EMTALA requires that Medicare participating hospitals not only provide a screening exam to patients with emergency psychiatric conditions, but also appropriately transfer patients requiring treatment in an acute care hospital with specialized capabilities that are not available in the transferring facility. Failure to adhere to EMTALA mandates may subject a hospital to civil liability and may invite an investigation by the Centers for Medicare & Medicaid Services. In Harmon v. Uintah Basin Medical Center et al., (2:20-cv-00669 [Dist. Ct. Utah 2021])(.pdf of decision here), a psychiatric patient suffered serious injuries when he jumped from a moving transport vehicle during a transfer to a psychiatric hospital for alleged EMTALA-related care. This district court ruling comes after defendants in the case filed motions to dismiss.
Case Background
The plaintiff in the case went to the emergency department after a suicide attempt. He had been admitted to the same hospital within the prior week for suicidal ideations and had also attempted suicide earlier that day. When he came to the emergency department, he stated he was “looking for other ways to kill himself.” The emergency medicine physician performed a medical screening examination and, realizing that the patient had a psychiatric emergency and required greater psychiatric care then was available at the hospital, made a transfer request to an emergency psychiatric unit 160 miles away at the University of Utah. Because no beds were immediately available at any psychiatric hospitals, the patient was admitted overnight to “observation” status. The following day, patient was transported to the psychiatric hospital by private vehicle with a eighty year-old woman driving and a paraplegic man riding alongside the patient. Neither of these transport personnel were trained in restraining a patient or in dealing with actively suicidal patients. The patient was neither restrained nor sedated during transport. As the transport vehicle was traveling 65 mph down the highway, the patient jumped from the vehicle in another suicide attempt. He suffered a traumatic brain injury, multiple skull fractures, a concussion, and diminished cognitive abilities. The patient then sued the hospital and the emergency physician for EMTALA violations and for medical malpractice. The defendants filed a motion dismiss the complaint stating that EMTALA did not apply.
District Court Ruling – Hospital may have EMTALA liability for improper psychiatric transfer
In evaluating the defendants’ motions to dismiss, the court first noted that EMTALA requires that patients receive a medical screening examination that is reasonably calculated to determine whether an emergency medical condition exists. If an emergency medical condition is found, the hospital must either use all resources available at the facility to stabilize the emergency medical condition or, if the resources to stabilize an emergency medical condition do not exist, must transfer the patient to another facility that has such resources available. If a transfer is required, the must be “appropriate” which, under EMTALA means that the transfer must involve “qualified personnel and transportation equipment.” The court also noted that there are certain events that can extinguish a hospital’s EMTALA duties. For example, if an individual with an emergency condition is admitted in good faith for further treatment to stabilize the emergency condition, the hospital’s EMTALA duties end. 42 C.F.R. § 489.24(a)(1)(ii). This decision is consistent with most court cases on the issue. In contrast, one federal case (Moses v. Providence Hosp., 561 F.3d 573 (6th Cir. 2009)) held that even after patients with emergency conditions have been admitted, EMTALA duties are not extinguished unless the patient has actually been “stabilized.” However, under guidance from Center for Medicare & Medicaid Services rulings, if a patient is admitted to a hospital under “observation status,” the patients are not considered as being “admitted” for purposes of EMTALA and therefore the hospital’s EMTALA obligations do not end.
In this case, the parties did not dispute whether an emergency medical condition existed. True suicidal ideation can be one of the psychiatric conditions considered a medical emergency. Instead, the dispute involved whether the acute care hospital’s EMTALA duties had been extinguished by virtue of the patient’s admission pending transport to a facility with specialized capabilities. The hospital alleged that the patient had received a mental health screening and had received a peripheral IV. The medical records also stated that the “reason for admission” was “observation,” implying that the patient had been “admitted.” The patient noted several portions of hospital records that stated that the patient was to be placed “in observation” and that he was being held for observation purposes rather than for inpatient care. The patient also alleged that his psychiatric emergency had not been stabilized – especially since the hospital was arranging for a transfer to another hospital offering specialized services.
The court ultimately ruled that the patient had presented sufficient evidence to show that he was being held under observation status and therefore the hospital was still bound by EMTALA rules.
