- Email: [email protected]
Medical staff knowledge of EMTALA at a large, tertiary-care hospital
Medical Staff Knowledge of EMTALA at a Large, Tertiary-Care Hospital JOSEPH ZIBULEWSKY, MD The study objective was to determine what percentage of a hospital’s medical staff have heard of the Emergency Medical Treatment and Active Labor Act (EMTALA) statute, and of those who have heard of it, to determine the extent of their knowledge. A questionnaire was mailed to 600 members of the active medical staff of an urban, 900-bed, private, tertiary-care hospital asking if they had ever heard of the EMTALA statute, and if so, to complete a 20-question multiple-choice quiz on specifics of EMTALA law. The main results were whether they had ever heard of EMTALA; if knowledge of EMTALA was related to specialty, age, years in practice, or frequency of ED call; and the quiz scores and any relationship they might have to those same demographic factors. Questionnaires were returned by 41.5% (n ⴝ 249). Thirty-one specialties were represented and seven had greater than 10 physicians each. Physician age and years in practice were skewed toward older ages. Approximately one-third (34.5%) took ED call at least monthly. Only 29.3% had ever heard of EMTALA. There was a significant linear correlation between on-call frequency and positive knowledge of the law, but of those who took call at least monthly, 50% had never heard of EMTALA. The average score on the 20-question quiz was 69%. Questions concerning definition of a transfer, definition of an emergency medical condition, investigations of EMTALA, on-call staff responsibilities, and the number of hospitals cited for EMTALA violations were answered correctly by <50% of the respondents. Most members of the medical staff of a large, tertiarycare hospital have never heard of EMTALA, and of those who have, the extent of their knowledge is limited. This presents challenges for the hospital to facilitate education efforts to reduce liability. (Am J Emerg Med 2003;21:8-13. Copyright 2003, Elsevier Science (USA). All rights reserved.)
In 1986, in an attempt to halt the practice of “patient dumping” and to ensure patient access and equity in emergency medical treatment, the U.S. Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA).1 These mere four pages of legislation have created a storm of controversy and litigation over the ensuing 15 years. It is one of the most significant laws that affects health care delivery, and although aimed primarily at emergency care, the law itself, as well as various interpretations by the Health Care Financing Administration (HCFA) and the courts, have extended the scope of the law to include virtually any physician that From the Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX, and the Department of Surgery, Division of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX. Manuscript received July 27, 2001, accepted September 28, 2001. Address reprint requests to Joseph Zibulewsky, MD, Baylor University Medical Center, Department of Emergency Medicine, 3500 Gaston Ave, Dallas, TX 75246. E-mail: [email protected] Key Words: EMTALA, COBRA. Copyright 2003, Elsevier Science (USA). All rights reserved. 0735-6757/03/2101-0002$35.00/0 doi:10.1053/ajem.2003.50000 8
treats patients in the hospital. Therefore, it is not only incumbent on ED physicians to know and understand this law, but virtually every physician on staff in the hospital should be at least minimally familiar with its content and implications. To date, the only study looking at EMTALA knowledge by the general medical staff has been one published in January 2001 by the Office of the Inspector General (OIG) of the Department of Health and Human Services (the agency that assesses penalties for EMTALA violations).2 It found that the vast majority of on-call hospital staff are “highly familiar” with EMTALA. Although the study looked at 123 hospitals, it sent surveys to only six randomly selected on-call physicians from each facility. In contrast, the study presented in this article uses a brief questionnaire to attempt to first determine whether members of a single hospital’s medical staff have heard of EMTALA, and secondly, for those who have heard of it, to determine their general knowledge of the law. MATERIALS AND METHODS In October 2000 a questionnaire was sent to the active medical staff of the study hospital. It is a private, urban, 900-bed, tertiarycare facility and is a level-one trauma center. It is also a teaching hospital with residency programs in internal medicine, surgery, obstetrics/gynecology, and radiology, as well as a number of fellowship programs. Its ED is a 43-bed facility, which in the year 2000 had a census of 75,500 patients, received 919 incoming transfers from other EDs, and transferred 318 patients out to other facilities. The total number of physicians with active medical staff privileges at the time was 650 (as determined by the medical staff office); however, radiology, pathology, and physical medicine and rehabilitation physicians were excluded from the survey, because they either did not primarily see patients or did not see them on an inpatient basis or on-call in the ED. This left 600 physicians who received the questionnaire. The forms were sent out through the medical staff office and returned to them by the physicians in prestamped envelopes. The survey instrument consisted of a cover letter explaining that the ED was conducting a survey of the active medical staff about their knowledge of EMTALA/COBRA regulations. The questionnaire began with four demographic items: specialty, age, years in practice, and how often on average in the prior year the physician took call in the ED per month. The next question simply asked if the physician had ever heard of or was familiar with the EMTALA/COBRA regulations. If the physician answered no, they did not have to respond to the remaining items and could return the questionnaire. If they answered yes, they were then asked how they had first heard of EMTALA, if they had any recent (within 5 years) continuing medical education that dealt with EMTALA, and if they had ever been personally cited or knew of any colleague who had been cited for an EMTALA violation. Finally, those who indicated familiarity with the law were asked 20 multiple-choice questions about EMTALA, consisting of general knowledge of the statute (who created it, who investigates violations, penalties, definitions of medical screening examination, emergency medical
JOSEPH ZIBULEWSKY ■ MEDICAL STAFF KNOWLEDGE OF EMTALA
TABLE 1.
Physician Specialties With ⬎10 Respondents
9
TABLE 3.
Physician Years in Practice
Specialty
No.
Percentage
Practice Years
No.
