Weiss: EMTALA- What the Intensivist needs to know!

Clinical Pearls

• Obligations per EMTALA:
  • Medical Screening Exam (MSE) in order to “diagnose emergency medical conditions (EMC)”
  • Stabilization
    • Loop hole: EMTALA does not predict inappropriate transfers of stable patients
  • Appropriately transfer to a “higher level of care”
• Patients can only sue hospitals for EMTALA violations, however physicians can be fined up to 50k per violation
• Early Cases:
  • Vickers v. Nash
    • Intoxicated patient with head trauma, observed x 11 hours, laceration closed, D/C, dead 4 days later s/p EDH
    • EMTALA violation suspected, however negligence has nothing to do with EMTALA
  • Green v. Toro
    • If a patient is “stable” EMTALA does not apply
• Transfers:
  • Patient or family request w/ informed consent
    • Can allow even an unstable patient to transfer
  • An oath/certification signed by a physician that the medical benefits outweigh the risks
  • The Transfer must be appropriate
    • Max potential to stabilization by the sending facility
    • Receiving facility has: space + personnel for care & accepts transfer
  • Must send appropriate medical records + qualified personnel and equipment travel with patient, AND we have a duty to report violations or face a fine
  • Smith v Janes
    • Serious smoke inhalation, seen locally with obvious inhalational injury, transferred without intubation, respiratory failure/arrest, death
    • EMTALA violation suspected
      • MSE performed, however not stabilized
      • Proper personnel not used for transfer!
• Misc provisions
  • “Reverse dumping”
    • If you have resources required for patient care but not available at the sending location, you must accept!
    • St. Anthony v DHHS
      • St. Anthony hospital rejected an appropriate transfer
• Sterling v Johns Hopkins
  • Preeclampsia, accepted at JHH, sent by ground, deteriorates en route, diverted to a community hospital, then flown to JHH, again deteriorates and expires
  • Determined: When you are a receiving physician you have no legal obligation to patient care until the patient arrives 
    • However: When you take a more active role (recommend treatments or ask for imaging) you create liability and risks to yourself
• 2003 Regulations
  • Law is written by Congress, then this law is delegated to a separate executive department to execute that law
  • Regulations are written by federal departments and agencies
  • Regulation: EMTALA does not imply to inpatients
  • Regulation: A physician can be on-call for multiple hospitals, but must find an alternative if they are unavailable (procedures)