EMTALA Q & A: Emergency care: What if it’s on campus, outside ED?

You don’t necessarily have to send staff

Question: Should we have a plan for responding to patients on the hospital property, but not in the ED area, when they need or request emergency care? The final rule seems to make clear that we are not obligated to rush out of the ED to provide care for anyone who does not come to a "dedicated emergency department," but we’re not clear on what should happen when that person is elsewhere on the campus.

Answer: EMTALA still can be triggered when a person needs emergency care outside the ED, but you don’t necessarily have to send ED staff out to take care of them, explains Charlotte Yeh, MD, FACEP, CMS regional administrator in Boston and a former practicing emergency physician.

The final EMTALA rule clarified the controversial "250-yard rule" that many ED managers interpreted to mean they had to provide care to anyone who showed up within 250 yards of the hospital campus even if that was on a public street or otherwise off the campus. It is now clear that EMTALA applies only to dedicated emergency services, other hospital departments, parking lots and driveways, or other hospital property within 250 yards, she says.

That eliminates a lot of situations in which ED managers previously might have thought EMTALA required a response, but Yeh says there still are some situations in which the law will be triggered outside the boundaries of the ED.

"Under the new EMTALA regulations, if a person shows up in an area that is not a dedicated emergency department as defined in the rules, EMTALA is triggered only if the patient or a prudent layperson observer would believe there is an emergency medical condition," she says. "If they need emergency care but just happen to come in the wrong door, or if they slip in the cafeteria and hit their head, those are situations in which EMTALA could be triggered on your campus."

When EMTALA is triggered in such situations, the hospital is obligated to provide a medical screening examination (MSE). But Yeh points out that the MSE can be performed anywhere on the campus. The patient does not have to be transported to the ED, and the exam does not have to be done by ED staff.

"How the hospital responds to those patients is left up to the hospital. From a practical matter, most hospitals tend to have some sort of emergency response protocol to bring the patient to the ED," she says. "Some hospitals have a code team ready to respond anywhere on campus, and smaller hospitals probably will use emergency staff for that. But each hospital has to decide how to respond based on the physical configuration, staffing, and time of day."

In such cases, EMTALA may not be the main concern anyway, Yeh says. Even if EMTALA is not triggered in such cases, the hospital still needs an emergency response plan for when someone is injured or falls ill on the campus. Such planning is just good medical practice, she says.

There will be some situations in which it is appropriate to call 911 for people needing emergency care on the hospital campus but away from the ED, Yeh says. She recalls working with one hospital that had an older building on campus, a considerable distance from the ED, with elevators too small for a standard stretcher or gurney. So that hospital’s policy required calling 911 for local paramedics, who had folding stretchers that allowed the patient to be brought down in the elevator.

"Hospital personnel still responded and cared for the patient, but the paramedics were called to assist with transportation," Yeh says. "Sometimes on a large campus, calling 911 might be necessary, but that doesn’t mean you can ignore the patient in the meantime. If EMTALA is triggered, you still have the obligation to perform that screening examination, even though you’ve called 911."