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[Editor’s note: This column addresses readers’ questions about the Emergency Medical Treatment and Labor Act (EMTALA). If you have a question you’d like answered, contact Steve Lewis, Editor, ED Management, 215 Tawneywood Way, Alpharetta, GA 30022. Phone: (770) 442-9805. Fax: (770) 664-8557. E-mail: firstname.lastname@example.org.]
Question: How Does EMTALA apply to law enforcement requests for services in the ED?
Answer: In the midst of a busy ED, police officers present with a handcuffed person and request a blood alcohol test. The police report that the person had a motor vehicle accident but give no details. The patient is behaving strangely and appears to be in pain, but does not request any medical services.
An emergency nurse asks the physician on duty: "Are we required to perform a medical screening examination [MSE] for this person?"
The EMTALA regulations are quite specific: A hospital must provide an MSE to an individual who presents to a dedicated ED seeking or in need of examination or treatment for a medical condition, notes M. Steven Lipton, JD, partner and head of the health care department at Davis Wright Tremaine in San Francisco. The rules may be clear in many cases, but how do they apply to law enforcement requests for a blood alcohol test, examination for rape or sexual assault victims, or pre-jail clearance?
In 2003, the Centers for Medicare & Medicaid Services (CMS) commented in the Federal Register that requests by law enforcement personnel for services in the ED would be reviewed on a case-by-case basis to determine whether the hospital is required to provide an MSE and other required EMTALA services. (The final amended EMTALA regulations were published in the Federal Register Sept. 9, 2003, and were effective Nov. 10, 2003.) The comments, however, only highlighted the dilemma faced by emergency personnel and did not elaborate on how hospitals and physicians should respond to law enforcement requests.
On May 13, 2004, Lipton notes, CMS issued new EMTALA interpretive guidelines that finally provide some direction for hospitals and physicians. In general, the guidelines provide that the gathering of evidence for criminal law cases — such as sexual assault or blood alcohol tests (BAT) — do not trigger the requirements for an MSE or other EMTALA-required services. However, the guidelines go on to qualify this exemption from EMTALA:
If an individual is brought to the ED, and law enforcement personnel request that emergency department personnel draw blood for a BAT only and [do] not request examination or treatment for a medical condition, such as intoxication, and a prudent lay person would not believe that the individual needed such examination or treatment, then the EMTALA’s screening requirement is not applicable to this situation because the request made on behalf of the individual was for evidence. However, if for example, the individual in police custody was involved in a motor vehicle accident or may have sustained injury to him- or herself and presents to the ED, an MSE would be warranted to determine if an EMC [emergency medical condition] exists.
The same guidance, Lipton says, also applies to rape and sexual assault cases. If a victim of sexual assault requests or needs examination or treatment for possible injuries, EMTALA applies and an MSE should be performed. However, if the request is limited to the gathering of evidence, and there is no request or apparent need for a medical examination, a screening is not required, he advises.
However, Lipton says, requests for pre-jail clearance are different. The guidelines clarify that these types of requests trigger the EMTALA obligations. Therefore, hospitals should provide an MSE to determine whether the individual in police custody has an EMC.
In summary, he notes, the EMTALA interpretive guidelines direct surveyors to review the facts of each case to determine whether an MSE and stabilizing treatment should be provided to individuals presenting to the ED in the company of law enforcement officers. In conducting staff inservice, hospitals should discuss the types of cases that may trigger the EMTALA obligations even if law enforcement personnel do not make a specific request that a hospital render medical care for a patient in custody. Above all, if a prudent layperson believes that the behavior or appearance of an individual in police custody shows evidence of the need for examination or treatment for a medical condition, emergency personnel should provide an MSE and stabilizing treatment as clinically indicated.
For more information on law enforcement requests for ED service, contact: