[This column is part of an ongoing series that will address reader questions about the Emergency Medical Treatment and Labor Act (EMTALA).]
Question: At a smaller critical access hospital, members of the community have been allowed to come to the emergency department (ED) to have their blood pressure checked. There is no documentation of the visit or the vital signs. Patients are not asked if they want a medical screening examination, and they leave without being checked in or registered. Is this practice an EMTALA violation?
Answer: The practice described in the question is similar to any number of "public relations" types of services provided by hospitals as a convenience to the community, says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. Other such services include health fairs where blood pressure, blood sugar, and cholesterol levels are checked free of charge, he adds. "The question does raise interesting EMTALA ramifications," Lawrence says. No EMTALA liability attaches for asymptomatic patients coming to merely have their blood pressure checked, he says. "After all, they could just as easily have the same blood pressure checked by a machine automatically down at the local pharmacy," Lawrence says.
He explains that under EMTALA, a patient must come to the ED for medical evaluation and treatment of an emergent medical condition before EMTALA requirements kick in. Therefore, Lawrence says that if a patient is not coming to the hospital for evaluation and treatment of an emergency medical condition (defined by the layperson standard "symptoms of such severity that a prudent layperson would conclude that an emergency medical condition exists"), EMTALA doesn’t apply. "These people requesting blood pressure checks are presumably asymptomatic," he says. "If not, then a simple blood pressure check should be refused, and the person should be encouraged to sign in as a patient and receive a full-screening exam."
A competent person may refuse a screening exam, Lawrence notes. A symptomatic patient with headache, shortness of breath, and chest pain, for example, should be registered and screened or a refusal of examination form should be signed, he says. Asymptomatic people with elevated blood pressures, the parameters of which need to be defined by each ED in accordance with the "comfort level" of the physicians, need to be offered a formal screening examination and be signed in. "In my experience, the majority of people requesting these blood pressure checks are the worried well,’ but a few people with seriously elevated blood pressures or who are symptomatic may show up," he says.
Lawrence cautions that those taking the blood pressure measurements should refrain from dispensing advice. "They may be asked, for example, whether a particular reading is normal or not. Certainly the range of normal blood pressures can be related," he says. "But any advice as to what should be done for any given measurement such as increasing or decreasing medication, for example, should be left to the person’s own physician or clinic."
He advises that any request by the person for more detailed advice should require registering as a patient. "Likewise, blood measurements clearly far off the normal range should trigger the ED to offer a screening exam," he says. "If refused, documentation of refusal should be documented."
For more information, contact:
• Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 30813. Telephone: (562) 491-9090. E-mail: email@example.com.