Percentage
Internal medicine Surgery Obstetrics Anesthesia Pediatrics Orthopedics Opthalmology Emergency medicine Not indicated Totals
89* 40† 16 16 14 12 11 8 43 249
35.7 16.1 6.4 6.4 5.6 4.8 4.4 3.2 17.3 100.0
⬍5 5-9 10-14 15-19 ⱖ20 Not answered Totals
40 32 33 37 102 5 249
16.1 12.9 13.3 14.9 41.0 2.0 100.0
*Includes allergy/immunology, cardiology, dermatology, endocrinology, family practice, gastroenterology, hematology/oncology, nephrology, neurology, psychiatry, pulmonary, and rheumatology. †Includes colorectal surgery, ENT, hand surgery, oral surgery, thoracic surgery, transplant surgery, trauma surgery, vascular surgery, and urology.
condition, transfers, and so on) and on-call physician responsibilities (establishment and maintenance of on-call panels, need for on-call physicians to respond to ED consults, and so on). The survey forms were created by the author and did not undergo any standardizing process. At the end of a 2-month period the returned surveys were collected from the medical staff office and analyzed. Data analysis was done with SPSS (Chicago, IL) using chi-squared analysis for comparison of groups with regard to their knowledge of EMTALA and analysis of variance to determine significance of quiz scores to demographic data.
RESULTS Two hundred forty-nine (41.5%) surveys were returned. Thirty-one physician specialties were represented and 7 specialties had at least 10 respondents (Table 1). Forty-three respondents (17.3%) did not list their specialties. For the purpose of data analysis, only specialties with greater than 10 respondents were used, and those subspecialties with less than 10 were included under the major specialties. For example, cardiology (n ⫽ 8) and psychiatry (n ⫽ 2) were included under internal medicine, and thoracic surgery (n ⫽ 2) and urology (n ⫽ 8) were included under surgery. The only exception to this was emergency medicine (n ⫽ 8), which remained its own category for further analysis. The ages of the physicians and their years in practice were skewed toward a slightly older age, with 44% being over 50 (Tables 2 and 3). Approximately one-half of the respondents never took ED call, and approximately one third took call at least monthly (Table 4). Only 29.3% (n ⫽ 73) of all the respondents had ever heard of EMTALA. All TABLE 2.
8 of the EPs had heard of EMTALA. Of those who had heard of it, most had first heard of it through hospital and medical staff meetings (Table 5). Only 17.8% (n ⫽ 13) of physicians who had heard of EMTALA had participated in continuing medical education over the prior 5 years that contained information about it. No physician with knowledge of EMTALA had ever been cited for an EMTALA violation or knew of a colleague who had. There was no relationship between knowledge of EMTALA and physician age or years in practice. Except for emergency medicine, there was no relationship between knowledge of EMTALA and specialty. There was a significant positive association (P ⬍ .001) between knowledge of EMTALA and frequency of ED call (Fig 1). However, of those physicians who took ED call at least monthly (n ⫽ 86), 50% had never heard of EMTALA. Of those who never took ED call (n ⫽ 117), 82% had never heard of it. Of those who had heard of EMTALA, the average score on the quiz was 69% (standard deviation [SD] ⫽ 16.4), with a range of 0% (n ⫽ 1) to 95%. When the single physician who received a zero on the quiz was removed, the mean rose to 70% (SD ⫽ 14.3) and the range became 35% to 95%. The 8 EPs had an overall mean of 84.4%, with 7 of the 8 scoring above the overall group mean. As to the individual 20 questions, there were 5 that were answered correctly less than half of the time (Table 6). Although the numbers were too small to achieve any power, there was no significant association between quiz scores and specialty (except for EPs), age, years in practice, or frequency of ED call. DISCUSSION EMTALA was enacted by Congress in 1986 after a number of reports in the lay press and in professional journals noted that indigent patients were being diverted from private to county hospital EDs based solely on their ability to pay.3,4 The statute imposes three legal duties on hospitals (only those hospitals that participate in Medicare are included, but this includes almost 98% of all facilities). First, hospitals must perform a medical screening examina-
Physician Ages TABLE 4.
Age (y)
No.
Percentage
⬍30 30-39 40-49 50-59 ⱖ60 Not answered Totals
4 49 82 67 43 4 249
1.6 19.7 32.9 26.9 17.3 1.6 100.0
ED Call Frequency
ED Call
No.
Percentage
None ⬍Once/mo Monthly ⬎Once/mo Not answered Totals
117 41 25 61 5 249
47.0 16.5 10.0 24.5 2.0 100.0
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 21, Number 1 ■ January 2003
10
TABLE 5.
Sources of Initial EMTALA Awareness Source
No.
Percentage
Hospital meetings Personal communications Journals/publications Professional/national Society meetings Other/do not know Did not answer Totals*
22 14 10
30.5 19.4 13.9
9 17 1 73
12.5 23.6 1.4 100.0
*Includes only those 73 physicians who indicated knowledge of EMTALA. Abbreviation: EMTALA, Emergency Medical Treatment and Active Labor Act.
tion (MSE) to determine whether an emergency medical condition EMC exists. This examination is more than merely a triage evaluation, and can include not only a history and physical, but any number of tests including computed tomography scans and ultrasounds. Basically, the physician is mandated by the law to perform as complete an evaluation as necessary to either identify or rule out the presence of an emergency medical condition as defined by the statute (Table 7). This evaluation can also include the consultation by on-call specialists if the EP considers it necessary. Toward this end, EMTALA mandates that the
FIGURE 1. Relationship of oncall frequency to EMTALA knowledge.
hospital (typically through its bylaws) establish ED on-call schedules for the specialties at its facility. These on-call lists must be prominently displayed in the ED work areas and be kept on file for 5 years. The on-call list must include all specialties represented by the hospital. The second mandate states that if an emergency medical condition exists, the hospital must either stabilize that condition to the extent of its abilities or transfer the patient to another hospital with the appropriate capabilities. Finally, hospitals with specialized capabilities or facilities (eg, burn units, neonatal intensive-care units) are required to accept transfers of patients in need of such specialized services if that hospital has the capacity to treat them. Suspected violations of the law are investigated by the HCFA and fines assessed by the Office of the Inspector General. Violation of the law can result in a fine of up to $50,000 per violation (not just per patient) and, more seriously, possible loss of the hospital’s Medicare privileges. To date approximately one-third of all hospitals in the United States have been investigated by the HCFA for EMTALA violations, and of those approximately one-third have been cited and fined by the OIG.5 Some of these citations have been given because the on-call physician failed to appear when requested or appeared unduly late, generally accepted to be over 30 to 60 minutes after being called. Although this is not a rule according to the HCFA, New Jersey and West Virginia have state laws mandating 30 minutes for the arrival of ED specialty consultations. Should the on-call physician not appear or appear late, it is
JOSEPH ZIBULEWSKY ■ MEDICAL STAFF KNOWLEDGE OF EMTALA
TABLE 6.
