HMGT 372 ASSESSMENT 1

QUICK LESSON

ICD-9 73.59

Author Neill Levy, BA, LLB

Cinahl Information Systems, Glendale, CA

Reviewers Dawn Stone, PhD(c), RN, ANP, COHN-S

Eliza Schub, RN, BSN Cinahl Information Systems, Glendale, CA

Nursing Practice Council Glendale Adventist Medical Center,

Glendale, CA

Editor Diane Pravikoff, RN, PhD, FAAN

Cinahl Information Systems, Glendale, CA

April 27, 2018

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2018, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

Legal Issues...Emergency Medical Treatment and Active Labor Act (EMTALA)

Issue Description For policy reasons the federal government decided that patients suffering emergency medical conditions should not be refused treatment in hospital emergency departments.(1)

Since it was inconvenient or impossible to directly compel all hospitals to provide such treatment, the federal government exercised leverage under the Medicare system where it pays hospitals to treat patients.

A new statute was therefore passed in 1986 requiring hospital emergency departments to treat all patients suffering an emergency medical condition, even patients not entitled to Medicare benefits. The new statute applied only to hospitals that were reimbursed by the federal government for patient care under the Medicare system. The government enforced the statute by levying monetary penalties against them or even expulsion from the Medicare program in serious cases.(2) However, the statute does not provide a federal medical malpractice claim.(3)

All or most hospitals in the US with emergency departments are reimbursed by the federal government for treating patients covered by Medicare. The new legislation, called the Emergency Medical Treatment & Labor Act of 1986 (EMTALA)(4), meant that those hospitals had to provide free treatment to indigent non-Medicare patients suffering emergency medical conditions. No longer could hospitals transfer them to other hospitals without good cause or send those indigent patients away.

Also protected under the new legislation are pregnant women who are in active labor rendering it unsafe to transfer them to another hospital.(5)

The EMTALA statute applies to “hospitals” as defined in the US Code, for which see Definitions, below. The EMTALA statute is associated with separate statutory provisions relating to skilled nursing facilities, which are defined as institutions primarily engaged in skilled nursing care for residents or rehabilitation services for injured, disabled, or sick persons.(8) Also, skilled nursing facilities must maintain proper standards to ensure quality care and a good quality of life for residents. Detailed provisions are included to enforce these requirements.(9) For the purposes of the EMTALA statute, the significance of the statutory requirements governing skilled nursing facilities is the following: they must be able to readily transfer their residents to a hospital pursuant to a written transfer agreement between the hospital and the skilled nursing facility should a resident require hospital care.(10)

The EMTALA statute requires that a patient who requests an examination or treatment for a medical condition at an emergency department must be given an appropriate medical screening examination to determine if an emergency medical condition exists (see Definitions, below).(11) A triage is insufficient because a triage only involves prioritizing when the patient will be seen by a physician or, if the hospital protocols permit, by other qualified medical or nursing personnel.(12) If the patient requires a level of care that is beyond the expertise of the hospital, a transfer should be arranged to another hospital capable of providing the required care (see Risks, below). Detailed rules apply to the way

the transfer is executed. Violations of the rules can be reported by anyone such as patients and healthcare workers.(13)

Hospitals are obliged to report to the Centers for Medicare and Medicaid Services (CMS) if a patient was rejected by another emergency room due to lack of insurance and there is no certificate from a physician that the benefits of the transfer exceed the risks.(14) However, the definition of “transfer” can be flexible under certain conditions. During the 2009 swine flu epidemic, the overwhelming number of patients in New York were triaged in emergency departments but given medical screening examinations elsewhere. It is believed that this method was EMTALA compliant.(15) In anticipation of a recurrence of the epidemic, contingency plans included increased use of home health care, temporary alternate sites of care within 250 yards of the hospital building, and use of the Internet for triage to enable patients to find the best places to seek care.(16) After a 15-year-old boy bled to death outside the Ravenswood Hospital, Chicago in 1998 (see Court Cases, below), the CMS amended the rules to require that hospitals must treat any patient that presents with an emergency condition within 250 feet of the hospital building(17) (increased to 250 yards in 2003).(18)

