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Hospital settles EMTALA violation for $12.5 million
The parent company of Ravenswood Hospital Medical Center in Chicago has agreed to pay $12.5 million to settle a lawsuit brought by the family of a 15-year-old boy who died when he was shot just outside the hospital and medical staff refused to treat him because he was not on hospital grounds.
The settlement brings an end to the legal wrangling over the incident, but it does not end the confusion over how hospitals must respond to similar situations in the future.
Ravenswood was heavily criticized after the 1998 incident, which many observers saw as evidence of a callous staff, but risk managers at the time sympathized with the quandary over when and how staff should leave hospital property to render aid. The hospital paid $40,000 to settle a federal complaint soon after the incident, according to an agreement signed by then hospital president John Blair. The hospital also agreed to place two quarter-page advertisements over the next year in the Sunday editions of the Chicago Sun-Times, reminding the community that the hospital will examine patients "without delay and regardless of their ability to pay."
The settlement was accepted by the federal Department of Health and Human Services, which had investigated the hospital for violations of the 1986 Emergency Medical Treatment and Labor Act (EMTALA), which requires all hospitals receiving Medicare payments to assess and stabilize emergency patients regardless of ability to pay. EMTALA violations carry a penalty of up to $50,000, so the settlement represented a savings of only $10,000 off the maximum fine. The Health Care Financing Administration (now the Centers for Medicare & Medicaid Services [CMS]) approved the hospital’s revised policy on treating victims outside the hospital building after threatening to end its Medicare participation if the policy were not changed.
The hospital has since closed. The family of the gunshot victim recently announced the settlement with the hospital’s parent company.
250-yard rule doesn’t answer all questions
The story began when 15-year-old Christopher Sercye was shot less than a block away from the hospital. Emergency department staff refused to go outside and help him, consistent with hospital policy. Police eventually dragged the boy inside the hospital, but he soon died.
At first, Ravenswood defended the policy as a necessary precaution for the protection of hospital staff. Under fire from the public and regulators, the hospital then announced that the policy had been changed to allow staff to go outside and render aid. The new policy required hospital employees to call a special internal telephone number to report cases where they believe someone on or near the hospital campus needs immediate medical assistance. Then an emergency department nurse or physician would determine how best to treat the person, including the option of leaving hospital property.
The Ravenswood incident prompted risk managers across the country to question their staff’s obligation to treat people who are near, but not in a treatment area such as the emergency department, says Lowell Brown, JD, a partner with the law firm of Foley and Lardner in Los Angeles and an expert in EMTALA interpretation. CMS offered an interpretation soon after the Ravenswood controversy, indicating that EMTALA obligations apply to an area 250 yards beyond the hospital’s doors. That "250-yard rule" only muddied the water, Brown says, and risk managers are eagerly awaiting a clarification that is due soon.
"Right after Ravenswood, a lot of hospitals were asking themselves if that meant they had to send personnel out of the emergency department to get people, perhaps even putting them in danger," he says. "I think the legal answer to that is no, as least as far as EMTALA is concerned. But there is still some confusion. The rule’s never been terribly clear."
Based on his readings of the CMS rules, Brown offers this advice: EMTALA applies when a person comes to your facility or within 250 yards in some circumstances. The regulation speaks of a patient being on your property, and your "property" means the whole campus — including parking lots, driveways, etc. But it also defines "campus" as the "physical area immediately adjacent to the provider’s main building, and other areas that are not strictly contiguous to the main building but are within 250 yards of the main building, and other areas determined on an individual case-by-case basis by the CMS regional office to be part of the campus."
That leaves plenty of room for interpretation, Brown says. The safety of staff members is always a concern, he says, and CMS does not expect hospital staff to rush into situations they are unprepared to handle safely, especially off the hospital campus.
"People still struggle with it, because if you read the regulations literally, it could mean the Dairy Queen across the street from the campus," he says. "The proposed clarification narrows that down somewhat and just says it’s the main campus, property that belongs to the hospital. Until we get that clarification, you’ll still have to look at your particular situation and see what areas might qualify."
Some facilities may have well-defined surroundings that make the decision fairly simple, but Brown says many will see opportunities for confusion. A policy such as the one implemented at Ravenswood, requiring emergency department staff to quickly consult with the risk manager or another designated resource, can be one solution, he suggests.