Critical Path Network: Cover your bases with EMTALA algorithm

Are you curious about how much your staff really knows about the Emergency Medical Treatment and Active Labor Act (EMTALA)?

A survey from the Department of Health and Human Services provided some insights. The Emergency Medical Treatment and Active Labor Act: Survey of Hospital Emergency Departments (EDs) surveyed ED staff.

"Key findings were that most staff members were familiar with EMTALA requirements, but not all were aware of recent policy changes," says Denise Casaubon, RN, owner and president of DNR Consultants, a Fountain Hills, AZ-based company specializing in health care corporate compliance.

Here are key findings:

Staff need a better understanding of definitions such as "emergency medical condition" and "medical screening examination."

Conduct review to determine compliance

Casaubon advises you to conduct clinical record reviews for compliance. "Draft a tool that includes the required EMTALA documentation elements," she explains.

"Then audit the clinical records to discover what areas staff need to improve." Observe staff during the course of business with regard to EMTALA requirements, she says.

"Is requesting insurance information delaying the medical screening examination?" Casaubon asks.

"Are patients being logged in correctly? Is all of the required information documented in the log?" The survey brings home the need for continuous inservices and training, she says.

Casaubon recommends holding at least two inservices a year for staff.

Staff had adequate knowledge about many areas of EMTALA.

Strengths included a basic understanding of "patient dumping" and increased communication between sending and receiving hospitals, she reports.

However, only 70% of those surveyed knew that transfer records must be kept for five years and that hospitals are forbidden from retaliating against employees who report violations or refuse to authorize inappropriate transfers, says Casaubon.

Specialists and part-time staff lacked knowledge of EMTALA.

The report showed that only 25% of on-call physicians have received training in EMTALA.

According to Todd Taylor, MD, FACEP, an attending ED physician at Good Samaritan Regional Medical Center in Phoenix, this is the "major fertile ground" for EMTALA violations right now.

"This is partly from a lack of guidance from [Centers for Medicare & Medicaid Services (CMS)] on what is required, and partly due to hospital and medical staff’s inability to reach viable solutions," he says.

Go to CMS web site

There is a lack of knowledge about recent changes in guidelines.

According to the report, only 65% of ED directors knew about interpretive guidelines published by the Health Care Financing Administration (now CMS) in June 1998.

Casaubon recommends using the Medicare Learning Network on the CMS web site ( as a resource.

"The Medicare Learning Network allows the user to search and get information on popular topics such as EMTALA," she says.

"It is easy to use and very informative. You can also keep abreast of the changes by checking the Federal Register weekly or monthly," Casaubon says.

As a health care professional, you need to keep abreast of recent changes, she urges.

"For example, the definition for hospital campus recently changed," she notes.

Review new definitions

Casaubon provides a review of the new definition: A hospital campus is defined as a physical area immediately adjacent to the hospital main buildings, other structures, and areas not strictly contiguous to main buildings but located within 250 yards of the main building [42 CFR 413.65 (a)(2)]. Parking lots, sidewalks, and driveways on hospital property are considered to be part of the hospital for EMTALA purposes, she adds [42 CFR 489.24(b)].

Focus should be on hospital policies

However, Taylor argues that education efforts should be focused on hospital polices, not EMTALA itself.

"Focusing on EMTALA training could leave the application of those principles up to individuals rather than in following hospital policy," he explains.

"It is important that the staff understand their hospital policies, not whether they are aware of the latest CMS bulletin," Taylor adds.

What the staff actually need to know about the EMTALA regulation is relatively little, says Taylor.

He developed a "KISS" (Keep It Short and Simple) outline to use during inservices. [See "EMTALA Keep it Short and Simple (KISS) Principles," below.]

Designate a compliance officer

The complexity and frequent updates of the law have forced most hospitals to designate a "compliance officer" responsible for keeping up with EMTALA, according to Taylor.

"The survey revealed that formal EMTALA training was not universal," he acknowledges. "But in reality, EMTALA compliance principles now are standard operating procedures for hospital EDs, and formal training is less important than in the past."

You must have a single referral resource for difficult EMTALA questions and situations, such as when to report suspected violations, Taylor points out.

"It would be impossible for every staff member to be an expert in EMTALA," Taylor says.

"In my experience, a little knowledge can do more harm than good," he adds.

Taylor recommends the use of an algorithm to use for most EMTALA situations. (See EMTALA/COBRA Algorithm below.)

"When patients fall off of this algorithm, the staff need to know who to call for help," he says.

"An EMTALA compliance officer is almost mandatory in the current regulatory environment," he explains.

[For more information on educating your staff about EMTALA, contact:

Denise Casaubon, RN, DNR Consultants, 16217 Balsam Drive, Fountain Hills, AZ 85268. Telephone: (480) 816-6695. Fax: (480) 836-8185.

Todd B. Taylor, MD, FACEP, 1323 E. El Parqué Drive, Tempe, AZ 85282-2649. Telephone: (480) 731-4665. Fax: (480) 731-4727. E-mail:

A complete copy of the report, The Emergency Medical Treatment and Active Labor Act: Survey of Hospital Emergency Departments (OEI-09-98-00220, 1/01) can be downloaded at no charge at the Office of Inspector General/Office of Evaluation and Inspections web site:
Click on "Search and Report," "Categorical Listing Search," and scroll down to find the report’s title under "EMTALA."]