Study: ED physicians lack basic EMTALA knowledge
Study: ED physicians lack basic EMTALA knowledge
Researchers surprised at the "extent of the knowledge gap"
Staci Kusterbeck, Contributing Editor
Knowledge of the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) is lacking in the emergency department (ED), according to a recent study.1 Researchers surveyed 123 physicians on 12 questions about EMTALA requirements. Physicians showed variable deficiencies in all areas of EMTALA tested: enforcement and liability, medical screening exam, stabilization, transfers, and on-call physicians.
No respondent gave all correct answers, and 13% answered all incorrectly, with a median score of 42%. Only 20% of the respondents said they had ever received any EMTALA education.
EMTALA violations can result in penalties of up to $50,000 per violation, and may result in termination of the hospital's Medicare agreements. Under EMTALA, the hospital is legally responsible for the acts of its medical staff in the treatment, discharge, and transfer of all patients presenting with an emergency medical condition.
In addition, patients who suffer harm may recover personal injury damages in a civil lawsuit against the hospital. Since the federal government may find a number of violations in a single patient encounter, the actual fine from a single patient visit may accumulate up to several hundred thousand dollars, warns Genie E. Roosevelt, MD, MPH, one of the study's authors and fellowship director of the section of emergency medicine at the University of Colorado at Denver and Health Sciences Center.
"Physicians' ignorance of EMTALA provisions has become more perilous since Congress amended EMTALA to allow enforcement actions even when physicians and hospitals are unaware of their own violations," says Roosevelt.
In addition, physicians in hospital clinics or other departments now have EMTALA obligations for patients who come to areas of the hospital other than the ED seeking emergency care. "As EMTALA has been extended to off-campus urgent care centers, on-call physicians, and hospital areas outside the ED, the need for familiarity and compliance with EMTALA has spread to the entire medical staff of the hospital," says Roosevelt.
Lack of training
Researchers were prompted to conduct the study when discussions among staff regarding the September 2003 changes in EMTALA regulations revealed substantial gaps in knowledge. A review of the literature suggested that physicians tend to be poorly informed about their EMTALA obligations, therefore research-ers were not surprised that the study showed substantial deficits in EMTALA knowledge.
"We were, however, somewhat surprised at the extent of the knowledge gap and the paucity of previous EMTALA training," says William M. McDonnell, MD, JD, the study's lead author and assistant professor of pediatrics for the division of pediatric emergency medicine at University of Utah in Salt Lake City. "We were particularly concerned that almost a quarter of the study group reported that they had never even heard of EMTALA."
At a minimum, ED staff should at least attend a lecture or seminar explaining EMTALA and its implications, says Roosevelt. "We found in our study that those physicians who had prior EMTALA training did significantly better on the questionnaire," she says.
The researchers concluded that hospital-based physicians in all pediatric specialties should be provided with formal EMTALA training, with the expectation that such training might improve compliance with the law and reduce physicians' and their hospitals' liability costs. "Study participants embraced this recommendation, with 80% stating that they would be interested in attending an EMTALA education program," reports McDonnell. "Accordingly, we have incorporated a formal EMTALA presentation into the department of pediatrics grand rounds program at the University of Utah."
All staff members who interact with ED patients should have an annual review of EMTALA regulations, and this should be mandatory, advises Shelley Cohen, RN, CEN, a consultant and educator for Health Resources Unlimited, a Hohenwald, TN-based consulting company specializing in ED triage.
The content and length of the information presented would vary for different staff members, she says. For example, registration staff don't need to know the medical aspects of a medical screening exam or what constitutes leaving against medical advice as opposed to a refusal of the medical screening exam. They need to know the basic intent of the law, and what to do when any patient at any time implies he/she wants to leave or are leaving, says Cohen.
"They need a review of the policy and guidelines they are to follow when patients present to them or they overhear these types of remarks about leaving the ED," says Cohen. "They also need to know when their actions are delaying the medical screening exam." Use specific scenarios such as: A patient with chest pain has been brought straight back to an exam room where one nurse is hooking up an EKG machine and another is initiating standing orders for chest pain. A registration clerk presents and implies they will only take up a minute while the patient fishes for their insurance card, or they ask for a signature. "They are causing a delay in the medical screening if the provider needs that EKG to determine absence or presence of an emergency," says Cohen.
Your ED should also have a process where any staff member can fill out a simple form that allows them to document any potential EMTALA concerns. "These forms should be reviewed by a group made up of ED nurses, ED doctors, one administrative person, and someone from risk management," says Cohen.
"In most states this would not be discoverable, however, it may be in some [states]," says Cohen. The form should be a checklist, therefore, whoever is completing it can quickly identify the concerns. The list could include:
- On-call physician returned call
- On-call physician presented as requested within timeframe defined by bylaws
- Attempt to transfer to hospital with specialty unsuccessful—hospital ABC stated due to "____"
- On-call physician returned call and stated "____"
- Registration clerk ____observed requesting insurance card from patient during IV start, EKG, etc.
The purpose of the form is to identify potential EMTALA violations of which staff are aware, but managers might not realize. For example, staff may not realize the difference between refusals of the medical screening exam and leaving prior to completion of care, or the triage nurse may suggest that because the ED is busy the patient should consider going to another location.
However, if a staff member does report any potential problems, it's important that these are addressed, says Cohen. "EMTALA requires that anything revealed in the quality improvement process be addressed," she underscores.
Reference
1. McDonnell WM, Roosevelt GE, Bothner JP. Deficits in EMTALA knowledge among pediatric physicians. Pediatr Emerg Care 2006;22(8):555-61.
Knowledge of the requirements of the Emergency Medical Treatment and Labor Act (EMTALA) is lacking in the emergency department (ED), according to a recent study.Subscribe Now for Access
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