented on hospital property other than
  hospitals dedicated ED and requests examination
  or treatment

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Comes to the ED 42 CFR 489.24 (b)

• If transported by ambulance owned and operated by
  the hospital even if the ambulance is not on
  hospital grounds.
• This provision does not apply if the
  hospital-owned ambulance is operating under
  community wide EMS protocols that direct it to
  transport the individual to another hospital

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Comes to the ED 42 CFR 489.24 (b)

• Nonhospital-owned ambulance if the individual
  arrives on hospital property for examination and
  treatment of a medical condition at the
  hospitals dedicated ED

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Dedicated Emergency Department 42 CFR 489.24 (b)

• 1) Is licensed by the state as an emergency
  department
• 2) Is held out to the public (by name,
  advertising, posted signs, other means) as a
  place that provides care to emergency situations
  on an urgent basis without an appointment
• 3) During the previous year provided at least 1/3
  of visits for emergency treatment without
  requiring a scheduled appointment

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Hospital Property Sec 413.65(a)

• Hospital property includes the entire hospital
  campus
• Encompasses any part of the hospital other than
  the dedicated emergency department
• Includes hospital departments, parking lot,
  sidewalk and driveway, and any buildings owned by
  the hospital that are within 250 yards of the
  hospital

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Emergency Medical Condition1395dd (e)

• A medical condition with acute symptoms
  (including pain, psychiatric sxs, or substance
  abuse) where the lack of immediate medical
  attention could reasonably be expected to
• 1) Place health of individual or unborn child in
  serious jeopardy
• 2) Cause serious impairment of bodily function
• 3) Cause serious dysfunction of body organ/part

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Caution!!

• Some intoxicated individuals may meet the
  definition of emergency medical
  conditionbecause the absence of medical
  treatment may place their health in serious
  jeopardy or result in serious dysfunction of a
  bodily organ. Further, it is not unusual for
  intoxicated individuals to have unrecognized
  trauma.

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Caution!!

• Likewise, an individual expressing suicidal or
  homicidal thoughts or gestures, if determined
  dangerous to self or others, would be considered
  an emergency medical condition.

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What is an Acceptable Medical Screening?

• CMS Interpretive Guidelines state the following
• Individuals coming to the emergency room must be
  provided a medical screening beyond initial
  triage.
• The medical screening must be the same medical
  screening that the hospital would perform on any
  individual coming to the hospitals emergency
  room with those signs and symptoms, regardless
  ..to pay.

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What is an Acceptable Medical Screening?

• A medical screening examination is the process
  required to reach with reasonable clinical
  confidence, the point at which it can be
  determined whether a medical emergency does or
  does not exist.
• Depending upon the patient, this process will
  vary from only a brief HP to a complex process
  involving ancillary studies and specialty
  consultations.

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What is an Acceptable Medical Screening?

• A medical screening is not an isolated event. It
  is an ongoing process.
• Hospital and Department medical staff should
  address, through policy and medical standards,
  how best to provide the screening.
• Medical Screenings are required to be documented.
• If it isnt written down, it never happened!!

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Medical Screening Documentation

• Need to document why the patient is now stable
  enough to be transferred.
• Is patient hemodynamically stable to the best of
  our capabilities?
• Has psychiatric condition been evaluated and
  treated to the best of our capabilities?
• Have any abnormal test (EKGs) been repeated if
  the first one was abnormal and the patient has
  been in our care for a lengthy period of time?

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Caution!!

• Regardless of a positive or negative patient
  outcome, a hospital will be in violation of the
  anti-dumping statute if it fails to meet any of
  the medical screening requirements.
• If a misdiagnosis occurs, but the hospital
  utilized all of its resources, a violation of the
  screening requirement does not occur.

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CAUTION!!!!!!

• Case history has not been kind to hospitals who
  utilized non-physician medical screeners even
  though by law it is allowed.
• TRAIGE IS NOT CONSIDERED TO BE A MEDICAL
  SCREENING!!!!!

