Reader Question

No EMTALA risk if patient elopes after screening

Question: What is our obligation under EMTALA when a patient leaves the emergency department after screening but before treatment is complete? We know that we can get in trouble when a patient leaves before being assessed and treated, but what if they’re in the middle of treatment and just slip out because they’re tired of waiting for the doctor to come back and release them?

We currently have a nurse call them at home, if possible, to check on them and assure them that they would have been treated fully. Is that enough?

Answer: This is a common situation in emergency departments, but it does not necessarily pose any risk of an EMTALA violation, says Holley Thames Lutz, JD, a health law attorney with the firm of Gardner Carton & Douglas in Washington, DC. There are other reasons to be concerned, however, and to make sure you have appropriate protocols in place.

The risk and necessary response increase when the patient has an emergency medical condition. she says the federal government has made clear in recent EMTALA interpretative guidelines that the hospital has not committed an EMTALA dump when a patient walks out unless you suggested the patient leave or you’re dragging your feet about making a timely transfer when the patient cannot be treated at your facility.

"Let’s say an emergency medical condition is identified, you start treatment and leave to go get the phlebotomist and the person decides to go home. In that kind of scenario, EMTALA is not your problem unless you met one of those two conditions," Lutz explains. "But that doesn’t mean you can forget that patient and move on to the next."

In essence, she says, the patient has left against medical advice (AMA). AMAs are not uncommon in hospitals and certainly not in emergency departments, so you probably have a protocol in place already to address that problem. When a patient just slips out of the emergency department, however, you may not be able to apply the same standards of talking to the patient about the risk of leaving, recruiting family members to talk him out of it, and having him sign statements acknowledging the risk.

"Assuming the patient just walks out and doesn’t afford you the opportunity for that kind of good communication, the next best thing is to call the patient at home and go over some of that information like the diagnosis, test results, anything you think the patient should know about his or her condition," Lutz says. "Tell the patient you have an emergency medical condition and you need to be treated somewhere.’ It’s a very good idea to tell the patient that you’d be glad to see him again if he wants to return to the emergency department, and that you would have completed treatment if he had stayed."

If the intake information included the patient’s personal physician, she suggests having a nurse call that physician to inform him or her that the patient was in the emergency department and left without completing treatment.

Lutz says risk managers should ensure that when a patient elopes after an emergency medical condition is identified, staff clearly document the situation. A patient with a simple headache who leaves the emergency department because he feels better is a different situation; the same level of diligence is probably not required or practical in a busy hospital. But an emergency medical condition is serious, by definition, so staff should document thoroughly.

"I would chart up one side and down the other about how the patient received an emergency medical screening, what condition you found, the plan of treatment, and what the plan of treatment was at X hour when the patient left," she says. "Document that you never suggested the patient go, that you were surprised when the patient left. Illustrate that you told the patient what was going to happen and for reasons unknown to you the patient just walked out. You’re painting a picture that the patient knew treatment would continue but just got impatient."

For patients who do not have an emergency medical condition and slip out of the emergency department during treatment, the gold standard would be following all the AMA protocol you would employ elsewhere in the hospital. A call to the patient’s home to follow up still is a good idea. But Lutz also acknowledges that, as a practical matter, the level of concern for that patient is lower and may not justify spending the limited resources in an emergency department.

"I’m more concerned about the patient with a documented emergency medical condition," she says. "That patient may accuse you of a constructive dump by saying you told him to leave because he had no insurance. If it comes to your word against the patient’s, you want the documentation to prove what happened. And if that patient with heart palpitations goes home and has a heart attack, you want to be able to show that you did your best to help him and he just left before you could."