• A Broad Overview of EMTALA, the Federal "Patient Anti-Dumping Act."
  • May 3, 2005
  • Law Firm: Buckingham, Doolittle & Burroughs, LLP - Canton Office
  • While the law of medical negligence is generally known, many are unfamiliar with the parallel, federal-law system that poses unique liability risks in the area of emergency medicine. In 1986, Congress enacted the Emergency Medical Treatment and Active Labor Act ("EMTALA"), 1 commonly known as the "Patient Anti-Dumping Act." Although enacted to prevent hospitals from refusing to treat patients who are unable to pay, it applies to all patients without regard to their financial resources. Anyone harmed as a result of a hospital's violation of the statutory requirements may recover damages under EMTALA.

    Hospital emergency departments have two duties under EMTALA: to provide an "appropriate medical screening examination" to determine whether an emergency condition exists and, if so, to stabilize the condition before discharging or transferring the patient.

    Screening Requirement
    EMTALA requires that hospitals provide "an appropriate medical screening examination within the capability of the hospital's emergency department...." A screening is "appropriate" if it conforms to the hospital's screening procedures, and is reasonably calculated to identify critical medical conditions that may be afflicting the patient. It isn't a guarantee of a proper diagnosis, and the question of whether a provider met the screening requirement isn't decided under a negligence standard. Rather, an appropriate screening is one that is applied uniformly to all emergency room patients.

    When a hospital fails to give an emergency room patient the same screening it regularly gives to others under similar circumstances, and the variation is more than de minimis, it can be liable for damages under EMTALA. For example, in Correa v. Hospital of San Francisco, 2 a woman who entered a hospital with complaints of chest pain was given a number (forty-seven) and told to wait. She left the hospital after waiting over two hours and went to another facility where she died from hypovolemic shock. The court held that the hospital violated the EMTALA screening requirement.

    Stabilization Requirement
    If the screening discloses that the patient has an emergency medical condition, the provider must stabilize the patient before discharge or transfer. Most courts have held the requirement applies only when the provider has actually identified an emergency condition. In other words, if the provider did an appropriate screening and discharged the patient without identifying an emergency medical condition, it isn't liable under EMTALA, even though it may have been negligent in failing to diagnose the condition.

    Once the provider determines that the patient has an emergency medical condition, it must use measures appropriate under the circumstances to stabilize the patient. The duty applies only where the patient is discharged or transferred; most courts have held it doesn't continue after the patient is admitted.

    What does a provider have to do to "stabilize" a patient? As in the case of the screening requirement, EMTALA doesn't give the patient any guarantees. In the trial of an EMTALA claim, the jury will consider whether the treatment and subsequent release or transfer were "reasonable in view of the circumstances that existed at the time the hospital discharged or transferred the individual." EMTALA requires that the provider "assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer" or discharge.

    Whether or not the patient is stabilized at the time of discharge or transfer is typically a judgment call, and courts will review the record for signs of acute distress. Hospitals transferring or discharging patients from emergency rooms face liability risks in cases where the patient's stabilization is tenuous. The risks underscore the importance of thorough documentation of patient care, monitoring, and assessment.

    Procedural issues
    EMTALA claims are subject to a strict two-year statute of limitations. The Ohio-law provision for 180-day letters to extend the statute of limitations in a medical negligence case won't apply to an EMTALA claim. Likewise, there is no tolling of the statute for minors or persons under a disability.

    Congress provided that plaintiffs suing under EMTALA can recover "those damages available for personal injury under the law of the state in which the hospital is located...." Because EMTALA claims don't involve the standard of care inquiry used in medical negligence cases, there's a dispute among the courts whether state-law damage caps on medical negligence claims apply to EMTALA lawsuits. Any state-law damage caps generally applicable to tort claims, however, would apply.

    Conclusion
    This overview highlights only the major points of EMTALA, and there are many sub-areas within the broad discussion headings where the law affects emergency medicine practice.3

    1 42 U.S.C. 1282.

    2 (C.A. 1, 2002), 69 F.3d 1184.

    3 Readers wanting more information on the subject can review a three-part series of articles in Buckingham's newsletter, The Advisor (Vol., 12, Issue 3; Volume 13, Issue 1 and Volume 14, Issue 1), available at www.bdblaw.com under the "News and Information" link.