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Stabilization 1395dd (e)

• No material deterioration of the condition,
  within reasonable medical probability, will
  result from or occur during the transfer of the
  individual
• Pregnant woman who is having contractions To
  deliver the fetus and placenta

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Transfer 1395dd (e)

• The movement (including the discharge) of an
  individual outside of the ED facilities at the
  direction of any person employed by or affiliated
  or associated, directly or indirectly, with the
  hospital
• Does not include
• the movement of a dead body
• person who leaves AMA

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Transfer

• Rule 1395 dd (c)(1) Must stabilize before
  transfer
• Only exceptions to stabilize before transfer rule
  
• 1) patient requests (without coercion) 1395 dd
  (c)(1)(A)(i)
• 2) benefits of transfer outweigh risks of
  transfer 1395 dd (c)(1)(A)(ii)
• 3) MD refuses or fails to appear 1395 dd
  (d)(1)(C)

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Appropriate transfer1395 dd (c) (B)

• 1) Before transfer to another hospital must
  contact receiving hospital
• 2) Receiving hospital must accept patient before
  he/she can be transferred
• 3) Patient must be transferred by appropriate
  means (including personnel)
• 4) Receiving hospital must report transfer
  without approval to CMS

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Transfer Documentation

• Must show that the transfer was initiated by
  either a written request by the patient (or
  his/her representative) or a physicians
  certification.
• Must state the reason for the transfer.
• The receiving facility and the accepting
  physician. Recommendation Include a brief
  statement that the patients full condition was
  discussed with the accepting physician.
• The risk and benefits of the transfer.

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Transfer Documentation

• Risk Benefits!!
• Need to be realistic and pertinent to the case.
• MVA is not usually a true risk of the transfer
  that needs to be documented in most cases.
• Worsening of condition, lack of medical
  equipment, increase of pain, increase exposure to
  infection and no physician for intervention are
  some examples of true risk.

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Delay in examination or treatment42 CFR 489.24
(d)(4)

• Hospital may not delay providing MSE or medical
  examination and treatment to inquire of method of
  payment
• Hospital may not seek, or direct an individual
  to seek, authorization until after MSE and
  medical examination and treatment has been
  initiated

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Delay in examination or treatment42 CFR 489.24
(d)(4)

• Hospitals may follow reasonable registration
  processes as long as it does not delay screening
  or treatment
• Registration processes may not discourage
  individuals from remaining for further evaluation
• Practitioner may contact individuals physician
  to seek information or advise relevant to the
  medical treatment

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Inpatients42 CFR 489.24 (d)(2)

• If a hospital has screened an individual under
  paragraph (a), found to the individual to have an
  EMC, and admits the individual as an inpatient in
  good faith in order to stabilize the EMC, the
  hospital has satisfied its responsibilities
• Not applicable to individuals admitted on an
  elective/nonemergent basis

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On-call physicians42 CFR 489.24 (j)

• Each hospital must maintain MD on-call list that
  best meets the needs of its patients
• The hospital must have written policies and
  procedures that
• Respond to situations where a particular
  specialty is not available or the on-call MD
  cannot respond because of circumstances beyond
  MDs control
• Assures emergency services are available
• if it elects to permit on-call physicians to
  schedule elective surgery when they are on-call
  or to permit simultaneous on-call duties

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EMTALA and psych patients

• Psychiatric emergency medical condition
• patient is danger to self or others
• patient has potential to be danger to self or
  others
• substance abuse
• Psychiatric emergency medical condition is
  stabilized when patient is no longer danger to
  self or others

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EMTALA and psych patients

• Screening essentials
• Physician must screen for
• physical and mental illness
• history of violence to himself or others
• suicide attempt or voiced suicidal ideation
• danger to herself or others by making violent
  acts, gestures, or threats
• signs of confusion or mental status changes
• substance abuse that can affect the patients
  cognition or judgment

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EMTALA and psych patients

• EMTALA does not require the patient to have
  laboratories or radiographies performed to ensure
  medical stability.
• It does require that psychiatric patients with
  medical problems are transferred to a psychiatric
  facility that is equipped to handle the patients
  medical problem.

