CMS issues guidance on interpreting EMTALA

Anticipating that its surveyors may have as much difficulty as ED managers in interpreting the final Emergency Medical Treatment and Labor Act (EMTALA) rule, the Centers for Medicare & Medicaid Services (CMS) recently issued a guidance memo that clarified some definitions and outlined three ways in which your EMTALA obligation comes to a halt.

The guidance memo noted that more official "interpretative guidelines" are under development; but in the meantime, Thomas E. Hamilton, director of the survey and certification group for CMS, offered some pointers. For example, he delineated three ways in which the ED’s EMTALA obligation can end.

EMTALA no longer applies if a physician or other qualified medical personnel makes any of these three decisions:

1. No emergency exists.

2. An emergency exists that requires transfer to another facility, or the patient requests transfer to another facility.

3. An emergency exists, and the patient is admitted to the hospital for further stabilizing treatment.

Admitted decision must be documented

The guidance memo also explained that "a patient is considered to be admitted when the decision is made to admit the individual to receive inpatient hospital services with the expectation that the patient will remain in the hospital at least overnight. Typically, we would expect that this would be documented in the patient’s chart and medical record as the time that the admitting physician signed and dated the admission order."

The memo also helped clarify when a patient is considered stable: "To be considered stable, a patient’s emergency medical condition must be resolved, even though the underlying medical condition may persist. For example, an individual presents to a hospital complaining of chest tightness, wheezing, and shortness of breath and has a medical history of asthma. A physician completes a medical screening examination [MSE] and diagnoses the individual as having an asthma attack, which is an emergency medical condition [EMC]."

After stabilizing treatment is provided, such as medication and oxygen, to alleviate the acute respiratory symptoms, the ED’s EMTALA obligation may end.

"In this scenario, the EMC was resolved, but the underlying medical condition of asthma still exists. After stabilizing the patient, the hospital no longer has an EMTALA obligation," the memo explained.

Off-campus facility should call EMS

The memo offered this further advice:

People (including visitors) presenting themselves at an area of a hospital on the hospital’s main campus other than a dedicated ED must receive a MSE only if they request, or have a request made on their behalf, for examination or treatment for what may be an EMC. "Where there is no verbal request, a request will nevertheless be considered to exist if a prudent layperson observer would conclude, based on the person’s appearance or behavior, that the person needs emergency examination or treatment," the memo said.

If a request were made for emergency care in a hospital department off the hospital’s main campus other than a dedicated ED, EMTALA would not apply. "The off-campus facility should call the local emergency medical service [EMS] to take the individual to an emergency department [not necessarily the emergency department of the hospital that operates the off-campus department, but rather the closest emergency department] and should provide whatever assistance is within its capability," the memo stated. Therefore, an off-campus location that does not meet the definition of a dedicated ED is not required to be staffed to handle potential EMCs."

For the full guidance memo, go to and choose item 10, "Emergency Medical Treatment and Labor Act (EMTALA) Interim Guidance (S&C 04-10)."