EMTALA Basics

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Introduction   

In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay.  

Essentially, hospitals are required to provide stabilizing treatment for patients with EMCs. If a hospital cannot stabilize a patient within its capability, or if the patient requests, an appropriate transfer should be implemented. [1] This has also been nicknamed the “anti-dumping law”. 

CMS Requires specific signage to be posted in Emergency Department or Emergency Room settings such as [1]: 

• “Know Your Rights” – (While this was initially created for Medicare recipients, it no longer applies to Medicare recipients but to anyone seeking Emergency Medical Screening, regardless of insurance or ability to pay.) 
• Participating in Medicaid 
• Non-Medicaid Participating 
• Notice of Language Availability  

Case Study 

More than 40 years ago, a healthcare provider could have been faced with a scenario similar to this:  

A 30-year-old female patient is brought to the ED by her husband for a severe headache that has lasted for several hours with little relief from over-the-counter analgesics. She states that this is one of the worst headaches she has ever had. She says she sometimes has some blurred vision, and at triage, she has the following: V/S – B/P 150/94, HR 86, RR 18, T 98.5 (o). She denies any past medical history or surgeries. She denies any recent accidents or falls.  

The clerk comes in and asks to see her healthcare insurance, at which time the husband says they do not have any since they just moved to the area after leaving their jobs in another state. They are still waiting for 90 days to finish so that they can start a new insurance plan. The clerk suggests this private hospital only accepts patients with insurance or cash up front. She also suggests they visit the public county hospital on the other side of town, which is only about 30-40 minutes away since they accept all patients regardless of insurance.  

The nurse, trying to be sympathetic, also tells the patient that it might be a good idea to go to the public hospital since they will not get a big bill, as they would at the current facility.  

They decide to take the advice, and the husband drives his wife in his vehicle, but on the way there, the woman has a significant seizure just as they are pulling into the emergency entrance. The husband gets immediate assistance, and the patient is taken quickly into an exam room. Her seizures progress, and she declines into respiratory arrest. All efforts to try to save her are futile, and she is pronounced dead 1 hour after arrival at the second facility.  

NOTE: On Autopsy, it was determined that this woman had a cerebral aneurysm that had ruptured, and this is what caused her death.  

**While this is a fictional scenario, similar stories played across the United States just a few short decades ago. 

HISTORY [1] [2] 

The triage practice arose from the difficulties of war and remained closely associated with military medicine. The earliest documented systems designed to distribute health care among wounded and sick warriors date back to the 18th century. Ancient and medieval armies made little or no formal effort to provide medical care for their soldiers, as treatment would have been minimal, if any, and most likely ineffective.  

To comply with the Medical Screening Examination (MSE) and Emergency Medical Condition (EMC), nurses at any port of entry in a facility (with or without a dedicated ED) must fully understand the Triage Process. This process is for any patient seeking emergent or urgent medical care.  

What is Triage?  

“Triage,” “rationing,” and “allocation” are terms commonly used to refer to the distribution of medical resources to patients. Although these terms are sometimes used interchangeably, they have apparent differences. The broadest of the 3, allocation, describes the distribution of medical and nonmedical resources and does not necessarily imply that the resource being distributed is scarce. (*For example, a host may allocate seats to the guests at a dinner party.)  

The Three Conditions of Triage (in its original intent) are: 

1. Modest scarcity of health care resources exists (this could be limited beds, staff, knowledgeable or certified medical personnel, etc.);
2. A (qualified) Heath Care Worker (HCW) assesses each patient’s medical needs, usually based on a brief exam; 
3. Triage personnel use an established system/plan based on an algorithm or set of (acceptable) criteria. This then determines a specific treatment or treatment priority for each patient. This condition distinguishes triage from purely ad hoc or arbitrary decisions about the distribution of health care resources. (NOTE: *This can also remove bias from decision-making.) 

Triage used in the United States [5] 

The most common triage system in the United States is the START (simple triage and rapid treatment) triage system. This Algorithm is utilized for patients above the age of 8 years. Using this Algorithm, triage status is intended to be calculated in less than 60 seconds.  