As stated above, the emergency room must give the patient an appropriate medical screening examination to determine if an emergency medical condition exists and if the patient requires a level of care that is beyond the expertise of the hospital, it may transfer the patient to another hospital. However, if the patient requires a level of care that is not beyond the expertise of the hospital, it may not transfer the patient but must provide appropriate treatment. However, the Fourth Circuit Court of Appeals held in Baxter v Holy Cross Hospital (48) that EMTALA only requires a hospital to stabilize a patient and there is no obligation under EMTALA to provide full treatment. State law then governs the situation after the patient is stabilized. On further appeal in the Baxter case, the US Supreme Court refused to hear the case thereby probably making the Fourth Circuit decision binding throughout the US.(50) However, there is disagreement on this issue – some physicians believe that a hospital is obliged to continue to treat patients if they are critically ill or require treatments that can only be administered in the hospital.(55)

EMTALA applies even if the patient enters the hospital other than through the emergency room, for example, the patient has just been born in the hospital and is in neonatal intensive care. In Lopez-Soto v Hawayek, the US Court of Appeals for the First Circuit (covering states from Maine down to Connecticut plus Puerto Rico) held that a Puerto Rico hospital violated EMTALA when it transferred a medically unstable newborn baby to another hospital where it died the next day. The hospital should have first stabilized the baby before transferring it.(49) This ruling is binding in the First Circuit and persuasive in other Circuits of the US.

Definitions › Emergency Medical Condition: The definition of this term in the EMTALA statute, subsection (e), references acute

symptoms, including pain, that are so severe as to (1) place the health of the patient in serious jeopardy or (2) cause serious impairment to bodily functions or (3) cause serious dysfunction of any bodily organ or part if immediate medical attention is not given. The definition also covers pregnant women in labor where there is no time for a hospital transfer or if a transfer may endanger the health or safety of mother or child. If a state’s statutory definition of this term is more stringent than the federal definition, the state’s definition must be followed.(19)

› The EMTALA statute applies to “hospitals” as defined in the US Code, namely institutions in which physicians supervise the diagnosis and treatment of injured, disabled or sick inpatients or provide rehabilitation services for those patients.(6)

Other elements of the definition of hospitals include keeping patient records, maintaining bylaws for physicians, providing a 24-hour nursing service supervised at all times by registered nurses, and being licensed by the state in which the hospital is located. There are other complex elements included in the definition of hospitals. For example, the definition includes religious nonmedical healthcare institutions and small rural hospitals that do not provide full services.(7)

Risks There have been suggestions that EMTALA contributes towards over-crowding of emergency departments by uninsured patients with non-emergent conditions seeking routine health care, although the statute applies also to insured patients.(20,62)

Over-crowding is exacerbated by the compulsory posting of notices in emergency rooms advising patients of their EMTALA rights, coupled with a shortage of Medicare and Medicaid funding and closure of private medical practices due to heavy professional liability insurance premiums.(21) Triage is, therefore, an important process enabling patients to receive only the care that they actually need, giving priority to the most needy. An emergency severity index developed in 1998 for triage categorizes patients into levels of urgency with the most urgent cases labeled level 1. The degree of urgency drops with each level until the lowest, level 5, which requires minimal treatment.(22) Users of the index aim to timely provide necessary

emergency treatment while conserving scarce medical resources. The index has proved to be reliable and accurate with those on the lowest acuity rating rarely requiring hospital admission. This encourages EMTALA compliance in a nondiscriminatory manner. However, one limitation of the index is that the reliability of the scale for infants has not been fully established.(23)

Hospitals, at least up to 2016, are still violating the provisions of EMTALA. One reason is that they sometimes treat patients inconsistently, one from the other, “outside of their normal processes”. For example, a nurse ran out to the ambulance to tell the EMS that the hospital does not take trauma cases, and an on-callphysician who refused to come in. These were practices not adopted for all their patients.(57) This inconsistent treatment, and other violations, should not happen because hospitals have policies and procedures in place for compliance with EMTALA. The problem is that staff members are regularly pulled from the hospital to the ED, or are new staff hired as temporary personnel, due to turnover and resultant shortages of ED staff. These staff members are often unfamiliar with the intricacies of EMTALA. The solution is that there should be a person in the hospital available at all times to answer staff questions about EMTALA issues.(58)

A press report in August-2014 indicated that the number of patients presenting to emergency rooms in Los Angeles County has dropped since the implementation of the Affordable Care Act (ACA, also known as Obamacare). The suggestion is that patients who formerly had no health insurance and used emergency rooms for primary healthcare services no longer need emergency rooms for that purpose because they are now insured under the ACA.(47)

