EMTALA - An Overview

The following program is now available as an online slide show with audio narration, accredited for Continuing Medical Education (CME) and Continuing Education Hours (CEHs).

You can learn more about the program by following this link

Updated 5/6/02 - You'll find access to additional information on our EMTALA Links page.

EMTALA establishes the following general requirements:

• Medical Screening Examination. A hospital that operates an emergency department must provide a medical screening examination to anyone on whose behalf a request is made for examination or treatment. The purpose of the examination is to determine whether or not the individual is in an emergency medical condition
• Necessary Stabilizing Treatment. If the individual has come to the hospital and the hospital has determined that he or she is in an emergency medical condition, the hospital must provide further medical examination and treatment to stabilize the medical condition.
• Restricting Transfers Until Stabilization. A hospital may not transfer an individual unless:
  1. The individual requests transfer having been informed of the hospital's obligation to provide further examination and treatment and of the risks of transfer, or a physician certifies in writing that the benefits reasonably expected from treatment at another facility outweigh the increased risks to the individual and/or the unborn child from effecting the transfer (if the physician is not present in the emergency department, a "qualified medical person" may sign the certification if a physician consulting with that person has made the determination that the benefits of transfer outweigh the risks, and subsequently countersigns the certification); and
  2. The transfer is an appropriate transfer.
• Appropriate Transfer.
  1. Transferring hospital provides medical treatment to minimize risks to the individual and/or unborn child.
  2. Receiving facility has available space and qualified personnel to treat the individual and has agreed to accept transfer of the individual.
  3. Transferring hospital sends all medical records related to the emergency condition, including emergency medical records, observations of signs and symptoms, preliminary diagnosis, treatment provided, results of any tests, the informed consent and/or certification provided under EMTALA and the name and address of any on-call physician who has refused or failed to appear within a reasonable time to provide necessary stabilizing treatment.
  4. Transfer is effected through qualified personnel and transportation equipment as required, including the use of necessary medically appropriate life support measures during transfer.
  5. Meet other requirements imposed by the Secretary.

Emergency Medical Treatment and Active Labor Act
(EMTALA)

by Paul Hudson
ACUTE CARE, INC.

In an effort to assist emergency care practitioners in coping with the increasing medicolegal complexity of the practice of medicine, ACUTE CARE, INC. has undertaken a review and discussion of current legal issues of interest to its associates. This article is the first of a series exploring the law as it applies to the Emergency Department.

The Emergency Medical Treatment and Active Labor Act (EMTALA) establishes specific responsibilities for physicians attending to the Emergency Department patient. "Emergency Department" is actually an inexact term, in that the provisions of the law apply to patients who present, on hospital property, for purposes of examination and treatment of medical complaint.

• Hospital property includes patients attended to by the staff of hospital-based ambulance services.
• Hospital property includes the arrival of an ambulance in the Emergency Department's entry with a patient who was not expected or diverted to another facility by direct radio contact.

EMTALA describes the need for an examination of each patient for the purpose of determining if that patient possesses an "emergency medical condition"

• An emergency medical condition is defined as a medical condition manifesting itself by symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to result in:
1. placing the health of the individual or with respect to a pregnant woman , the health of the woman (or her unborn child) in serious jeopardy;
2. serious impairment of bodily functions; or
3. serious dysfunction of any bodily organ or part.
• Active labor is addressed as well. A pregnant woman who is having contractions is said to be in true labor unless a physician certifies that , after a reasonable time of observation, the woman is in false labor.

The Act describes the need for the provision of stabilizing treatment for all patients who possess an emergency medical condition. There exists an element of controversy in that EMTALA preempts state law and does not make exceptions for anencephalic infants, comatose patients, cancer patients, or others with chronic conditions that affect quantity or quality of life. The physician is held to this standard of care in making decisions regarding the stabilization

A large number of EMTALA investigations arise because on-call physicians refuse to come in to see the patient, come in late, or order the patient transferred without coming in to stabilize the patient. The Act is specific in its application to on-call physicians. Generally, on-call physicians are expected to attend the patient physically. If the on-call physician refuses to attend to the patient or fails to appear within a reasonable time this fact must be reflected in the patient record and transfer materials. Furthermore, the hospital's records must reflect quality assurance and disciplinary records regarding the incident.

The patient's decisions during the emergency department visit are also addressed in EMTALA. Documentation is required in each of the following instances.

• Refusal to consent to treatment. The record must reflect the examination and/or treatment refused by the patient.
• Refusal to consent to transfer. Documentation must reflect if the patient refuses a transfer recommended by the physician after being informed of the risks and benefits of that transfer. The medical record must include notation of that refusal, details of the proposed transfer and the risk/benefit ratio as described to the patient.
• Request for transfer. If the patient or their delegate requests a transfer the record is to include that request, its rationale and the fact that the individual had been made aware of the risks and benefits of the transfer.

EMTALA also addresses the matter of transfer of the Emergency Department patient to another facility. The Act imposes restrictions upon how and when a patient may be transferred.

• The hospital is obligated to assure (and document) that the patient has been provided information regarding the hospital's obligation for examination and treatment and the risk/benefit ratio of the proposed transfer.
• The transfer is only deemed appropriate if qualified staff possessing adequate equipment provide "necessary life support measures" en route to the receiving facility and that facility has agreed to accept the patient.
• Complete documentation, including consent forms and records of the medical examination and treatment of the patient, are delivered to the receiving facility.

Violation of the Emergency Medical Treatment and Active Labor Act
can yield significant penalties.

• A hospital knowingly, willingly or negligently violating EMTALA is subject to termination of its provider agreement.
• A hospital may be fined between $25,000-$50,000 per violation
• The physician responsible for examination, treatment or transfer can be fined $50,000 per violation for knowingly and/or willfully violating EMTALA. This provision applies to on-call physician violations as well.
• The physician involved can be excluded from Medicare and Medicaid programs
• A patient can sue the hospital for personal injury in civil court.
• A receiving facility, having suffered financial loss as a result of another hospital's violation of EMTALA, can bring suit to recover those damages.

The Emergency Medical Treatment and Active Labor Act serves to provide structure to the proper examination, treatment and transfer of Emergency Department patients. Adherence to the law is dependent upon attendance to those who present for care on hospital property, life sustaining care, and informed patient transfer. Documentation of each aspect of care and communication is central to compliance with the law.

Link to a copy of the statute

Link to a copy of the regulations

Link to HCFA position on preauthorization for emergency department visit

Link to an excerpt from the Office of Inspector General's (OIG) Semi-Annual Report

We hope that this brief overview of EMTALA has provided an element of insight or review. We would also recommend Steven Frew, J.D.'s website medlaw.com and emtala.com, a site hosted by attorneys specializing in EMTALA compliance.

DISCLAIMER. The information provided is not intended as legal or medical advice, but are written for educational purposes only. The information may have changed or been amended. You should consult a qualified and licensed attorney with specific questions. Any references to any specific professional is not an endorsement of their services, products or qualifications.