Various criteria are taken into consideration, including:  

• The patient’s pulse, respiratory rate, capillary refill time, presence of bleeding, and the patient’s ability to follow commands.  
• A commonly used triage algorithm is the Jump-Start (simple triage and rapid treatment) triage system for children.  
• This Algorithm is based on the START triage algorithm discussed earlier. However, it takes into consideration the increased likelihood of children experiencing respiratory failure and their inability to follow verbal commands.  
• NOTE: Other systems may be used, and a nurse or other HCW performing triage must follow the policy of the respective facility. Also, Field Triage, i.e., what is typically used by EMS, differs from hospital triage. 

It is essential to understand that triage is a dynamic process, meaning a patient can change triage statuses with time, and therefore, frequent observations and evaluations of the patient are of utmost importance. 

Strong Traits of a Triage Nurse (Officer): [2] 

• Clinically experienced  
• Good judgment and leadership  
• Decisive  
• Sense of humor  
• Available  
• Well recognized  
• Cool under stress  
• Knowledge of available resources Imaginative and creative problem-solving  
• Knowledge about anticipated casualties 

Indications / Process 

The Triage Nurse Must utilize the Emergency Severity Index (ESI) Triage Algorithm as follows: [5] (NOTE: this is a 5-tiered system used to determine status and stability) 

The first question in the ESI triage algorithm for triage nurses asks whether “the patient requires immediate life-saving interventions” or “Is the patient dying?” The nurse determines this by looking to see if the patient has a patent airway if the patient is breathing, and if the patient has a pulse. The nurse evaluates the patient, checking pulse, rhythm, rate, and airway patency. Is there concern for inadequate oxygenation? Is this person hemodynamically stable? Does the patient need immediate medication or interventions to replace volume or blood loss? Does this patient have pulselessness, apnea, severe respiratory distress, oxygen saturation below 90, acute mental status changes, or unresponsiveness?  

If the nurse can accurately diagnose the patient with these criteria and mark them as a Level 1 trauma patient, the patient will need immediate life-saving therapy. Immediate physician involvement in the patient’s care is critical and is one of the differences between level 1 and level 2 patient designations.  

Another scale nurses use in the assessment is if the patient meets the criteria for a proper level 1 trauma, the AVPU (alert, verbal, pain, unresponsive) scale. The scale is used to evaluate if the patient has had a recent or sudden change in consciousness and needs immediate intervention. Patients only responsive to painful stimuli (P) or unresponsive (U) are categorized as level 1. 

If the patient is not categorized as a level 1, the nurse then decides whether the patient should wait. Three questions determine this: is the patient in a high-risk situation confused, lethargic, or disoriented? Or is the patient in severe pain or distress? The high-risk patient could quickly deteriorate, one who could have a threat to life, limb, or organ. This is where the experience of the nurse comes into play. The nurse’s clinical experience allows for pinpointing the unusual presentations of diseases that may progress with rapid deterioration.  

Once the level 1 and 2 questions are ruled unfavorable, the nurse must ask how many different resources are required for the physician to provide adequate care and allow the physician to decide. That decision means discharge, admittance to the observation unit, or admission to the hospital floor. The experience of the triage nurse is again referenced to make a clinical judgment on what is done for patients who typically present with these symptoms. The nurse uses experience and the routine practice of the emergency department to make this decision. 

Before moving on, if the nurse has concluded that the patient will need many hospital resources during the visit, the nurse will again evaluate the patient’s vital signs and look for unstable vital signs. If the patient is outside the normal or acceptable limits and approaching dangerous vitals, the patient would then be triaged as a Level 2. The problematic vital signs are adjusted according to age. For example, if the patient was a 58-year-old man who would need multiple resources as decided by the triage nurse, and the vitals showed a heart rate of 114, oxygen saturation lower than 90%, and a respiratory rate of 26/min, that patient would be triaged as a Level 2. These findings, along with the patient’s history and physical, consider whether the triage nurse is concerned for the patient and decides on a Level 2 or 3/4/5 level triage. 

Differentiating between levels 3, 4, and 5 is determined by how many hospital resources the patient will most likely need. If the patient requires two or more hospital resources, the patient is triaged as a level 3. If the patient needs one hospital resource, the patient would be labeled a 4. If the patient does not require any hospital resources, the patient would be labeled a 5.  

