Reviewing trouble spots ensures good compliance

Question: I think we've done a good job of educating our staff about compliance with the Emergency Medical Treatment and Labor Act (EMTALA), but I still worry that someone will slip up. How can I be sure we've done all we can to comply with EMTALA?

Answer: You can't let your guard down with EMTALA, warns Linda Parish, JD, a partner in the litigation and health care section of the law firm Jackson Walker LLP in Houston. No matter how good your compliance efforts have been so far, you must periodically reassess your EMTALA education and awareness levels, plus how well your policies and procedures are actually followed in the hospital.

Parish advises risk managers to thoroughly assess EMTALA compliance at least once a year. An annual review will help you stay compliant even with a high turnover rate of staff in the emergency department, she says. A key part of the review should be verifying that all emergency staff have participated in an EMTALA education course recently, and any new staff who have not should be scheduled immediately.

"It's a good idea at this point to sit everyone in the emergency department down for at least a little refresher course, if not a more complete educational effort," she says. "Everyone can use a reminder. Hospitals get into trouble a lot just because people start talking about insurance or financial status before the screening, without even realizing they're doing anything wrong."

The annual checkup also will involve a review of your organization's policies and procedures, but it doesn't stop there. For instance, Parish notes that you should review the medical staff bylaws because a lot of EMTALA compliance activities are based on those rules.

"There's a limit to how much you can do with your own policies and procedures," she says. "Ultimately you have to depend on the physician to do what he or she should do regarding EMTALA, and that's going to depend on the bylaws."

The bylaws should specify a time period in which medical specialists have to report to the emergency department, as well as a backup plan for when the on-call physician can not respond in a timely manner. Make sure that physicians on call are aware of the requirements, including any specific limits during the on-call period such as not being too far away from the hospital or not scheduling elective surgeries.

"It also is important to remind the physicians that they will have to get up and come to the hospital, rather than trying to handle the call by phone," Parish says. "And remind them that they can not discuss the financial status of the patient before examining him. It's easy for doctors to think that the EMTALA obligation has passed once they get a call at home, but that's not necessarily true."

Parish says you should ensure during your annual review that there is a procedure for what staff are to do when an on-call physician does not respond. The procedure should clearly indicate how many times staff should try to reach the physician, and how long they should wait for the physician to show up before taking other action.

"You want to avoid a situation in which staff just keep trying to reach the doctor over and over, or they let the patient wait forever because the doctor said he was coming," Parish says. "There should be a clear procedure in which the staff takes other action, such as calling the backup physician, instead of just waiting."

With your facility's own staff, your EMTALA review should ensure that policies and procedures are up to date, especially since the law has changed significantly in the past few years. Parish suggests taking a close look at who is allowed to do the initial medical screening examination. Though EMTALA allows a nonphysician to conduct the screening, Parish advises having a policy that requires a physician to do the exam.

"You're just asking for trouble if you have anybody other than an MD do that initial examination," she says.

(Editor's note: Do you have a question about EMTALA or any other risk management dilemma? Send your question to Healthcare Risk Management, and we will find an expert answer for an upcoming issue. Your name and affiliation will not be published. Contact editor Greg Freeman at or Healthcare Risk Management, Attn: Lee Landenberger, 3525 Piedmont Road, Building Six, Suite 400, Atlanta, GA 30305.)