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American Academy of Emergency Medicine

Part 15: EMTALA for All

by Robert V. West, MD JD FAAEM

The Emergency Medical Treatment and Active Labor Act (EMTALA) has been on the books since 1986 and part of the duty imposed upon practice in the emergency department. There were still some questions that remained unanswered as to how far the scope of EMTALA extended after the ED care. Recently, however, the U.S. Supreme Court shed some light on this very important statute in the case of Roberts vs. Galen of Virginia, Inc. The purpose of this article is to advise you as to the very practical impact of that decision on hospital attending staff and how this may facilitate their acceptance of a "difficult" patient.

You presumably already know quite a bit about EMTALA. It was originally passed by Congress to prevent "dumping" of indigent patients from the ED. The core of EMTALA is a two-part provision which requires: (1) An appropriate screening exam for anyone who presents for treatment at a hospital with an emergency medical condition; and (2) That, with limited exceptions, the patient not be transferred to another facility unless the patient's condition is stabilized and/or the benefits of care available at the receiving facility outweighed the risks of transfer.

The facts of this case are as follows. Wanda Johnson had the misfortune of literally being hit by a truck one day. She was taken to a local hospital in Louisville, KY, where she remained as an inpatient for a full six weeks. She never returned to normal health during her stay. Her condition was described as being "volatile." We presume that to mean that she never was truly stable. In any event, a decision ultimately was made to transfer her to another facility in Indiana. Upon arrival at the new facility, she deteriorated markedly and had to be transferred yet again to another facility where she remained for many months running up some pretty sizable medical expenses in the process. Suit was filed claiming that she should not have been transferred from Louisville in the first place because her condition had never stabilized.

The case was initially dismissed because Ms. Johnson never could prove that her transfer was prompted because of any improper reasons such as race, sex, or, most importantly, her indigence. In other words, since the law was passed to prohibit "dumping," which typically was a financially-based decision, the court reasoned that absent proof that Ms. Johnson was sent away because of financial concerns, her claim had no legal merit. Wrong!

Despite being on the books for 14 years, the U.S. Supreme Court had yet to address EMTALA. Thanks to Ms. Johnson, now they have for the first time, and their ruling wasn't exactly good news to the attending physicians who are now in the same boat as the ED physicians have been in since 1986.

Many health law attorneys had understood EMTALA to apply only to those circumstances in which a patient was presented to an emergency room for urgent/emergent care. After all, the very name of the statute itself includes the word "Emergency." Unfortunately, the Supreme Court didn't view the law in such a narrow light. Instead, they applied the statute to a case in which the patient had long since entered the hospital and, although her condition remained turbulent, she was no longer in a true state of emergency. Since this decision was rendered, officials at the Department of Health and Human Services have cited it in support of their position that EMTALA applies to patients anywhere within the hospital and not merely those found within the emergency room. Therefore, whereas many people thought the requirements of EMTALA need only be known to those working in ERs or responding to ER calls, the Roberts case clearly indicates all doctors are subject to it so long as their patient is in the hospital and whose condition is "volatile."

A second lesson to be learned from the Roberts decision is equally concerning. Many commentators had believed that EMTALA would not apply if the decision to transfer a patient was in good faith and not tainted by impermissible reasons such as race, sex, or indigence. The Supreme Court has now determined that the doctor's subjective viewpoint isn't necessarily relevant. Although other courts have decided that the plaintiff has to prove that the transfer was motivated by impermissible reasons, the Supreme Court declined to place the burden on the patients. For example, we still don't know for a certainty whether the doctor's ignorance of the presence of an emergency medical condition will justify a decision to transfer the patient to another facility. As a practical matter, before transferring any unstable patient to a different location, it is crucial that the doctor know how EMTALA works. The statute does not permit transfers of unstable, critically-ill patients unless there is medical necessity involved!