11
Quiz Questions With ⬍50% Correct Responses.
1. EMTALA/COBRA includes in its definition of a transfer: a. Patients discharged home from the ED. b. Patients discharged home from the hospital after inpatient stay. c. Patients transferred from one ED to another. d. All of the above. (Correct response: d; 49% correct response rate) 2. During an investigation of an EMTALA/COBRA violation: a. Only the records of the index patient can be reviewed by the investigators. b. If cited, the hospital can appeal but loses its Medicare privileges and reimbursement in the interim. c. The hospital usually receives ample warnings of the investigators visit to prepare their documents. d. The hospital has an opportunity to question the complainant who files the initial charges against it. (Correct response: b; 38% correct response rate) 3. The EP is generally free from liability under EMTALA/COBRA: a. Once he has discussed an ED case with the on-call physician. b. Once the on-call physician agrees to admit the patient to the hospital. c. Once the patient is physically admitted to the ward or ICU from the ED. d. If documentation on the chart notes that, despite repeated attempts, the on-call physician failed to come in to see the patient, necessitating transfer to another facility. (Correct response: d; 37% correct response rate) 4. According to EMTALA/COBRA, an emergency medical condition: a. Needs to be decided by a doctor on a case-by-case basis. b. Includes only those conditions that can lead to death or permanent disability. c. Is defined by the legal statute itself. d. Does not include subjective problems such as pain. (Correct response: c; 32% correct response rate) 5. Since the inception of EMTALA/COBRA: a. Virtually no hospitals have been investigated for violations. b. Approximately 10% of the country’s hospitals have been investigated. c. Approximately one third of the country’s hospitals have been investigated. d. The vast majority of citations have been overturned on appeal. (Correct response: c; 8% correct response rate)
the responsibility of the ED physician to report it to the HCFA. If the incident is well documented and all efforts were made to obtain on-call consultation (eg, calling the head of the department or the hospital administrator), then the ED physician is generally immune from sanctions by the HCFA. When EMTALA was created, it was considered so straightforward a law as to be self-enforcing, thus not requiring any further interpretive guidelines.6 This has proven not to be the case, because numerous guidelines from the HCFA and court cases have attested to this. One case of note is that of Lopez-Soto v Hawayek (1999) in the 1st Circuit Court (because EMTALA is a Federal law, cases arising from it are heard in the Federal courts).7 The case concerned the birth of a baby in the labor and delivery ward who had meconium aspiration syndrome and a pneumothorax, who was transferred to another hospital before stabiliTABLE 7.
zation of its problems, and who ultimately died. In the court’s opinion, “patient dumping is not a practice that is limited to emergency rooms. If a hospital determines that a patient on the ward has developed an emergency medical condition, it may fear that the costs of treatment will outstrip the patient’s resources, and seek to move the patient elsewhere.” Thus, EMTALA is not restricted to the ED but is a law that applies “housewide.” HCFA’s most recent guidelines, released in January 2001, also extend the scope of EMTALA’s requirements to any facility on the hospital’s “campus” within 250 yards of the main facility. Thus, clinics, laboratories, and outpatient surgical centers, for example, must adhere to the same requirements for medical screening, stabilization, and transfer as the ED. This then extends the burden EMTALA penalties to the rest of the hospital’s medical staff, even those not routinely on ED call, and makes knowledge of the law mandatory for them. The
EMTALA Definition of Emergency Medical Condition
1. A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably by expected to result in: a. Placing the health of the individual (or, with respect to a pregnant women, the health of the woman or her unborn child) in serious jeopardy. b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part, or d. With respect to a pregnant woman who is having contractions: i. That there is inadequate time to effect a safe transfer to another hospital before delivery; or ii. That transfer may pose a threat to the health or safety of the woman or the unborn child.