Statistical research by an economist with the Federal Trade Commission led him to suggest that repealing EMTALA would increase the number of people with medical insurance and at the same time decrease the cost of the insurance.(51)

Homelessness is a problem in Los Angeles, partly due to its mild climate attracting homeless people from more extreme zones. One hospital discharged a homeless woman who later needed acute medical care for pneumonia. The time lapse from discharge to later diagnosis of pneumonia was not specified. The Los Angeles City Attorney apparently could not prove a violation of EMTALA so he resorted to California state laws when he sued the hospital for damages. The court awarded damages of $550,000 and the hospital had to adopt an approved homeless discharge protocol.(53)

Minimizing risks of transfer: If an emergency department lacks the necessary medical expertise to stabilize a patient suffering an emergency medical condition it may transfer the patient to another hospital.(24) However, the transfer process must comply with strict rules under the statute.(58) Firstly, the patient (or someone acting on the patient’s behalf) should be informed of the risks and benefits of such transfer. If the patient refuses, the hospital shall take all reasonable steps to obtain the patient’s written informed consent to the refusal(25) or the transfer.(26) Secondly, a physician signs a certificate that the medical benefits of transfer to another facility outweigh the risks of not being transferred.(27) If a physician is not present, a “qualified medical person” as defined by federal regulation signs the certificate in consultation with a physician who subsequently countersigns the certificate.(28) Thirdly, the transfer must be an “appropriate” transfer.(29) This means that the transferring hospital minimizes the risk to the patient and, in the case of a woman in labor, to the unborn child.(30) Also, the receiving facility must have available space and qualified personnel to treat the patient and has agreed to accept the patient for appropriate treatment.(31) There are also rules on transfer of the written informed consent and all available medical records including name and address of any on-call physician who would not come to the transferring emergency room to stabilize the patient.(32) The actual transfer of the patient must be medically safe and effectuated by qualified personnel.(33) Finally, federal regulations may prescribe further requirements from time to time.(34)

As of 2007, the situation in California regarding on-call specialist availability at emergency departments had deteriorated since the publication in 2003 of comprehensive regulations governing the interpretation of the EMTALA statute. This resulted in long delays in patient care and the potential for patient harm.(35)Sometimes a “trauma protocol” is activated if a patient requires specialized care at the ED. Specialists who are called in under the protocol become dissatisfied with their insurance remuneration, which is at the same rate as other physicians. They are even more dissatisfied if the patient is not insured.(56)

Units Potentially Involved Emergency departments are the only units that appear to be directly affected by the statute. However, emergency departments sometimes perform the function of psychiatric units and they are still required to comply with the statute. An experienced Chicago medical malpractice attorney said that ensuring compliance with the statute in dealing with psychiatric patients will enable emergency departments to avoid both violations of the statute and medical malpractice lawsuits.(36) Emergency departments should not confine their medical screening examination only to the psychiatric emergency. The examination

should also include medical issues such as heart disease, diabetes and trauma. For example, the obvious symptoms of a mentally unstable patient could mask a medical emergency such as a stroke.(61)

CMS regards an emergency physician (EP) as qualified to perform the psychiatric portion of a medical screening under EMTALA. To avoid an EMTALA violation the EP should insist on performing a psychiatric evaluation even if the EP does not comply with state law in doing so.(61) Also, insurers sometimes specialize in behavioral care and restrict their contracts to a limited number of hospitals. An EP may violate EMTALA by transferring a patient to one of those hospitals.(61)

Court Cases The EMTALA term “appropriate medical screening examination” was interpreted by the Michigan federal court of appeals to mean a screening that an emergency department would give to any paying (insured) patient and “emergency medical condition” to mean a condition within the actual knowledge of either doctors on duty or those doctors that would have been provided to any paying patient.(37) The appeal court held that the plaintiffs in the case, the parents of a 15-year-old boy, Clair Cleland, made no allegations that would allow a finding that the defendant hospital, Bronson Health Care Group, breached its duties under EMTALA when it treated Clair in its emergency room. The court also held that Congress intended by the plain language of the statute to benefit insured, paying patients as well as non-insured, non-paying patients.

