Do you know how to comply with the 250-yard rule?

It may be the single most confusing aspect of the Emergency Medical Treatment and Active Labor Act (EMTALA): the infamous "250-yard rule."

"The 250-yard rule was rated by one [Centers for Medicare & Medicaid Services] office as their No. 1 issue for 2002," reports Stephen Frew, JD, risk manager at Physicians Insurance Co. of Wisconsin, based in Loves Park, IL, and former president of the Rockford, IL-based Frew Consulting Group, which specialized in EMTALA compliance. "This topic has a lot of people confused."

The rule is a recent expansion of EMTALA regulations to cover areas surrounding the hospital and off-site locations, according to Frew. "The rule says that the patient has presented to the hospital if they come to the hospital seeking care, or fall victim to a medical event or accident on hospital-controlled property within a 250-yard zone surrounding the main buildings of the hospital," he explains. The hospital must be made aware of the patient’s presence through one or more of its agents, employees, staff members, or medical staff members, he adds.

The rule came about after a young man was shot while playing basketball in an alley near Ravenswood Hospital in Chicago, Frew explains. "Friends dragged him to the edge of the hospital property and sought assistance from ED personnel, who refused to leave the building to assist the patient, who died following a substantial delay in getting him into the ED," he says.

Here are things to consider when developing a policy for the 250-yard rule:

• Have a system to alert ED staff when an incident occurs. At United Hospital Medical Center in Port Chester, NY, if a patient succumbs to a medical problem or has an accident on hospital property, the operator pages the house officer, chief of security, and the ED nursing supervisor, according to Kathie Carlson, RN, MSN, CEN, patient care manager.

The following information is given:

  • location of incident;
  • approximate age of patient;
  • how the injury occurred;
  • whether the patient is conscious or unresponsive.

• Bring appropriate equipment. The ED nurse in charge reports to the scene in person or designates another ED nurse to report to the scene, says Carlson. "We bring the ED medical record, stethoscope, blood pressure cuff, a neck brace and some gauze," she adds. "Usually the ambulance is there within minutes, so we probably wouldn’t need additional equipment." Security officers carry radios when they respond, so the hospital switchboard can be alerted if more equipment is needed, says Carlson.

• Determine who your "first responder" will be. At East Jefferson General Hospital in Metairie, LA, the hospital’s security officers are the first ones to respond to any emergency on the campus, says Trudy A. Meehan, RN, CHE, ED director. "In turn, their dispatch will notify the ED of the situation and any equipment needed," she says. "If the location is a distance from the ED, security will bring a car to the ED entrance and pick up a nurse and the necessary equipment."

If the situation warrants, emergency medical services (EMS) also will be called, adds Meehan. "Our ED is on the second floor of the hospital and difficult to reach, not to mention the public perception of wheeling someone from one side of the hospital to the other and up an elevator to reach the ED," she notes. The key is to have a clear policy for who will respond, and in what order, says Meehan. "Essentially, security is the first responder, then the ED nurse, with emergency medical services as backup if needed," she says.

• Decide how the medical screening examination will be provided. For off-campus areas such as occupational medicine, a medical screening examination is be provided by the most qualified person available, says Meehan. "We also developed a form for our internal use that provides us the patient’s name, reason they presented to that particular location, the screening provided, and the credentials of the person providing the screening," she adds. (To see Off-Site Location Screening Tool, click here.)

Because there may not be a nurse or physician at these sites, Meehan stresses that individuals at remote sites should do no more than they are qualified for when providing medical care. "They are instructed to call EMS if the situation warrants, and contact the ED to inform staff that they have done so and provide a short report of the presenting patient’s condition," she says.

• Have a policy for transport as needed. Meehan reports that the county’s EMS policy always has required the patient to be taken to the nearest location if their condition is critical or life-threatening. "So we are covered as to the agreement with other hospitals between our off-site locations and our ED," she explains. If the patient is stable, they are taken to the hospital of their choice, provided that facility can provide appropriate care, Meehan says.

• Include representatives from all sites to develop policy. When a policy was developed to comply with the 250-yard rule, a committee was formed including Meehan, the director of EMS, the ED director, the director of security, and the directors of all off-site facilities. (To see Care of Accident Victims of Hospital Property policy, click here.) "This ensured we did not make policy that was beyond the scope of any area or location’s abilities," she says. "Fortunately, to date, no one has mistaken our off-site locations as providers of emergency care."


For more information on complying with the 250-yard rule, contact:

Kathie Carlson, RN, MSN, CEN, Patient Care Manager, United Hospital Medical Center, Port Chester, NY 10573. Telephone: (914) 934-3087. Fax: (914) 934-3586. E-mail:

Stephen Frew, JD, Risk Manager, Physicians Insurance Company of Wisconsin, P.O. Box 15665, Loves Park, IL 61132. Telephone: (815) 654-2123. Fax: (815) 654-2162. E-mail: Web:

Trudy A. Meehan, RN, CHE, Director, Emergency Department, East Jefferson General Hospital, 4200 Houma Blvd., Metairie, LA 70006. Telephone: (504) 454-4018 Fax: (504) 456-5428. E-mail: