HCA 201: Chapter 10 Emergency Care

Should every hospital have to provide ED services?
Some states have enacted statues that require hospitals
to maintain Emergency Departments (EDs).

No duty to respond in an emergency under common law
• A physician had no responsibility to respond to a call for help absent a preexisting relationship with the patient.
• Starting in the 1960s, courts begin establishing a duty for hospitals to provide aid to individuals – particularly when they needed emergency care.

State statues can require public employees (e.g. police,
fire, EMTs) to aid victims of accidents or emergencies.
Depending on local law, they may be immune from resulting injury

EMTALA (Emergency Medical Treatment & Active Labor Act (1985))
Prompted by concerns of patient dumping – refusing to
treat or transferring uninsured patients who can’t
pay for care

EMTALA: “Sec. 1395dd. Examination and treatment for emergency medical conditions and women in labor.
(a) Medical screening requirement
(b) Necessary stabilizing treatment for emergency
medical conditions and labor
(e) Definitions: term “emergency medical condition”

A transfer by a hospital must be in the best interest of the
patient and meet standards of care, which include:
1. Providing treatment to minimize risks
2. Finding a capable hospital willing to accept a patient
3. Transferring medical records to accompany the patient
4. Using qualified staff and proper equipment for the transfer

Other EMTALA Considerations
• EMTALA provisions apply to all patients.
• EMTALA provisions apply to any hospital that participates in the Medicare Program.
• The patient only has to be stabilized; post stabilization
discharge or transfer does not violate EMTALA.
• The hospital can not delay stabilizing care to determine
the patient’s “method of payment” ((42 USC 1394dd(h))

EMTALA Violations: Civil fines
• “A participating hospital that negligently violates a requirement of this section is subject to a civil money penalty of not more than $50,000 (or not more than $25,000 in the case of a hospital with less than 100 beds) for each such violation”
• “[…] any physician who is responsible for the examination, treatment, or transfer of an individual in a participating hospital, […] and who negligently violates a requirement of this section […] is subject to a civil money penalty of not more than $50,000 for each such violation”

EMTALA Violations: Exclusion from Medicare
• E.g. “if the violation [by the physician] is gross and flagrant or is repeated, to exclusion from participation in this subchapter and State health care programs”

EMTALA Violations: Civil Money Damages
• “Any individual who suffers personal harm as a direct result of a participating hospital’s violation of a requirement of this section may, in a civil action against the participating hospital, obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate”

Some of EMTALA’s requirements
may be confusing in practice.
1. What is an “appropriate medical screening examination”?
2. When does the duty to stabilize the patient begin? When has the patient
come to the hospital?
3. Does it matter why the hospital denies treatment?

“Appropriate medical screening”
• EMTALA requires covered entities to determine if a
person has an “emergency medical condition.”
• To do so, an “appropriate medical screening” must be
conducted.

EMTALA does not define “appropriate medical screening.”
Generally, “appropriate medical screening” is interpreted to mean treating ALL patients who present in the ED as other patients who are similarly situated – not a duty to provide non-negligent care.

Per HHS Regulations, coming to a hospital can mean being:
• In other hospital buildings or departments besides the ED
• Within 250 yards of the main hospital building
• In ambulances owned or operated by the hospital
• On hospital property in non-hospital owned ambulances
• In any hospital that offers emergency service, regardless of whether is has a separate ED.

Generally, a patient en route to a hospital in an
ambulance is considered to be at the hospital.
This is consistent with EMTALA’s goal to prevent patient dumping.

Motive: For an EMTALA violation to exist, must the decision to “dump” the patient be motivated by an inability to pay?
• No – no particular motive has to be alleged or proven.
• The requirement is uniform treatment of all patients – regardless of ability to pay.

Exercising reasonable care: After the provision of emergency care begins, due care must be exercised.
• This applies to both physicians and hospitals; hospitals have independent duties to ensure care that meets the standard.
• The slightest aid can be construed as the provision of care.

Admission, transfer, or discharge
• Patients must be admitted, transferred, or discharged in a
timely manner and consistent with hospital policies.
• Transfer is appropriate when the patient’s condition is
stabilized or otherwise meets EMTALA obligations.
• Discharge should include instructions for continuing care
for the patient and to the provider to whom the patient is
referred.

Duty to provide an ED that:
• Is well-organized
• Has qualified practitioners and staff
• Contains proper facilities and equipment
• Is engineered to provide timely diagnosis, stabilization, treatment, and referral.

The governing body is ultimately responsible for the
standards in the ED
• Doctors who provide care in the ED should be trained in
emergency medicine.
• Medical staff privileges should be determined for each ED doctor.

ACA experiments
Provides funding for pilot projects to explore innovative models of regionalized, accountable, and comprehensive emergency and trauma care.

What happens if you aid at the scene of an
accident?
• Few lawsuits allege negligence against Good
Samaritans.
• Absent a Good Samaritan statute to the contrary, a
person who starts to assist at the scene has a duty to
exercise reasonable care under the circumstance.

Good Samaritan laws, enacted in
many states, are meant to
encourage doctors, other
professionals, and sometimes
any person to aid strangers in an
emergency.
• State specific!
• Typically, immunize Good Samaritans from liability for ordinary negligence in providing aid at the scene of an
emergency as long as they assist in good faith.

good samaritan continued
• Some states limit immunity to practitioners licensed in that state.
• A few states cover doctors providing aid in a hospital if
there is an emergency.
• Typically, these statutes do not cover people with an
existing duty to respond (e.g. patient-physician
relationship).

There is some question about whether they are needed
because of the requirement to provide reasonable care
under the circumstances.
Have they had an impact on willingness to help?

good samaritan example
No person, including a person licensed to practice
medicine or dentistry, who in good faith renders emergency
care at the scene of an accident or to a victim at the scene
of a crime, without remuneration, shall be liable for any civil
damages as the result of any act or omission in rendering
such emergency care”

authorized by a medical director to give medications and provide emergency care. The transfer of such authorization is an extension of the Medical Director’s license to practice medicine. Designated Agent description of medical techniques or practices that are supported by …

According to the second primary requirement when the patient comes to the hospital for the medical screening examination, the hospital must provide necessary treatment and stabilize the medical condition of the patient or transfer the patient to another medical facility. …

As part of the Consolidated Omnibus Budget Reconciliation Act in 1985, EMTALA was created by Congress in 1986. (Trisha Torrey, 2009). The full form of EMTALA is Emergency medical Treatment and Active Labor Act. This act is a statute that …

In 1986 congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA) as a result of clients being transferred from private hospitals to public hospitals without appropriate screening and stabilization (Potter & Perry, 2009). This act states that most …

advanced EMT (AEMT) An individual who has training in specific aspects of advanced life support, such as intravenous therapy, and the administration of certain emergency medications. advanced life support (ALS) Advanced lifesaving procedures, some of which are now being provided …

The third primary principle of EMTALA states that when the participating hospital has specialized facilities or capabilities like shock-trauma units, burn units, neonatal intensive care units etc, should not refuse to accept the transfer of the patient who is in …

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