Clair had presented at the emergency room with cramps and vomiting and was diagnosed with influenza and discharged. However, he was suffering intussusception where the intestine telescopes within itself. Clair suffered cardiac arrest less than 24 hours later and died. Instead of filing a medical malpractice lawsuit, Clair’s parents filed a lawsuit under EMTALA claiming that there was no appropriate medical screening plus a failure to treat his emergency medical condition. The court dismissed the lawsuit holding that Clair had been stabilized to the extent required by the EMTALA statute.(38) The court also held that the medical screening was “appropriate” within the meaning of the statute because the hospital acted with the same motives and in the same manner as it would have for the usual paying patient.(39)

This case is supported by a Louisiana case, where it was held that the appropriateness of a medical screening examination is not judged by whether the diagnosis is correct but whether it is as thorough as examinations generally given to patients with similar symptoms, and is in accordance with hospital regulations.(40)

In 1998 a 15-year-old boy was shot outside the Ravenswood Hospital Medical Center but staff refused to go outside and carry him in for treatment. The CMS levied a penalty of $40,000 on the hospital ($10,000 less than the maximum) and approved the hospital’s revised policy on treating victims outside hospital buildings. The family filed a lawsuit and the hospital settled for $12.5 million.(41) One wonders how the gigantic sum of $12.5 million in any way reduced the family’s suffering as against a lower payment of, say, $500,000.

A Michigan case starkly contrasted a state claim under Michigan medical malpractice law with a federal claim based on a hospital’s duty to stabilize a patient under the EMTALA statute. The decedent, Smith, suffered an open comminuted fracture of the left femur in an SUV rollover accident and was brought to Botsford General Hospital in Detroit. He was difficult to treat because he weighed 600 pounds and used alcohol and cocaine. The hospital contended that it could not treat the patient because his size prevented it from assessing the patient with a CT scan and its operating room lacked the facilities to hold the patient’s weight should surgery become necessary. Therefore, he had to be stabilized and transferred to another hospital. The EMTALA requirement for stabilization is to provide medical treatment to assure within reasonable medical probability that the patient’s condition will not deteriorate during the transfer. However, he died en route. His family filed a lawsuit in federal court under the EMTALA statute to circumvent a $359,000 medical malpractice general damages cap under Michigan law. Therefore, the usual medical malpractice negligence factors such as breach of the standard of care were irrelevant. The only issue at trial was whether the hospital had stabilized the patient in compliance with the EMTALA statute. The plaintiff contended that the patient was not stabilized. The blood loss from a serious fracture in a restless patient thrashing around, coupled with other factors such as low blood pressure, made it probable and foreseeable that the patient would materially deteriorate during a 30-minutetransfer. The jury found that the patient had not been stabilized and returned a verdict for the plaintiff of $5,035,000 in damages because the trial court had ruled that the Michigan damages cap did not apply since it was not a medical malpractice claim. The hospital appealed the court’s ruling that the damages cap did not apply. In establishing whether it was a medical malpractice claim the federal appeals court had to decide (1) whether the claim was brought against an entity that was capable of malpractice, (2) whether the claim arose out of a professional relationship, and (3) whether the claim raised questions of medical judgment beyond the realm of common knowledge and experience. The first two questions were easily decided in the affirmative. On the third question, the plaintiff argued that no questions of medical judgment were raised because breach of the EMTALA provision regarding stabilization does not require breach of the applicable medical

professional standard of care. However, the appeals court approached the issue from a different angle – if expert medical testimony is required to prove that the patient was not stabilized in compliance with the EMTALA statute before transfer, then the plaintiff’s claim involved medical judgment and the answer to the third question was in the affirmative. Since expert medical testimony was required, the claim was a medical malpractice action under Michigan law and the damages cap applied. Plaintiff was therefore awarded the maximum of $359,000 in general (non-economic) damages plus $35,000 in economic damages.(42)

However, the federal court in Louisiana came to a different conclusion around the same time. In the Jeff case the federal district (trial) court in New Orleans concluded that a claim for refusal to provide a medical screening examination and stabilizing treatment under EMTALA was not a medical malpractice claim. Under Louisiana law (as in all other states) a medical malpractice claim is an “unintentional” tort (civil wrong) because it involves a negligent act or omission and not an intentional act or omission (for a description of negligence see Quick Lesson About … Legal Issues…Burns: an Overview ). The court ruled that a failure to properly screen and stabilize under the EMTALA statute is an intentional tort. Therefore, an EMTALA claim could not be a malpractice claim under Louisiana law and the Louisiana damages cap did not apply.(43) It is possible that the contrary court ruling in the Michigan case, above, was different because the Michigan physician had tried, but failed, to stabilize the obese patient and was, therefore, negligent and the malpractice law accordingly applied. A commentary on the same issue observed that a hospital or physician would have difficulty in avoiding malpractice liability for treatment if that same treatment constituted a violation of EMTALA.(60)

