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[Editor’s note: This column is an ongoing series that will address reader questions about the Emergency Medical Treatment and Active Labor Act (EMTALA). If you have a question you’d like answered, contact Staci Kusterbeck, Editor, ED Management, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: StaciKusterbeck@aol.com.]
Q: If a patient is discharged from the ED and is referred to an on-call physician for treatment the next day, is the physician bound by EMTALA to see the patient?
A: This is a very controversial question and a gray area, according to Gloria Frank, JD, owner of EMTALA Solutions, an Ellicott City, MD-based consulting firm, and former lead enforcement official on EMTALA for the Baltimore-based Health Care Financing Administration (HCFA).
"Some people think that the physician is bound if the hospital telephones the physician to notify him or her that the patient will be there the next day [or whatever time period]," she explains. "The counterargument is that once the patient is stable for discharge, no further EMTALA obligations attach to the physician or the hospital." The arguments for imposing a continuing obligation on the hospital are as follows, says Frank:
According to Grena Porto, ARM, CPHRM, director of clinical risk management for VHA, a Berwyn, PA-based alliance of community-owned health care organizations, the key to whether EMTALA applies is whether an emergency medical condition exists. "In this scenario, it sounds like the emergency medical condition no longer exists, so EMTALA no longer applies," she says.
Q: What are the EMTALA implications if a hospital does not have the resources to provide ED patients with a certain test, such as echocardiography, in the off hours? While most clinical situations will be able to be resolved with alternative testing such as chest X-rays or nuclear medicine, there may be occasions where the only appropriate test would be an echocardiography that would not be available in the middle of the night.
A: This scenario involves three issues, says Porto:
To answer the first question, consider the original basic requirements of EMTALA, says Porto. "Under EMTALA, the hospital is required to provide a medical screening exam to determine whether or not an emergency medical condition exists," she notes.
If such a condition exists, the hospital must offer sufficient treatment to stabilize or resolve the emergency medical condition, Porto says. "Once that happens, EMTALA no longer applies," she explains. If it seems as though echocardiography is not required to determine whether an emergency medical condition exists or to stabilize the patient because other alternatives are available, "it would not be required under EMTALA," says Porto.
Regarding whether the hospital is required to provide definitive treatment, Porto points to the example mentioned. "Echocardiography may be state of the art’ or definitive diagnostic testing, but that is not required under EMTALA," she says.
Porto also offers a different example: If a patient presents with a dissecting aneurysm of the aorta, but the hospital does not have bypass capability, does the hospital violate EMTALA by not doing the treatment? "The answer is no," she says. "The hospital need only screen, treat, and stabilize. Again, once the emergency has passed, the hospital has no further obligations under EMTALA."
The answer to the third question, as to whether the hospital can make adjustments to availability of services based on resource constraints, is yes, according to Porto. "As long as the hospital treats all patients the same, within its capability to provide care, then there is no violation of EMTALA," she says.
Thus, if there is no neuroradiologist available at night or on certain days, that is not a violation of EMTALA, provided all patients are treated the same, Porto clarifies. "Under these circumstances, the hospital would be required to stabilize, and then transfer the patient to a facility that has the necessary capabilities to treat the emergency medical condition," she says.
For more information about EMTALA, contact:
• Grena Porto, ARM, CPHRM, VHA, 200 Berwyn Park, Suite 202, Berwyn, PA 19312. Telephone: (610) 296-2558. Fax: (610) 296-9406. E-mail: firstname.lastname@example.org.