ENA Emergency Nurses Association - Governemnt Relations

EMTALA: Frequently Asked Questions (FAQS)

If we suspect that our Emergency Department has committed an EMTALA violation, do we have to self-report?

The EMTALA statute and regulations do not contain a requirement for self-reporting of a suspected EMTALA violation. However, the regulations, published in June of 1994, do require a hospital to report to CMS (Centers for Medicare and Medicaid Services; formerly known as HCFA, renamed June 14, 2001) or the state survey agency any time the hospital believes it may have received an individual whom they have transferred in an unstable emergency medical condition from another hospital violating the transfer requirements under EMTALA.

An improper patient transfer under EMTALA, leading to a potential violation, includes the following:

Transferring an unstable patient without obtaining the acceptance of the receiving hospital;
Transferring an unstable patient without using available equipment, transportation or appropriate personnel during the transfer;
Refusal to provide stabilizing treatment to a patient with an emergency medical condition;
Refusal of an on-call physician to provide stabilizing treatment to a patient with an emergency medical condition, which requires a transfer.

The comments to the regulations state that to be in compliance with this requirement, the receiving hospital should report the suspected violation within 72 hours of occurrence. However, because the regulation does not contain this requirement, CMS may have difficulty enforcing this time frame. The best approach is for the receiving hospital to take the appropriate time necessary to investigate if a potential violation has occurred.

If we receive a patient from another hospital and we think that the hospital has committed an EMTALA violation are we required to report them to CMS?

Yes! The language used in the law is, "if you think" you have been involved in an inappropriate transfer, you have seventy-two (72) hours to report the other facility or your facility is subject to the same civil monetary penalty/fine. If found in a review of records up to two (2) years from the infraction your facility will be fined if reported no fine usually occurs. 100 bed facility = $25,000 per violation, > than 100 beds = $50,000 per violation.

It seems there is so much to know about the EMTALA regulations. How can I, as a staff nurse in the emergency department, know that I am meeting the requirements?

Trying to insure that you are in compliance with EMTALA regulations and interpretations can make you feel like you are peeling an onion with never-ending layers. You are not alone. Uncertainty continues to exist about the application of the EMTALA regulations even among the experts.
As with any complex process or procedure that we perform in the emergency department, the first order of business is to make sure that we have the basics covered.

Review your organization's EMTALA-related policies and procedures. If you identify procedural gaps from your own experience, ask for clarification or recommend revisions.
Develop tools and forms that support the procedure and guide you through particular processes, such as how to appropriately transfer and accept patients.
Know who your resources are 24/7. Hospitals need a mechanism to provide oversight for EMTALA compliance. This may mean that a person is delegated this responsibility or a group may serve as your internal experts. You need someone to provide you and the medical staff with objective advice when EMTALA issues arise. It is not a good idea to hope that you made the right decision. EMTALA issues are often clouded with emotion. Feeling confident about some decisions in a climate of anxiety and uncertainty is often difficult.
Identify vulnerable areas for your department and organization. Do issues exist that need to be addressed with triage, components of the medical screening examination, the definition of qualified evaluator, or the medical staff availability for on-call specialists?
Establish EMTALA monitoring indicators, especially for the vulnerable areas that you have identified.
Finally, prevention begins with education. EMTALA education needs to be ongoing and built into your personal and departmental education plan.

How does the "250 yard rule" impact the ED?

The regulations that went into effect January 10, 2001, require hospitals to be capable of responding directly (not just EMS) to patients requiring assistance who present within 250 yards of the hospital building. This also includes off-site departments that are separated by non-hospital buildings and are within 250 yards of the hospital building.

What happens when there are questions relating to the stability of the patient when transferring them from a rural healthcare setting to more definitive care?

If disagreement exists between the treating physician and the off-site physician (i.e., the off-site primary care physician or the off-site receiving physician) about whether the patient is stable for transfer, the medical judgment of the treating physician usually takes precedence over that of the off site physician.

What requirements need to be met when a patient refuses treatment?

The medical record must contain a description of the examination, treatment, or both if applicable, that was refused by or on behalf of the individual. Interpretatively this means that the medical record should reflect that screening, further examination, and/or treatment was offered by the hospital before the individual's refusal. If the individual refuses to consent to further examination or treatment (after the initial screening), the hospital must show in writing the risks/benefits of the examination or treatment refused. The record should also indicate that the individual has been informed of the risks and benefits of the exam, treatment or both. In addition, the hospital must take all reasonable steps to secure the individual's written informed refusal (or that of a person acting in his or her behalf). A hospital cannot be left without recourse if an individual refused treatment, refused to sign a statement to that effect, and leaves against medical advice. Hospitals may document such refusals as they see fit.