How is emtala enforced

The request may be made by anyone, and it may be expressed or implied by word or by deed. The request may be made by the patient, a family member, a medic, or a law enforcement officer; it doesn't have to come from the patient.

Additionally, in absence of an actual request, CMS will presume a request exists if a prudent layperson observer would believe the individual needs examination or treatment for a medical condition. Although CMS recognizes that hospital personnel must be aware of the individual's presence and appearance or actions that indicate a need for examination or treatment for a medical condition before the hospital would incur a duty to screen the individual under EMTALA. This PLP standard for creating a 'request' is especially relevant in persons brought to the ED for BAT; commonly their behavior, appearance, or obvious intoxication would lead a PLP to believe the person needs examination or treatment for a medical condition.

Therefore, the only way the hospital can avoid its duty to provide an MSE is if the individual refuses the MSE offered by the hospital. The refusal would need to be an informed refusal, after the emergency physician has determined that the patient was medically competent to refuse examination and treatment. However, this new regulation didn't change anything! Thus, all patients presenting with a medical condition must be provided an MSE to determine if that medical condition is an emergency medical condition.

CMS's Interpretive Guidelines of May 13, , state the following regarding police blood alcohol testing in the emergency department:. However, CMS's guidelines further state:. If an individual is brought to the ED and law enforcement personnel request that emergency department personnel draw blood for a BAT only and does not request examination or treatment of a medical condition, such as intoxication and a prudent lay person observer would not believe that the individual needed such examination or treatment, then the EMTALA's screening requirement is not applicable to this situation because the only request made on behalf of the individual was for evidence.

However, if for example, the individual in police custody was involved in a motor vehicle accident or may have sustained injury to him or herself and presents to the ED, an MSE would be warranted to determine if an EMC exists. In my experience, CMS considers persons with substance abuse problems, including alcohol-related problems, to be a 'protected class', and therefore applies greater scrutiny in evaluating their care by the hospital.

Many state surveyors and regional offices also question whether an intoxicated patient can make an informed refusal of care. For example, in the case of Evans v Montgomery Hospital Medical Center, 13 police arrested a man for "driving erratically and acting abnormally. A nurse drew the blood, but the patient was not seen by the emergency physician, and police took the man to jail.

The next morning, he was found dead in his cell from a stroke; his aberrant behavior the night before was the result of cerebral hypoxia, not alcohol. The court determined that the man had requested examination or treatment for a medical condition and accepted the plaintiff's argument, for two reasons:.

The court held that signing the standard hospital consent form was substantial evidence that the man had sought treatment for a medical condition; and. In a case decided after CMS's new 'request' rules became effective, Kraft v. Laney, 14 the patient went into cardiac arrest while the nurse was drawing blood for the police-requested blood alcohol test. Here too, the patient had not been seen by the emergency physician. The court disagreed, holding that EMTALA did not apply yet because neither the patient nor the police requested examination or treatment; and the hospital had no duty to provide an MSE unless it was clear to it that the patient was suffering an emergency medical condition i.

The court noted that the hospital did perform an MSE and attempted stabilizing treatment once the physician became aware that the patient went into cardiac arrest. Actually, the court erred a bit; EMTALA only requires that the patient appear to be suffering from a 'medical condition' that needs examination or treatment, not from an ' emergency medical condition'.

See earlier discussion above. Under CMS's new standard, the only way for the hospital to ensure that BAT patients brought by police don't have medical or trauma issues, and that the PLP standard is not present, is for its clinical staff to interact with the patient. Potentially intoxicated patients are at high risk for harm, and the hospital should always attempt to provide an MSE.

CMS believes alcohol intoxication to be a "sufficiently severe medical symptom to warrant the label "emergency medical condition," 12 and therefore, an intoxicated individual has an EMC until the hospital proves otherwise.

If such an individual has an adverse outcome, CMS can easily conclude retrospectively that the individual had an EMC at the time of presentation and that the hospital failed to perform an appropriate MSE and failed to stabilize the EMC. Nurses may be able to judge the situation in most instances, but not as well as physicians, and they can't determine medical competence under the state's nurse practice act. The crux of the message is that emergency physicians need to be actively involved in the management of these patients in the ED.

In light of the above, I believe that anytime an individual is brought to the ED by police officers for blood alcohol testing, the emergency physician , for both medical and legal reasons, should personally interact with that person, offer to provide an MSE to determine if an emergency medical condition EMC exists, and ascertain whether the person is medically competent to refuse the offered screening examination.

The following approach is suggested for handling the scenario of law enforcement personnel bringing individuals under their custody to the ED for blood alcohol testing:. All such persons are triaged, including vital signs, just like any other person presenting to the ED.

The triage nurse determines the individual's presenting complaint. In practice, the triage nurses are generally correct, and the physician would only need to spend a few minutes with Track A patients.

Issue of 'Disparate Treatment'. Some may question whether this process is disparate treatment in violation of the intent of EMTALA and the letter of the law. Each hospital is allowed to determine the process it will use to screen different types of patients coming to its ED, depending upon the presenting complaint and medical triage criteria. The critical element is that all individuals who meet the established medical criteria go through the same process and that the criteria are not discriminatory.

As long as all persons brought by police for legal blood alcohol draws are put through the same process, the hospital is clearly in compliance with EMTALA, even if it accelerates the patient's care through the ED to accommodate the needs of the police.

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It is mandatory to procure user consent prior to running these cookies on your website. Emergency physicians provide the most charity care of all physicians AMA ACEP advocates for recognition of uncompensated care as a legitimate practice expense for emergency physicians and for federal guidance in how to fulfill the requirements of the EMTALA mandate in light of its significant burden on the nation's emergency care system.

Everyone is only one step away from a medical emergency. Referred to as the "anti-dumping" law, it was designed to prevent hospitals from transferring uninsured or Medicaid patients to public hospitals without, at a minimum, providing a medical screening examination to ensure they were stable for transfer.

As a result, local and state governments began to abdicate responsibility for charity care, shifting this public responsibility to all hospitals. EMTALA requires Medicare-participating hospitals with emergency departments to screen and treat the emergency medical conditions of patients in a non-discriminatory manner to anyone, regardless of their ability to pay, insurance status, national origin, race, creed or color.

A new EMTALA would continue to protect patients from discrimination in treatment, while enabling and encouraging communities to test innovations in emergency care system design, for example, direct transport of patients to non-acute care facilities, such as dialysis centers and ambulatory care clinics, when appropriate.

Hospitals have three main obligations under EMTALA: Any individual who comes and requests must receive a medical screening examination to determine whether an emergency medical condition exists. Examination and treatment cannot be delayed to inquire about methods of payment or insurance coverage.

Emergency departments also must post signs that notify patients and visitors of their rights to a medical screening examination and treatment. If an emergency medical condition exists, treatment must be provided until the emergency medical condition is resolved or stabilized.