12
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 21, Number 1 ■ January 2003
hospital thus has a vested interest to ensure that its physicians are well informed about the law and its ramifications. The results of this survey of the medical staff of a large, private teaching hospital show that the majority of the medical staff, including a significant number of physicians who take call regularly for the ED, have no knowledge of EMTALA. In addition, those who are familiar with the law have a limited breadth of knowledge about it. Important issues, such as the definition of a transfer, definition of an emergency medical condition, and the fact that the hospital can lose its Medicare funding during an investigation, were answered correctly by less than half the respondents who indicated knowledge of the law. These results are in contrast to the OIG report which found that approximately 70% of on-call physicians surveyed were “highly familiar” with EMTALA. Although their exact survey device is not described in detail, they defined “highly familiar” to mean that respondents were familiar with at least 12 of the 15 EMTALA requirements listed on its survey. Over 90% of EPs surveyed in the OIG report were “highly familiar” with EMTALA, which is similar to the 84% mean correct response rate noted for EPs in this study. As noted, the OIG study included a small sampling of staff at a number of hospitals of varying sizes, which would not be expected to predict the response rates at any single facility. Their response rates also were slightly less than in this study: 36% for EPs and 32% for on-call staff. Despite the methodologic differences, the discrepancy between the OIG report and this study should make it clear that each hospital needs to assess its own medical staff’s knowledge of EMTALA. This study does have important limitations. The response rate was only 42%, which means that a substantial number of physicians on staff did not respond. One could assume that many of those probably were not familiar with EMTALA or they would have responded, but in reality one cannot estimate the knowledge of the remaining 58% of the staff. The decision to exclude radiologists and rehabilitation physicians was made before the most recent advisory from the HCFA in January 2001, stating that all hospital facilities on the 250-yard campus of the hospital must adhere to EMTALA guidelines. Thus, radiologists that staff on-campus outpatient radiology centers and rehabilitation physicians in on-campus rehabilitation units will need to be knowledgeable about EMTALA guidelines concerning medical screening examinations and transfer guidelines. It is likely that these physicians know little about EMTALA, but had these guidelines been announced before the start of the study, these physicians would have been included and should be included if any other hospital seeks to survey their staff. Other limitations include the fact that the physician population at the study hospital is skewed toward older ages and longer years in practice. A hospital with a younger physician population, and thus one that could have trained after EMTALA became law, might have better knowledge of its existence. Almost half (47%) of the physicians surveyed indicated they never took ED call. This certainly could be expected to skew the results toward a lower percentage of physicians having knowledge of EMTALA. However, because the law can also apply to patients discharged home or transferred from the inpatient units, the law should be at least minimally understood by all medical staff, even those who do not normally take ED call. The
questionnaire, and especially the quiz, was never validated; however, each question was answered correctly at least 50% of the time, except for the five questions already noted in the Results section, and 10 of the questions were answered correctly at least 70% of the time. Finally, it could be argued that many of the physicians who expressed no knowledge of EMTALA might have known it under a different, possibly more generic name, such as the patient antidumping or antidiscrimination law. It was decided to ask only about it in terms of EMTALA/COBRA because this is the accepted name for the statute, thus not to confuse it with any other antidiscrimination laws the physicians may have been familiar with. Unfortunately, EMTALA, if poorly understood by the medical staff as demonstrated in this study, can become a divisive problem for ED physicians in dealing with their consultants. Before EMTALA, the on-call list was considered a responsibility of a physician for being on staff at the hospital. It was also a way for young physicians to build their practices. One of the problems today is that physicians in managed care plans get referrals through those plans and no longer have a need for being on-call for the hospital.7 EMTALA, however, provides no provisions or protection for managed care. Many on-call physicians do not understand the purpose of the law and think they do not have to come in to see a patient at the “whim” of the EP. This has become a heated issue in many hospitals across the country, where some physicians have threatened to leave the hospital if forced to take ED call or if not guaranteed some compensation for care rendered on-call to the ED.8,9 The fact that many on-call physicians do not understand is that when they are on-call for the ED they represent not themselves, their groups, or their managed care plans, but they represent the hospital. This is particularly a problem at tertiary-care centers when the specialist on-call is contacted either by the ED of an outlying hospital, or by their own ED, informing them about a patient who is being transferred to their facility for a higher level of care. They often do not understand why their ED must accept those patients. Often there are complaints that the patients were not insured and so should not have been accepted. Other complaints are that the on-call specialist may not care for the particular problem that is being transferred. One example of this is the on-call orthopedist who does not routinely care for spinal problems but is being asked by the ED physician to evaluate a patient accepted in transfer from an outlying hospital for severe back pain or trauma. Again, the issue, as far as EMTALA is concerned, is not what the on-call specialist is comfortable with; it is what services the hospital normally provides. If they normally do spinal surgery, then that on-call physician is obligated to see the patient. If unable to care for the problem, they must then consult one of his or her orthopedic colleagues. This study emphasizes the need for physician education about EMTALA, both to reduce the liability of the hospital and to ensure better working relations between the ED and on-call staff. The OIG study found that training in EMTALA does increase awareness; however, only approximately one fourth of the on-call staff surveyed received any formal training on EMTALA guidelines. They also found that staff, including nurses and registration personnel, in higher-volume EDs received less training than their coun-
JOSEPH ZIBULEWSKY ■ MEDICAL STAFF KNOWLEDGE OF EMTALA
terparts in less busy environments. The study hospital is a large, tertiary-care hospital with a high-volume ED; therefore, formal education could be more difficult. The irony to this is that nowhere is knowledge of the statute more important than in a major teaching hospital that receives a large number of out-of-hospital transfers and whose physicians are called on to treat a large proportion of indigent patients. It is interesting to note that most of the participating physicians that knew of EMTALA first heard of it through hospital meetings, thus emphasizing the need for hospital administrations, with the help of their ED leaders, to incorporate teaching of EMTALA in staff meetings and in orientation sessions with new physicians. CONCLUSIONS This survey of the medical staff of a large, tertiary-care hospital shows a limited awareness of EMTALA and its specific provisions, even among physicians who take call frequently for the ED. Since its inception, EMTALA has become significantly broader in its scope and, at the same time, HCFA has made enforcement of its provisions a major part of its regulatory agenda. Hospitals, to reduce liability, should make efforts to survey their own medical staff and determine the best ways to educate them on the specifics of EMTALA law.
13
The author thanks Gunjan Bahl of medical staff services for help in distributing and collecting the survey instrument, and Billy Moore, PhD for help with the statistical analysis.