One aspect of ESI that may differ at various institutions is what they consider an ESI resource. ESI triage resource examples are laboratory tests, electrocardiograms, radiographic imaging, parenteral or nebulizer medications, consultations, and simple procedures such as a laceration repair or a complex procedure. Resources qualified as “not resources” by ESI are history and physical examination (including pelvic exams), peripheral intravenous access placement, oral medications, immunizations, prescription refills, phone calls to outside physicians, simple wound care, crutches, splints, or slings. Whether or not some emergency departments (EDs) send specific tests, such as a urinalysis or pregnancy test, to the laboratory would change the ESI level between a four and a five. Regardless, ESI is a simple and effective way for nurses to assess patient needs. 

An inpatient who declines is not covered under the EMTALA Law. 

NOTE: This is a highly complex process, which is another reason why education, training, and experience play vital roles in determining the best fit for the Triage Nurse. 

Concerns 

When triaged accurately, patients receive appropriate and timely care from emergency care providers, limiting their injuries and complications. However, incorrectly triaged patients could sustain further injury and complications. Additionally, the main limitations of today’s triage systems lie in their need for more sensitivity and specificity. Given the many variables present during prehospital triage, it is difficult to establish a triage system that appropriately applies to all situations. 

Modern emergency departments are crowded places with many different people with different complaints, all with varying levels of severity. Nurses must be able to scan crowded emergency departments for critically ill patients and move them to the front. If this occurs, nurses must be able to anticipate the prioritization and status of available treatment areas. An optimal arrival to proper patient triage should occur in 10-15 minutes. As patients wait in busy emergency rooms, they should advise the nursing staff if there have been any changes in their condition. [5] 

NOTE: The more prominent and busier an Emergency Department becomes, the harder it is for Triage Nurses to accomplish timely assessments for all patients entering through their doors. It is even more frustrating when patients or families fail to report a change of status that could require more urgent or emergent care. 

The Nurse’s Role / Considerations / Legal Responsibilities:   

Nurse knowledge and expertise in the Emergency Medical Treatment and Labor Act (EMTALA) are prerequisites to meet emergency department practice laws and regulatory standards. EMTALA is a federal law that requires anyone coming to an emergency department for care to be stabilized and treated, regardless of their insurance status or ability to pay.  

Regulatory standard infractions resulting from an EMTALA violation complaint may include:  

1. penalties and fines,  
2. future unannounced Centers for Medicare & Medicaid Services surveys,  
3. documented Centers for Medicare & Medicaid Services deficiencies that require timely response, action plans, and audits for expected outcomes,  
4. Medicare/Medicaid nonpayment for services, and  
5. termination of a hospital’s Medicare agreement.  

The consequences of EMTALA violations target physicians and hospitals; however, nurses are often the first providers the patient encounters upon arrival at the emergency department. Therefore, nurses must maintain a proficient understanding of EMTALA laws, which require special training, monitoring, periodic competency assessment strategies, and continuing education throughout their careers.  

Furthermore, additional clinician education is needed to manage the complex expectations imposed on healthcare providers by regulatory policy. Doing this promotes safe, effective, patient-centered, timely, and efficient healthcare regulations from the beginning of one’s introduction to the healthcare industry and throughout his or her career. 

Nurses should conduct a minimum annual review and competency assessment (especially if this is an unusual situation within the facility). Most facilities mandate yearly awareness and competencies on topics for patients who fall under their direct care. This is also an ethical nurse responsibility based on the area one chooses to work in, mainly if that area includes triaging new incoming patients. 

Summation 

“Know Your Rights” is probably one of the most written forms/posters for potential patients to understand their rights when seeking treatment for a possible emergency medical condition.  

The four (4) rights are listed below: [1] 

EMTALA guarantees access to emergency medical services for individuals who present to a hospital emergency department regardless of an individual’s ability to pay. 

• It also provides for appropriate transfers if the presenting facility cannot provide the care or services necessary to stabilize a medical condition.  

All individuals must be screened. 

• Qualified Medical Personnel must screen all individuals who present to a hospital emergency department to determine the presence or absence of an emergency medical condition.  
• EMTALA applies until either: 
• The medical screening exam does not identify an emergency medical condition or 
• The patient is provided with stabilizing treatment and an appropriate transfer. 