Moy, MM EMTALA and Psychiatry in The EMTALA
Answer Book 2nd Edition. Gaithersburg, MDAspen
2000
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Short mental status examinations

• Mini-Mental State Exam
• The Brief Mental Status Examination
• Short Portable Mental Status Questionnaire
• Cognitive Capacity Screening Examination

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Short mental status exams in the ED

• Used the Brief Mental Status Examination in an
  inner city ED.
• Score 0-8 normal, 9-19 mildly impaired, 20-28
  severely impaired
• 100 randomly selected subjects
• 100 subjects with indications for the exam
• 72 sensitivity and 95 specificity in
  identifying impaired individuals in the ED

Kaufman, DM, and Zun, LS A Quantifiable, brief
mental status examination for emergency patients
J Emerg Med, 13449-456, 1995.
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Brief Mental Status Examination Questions
Score (number of errors) x (weight)
  What year is it now? 0 or 1
x 4   What month is it? 0 or 1 x
3   Present memory phase after me and remember
it John, Brown, 42, Market Street, New
York   About what time is it? 0 or 1 x
3 (Answer correct if within 1 hour)   Count
backwards from 20 to 1. 0.1. or 2 x2   Say
the months in reverse 0, 1, or 2 x2   Repeat
the memory phase 0,1,2,3,4 or 5 x 2
(each underlined portion is worth 1
point)   Final score equal to the sum of the
total(s)   Katzman, R, Brown, T, Fuld, P,
Peck, A, Schechter, R, Schimmel, H Validation of
a short orientation-memory concentration test of
cognitive impairment. Am J Psych 1983 140734-9.

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Need laboratory studies

• 46 of psychiatric patients had unrecognized
  medical illness.
• Hall, RC, Gardner, ER, Popkin, MK, et. al
  Unrecognized physical illness prompting
  psychiatric admission A prospective study. Am J
  Psych 1981 138 629-633.
• 92 of one or more previously undiagnosed
  physical diseases.
• Bunce, DF Jones, R, Badger, LW, Jones, SE
  Medical Illness in psychiatric patients Barriers
  to diagnoses and treatment. South Med J 1982
  75941-944.
• 43 of psychiatric clinic patients had one or
  several physical illnesses.
• Koranyi, E Morbidly and rate of undiagnosed
  physical illness in a psychiatric population.
  Arch Gen Psych 1979 36 414-419.

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Need laboratory studies

• Retrospective review of 158 patients, 6 of the
  psych patients had undiagnosed physical illness
  that might contribute to psychiatric illness.
• Skelcy, K, Wagner, MJ Medical clearance of the
  psychiatric patient, ACEP Research Forum, 2000.

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New onset psych presentation

• 100 consecutive patients aged 16-65 with new
  psychiatric symptoms
• 63 of 100 had organic etiology for their symptoms
• History (100) 53 ABN 27
  sign
• PE (100) 64 ABN 6 sign
• CBC (98) 72 ABN 5 sign
• SMA-7 (100) 73 ABN 10 sign
• Drug
• screen (97) 37 ABN 29 sign
• CT scan (82) 28 ABN 10 sign
• LP (38) 55 ABN 8 sign
• Point Patients may need extensive laboratory and
  radiographic evaluations including CT and LP

Hennenman, PL, Mendoza, R, Lewis, RJ Prospective
evaluation of emergency department medical
clearance. Ann Emerg Med 199424672-677.
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Medical workup not necessary

• Most laboratories, EKG and radiographic testing
  should be abandoned in favor of a more clinically
  driven and cost effective process.
• Allen, MH, Currier, GW Medical assessment in the
  psychiatric emergency service. New Directions in
  Mental Health Services 19998221-28.
• Patients with primary psychiatric complaints with
  other negative findings do not need ancillary
  testing in the ED.
• Korn,CS, Currier, GW, Henderson, SO Medical
  Clearance of psychiatric patients without
  medical complaints in the emergency department. J
  Emerg Med 200018173-176.

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Medical workup not necessary

• Medical and substance abuse problems identified
  by initial vital signs along with a basic history
  and physical examination
• Olshaker, JS, Browne, B, Jerrard, DA,
  Prendergast, H, Stair, TO Medical clearance and
  screening of psychiatric patients in the
  emergency department. Acad Emerg Med
  19974124-128.
• Universal laboratory and toxicological screening
  are low yield
• Olshaker, JS, Browne, B, Jerrard, DA,
  Prendergast, H, Stair, TO Medical clearance and
  screening of psychiatric patients in the
  emergency department. Acad Emerg Med
  19974124-128.