REFERENCES 1. 42 United States Code of Federal Regulations (CFS), 1395dd of Section 1867 of the Social Security Act 2. The Emergency Medical Treatment and Labor Act: Survey of hospital emergency departments. Department of Health and Human Services, Office of the Inspector General. January 2001. Available at: http://www.dhhs.gov/progorg/oei. Accessed March 15, 2001 3. Ansell DA, Shiff RL: Patient dumping: Status, implications, and policy recommendations. JAMA 1987;257:1500-1502 4. Schiff RL, Ansell DA, Schlossen JE, et al: Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med 1986; 314:552-557 5. Levine RJ, Guisto JA, Meislin HW, et al: Analysis of federally imposed penalties for violations of the Consolidated Onmibus Reconciliation Act. Ann Emerg Med 1996;28:45-50 6. Introduction to patient transfer regulations. In: Frew SA, ed: Patient transfers: How to comply with the law. Dallas: American College of Emergency Physicians, 1995:1-2 7. Lopez-Soto v Hawayek, 98 F3d 1594 (1st Circuit, 1999) 8. Groth SJ, Begley D, Calabro JJ, et al: Emergency department back-up panels: A critical component of the safety net problem. In: Fields, et al, eds: Defending American’s safety net. Dallas: American College of Emergency Physicians, 1999:25-28 9. Cause for concern: Ensuring adequate and timely on-call physician coverage in the emergency department. ED Watch Issue #4. Washington, DC: The Advisory Board Co, May 2000
In 1986, in an attempt to halt the practice of “patient dumping” and to ensure patient access and equity in emergency medical treatment, the U.S. Congress passed the Emergency Medical Treatment and Active Labor Act (EMTALA) as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA).1 These mere four pages of legislation have created a storm of controversy and litigation over the ensuing 15 years. It is one of the most significant laws that affects health care delivery, and although aimed primarily at emergency care, the law itself, as well as various interpretations by the Health Care Financing Administration (HCFA) and the courts, have extended the scope of the law to include virtually any physician that From the Department of Emergency Medicine, Baylor University Medical Center, Dallas, TX, and the Department of Surgery, Division of Emergency Medicine, University of Texas, Southwestern Medical Center, Dallas, TX. Manuscript received July 27, 2001, accepted September 28, 2001. Address reprint requests to Joseph Zibulewsky, MD, Baylor University Medical Center, Department of Emergency Medicine, 3500 Gaston Ave, Dallas, TX 75246. E-mail: [email protected] Key Words: EMTALA, COBRA. Copyright 2003, Elsevier Science (USA). All rights reserved. 0735-6757/03/2101-0002$35.00/0 doi:10.1053/ajem.2003.50000 8
treats patients in the hospital. Therefore, it is not only incumbent on ED physicians to know and understand this law, but virtually every physician on staff in the hospital should be at least minimally familiar with its content and implications. To date, the only study looking at EMTALA knowledge by the general medical staff has been one published in January 2001 by the Office of the Inspector General (OIG) of the Department of Health and Human Services (the agency that assesses penalties for EMTALA violations).2 It found that the vast majority of on-call hospital staff are “highly familiar” with EMTALA. Although the study looked at 123 hospitals, it sent surveys to only six randomly selected on-call physicians from each facility. In contrast, the study presented in this article uses a brief questionnaire to attempt to first determine whether members of a single hospital’s medical staff have heard of EMTALA, and secondly, for those who have heard of it, to determine their general knowledge of the law. MATERIALS AND METHODS In October 2000 a questionnaire was sent to the active medical staff of the study hospital. It is a private, urban, 900-bed, tertiarycare facility and is a level-one trauma center. It is also a teaching hospital with residency programs in internal medicine, surgery, obstetrics/gynecology, and radiology, as well as a number of fellowship programs. Its ED is a 43-bed facility, which in the year 2000 had a census of 75,500 patients, received 919 incoming transfers from other EDs, and transferred 318 patients out to other facilities. The total number of physicians with active medical staff privileges at the time was 650 (as determined by the medical staff office); however, radiology, pathology, and physical medicine and rehabilitation physicians were excluded from the survey, because they either did not primarily see patients or did not see them on an inpatient basis or on-call in the ED. This left 600 physicians who received the questionnaire. The forms were sent out through the medical staff office and returned to them by the physicians in prestamped envelopes. The survey instrument consisted of a cover letter explaining that the ED was conducting a survey of the active medical staff about their knowledge of EMTALA/COBRA regulations. The questionnaire began with four demographic items: specialty, age, years in practice, and how often on average in the prior year the physician took call in the ED per month. The next question simply asked if the physician had ever heard of or was familiar with the EMTALA/COBRA regulations. If the physician answered no, they did not have to respond to the remaining items and could return the questionnaire. If they answered yes, they were then asked how they had first heard of EMTALA, if they had any recent (within 5 years) continuing medical education that dealt with EMTALA, and if they had ever been personally cited or knew of any colleague who had been cited for an EMTALA violation. Finally, those who indicated familiarity with the law were asked 20 multiple-choice questions about EMTALA, consisting of general knowledge of the statute (who created it, who investigates violations, penalties, definitions of medical screening examination, emergency medical
JOSEPH ZIBULEWSKY ■ MEDICAL STAFF KNOWLEDGE OF EMTALA
TABLE 1.
Physician Specialties With ⬎10 Respondents
9
TABLE 3.
Physician Years in Practice
Specialty
No.
Percentage
Practice Years
No.
Percentage
Internal medicine Surgery Obstetrics Anesthesia Pediatrics Orthopedics Opthalmology Emergency medicine Not indicated Totals
89* 40† 16 16 14 12 11 8 43 249
35.7 16.1 6.4 6.4 5.6 4.8 4.4 3.2 17.3 100.0
⬍5 5-9 10-14 15-19 ⱖ20 Not answered Totals
40 32 33 37 102 5 249
16.1 12.9 13.3 14.9 41.0 2.0 100.0
*Includes allergy/immunology, cardiology, dermatology, endocrinology, family practice, gastroenterology, hematology/oncology, nephrology, neurology, psychiatry, pulmonary, and rheumatology. †Includes colorectal surgery, ENT, hand surgery, oral surgery, thoracic surgery, transplant surgery, trauma surgery, vascular surgery, and urology.
condition, transfers, and so on) and on-call physician responsibilities (establishment and maintenance of on-call panels, need for on-call physicians to respond to ED consults, and so on). The survey forms were created by the author and did not undergo any standardizing process. At the end of a 2-month period the returned surveys were collected from the medical staff office and analyzed. Data analysis was done with SPSS (Chicago, IL) using chi-squared analysis for comparison of groups with regard to their knowledge of EMTALA and analysis of variance to determine significance of quiz scores to demographic data.
