Regulations and laws regarding emergency departments and receiving patients can be complex as they are meant to both protect patients but also maintain the quality of healthcare provision. EMTALA is one of these regulations meant to promote the non-discriminatory nature in emergency departments. This report will examine a scenario through the EMTALA regulatory lens to determine the correct course of action and responsibility for any potential violations.
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The Emergency Medical Treatment and Labor Act (EMTALA) is a federal regulation that was passed in 1986. It requires emergency departments in hospitals to accept anyone coming in with an emergency or women in labor regardless of their insurance, citizenship status, or payment capabilities. All hospitals participating in the Medicare program (which constitutes the large majority) are required to adhere to EMTALA, but the care provided is not covered by the government, thus often criticizing the law as an unfunded mandate. EMTALA states that anyone seeking medical care must undergo a basic medical screening examination (MSE) to determine the nature of the emergency and attempt to stabilize the patient. The regulation is sometimes referred to as an “anti-dumping” law to prevent private hospitals from declining or transfer uninsured patients (American College of Emergency Physicians, n.d.). It offers a set of guidelines on how to receive, stabilize, document, and, if necessary, transfer patients to receive proper treatment.
Rejecting the Patient
EMTALA has a direct provision that would apply to this scenario. It states that treatment must be provided in cases of an emergency condition, and an appropriate transfer is allowed if the patient is stable and the hospital lacks the specialization to address the issue. The receiving hospital, which is more specialized, is obligated to accept the transfer of the original medical facility lacks the capabilities to treat. However, other than ensuring the benefits of the transfer outweigh the risks as well as appropriate paperwork, the receiving hospital must have qualified personnel that is able to and have agreed to accept the patient (Centers for Medicare and Medicaid Services, n.d.).
Rejecting the patient in this scenario would not seem to be a violation of EMTALA for several reasons. First, the patient complaint, albeit serious, is not a critical or complex matter. As advised by the EMT on call, it is a procedure that any emergency department should be able to perform. Therefore, the original request for transfer is not warranted, nor is it ever clarified how Hospital A is more specialized in this matter than Hospital B. Second, the qualified physicians at the receiving Hospital A have not agreed to the transfer. Both agreeing that a higher level of care is not necessary, nor would the benefits of the transfer outweigh the risks since the patient complaint seems to be a time-sensitive issue while the ear is still salvageable. Therefore, legally this should not be an issue, and the EMTALA guidelines discussed were created for the purposes to prevent patient dumping among hospitals without concrete justification to do so, which is not the case in the scenario.
Making the Decision
As an administrator, the decision is inherently difficult. It could be made based on the preferences and recommendations of the two ENT physicians. Therefore, rejecting the transfer would be the most logical decision in this case. However, EMTALA is notoriously difficult to argue unless there are concrete causes for rejection, such as there is lack of bed space, the inability of the ENT to take on additional patients, or an extremely specialized level of care. While it is allowed to reject the patient based on the fact that they may not require special capabilities, it is difficult to determine through the phone. Many times, the sending hospital can argue the special capabilities of the receiving hospital, even in minor details such as bedside monitors. However, under EMTALA transfer rules, if the patient can be cared for at the original hospital and the transfer was put in simply as a preference by the patient, family, or physician, there are grounds for denial (Conover, 2003). Thus, in consideration of physician recommendations and current guidelines, as an administrator, the decision would be to reject the transfer.
Preventing the Situation
In order to avoid such situations in the future, as well as general EMTALA penalties, several systematic changes can be made. The primary factor can be emphasized in terms of personnel. It is vital to maintain qualified and well-trained staff at all hospitals which can be competent, responsive, and maintain a wide scope of practice to avoid the necessity of a transfer, particularly for such non-complex emergencies. Furthermore, personnel training should be conducted regularly, including on the intricacies of EMTALA and how to avoid issues. Another factor to consider is maintaining a written policy that enables staff to comply with guidelines and be aware of the various provisions for EMTALA. Implemented policies also aid in protecting the hospital against penalties in case regulations are violated. Policies should be up to date and track regulatory requirements. Finally, maintaining a timely response in the emergency department, including conducting a qualified medical screening exam, performing stabilizing treatments, and competently processing all the required documentation under regulatory standards. It is possible the situation could be avoided through changes in systematic factors in all hospitals, allowing for better provision of care for the patient.
As a physician at a receiving hospital, one can be responsible for an EMTALA violation if one declines to receive a valid request for a transfer or fail to report an invalid transfer. One can assume that after the scene in which the transfer is declined, the ED attempts to provide treatment, and complications arise due to factors that could have been prevented with a more specialized ED or qualified ENTs. Furthermore, the physician at Hospital A would be in violation of EMTALA if, during an investigation, it was determined that the transfer was declined for non-clinical reasons. Another potential scenario is if Hospital A receives the patient but fails to properly document them and conduct an independent MSE on site, which would be against EMTALA regulations. Otherwise, the primary burden remains on the original transferring Hospital B, and there are few instances where the receiving physician would be responsible.
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It is evident that EMTALA regulations are inherently complex, and it is important for hospitals to maintain vigilance in order to avoid even accidental violations. It seems that structure, documentation, and communication are vital to ensure compliance from both the transferring and receiving hospitals. The scenario offers a situation that is not straightforward, but in the end Hospital, A seems to have grounds for a valid denial of transfer under EMTALA guidelines.
American College of Emergency Physician. (n.d.). EMTALA fact sheet. Web.
Centers for Medicare and Medicaid Services. (n.d.). Certification and compliance for The Emergency Medical Treatment and Labor Act (EMTALA). Web.
Conover, K. (2003). Federal law and the physician: Excerpts related to refusal to accept transfers. Web.