Legal Eagle Eye Newsletter for the Nursing Profession (7)8 Aug 99

Quick Summary: A hospital patient admitted through the emergency room cannot be transferred to skilled nursing care unless the patient is medically stable, that is, unless the patient’s needs can be met outside an acute-care setting.

  To sue, the patient does not have to prove the hospital was motivated by finances in making the transfer, only that the transfer was inappropriate.

  The Emergency Medical Treatment and Active Labor Act (EMTALA) places the obligation upon any hospital that has an emergency room to screen and stabilize any patient the hospital receives who is suffering from an emergency medical condition.

   There is no language in the Act that a patient must prove that the hospital acted with an improper motive in failing to stabilize the patient.

   The law says explicitly, if any individual comes to a hospital emergency department and the hospital determines that the individual has an emergency medical condition, the hospital must provide either -

   Within the staff and facilities available at the hospital, for such further medical examination and such treatment as may be required to stabilize the medical condition, or -

   For an appropriate transfer of the individual to another medical facility which will not, within reasonable medical probability, result in significant deterioration of the patient’s condition during or as a result of the transfer.  UNITED STATES SUPREME COURT, 1999.

   The Emergency Medical Treatment and Active Labor Act (EMTALA) is a Federal law that was enacted because of highly publicized incidents where hospital emergency rooms refused to provide medical screening and turned away or prematurely transferred or discharged patients who lacked the means to pay for emergency treatment or inpatient hospital care.

   Nurses are often directly involved in assessing and screening emergency room patients, in deciding what level of care they will receive, in determining who will be admitted and in planning for discharge of patients from acute care.

   Decisions made by nurses, physicians and other hospital personnel have been a persistent source of lawsuits since the EMTALA came into being. Under the law, however, only the hospital itself can be sued and forced to compensate the patient for an EMTALA violation.

   Although the wording of the EMTALA, like all other Federal statute laws and regulations, is uniform throughout the U.S., the all-important interpretation of the EMTALA by the courts had not been consistent until a recent decision by the U.S. Supreme Court.

   Some courts had imposed a major stumbling block to patients’ lawsuits for EMTALA violations. They required the patient to prove that the hospital was motivated by financial considerations when the patient was not properly screened for an emergency medical condition or was prematurely transferred or discharged. Proof of what happened to a patient is relatively straightforward; proof of underlying motive can be elusive.

  Other courts acknowledged that the EMTALA was meant to outlaw "patient dumping," but noted that Congress had nevertheless put no language in the law requiring proof of any financial motive by the hospital in how it acted toward the patient.

   The U.S. Supreme Court endorsed the second approach to interpreting the EMTALA. The Court agreed there is no language in the law about the hospital’s motivation in how it deals with an emergency patient. This means when an emergency patient is not appropriately screened or is transferred or discharged in unstable condition, the patient has the right to sue. It does not matter whether the hospital is aware of the patient’s insurance or financial status or what the patient’s actual financial or insurance status is in fact.

   This case also makes another important point. That is, this patient had been in the hospital for nearly two months before she was illegally sent to a skilled nursing facility.

   The point is the EMTALA does not only apply to what happens, or fails to happen, in the emergency room. Once a patient has presented in the emergency room with an emergency medical condition, the EMTALA continues to define the patient’s right to necessary stabilizing medical care before the patient can be sent home or to another healthcare facility.

   This patient came in with massive trauma from a motor vehicle accident. Two months later, at the time of her transfer to skilled nursing care, she had developed a suspected urinary tract infection and had an elevated white count. Her personal physician, who was not directly involved in her care at the hospital at the time, testified long after the fact in court she should have been kept in the hospital for the results of bacterial cultures and a determination whether antibiotics should have been used to treat the infection.

   She had no hospitalization insurance. The hospital administration knew this. They put pressure on the hospital social worker to place her in a nursing home so that she could be discharged from the hospital. Representatives of two nursing homes came to the hospital, evaluated the patient and turned her down, according to the court because her medical condition was too unstable for her to leave the hospital and receive care in a nursing home.

   Then a skilled nursing facility agreed to take her. The medical resident who signed her hospital discharge papers had no knowledge one way or the other about her insurance or financial status. He was honestly unaware the hospital was actively trying to "dump" the patient for purely financial reasons.

   The skilled nursing facility was unable to care for her. She suffered serious deterioration of her medical condition at the skilled nursing facility and had to be re-hospitalized for several more months at another hospital, one that was willing to take her and keep her despite her lack of hospitalization insurance.

   The U.S. Circuit Court of Appeals for the Sixth Circuit ruled the patient could not sue the hospital because the medical resident who brought about her transfer had no improper financial motivation himself. But the U.S. Supreme Court overruled the Sixth Circuit and finally laid to rest as irrelevant the issue of financial motivation.

   According to the Supreme Court, the resident erred by approving the patient’s transfer while she was medically unstable, that is, while she still needed acute hospital care. By law that made her transfer inappropriate and an EMTALA violation. The patient was an emergency patient, she was not stable when transferred to skilled nursing and the transfer was by law inappropriate, period. That was the end of the analysis. She could sue the hospital.

   According to the court, a hospital patient could get less than standard attention in the E.R. on in the hospital for many reasons. It could be racial, ethnic or gender prejudice, fear of the patient’s condition (e.g. AIDS), personal antagonism between the patient and medical, nursing or other personnel at the hospital, cultural or language barriers, or concern that the patient has no insurance or is not on Medicare or eligible for Medicaid. Some of these could be separate grounds for a discrimination suit under the civil rights laws or the Americans With Disabilities Act.

   However, to decide if an EMTALA violation has occurred courts are no longer allowed to require the patient to have proof of a financial motive in order to sue a hospital.

   The EMTALA also applies to patients who come into the emergency room in active labor, but interpreting that aspect of the law was not an issue in this case. Roberts v. Galen of Virginia, Inc., 525 U.S. ____, 119 S. Ct. 685, 142 L. Ed. 2d 648 (1999).