Stabilizing treatment must be provided. 

• Hospitals must ensure that the patient receives stabilizing treatment (within the capabilities of the hospital’s staff and facilities) before they can transfer to another hospital or medical facility or discharge the patient.  

No delay in examination and treatment. 

• Hospitals may not delay providing an appropriate medical screening examination or stabilizing medical treatment for any reason, including asking about an individual’s payment method or health insurance status. 

Four Requirements for Appropriate Transfer: 

• A patient with an emergency medical condition may only be transferred when these four (4) requirements are met:  
• The transferring hospital provides the medical treatment within its capacity to minimize the medical risks (and in the case of a woman in labor, the medical risks of the fetus as well). 
• The receiving medical facility has available space and qualified personnel for the treatment and agrees to accept the transfer. 
• The transferring hospital sends all medical records related to the emergency condition available at the time of transfer and any other records yet to be available as soon as practical. 
• The patient is transferred using appropriate personnel and transportation, including necessary and appropriate life support measures during the transfer.  

Case Study  

A 25-year-old pregnant patient comes into your ED. She is Gravida 1 Para 0 (first pregnancy, no live children). She is being followed regularly by an Obstetrician. She states she is 27-28 weeks pregnant, and her chief complaint is that she feels like she is having contractions. She seems very scared and a bit anxious because a friend of hers lost a baby at 29 weeks, and she is afraid this is happening to her. 

Her Vital signs are as follows: B/P 120/76, HR 90, RR 16, Pulse Ox 96% on room air, and you place her on a fetal monitor and get FHTs in the 130’s. You do not see any apparent contractions, so you call a nurse from Labor & Delivery to give you her expert evaluation. The L & D nurse says she cannot feel contractions or see any on the Fetal Monitoring tracing. She confirms that the FHR in the 130s is correct and sees no signs of distress to the fetus during the 1-hour observation of the patient. She also calls the patient’s OB to get advice on whether she should perform an internal exam, and the OB says to do so, so she writes the order.  

Upon internal examination, the cervix is closed (no dilation), and the cervix is thick, with no signs of effacement (*these are the only two actual signs of active labor). The L & D nurse advises the OB, and the ED Nurse advises the ED physician. Both physicians confer and agree that the patient may be having Braxton Hicks contractions, especially since they seem to subside when she is resting.  

They all agreed that the patient should be discharged, drink plenty of fluids, and follow up with her OB. They all explain that Braxton Hicks contractions are just a way the uterus is “getting in shape” for the eminent delivery, and they do not pose a threat for premature delivery, but if they become worse or more frequent to comeback or contact her OB for further evaluation. 

The patient refuses and says she wants to be admitted to be safe!  

Conclusion

Nurse knowledge and expertise in the Emergency Medical Treatment and Labor Act (EMTALA) are prerequisites to meet emergency department practice laws and regulatory standards. EMTALA is a federal law that requires anyone coming to an emergency department for care to be stabilized and treated, regardless of their insurance status or ability to pay.  

The consequences of EMTALA violations target physicians and hospitals; however, nurses are often the first providers the patient encounters upon arrival to the emergency department (or other port of entry, e.g., the Labor and Delivery Department). Therefore, nurses must maintain a proficient understanding of EMTALA laws, which require special training, monitoring, periodic competency assessment strategies, and continuing education throughout their careers. Furthermore, additional clinician education is needed to manage the complex expectations imposed on healthcare providers by regulatory policy. Doing this promotes safe, effective, patient-centered, timely, and efficient healthcare regulations from the beginning of one’s introduction to the healthcare industry and throughout his or her career. [4] 

Special Note: While the Emergency Department in a Hospital is the most common port of entry where an EMTALA Violation could happen, Free-standing Urgent Care Centers and Emergency Departments can also fall under the same requirements and risks, especially if they advertise or identify as such. The Enforcement of EMTALA is a complaint-driven process, meaning there will only be an investigation if a complaint is filed (usually to a state-wide organization or to CMS). Information for this is provided directly on the Posters that must be displayed in participating facilities. 

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