RESULTS Two hundred forty-nine (41.5%) surveys were returned. Thirty-one physician specialties were represented and 7 specialties had at least 10 respondents (Table 1). Forty-three respondents (17.3%) did not list their specialties. For the purpose of data analysis, only specialties with greater than 10 respondents were used, and those subspecialties with less than 10 were included under the major specialties. For example, cardiology (n ⫽ 8) and psychiatry (n ⫽ 2) were included under internal medicine, and thoracic surgery (n ⫽ 2) and urology (n ⫽ 8) were included under surgery. The only exception to this was emergency medicine (n ⫽ 8), which remained its own category for further analysis. The ages of the physicians and their years in practice were skewed toward a slightly older age, with 44% being over 50 (Tables 2 and 3). Approximately one-half of the respondents never took ED call, and approximately one third took call at least monthly (Table 4). Only 29.3% (n ⫽ 73) of all the respondents had ever heard of EMTALA. All TABLE 2.
8 of the EPs had heard of EMTALA. Of those who had heard of it, most had first heard of it through hospital and medical staff meetings (Table 5). Only 17.8% (n ⫽ 13) of physicians who had heard of EMTALA had participated in continuing medical education over the prior 5 years that contained information about it. No physician with knowledge of EMTALA had ever been cited for an EMTALA violation or knew of a colleague who had. There was no relationship between knowledge of EMTALA and physician age or years in practice. Except for emergency medicine, there was no relationship between knowledge of EMTALA and specialty. There was a significant positive association (P ⬍ .001) between knowledge of EMTALA and frequency of ED call (Fig 1). However, of those physicians who took ED call at least monthly (n ⫽ 86), 50% had never heard of EMTALA. Of those who never took ED call (n ⫽ 117), 82% had never heard of it. Of those who had heard of EMTALA, the average score on the quiz was 69% (standard deviation [SD] ⫽ 16.4), with a range of 0% (n ⫽ 1) to 95%. When the single physician who received a zero on the quiz was removed, the mean rose to 70% (SD ⫽ 14.3) and the range became 35% to 95%. The 8 EPs had an overall mean of 84.4%, with 7 of the 8 scoring above the overall group mean. As to the individual 20 questions, there were 5 that were answered correctly less than half of the time (Table 6). Although the numbers were too small to achieve any power, there was no significant association between quiz scores and specialty (except for EPs), age, years in practice, or frequency of ED call. DISCUSSION EMTALA was enacted by Congress in 1986 after a number of reports in the lay press and in professional journals noted that indigent patients were being diverted from private to county hospital EDs based solely on their ability to pay.3,4 The statute imposes three legal duties on hospitals (only those hospitals that participate in Medicare are included, but this includes almost 98% of all facilities). First, hospitals must perform a medical screening examina-
Physician Ages TABLE 4.
Age (y)
No.
Percentage
⬍30 30-39 40-49 50-59 ⱖ60 Not answered Totals
4 49 82 67 43 4 249
1.6 19.7 32.9 26.9 17.3 1.6 100.0
ED Call Frequency
ED Call
No.
Percentage
None ⬍Once/mo Monthly ⬎Once/mo Not answered Totals
117 41 25 61 5 249
47.0 16.5 10.0 24.5 2.0 100.0
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 21, Number 1 ■ January 2003
10
TABLE 5.
Sources of Initial EMTALA Awareness Source
No.
Percentage
Hospital meetings Personal communications Journals/publications Professional/national Society meetings Other/do not know Did not answer Totals*
22 14 10
30.5 19.4 13.9
9 17 1 73
12.5 23.6 1.4 100.0
*Includes only those 73 physicians who indicated knowledge of EMTALA. Abbreviation: EMTALA, Emergency Medical Treatment and Active Labor Act.
tion (MSE) to determine whether an emergency medical condition EMC exists. This examination is more than merely a triage evaluation, and can include not only a history and physical, but any number of tests including computed tomography scans and ultrasounds. Basically, the physician is mandated by the law to perform as complete an evaluation as necessary to either identify or rule out the presence of an emergency medical condition as defined by the statute (Table 7). This evaluation can also include the consultation by on-call specialists if the EP considers it necessary. Toward this end, EMTALA mandates that the
FIGURE 1. Relationship of oncall frequency to EMTALA knowledge.
hospital (typically through its bylaws) establish ED on-call schedules for the specialties at its facility. These on-call lists must be prominently displayed in the ED work areas and be kept on file for 5 years. The on-call list must include all specialties represented by the hospital. The second mandate states that if an emergency medical condition exists, the hospital must either stabilize that condition to the extent of its abilities or transfer the patient to another hospital with the appropriate capabilities. Finally, hospitals with specialized capabilities or facilities (eg, burn units, neonatal intensive-care units) are required to accept transfers of patients in need of such specialized services if that hospital has the capacity to treat them. Suspected violations of the law are investigated by the HCFA and fines assessed by the Office of the Inspector General. Violation of the law can result in a fine of up to $50,000 per violation (not just per patient) and, more seriously, possible loss of the hospital’s Medicare privileges. To date approximately one-third of all hospitals in the United States have been investigated by the HCFA for EMTALA violations, and of those approximately one-third have been cited and fined by the OIG.5 Some of these citations have been given because the on-call physician failed to appear when requested or appeared unduly late, generally accepted to be over 30 to 60 minutes after being called. Although this is not a rule according to the HCFA, New Jersey and West Virginia have state laws mandating 30 minutes for the arrival of ED specialty consultations. Should the on-call physician not appear or appear late, it is
JOSEPH ZIBULEWSKY ■ MEDICAL STAFF KNOWLEDGE OF EMTALA
TABLE 6.
11
Quiz Questions With ⬍50% Correct Responses.