If EMTALA did apply to the hospital’s actions, then the hospital was required to provide an “appropriate transfer.” The plaintiff alleged that the hospital failed to provide an appropriate transfer because it provided unqualified personnel and inappropriate transport equipment that ultimately allowed the patient to injure himself. The hospital replied that EMTALA does not establish a standard of care and was not intended to be a federal malpractice law. While the court cited several court decisions that bolstered the hospital’s defense, the court also noted that EMTALA sets forth specific requirements for what constitutes an “appropriate transfer” and failure to meet those requirements could constitute a violation of EMTALA independent of any medical malpractice claim. The case was therefore allowed to proceed to trial.
Takeaway Points
- This decision was based on a “motion to dismiss” which is an attempt by defendants to dispose of a case early in the course of a lawsuit by alleging that the plaintiff has not made allegations that are sufficient to establish a viable lawsuit. When a judge denies such a motion, it does not mean that the plaintiff wins the case, only that the case may proceed to trial. The plaintiff still has to prove any allegations at trial. In this case, the hospital may still be able to win the case. For example the hospital may show that the transfer by private vehicle was “appropriate” if the patient was calm and cooperative during his observation stay at the transferring facility and he expressed no imminent intent to commit suicide.
- Plaintiff attorneys may use allegations of EMTALA violations to their advantage in a malpractice lawsuit. To be successful in an EMTALA claim, a plaintiff does not have to even show an injury. The plaintiff must only show that a hospital violated the requirements in the statute. In addition, the Center for Medicare & Medicaid Services will investigate EMTALA claims, which may relieve the plaintiff attorney of the paperwork and expense of performing a similar separate investigation. Because Medicare participating hospitals may lose their Medicare certification for EMTALA violations, they often have an incentive to quickly settle such claims without admitting liability. Finally, unlike the limits imposed on many state medical malpractice awards, there are no caps on damages for federal EMTALA claims. This allows plaintiffs to potentially receive a much larger verdict when allegations involve EMTALA-related medical care.
- Emergency medical conditions are not limited to physical manifestations. Psychiatric issues can also constitute emergency medical conditions – especially with issues involving suicidality or acute psychosis. Unfortunately, funding for psychiatric hospitals is woefuly inadequate, making it increasingly difficult to find a psychiatric facility able to provide medical care for psychiatric patients. This can result in emergency department boarding of psychiatric patients for days or even weeks as they wait for a psychiatric evaluation at a psychiatric hospital.
- There are several ways in which a hospital’s EMTALA duties can end. If a patient refuses a medical screening exam, EMTALA no longer applies. If an emergency medical condition has been stabilized, EMTALA no longer applies. If a patient has been transferred and arrives at the receiving facility, the transferring hospital’s EMTALA duties end. Finally, a patient’s admission status can have a significant effect on a hospital’s EMTALA duties. Patients who are kept in a hospital under “observation” status are technically not even considered “patients” under EMTALA. EMTALA repeatedly refers to such people as “individuals” rather than “patients.” Only when an “individual” is formally admitted to the hospital does that individual become a “patient.” EMTALA duties of stabilization and transfer still apply to any individual who is kept in a hospital under observation status even if the patient is no longer in the emergency department. Also of note is that a receiving hospital’s EMTALA duty to accept a patient in transfer continues to apply even though that patient may no longer be in the emergency department. Receiving hospitals can be cited for “reverse dumping” by refusing to accept transfer of a patient with an emergency medical condition who is in the hospital under observation status. See this Washington University article for more information on reverse dumping.
- EMTALA requires that hospitals provide an “appropriate transfer” of any patients to a receiving facility. Under EMTALA, an appropriate transfer is one in which the transferring hospital provides all medical treatment within its capacity to minimize the risk to the patient’s health, the receiving facility has available space and personnel for treatment of the emergency medical condition and has agreed to accept the patient, the transferring hospital sends all medical records relating to the patient’s care (including test results) with the patient during transfer, and that the transfer is “effected through qualified personnel and transportation equipment, as required including the use of necessary and medically appropriate life support measures during the transfer.” 42 USC § 1395dd(c)(2). With regard to the “qualified personnel and transportation equipment” requirement, the transport team should be able to address reasonably foreseeable complications that could occur during transport. For example, transferring a premature newborn infant in respiratory distress using a BLS ambulance crew might not be considered “appropriate” because that crew would likely not be able to adequately address most issues that could occur with the infant during transport. In this case, the court held that using a frail elderly person and a partially paralyzed person as transport personnel for a suicidal patient may not have met standards for being an “appropriate” transfer because those personnel were unlikely to have been able to prevent the patient from making further suicide attempts during transport.
To learn more about EMTALA requirements, see this book chapter I wrote on EMTALA’s history and how EMTALA applies to obstetrical emergencies.