SGEM#257: EMTALA – It’s the Law of the Land

Date: May 15th, 2019 Reference: Terp et al. Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. AEM May 2019 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You are working in your emergency department at a hospital that has an on-site psychiatric unit. You are holding several patients in the department who have been placed on involuntary holds for suicidal ideation while a bed search occurs at facilities elsewhere in the region. Your charge nurse tells you that she has learned the psychiatric unit has open beds that currently aren’t being used. Background: The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 to combat and prevent delayed, denied, or inadequate treatment of uninsured ED patients. This federal US law mandates that patients who present to an emergency department must have a medical screening evaluation, stabilization of their emergent needs and arrange transfer to higher level of care if necessary. There is also an obligation on the receiving hospital. They must accept these patients in transfer if they have a specialist on-call with the ability to manage the patient. The Center for Medicare and Medicaid Services (CMS) has clarified that EMTALA applies to psychiatric emergencies. CMS has terminated Medicare provider agreements to 12 hospitals, four of which were related to psychiatric emergencies. Civil monetary penalties may also be levied for EMTALA violations. Clinical Question: What are the characteristics of civil monetary penalties related to EMTALA violations involving psychiatric emergencies compared to non-psychiatric emergencies? Reference: Terp et al. Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. AEM May 2019 Population: All civil monetary penalty settlements between 2002 and December 11, 2018 Exposure: EMTALA violations related to psychiatric emergencies. Comparison: EMTALA violations not involving psychiatric emergencies. Outcome: Civil monetary penalties levied by the Office of the Inspector General (OIG). Dr. Sophie Terp This is an SGEMHOP episode which means we have the lead author on the show. Dr. Sophie Terp is an is an assistant professor of clinical emergency medicine in the Department of Emergency Medicine at the Keck School of Medicine of USC. Her research focuses primarily on access to emergency care for vulnerable populations and specifically on enforcement of the Emergency Medical Treatment and Labor Act (EMTALA). Authors’ Conclusions: “Nearly one in five civil monetary penalties related to Emergency Medical Treatment and Labor Act violations involved psychiatric emergencies. Settlements related to psychiatric conditions concentrate in two of the 10 Centers for Medicare & Medicaid Services regions, with half of all settlements occurring in three states (Florida, North Carolina, and Missouri). Average financial penalties related to psychiatric emergencies were over twice as high as penalties for nonpsychiatric complaints. Recent large penalties related to violations of the Emergency Medical Treatment and Labor Act law underscore the importance of improving access to and quality of care for patients with psychiatric emergencies.” Quality Checklist forObservational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Unsure