1. EMTALA/COBRA includes in its definition of a transfer: a. Patients discharged home from the ED. b. Patients discharged home from the hospital after inpatient stay. c. Patients transferred from one ED to another. d. All of the above. (Correct response: d; 49% correct response rate) 2. During an investigation of an EMTALA/COBRA violation: a. Only the records of the index patient can be reviewed by the investigators. b. If cited, the hospital can appeal but loses its Medicare privileges and reimbursement in the interim. c. The hospital usually receives ample warnings of the investigators visit to prepare their documents. d. The hospital has an opportunity to question the complainant who files the initial charges against it. (Correct response: b; 38% correct response rate) 3. The EP is generally free from liability under EMTALA/COBRA: a. Once he has discussed an ED case with the on-call physician. b. Once the on-call physician agrees to admit the patient to the hospital. c. Once the patient is physically admitted to the ward or ICU from the ED. d. If documentation on the chart notes that, despite repeated attempts, the on-call physician failed to come in to see the patient, necessitating transfer to another facility. (Correct response: d; 37% correct response rate) 4. According to EMTALA/COBRA, an emergency medical condition: a. Needs to be decided by a doctor on a case-by-case basis. b. Includes only those conditions that can lead to death or permanent disability. c. Is defined by the legal statute itself. d. Does not include subjective problems such as pain. (Correct response: c; 32% correct response rate) 5. Since the inception of EMTALA/COBRA: a. Virtually no hospitals have been investigated for violations. b. Approximately 10% of the country’s hospitals have been investigated. c. Approximately one third of the country’s hospitals have been investigated. d. The vast majority of citations have been overturned on appeal. (Correct response: c; 8% correct response rate)
the responsibility of the ED physician to report it to the HCFA. If the incident is well documented and all efforts were made to obtain on-call consultation (eg, calling the head of the department or the hospital administrator), then the ED physician is generally immune from sanctions by the HCFA. When EMTALA was created, it was considered so straightforward a law as to be self-enforcing, thus not requiring any further interpretive guidelines.6 This has proven not to be the case, because numerous guidelines from the HCFA and court cases have attested to this. One case of note is that of Lopez-Soto v Hawayek (1999) in the 1st Circuit Court (because EMTALA is a Federal law, cases arising from it are heard in the Federal courts).7 The case concerned the birth of a baby in the labor and delivery ward who had meconium aspiration syndrome and a pneumothorax, who was transferred to another hospital before stabiliTABLE 7.
zation of its problems, and who ultimately died. In the court’s opinion, “patient dumping is not a practice that is limited to emergency rooms. If a hospital determines that a patient on the ward has developed an emergency medical condition, it may fear that the costs of treatment will outstrip the patient’s resources, and seek to move the patient elsewhere.” Thus, EMTALA is not restricted to the ED but is a law that applies “housewide.” HCFA’s most recent guidelines, released in January 2001, also extend the scope of EMTALA’s requirements to any facility on the hospital’s “campus” within 250 yards of the main facility. Thus, clinics, laboratories, and outpatient surgical centers, for example, must adhere to the same requirements for medical screening, stabilization, and transfer as the ED. This then extends the burden EMTALA penalties to the rest of the hospital’s medical staff, even those not routinely on ED call, and makes knowledge of the law mandatory for them. The
EMTALA Definition of Emergency Medical Condition
1. A medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably by expected to result in: a. Placing the health of the individual (or, with respect to a pregnant women, the health of the woman or her unborn child) in serious jeopardy. b. Serious impairment to bodily functions, or c. Serious dysfunction of any bodily organ or part, or d. With respect to a pregnant woman who is having contractions: i. That there is inadequate time to effect a safe transfer to another hospital before delivery; or ii. That transfer may pose a threat to the health or safety of the woman or the unborn child.
12
AMERICAN JOURNAL OF EMERGENCY MEDICINE ■ Volume 21, Number 1 ■ January 2003
hospital thus has a vested interest to ensure that its physicians are well informed about the law and its ramifications. The results of this survey of the medical staff of a large, private teaching hospital show that the majority of the medical staff, including a significant number of physicians who take call regularly for the ED, have no knowledge of EMTALA. In addition, those who are familiar with the law have a limited breadth of knowledge about it. Important issues, such as the definition of a transfer, definition of an emergency medical condition, and the fact that the hospital can lose its Medicare funding during an investigation, were answered correctly by less than half the respondents who indicated knowledge of the law. These results are in contrast to the OIG report which found that approximately 70% of on-call physicians surveyed were “highly familiar” with EMTALA. Although their exact survey device is not described in detail, they defined “highly familiar” to mean that respondents were familiar with at least 12 of the 15 EMTALA requirements listed on its survey. Over 90% of EPs surveyed in the OIG report were “highly familiar” with EMTALA, which is similar to the 84% mean correct response rate noted for EPs in this study. As noted, the OIG study included a small sampling of staff at a number of hospitals of varying sizes, which would not be expected to predict the response rates at any single facility. Their response rates also were slightly less than in this study: 36% for EPs and 32% for on-call staff. Despite the methodologic differences, the discrepancy between the OIG report and this study should make it clear that each hospital needs to assess its own medical staff’s knowledge of EMTALA. This study does have important limitations. The response rate was only 42%, which means that a substantial number of physicians on staff did not respond. One could assume that many of those probably were not familiar with EMTALA or they would have responded, but in reality one cannot estimate the knowledge of the remaining 58% of the staff. The decision to exclude radiologists and rehabilitation physicians was made before the most recent advisory from the HCFA in January 2001, stating that all hospital facilities on the 250-yard campus of the hospital must adhere to EMTALA guidelines. Thus, radiologists that staff on-campus outpatient radiology centers and rehabilitation physicians in on-campus rehabilitation units will need to be knowledgeable about EMTALA guidelines concerning medical screening examinations and transfer guidelines. It is likely that these physicians know little about EMTALA, but had these guidelines been announced before the start of the study, these physicians would have been included and should be included if any other hospital seeks to survey their staff. Other limitations include the fact that the physician population at the study hospital is skewed toward older ages and longer years in practice. A hospital with a younger physician population, and thus one that could have trained after EMTALA became law, might have better knowledge of its existence. Almost half (47%) of the physicians surveyed indicated they never took ED call. This certainly could be expected to skew the results toward a lower percentage of physicians having knowledge of EMTALA. However, because the law can also apply to patients discharged home or transferred from the inpatient units, the law should be at least minimally understood by all medical staff, even those who do not normally take ED call. The