A Kentucky hospital complied with EMTALA requirements for a medical screening of a homeless, indigent, and paraplegic man who came to the ED twice with severe pain. He was discharged after both visits but died of a ruptured ulcer after his second visit. The jury found that the hospital did not stabilize the patient pursuant to EMTALA and awarded $1.5 million (reduced to $1.45 million) to be paid by the hospital.(59)

A Florida lawsuit brought under the EMTALA statute led to a ruling that a hospital’s medical screening of a pregnant woman that is consistent with the screening that any other woman in the care of a private obstetrician would receive, is an appropriate screening under the statute. The screening was the same as given to any other hospital outpatient in the plaintiff’s condition. The hospital may tailor screenings according to the patient’s condition and each screening does not have to be identical. The patient was screened for signs of labor but her physician who examined her at the hospital concluded she was not in labor. She was discharged but went into pre-term labor the next day. The court rejected her claim for damages.(44)

The federal court of appeals in Boston heard an appeal by one Ms. Vazquez against the Mennonite General Hospital in Puerto Rico. Ms. Vazquez claimed that the hospital did not follow its own protocol for screening pregnant women in the third trimester who had vaginal bleeding. Thus the hospital violated EMTALA for not screening her properly and for not stabilizing her emergency medical condition before discharging her. The court held that the screening was not according to hospital protocol and, therefore, there was enough evidence for a jury to find that the screening violated EMTALA when Vazquez was discharged.

At the emergency room Vazquez complained of vaginal discharge and blood spotting but denied dysuria, pelvic pain, or fever. The ER physician, Dr. Torres, performed a pelvic exam. She did not perform any other tests but she consulted Vazquez’ regular obstetrician who advised Dr. Torres to administer Brethene and Vistaryl, discharge Vazquez, and tell Vazquez to see the obstetrician early the next morning. Dr. Torres followed this advice. The obstetrician examined Vazquez the next morning and found a 7cm dilated cervix with the fetus floating in a breech position. He diagnosed an incompetent cervix and sent her to another hospital where she had a cesarean section. The baby died two days later of unstated causes. The reporter of the court case said that hospital protocol should have been followed and EMTALA was violated, although Dr. Torres took the obstetrician’s advice and“honestly felt she was doing the right thing.” The reporter also expressed the opinion that the screening was probably not negligent although it was disparate.(51)

On the same theme, it is inadvisable to make assumptions when a patient is brought to the emergency room. A 64-year-old woman, an alcoholic, repeatedly came to a hospital emergency room where she was well-known. She usually slept off her intoxication and her discharge then followed in the morning. One night the patient came in obviously intoxicated and by 7:15am was awake, responsive, hungry, and able to walk. Fifteen minutes after her discharge she was brought back because she had difficulty walking. Her blood was tested at 0.261. She was placed back in bed to sleep it off. However, her condition deteriorated and a CT scan the next morning indicated that she had suffered a stroke. She died three days later. Relatives (who had not been present to assist the patient) sued the hospital under EMTALA, and the hospital settled the case out of court. The reporter said that an appropriate medical screening exam had not been performed and the emergency room staff should not have assumed that the patient suffered only from alcoholic intoxication when she was admitted on this occasion.(52)

It is important for staff to follow the hospital policy and protocol for medical screenings in the ER. If they do not, the practical result is that they and the hospital effectively guarantee a good outcome. This happened when a women, 48 years old, was admitted to the ER with chest pain. The physician and the nurse practitioner did not know the hospital screening protocol for chest pain in this type of patient. She died of a hemopericardium from a ruptured aortic dissection six hours after arriving at the ER. The hospital settled the lawsuit for $1 million because the physician and the nurse practitioner were not aware of the appropriate hospital protocol.(54)

In a Louisiana case the court of appeal held that there was no violation of the EMTALA statute when the patient was brought in by ambulance after being found on the ground outside a bar. He was seen by a nurse and a physician who sutured a small laceration on his temple. He was alert and awake, and there were no abnormal neurological signs except for lethargy. He was discharged without a CT scan, but later that day he was treated at another hospital for right frontal and temporal lobe hematoma. Medical staff testified that no intoxicated patient with a normal neurological assessment would get a CT scan just because he was lethargic. The court held that it would not challenge the professional judgment of medical staff – the patient was given the same care and attention any other patient with the same signs and symptoms would have been given.(45)

