Overview of EMTALA

The Emergency Medical Treatment and Active Labor Agreement (EMTALA) was enacted in 1986 as part of the Comprehensive Omnibus Budget Reconciliation Act. Occasionally referred to as the “Anti-Dumping Act,” Congress adopted the agreement to ensure emergent care is appropriately provided to patients, regardless of their ability to pay (Moffat, 2020). This law enacted protections, which are designed to prevent patient dumping, characterized as discharging patients in need of emergency care or transferring patients to another facility due to their inability to pay (Doubek & Schweikart, 2023).

Case Study

You are a triage nurse in a rural emergency department. An elderly man approaches the front door and reports he needs assistance getting his wife out of the car. After you confirm the patient is responsive and breathing, you provide a wheelchair, and one of your team members assists the patient out of the vehicle into the chair. The elderly man pushes the patient to the triage desk, where you obtain a history and complete an initial primary assessment. You note that the patient is responsive, although her responses are sluggish. She appears diaphoretic. After you complete your physical assessment, you realize the patient requires services that are not provided by your facility.

You determine that the patient will need to be transferred from your emergency department to a specialty care facility. At that moment, you wonder if it would make more sense for the elderly man to take his wife to the specialty facility now. You realize this course of action would prevent an unnecessary charge from this emergency department and interfacility transport. Not to mention, she could receive the care she requires sooner.

You pause for a moment to reflect on the EMTALA seminar you recently attended. What does EMTALA require? You recall that “subsection (a) requires that if an individual presents to the emergency department requesting care, the hospital must provide an appropriate screening examination to determine if the individual suffers from an emergency medical condition” (Moffat, 2020, p. 2-1). Subsequently, you recall that “subsection (b) requires the hospital, within its capability, to provide the medical treatment necessary to stabilize the patient. Subsection (c) prohibits the transfer of patients who are not stabilized unless specific requirements are met” (Moffat, 2020, p. 2-1).

Your patient presented to the emergency department seeking emergency care. You question if your initial triage is sufficient to meet the EMTALA requirement of an appropriate screening examination. The EMTALA Answer Book defines the medical screening examination as the following:
A medical screening examination is the process required to reach, with reasonable clinical confidence, the point at which it can be determined whether the individual has an emergency medical condition or not. A medical screening examination is not an isolated event. It is an ongoing process that begins, but typically does not end with triage. (Moffat, 2020, p. 3-2)

Each hospital is responsible for determining the specifics of its screening practice. You consult your organization’s policy and procedure manual for further clarification.

Your recent seminar training has proved useful. You determine that you have not met the obligations of EMTALA and decide to avoid recommending that the patient leave and go to another facility. You continue to follow your department policy and escort the patient to the treatment area. Once your patient is roomed, she is immediately evaluated by an attending physician. A STAT electrocardiogram and laboratory studies are ordered.

Since the attending physician ordered diagnostic tests as a part of their initial screening, you cannot be certain the EMTALA screening obligations have been met. The intent of this requirement is to determine the presence of an emergency medical condition. Unfortunately, there is no clear guidance on when this requirement will be met.

Your patient is diagnosed with an ST-segment myocardial infarction and requires an emergent cardiac catheterization, although your organization does not have a cardiac catheterization laboratory. As a result, you must now determine if the patient has an emergency medical condition. An emergency medical condition is defined as “a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in: a) 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, b) serious impairment to bodily functions, or c) serious dysfunction of any bodily organ or part” (Moffat, 2020, p. 3-30). Accordingly, your patient does have an emergency medical condition.

Now that you have determined that an emergency medical condition exists, you have a duty to stabilize. You have identified that the patient requires services that are not available at your facility. So, how can you meet this standard? EMTALA states the following:
Hospital must provide either (a) within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or (b) for transfer of the individual to another medical facility. (Moffat, 2020, pp. 4-2-4-3)

While arranging transport to the nearest cardiac intervention center, you and your colleagues stabilize the patient. Although your facility is not equipped to provide definitive care, you remain responsible to provide a reasonable level of care prior to transport.

Summary

It is essential nurses understand EMTALA as they are the first healthcare providers to interact with patients presenting to emergency departments for care (Shultz et al., 2024). While the case study illustrates one example of EMTALA, there are many factors to consider. No one case is unique, and each requires its own review of circumstances. There are many resources available to become more familiar with the regulations. However, there may be differing interpretations of the regulations. Due to the space constraints of the article, the authors did not review many factors that occur frequently. These include but are not limited to patients presenting within 250 yards of the main or principal building, patients who are in a hospital-owned ambulance, and patients who are deemed not to have an emergency medical condition. Healthcare providers should consult their organizational policies and procedures to ensure they remain in compliance with EMTALA regulations.

References

Doubek, M., & Schweikart, S. J. (2023). Why should physicians care about what the law says about turfing and dumping patients? AMA Journal of Ethics, 25(12), 892 – 897. 10-1001/amajethics.2023.892.

Moffat, J. C. (2020). EMTALA answer book: 2020 edition. Wolters Kluwer.

Schultz, T. R., Forbes, J., & Hafen Packard, A. (2024). Emergency Medical Treatment and Labor Act: Impact on health care, nursing, quality, and safety. Quality Management in Health Care 33(1), 39-43. DOI: 10.1097/QMH.0000000000000438