questionnaire, and especially the quiz, was never validated; however, each question was answered correctly at least 50% of the time, except for the five questions already noted in the Results section, and 10 of the questions were answered correctly at least 70% of the time. Finally, it could be argued that many of the physicians who expressed no knowledge of EMTALA might have known it under a different, possibly more generic name, such as the patient antidumping or antidiscrimination law. It was decided to ask only about it in terms of EMTALA/COBRA because this is the accepted name for the statute, thus not to confuse it with any other antidiscrimination laws the physicians may have been familiar with. Unfortunately, EMTALA, if poorly understood by the medical staff as demonstrated in this study, can become a divisive problem for ED physicians in dealing with their consultants. Before EMTALA, the on-call list was considered a responsibility of a physician for being on staff at the hospital. It was also a way for young physicians to build their practices. One of the problems today is that physicians in managed care plans get referrals through those plans and no longer have a need for being on-call for the hospital.7 EMTALA, however, provides no provisions or protection for managed care. Many on-call physicians do not understand the purpose of the law and think they do not have to come in to see a patient at the “whim” of the EP. This has become a heated issue in many hospitals across the country, where some physicians have threatened to leave the hospital if forced to take ED call or if not guaranteed some compensation for care rendered on-call to the ED.8,9 The fact that many on-call physicians do not understand is that when they are on-call for the ED they represent not themselves, their groups, or their managed care plans, but they represent the hospital. This is particularly a problem at tertiary-care centers when the specialist on-call is contacted either by the ED of an outlying hospital, or by their own ED, informing them about a patient who is being transferred to their facility for a higher level of care. They often do not understand why their ED must accept those patients. Often there are complaints that the patients were not insured and so should not have been accepted. Other complaints are that the on-call specialist may not care for the particular problem that is being transferred. One example of this is the on-call orthopedist who does not routinely care for spinal problems but is being asked by the ED physician to evaluate a patient accepted in transfer from an outlying hospital for severe back pain or trauma. Again, the issue, as far as EMTALA is concerned, is not what the on-call specialist is comfortable with; it is what services the hospital normally provides. If they normally do spinal surgery, then that on-call physician is obligated to see the patient. If unable to care for the problem, they must then consult one of his or her orthopedic colleagues. This study emphasizes the need for physician education about EMTALA, both to reduce the liability of the hospital and to ensure better working relations between the ED and on-call staff. The OIG study found that training in EMTALA does increase awareness; however, only approximately one fourth of the on-call staff surveyed received any formal training on EMTALA guidelines. They also found that staff, including nurses and registration personnel, in higher-volume EDs received less training than their coun-
JOSEPH ZIBULEWSKY ■ MEDICAL STAFF KNOWLEDGE OF EMTALA
terparts in less busy environments. The study hospital is a large, tertiary-care hospital with a high-volume ED; therefore, formal education could be more difficult. The irony to this is that nowhere is knowledge of the statute more important than in a major teaching hospital that receives a large number of out-of-hospital transfers and whose physicians are called on to treat a large proportion of indigent patients. It is interesting to note that most of the participating physicians that knew of EMTALA first heard of it through hospital meetings, thus emphasizing the need for hospital administrations, with the help of their ED leaders, to incorporate teaching of EMTALA in staff meetings and in orientation sessions with new physicians. CONCLUSIONS This survey of the medical staff of a large, tertiary-care hospital shows a limited awareness of EMTALA and its specific provisions, even among physicians who take call frequently for the ED. Since its inception, EMTALA has become significantly broader in its scope and, at the same time, HCFA has made enforcement of its provisions a major part of its regulatory agenda. Hospitals, to reduce liability, should make efforts to survey their own medical staff and determine the best ways to educate them on the specifics of EMTALA law.
13
The author thanks Gunjan Bahl of medical staff services for help in distributing and collecting the survey instrument, and Billy Moore, PhD for help with the statistical analysis.
REFERENCES 1. 42 United States Code of Federal Regulations (CFS), 1395dd of Section 1867 of the Social Security Act 2. The Emergency Medical Treatment and Labor Act: Survey of hospital emergency departments. Department of Health and Human Services, Office of the Inspector General. January 2001. Available at: http://www.dhhs.gov/progorg/oei. Accessed March 15, 2001 3. Ansell DA, Shiff RL: Patient dumping: Status, implications, and policy recommendations. JAMA 1987;257:1500-1502 4. Schiff RL, Ansell DA, Schlossen JE, et al: Transfers to a public hospital. A prospective study of 467 patients. N Engl J Med 1986; 314:552-557 5. Levine RJ, Guisto JA, Meislin HW, et al: Analysis of federally imposed penalties for violations of the Consolidated Onmibus Reconciliation Act. Ann Emerg Med 1996;28:45-50 6. Introduction to patient transfer regulations. In: Frew SA, ed: Patient transfers: How to comply with the law. Dallas: American College of Emergency Physicians, 1995:1-2 7. Lopez-Soto v Hawayek, 98 F3d 1594 (1st Circuit, 1999) 8. Groth SJ, Begley D, Calabro JJ, et al: Emergency department back-up panels: A critical component of the safety net problem. In: Fields, et al, eds: Defending American’s safety net. Dallas: American College of Emergency Physicians, 1999:25-28 9. Cause for concern: Ensuring adequate and timely on-call physician coverage in the emergency department. ED Watch Issue #4. Washington, DC: The Advisory Board Co, May 2000