Recommendations The American College of Emergency Physicians published a policy statement in 2006, revised in 2013, stating that “[h]ospitals, medical staff, and payers share an ethical responsibility for the provision of emergency care.” A reliable system should be in place for on-call physicians and specialists for consultation in evaluation and treatment of patients, complying with EMTALA requirements. In particular, hospitals with specialized capabilities should accept transfer of patients when necessary to stabilize an emergency medical condition.(46)

References 1. Sally Austin, "What does EMTALA mean for you?", Nursing, Vol. 41 No. 6, Jun. 2011, p. 55; Getachew Teshome et al, "Emergency Medical Treatment and Labor Act: The

Basics and Other Medicolegal Concerns", Pediatric Clinics of North America, Vol. 53 No. 1, Feb. 2006, pp. 139, 140.

2. Sally Austin, supra, at p. 58; Getachew Teshome et al, supra, at p. 140.

3. Paul A. Testa et al, "Triage, EMTALA, Consultations, and Prehospital Medical Control", Emergency Medicine Clinics of North America, Vol. 27 No. 4, Nov. 2009, p. 627 at p. 629.

4. 42 United States Code §1395dd.

5. 42 United States Code §1395dd(e)(1)(B).

6. 42 United States Code §1395x(e).

7. 42 United States Code §1395x(e)(9).

8. 42 United States Code §1395i-3(a).

9. 42 United States Code §1395i-3(b),(c), (d).

10. 42 United States Code §1395i-3(a)(2).

11. 42 United States Code §1395dd(a).

12. State Operations Manual Appendix V page 36 of 68, accessed on Apr. 12, 2018 at <http://www.cms.gov/manuals/Downloads/som107ap_v_emerg.pdf>; Sally Austin, supra, at p. 56. Retrieved from http://www.cms.gov/manuals/Downloads/som107ap_v_emerg.pdf

13. Sally Austin, supra, at p. 58.

14. Getachew Teshome et al, supra, at p. 141.

15. Paul A. Testa et al. supra at p. 628.

16. Andrew R. Roszak et al, "Implications of the Emergency Medical Treatment and Labor Act (EMTALA) During Public Health Emergencies and on Alternate Sites of Care", Vol, 3 Suppl. 2, Dec. 2009, p. S172.

17. Gregg Blesch, "Stretching the limits", Modern Healthcare, Vol. 39 No. 51, Dec. 21-28, 2009, p. 6 at p. 16.

18. 42 Code of Federal Regulations 413.65(a)(2).

19. Sally Austin, supra, at p. 56.

20. Getachew Teshome et al, supra, at p. 143; Paul A. Testa et al, supra, at p. 629.

21. Getachew Teshome et al, supra, at p. 143.

22. Paul A. Testa et al. supra at p. 628.

23. Paul A. Testa et al. supra at p. 628.

24. 42 United States Code §1395dd(b)(1)(B).

25. 42 United States Code §1395dd(b)(3).

26. 42 United States Code §1395dd(c)(1)(A)(i).

27. 42 United States Code §1395dd(c)(1)(A)(ii).

28. 42 United States Code §1395dd(c)(1)(A)(iii).

29. 42 United States Code §1395dd(c)(1)(B).

30. 42 United States Code §1395dd(c)(2)(A).

31. 42 United States Code §1395dd(c)(2)(B).

32. 42 United States Code §1395dd(c)(2)(C).

33. 42 United States Code §1395dd(c)(2)(D).

34. 42 United States Code §1395dd(c)(2)(E).

35. Michael D. Menchine et al, "On-call Specialists and Higher Level of Care Transfers in California Emergency Departments", Academic Emergency Medicine, Vol. 15 No. 4, Apr. 2008, p. 329 and at p. 330.

36. Stacy Kusterbeck, "Stop Psych-related EMTALA Violations", ED Legal Letter, Suppl, Sep. 2011, p. 19.

37. Cleland v Bronson Health Care Group, Inc, 917 F.2d 266 (6th Cir. 1990) rehearing denied en banc, 1990.

38. Cleland supra, at p. 271.

39. Cleland supra, at p. 272.

40. Paul A. Testa, supra, citing Marshall v East Carroll Parish Hosp. Serv. Dist, 134 F.3d 319 (5th Cir. 1998).

41. "Hospital settles EMTALA violation for $12.5 million", Healthcare Risk Management, Vol. 25 No. 7, Jul. 2003, p. 79 and at p. 80.