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Poor documentation of medical aspect ofMedical
Screening Examination in psych patients

• 298 charts reviewed in 1991 at one hospital
• Triage deficiencies
• Mental status 56
• Physician deficiencies
• Cranial nerves 45
• Motor function 38
• Extremities 27
• Mental status 20
• Medically clear documented in 80

Tintinalli, JE, Peacodk, FW, Wright, MA
Emergency medical evaluation of psychiatric
patients. Ann Emerg Med 1994 23859-862.
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Medically Clear

• Medically stable vs medically clear
• Both terms have great capacity to mislead
• Concern about misdiagnosis, premature referral,
  and misunderstandings
• Better to write Discharge Note
• History and physical examination
• Mental status and neurologic exam
• Laboratory results
• Treatment plan
• Transfer/discharge instructions
• Follow up plans
• Weissberg, M Emergency room clearance An
  educational problem. Am J Psych
  1979136787-789.

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• Medical Clearance Checklist
• Patients name _______ Race ______________
• Date _________________ Date of birth________
• Gender ________________ Institution
  _____________
• Yes No
• 1. Does the patient have new psychiatric
  condition? ? ?
• 2. Any history of active medical illness needing
  evaluation? ? ?
• 3. Any abnormal vital signs prior to
  transfer ? ?
• Temperature gt101oF __ __
• Pulse outside of 50 to 120 beats/min __ __
• Blood pressurelt90 systolic orgt200gt120
  diastolic __ __
• Respiratory rate gt24 breaths/min __ __
• (For a pediatric patient, vital signs indices
  outside the normal range for his/her age and sex)
• 4. Any abnormal physical exam (unclothed)
• a. Absence of significant part of body, eg,
  limb __ __
• b. Acute and chronic trauma (including signs of
  abuse) __ __
• c. Breath sounds __ __

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• g. Neurological with particular focus on
• i. Ataxia ____ iv. Paralysis ___
• ii. pupil symmetry, size ___ v. meningeal
  signs ___
• iii. Nystagmus ___ vi. Reflexes ___
• 5. Any abnormal mental status indicating medical
  illness such as lethargic, stuporous, comatose,
  spontaneously fluctuating mental status? _____
• If no to all of the above questions, no further
  evaluation is necessary. Go to question 9
• If yes to any of the above questions go to
  question 6, tests may be indicated.
• 6. Were any labs done? ? ?
• What lab tests were performed?
  ________________________________
  
• What were the results? _____________________
  ___________
• Possibility of pregnancy ? ? ?
• What were the results? _____________________
  ___________
• 7. Were X-rays performed? ? ?
• What kind of x-rays performed?
  _________________________________
  
• What were the results? _________________________
  _______________

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• 9. Has the patient been medically cleared in the
  ED? _________ ? ?
• 10. Any acute medical condition that was
  adequately treated in the emergency department
  that allows transfer to a state operated
  psychiatric facility (SOF)? ? ?
• What treatment? _____________________
  ____________________
• 11. Current medications and last administered?
  __________________________________________________
  ___________
• ___________________________________________
  __________________
• 12. Diagnoses Psychiatric______________________
  __________________
• Medical____________________________
  ________________________
• Substance abuse____________________
  ________________________
• 13. Medical follow-up or treatment required on
  psych floor or at SOF? ___________________________
  ________________________________
• 14. I have had adequate time to evaluate the
  patient and the patients medical condition is
  sufficiently stable that transfer to ___SOF or
  ___ psych floor does not pose a significant risk
  of deterioration. (check one)
• ____________________________________MD/DO
• Physician Signature 

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Case

• A local law enforcement agency presents to the ER
  with a subject whom they have arrested. They
  request a psychiatric evaluation on the subject.
  The hospital is on psychiatric diversion due to
  no beds. The triage nurse advises the law
  officers of this and they voluntarily take the
  subject to another hospital.
• Is this a violation of EMTALA?

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EMTALA Violation?

• Answer --- YES
• Why ?
• The patient was present on hospital grounds and a
  request for services was made. At a minimum, the
  patient should have had a medical screening
  completed and documented. If the law officers
  voluntarily decide to leave without a medical
  screening, it should be documented with the
  appropriate details that the patient left without
  being seen.

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Rules of Thumb

• Never turn a patient away once they are on
  hospital property.
• Always perform an appropriate medical screening
  if the patient (or representative) is requesting
  medical services.
• Document Everything!!
• Make Sure You Document Everything!!
• Document, document, document!!!!!

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