42. Robert A. Bitterman, "Michigan's non-economic damages cap ruled constitutional; the cap applies to EMTALA claims", ED Legal Letter, Vol. 17 No. 10, Oct. 2006, p. 109, reporting Smith v Botsford General Hospital, 419 F.3d 513 (6th Cir. 2005).

43. Robert A. Bitterman, "LA courts find malpractice damages cap inapplicable to EMTALA claims and unconstitutional", ED Legal Letter, Vol. 17 No. 12, Dec. 2006, p. 133, reporting Jeff v Universal Health Services, No. Civ.A.04-1507 (E.D. La, Jul. 27 2005).

44. "Labor & Delivery Nursing: Court Rules Nurse, Doctor Did Not Violate EMTALA" Legal Eagle Eye Newsletter for the Nursing Profession, Vol. 12 No. 7, Jul. 2004, p. 7, reporting Nolen v Boca Raton Community Hosp, Inc, __ F.3d__, 2004 WL 1367490 (11th Cir, Jun. 18, 2004).

45. "EMTALA: E.R. Patient Smelled Of Alcohol, No CT, No Liability", Legal Eagle Eye Newsletter for the Nursing Profession, Vol. 11 No. 6, Jun. 2003, p. 2, reporting Scott v Dauterive Hosp. Corp, 851 So.2d 1152 (La. App. Ct. 2003).

46. EMTALA and On-call Responsibility for Emergency Department Patients, Policy Statement, 2013, accessed on Apr. 12, 2018 at http://www.acep.org/Content.aspx? id=29434&terms=emtala. Retrieved from http://www.acep.org/Content.aspx?id=29434&amp;terms=emtala

47. Soumya Karlamangla et al, “Fewer patients visit public hospitals’ ERs”, Los Angeles Times, Aug. 22, 2014, p. AA1.

48. Baxter v Holy Cross Hospital of Silver Spring, US No. 98-1169, cert. denied Mar. 22, 1999.

49. Lopez-Soto v Hawayek, 98-1594, 1st Circuit, 1999.

50. James L. Thorne, “EMTALA: The Basic Requirements, Recent Court Interpretations, and More HCFA Regulations to Come”, American Academy of Emergency Medicine, www.aaem.org/.

51. Thomas G. Koch, “Bankruptcy, medical insurance, and a law with unintended consequences”, Health Economics, Vol. 23 No. 11, 2014, p. 1326.

52. Ann W. Latner, “Legal Advisor: Emergency ignored in an alcoholic”, The Clinical Advisor, Vol. 18 No. 12, Dec. 2015, p. 59.

53. Will Jay Pirkey, “A shameful practice”, Los Angeles Lawyer, Jul./Aug. 2016, p. 20.

54. Ann W. Latner, “Legal Advisor: Know your EMTALA policies”, The Clinical Advisor, Vol. 17 No. 7, Jul. 2014, p. 59.

55. Heena P. Santry et al, “Rates of Insurance for Injured Patients Before and After Health Care Reform in Massachusetts: A Possible Case of Double Jeopardy”, American journal of Public Health, Vol. 104 No. 6, Jun. 2014, p. 1066.

56. Robert J. Milligan et al, “ED registration processes can trigger litigation against hospital”,Hospital Access Management, Vol. 36 No. 2, Feb. 2017, p. 19.

57. “EDs still tagged with EMTALA violations”, ED Legal Letter, Vol. 27 No. 7, Jul. 2016, p. 77.

58. “EMTALA still a risk, but some are letting down their guard”, Healthcare Risk Management, Vol. 38 No. 7, Jul. 2016, p. 73.

59. “$1.45 million EMTALA award despite rendering aid”, Healthcare Risk Management, Vol. 38 No. 7, Jul. 2016, p. 76.

60. “EMTALA violation could bolster weak malpractice claim against EP”, ED Legal Letter, Vol. 27 No. 9, Sep. 2016, p. 104.

61. “EPs often unaware of psychiatric patients’ EMTALA risks” ED Legal Letter, Vol. 27 No. 2, Feb. 2016, p. 21.

62. “Remove non-emergent patients from the ED with care” ED Legal Letter, Vol. 27 No. 9, Sep. 2016, p. 97.