Avoid EMTALA violations: Never say these 3 things

Your ED’s waiting room is packed with patients, and stress levels are rising fast. A man with an ankle injury asks angrily, "How much longer will I have to wait?" You roll your eyes and tell him it could be hours.

You may not intend this, but the patient may feel you’re discouraging him from seeking care — leading to a potential violation of the Emergency Medical Treatment and Labor Act (EMTALA).

"Oftentimes it’s body language, the shrugging of shoulders, failing to make eye contact, the rolling of eyes, or just the tone of a curt response, that causes a patient to leave," says Pamela Rowse, RN, quality/risk consultant for the ED at Saint Rose Dominican Hospital in Henderson, NV.

These probably are the leading causes of patients determining that they should go elsewhere, she says. "The patient’s mindset is, they are treating me this way because I don’t have insurance, or I’m homeless, or I’m Hispanic or black or Asian."

What you say and do can trigger a complaint to the Centers for Medicare & Medicaid Services (CMS), says Jeff Strickler, RN, clinical director of emergency services at University of North Carolina Hospitals in Chapel Hill. "To avoid this, be particularly cognizant about what you tell a patient prior to the medical screening examination [MSE] occurring," he says.

Never make any statement to patients about wait times, payment, or alternatives to care, especially before a full clinical triage assessment has been done, including history and medications, warns Rowse. "When a patient’s outcome is bad because they have left without receiving their MSE, then state and CMS surveyors will have red flags when they come in to review the chart," she says.

Here are three things to avoid saying to patients:

• Anything that could be interpreted as encouraging a patient to leave.

Something as simple as telling a patient with a seemingly minor complaint, "The wait could be several hours," could cause the patient to leave without being seen and file a complaint with CMS for a failure or delay in providing an MSE, says Strickler.

Avoid phrases of irritation such as "whatever" or "it’s your choice," if patients ask about wait times or tell you they are leaving, says Rowse. "Offer to reassess their condition," she advises. "Explain to them that it is important that they be seen by the physician to determine if there is anything that needs to be treated immediately."

• Complaints about other practitioners or hospitals.

Avoid venting your frustrations about delays or inappropriate staff behavior to patients, advises Strickler. "Comments about another institution refusing to accept a patient’s case on transfer, or lack of a timely response from a consultant, also could trigger a complaint to CMS."

The bottom line is to avoid any statements that could be construed as the ED delaying the MSE for any reason, says Strickler. "Especially troublesome are any statements that reflect on financial screening practices, such as Before we can get you back, I need you to give your insurance information to registration.’"

• Statements about long wait times.

It’s easy to become frustrated when your waiting room is crowded with patients who all want to be seen first, says Rowse. "Both patients and family members become angry and agitated, leading to a confrontational environment," she says. "This sets the arena for potential EMTALA violations with even well-intended and caring health care personnel."

Avoid the following statements, recommends Rowse:

— "As you can see, we are extremely busy. You are going to have a very long wait."

— "You will have to understand that there will be a minimum of a four-hour wait to get into the back."

— "There are a lot of people that are more critical than you, and you will just have to wait your turn."

— "We’ve had many ambulance patients that have arrived, and we are very overwhelmed right now. We’ll get to you as soon as we can."

These statements often are made before the potential for a medical emergency has been assessed, adds Rowse. "I have even heard triage nurses tell patients that the wait at the urgent care would be much less,’" she says. "Those patients routinely were referred back to the ED because the necessary diagnostic capabilities were not available at the urgent care."

If patients do ask about wait times, Rowse recommends saying, "We care about you and want to provide you with the services that you need, but right now there are others that need immediate attention because they are in a potentially life-threatening situation. We will do anything that we can to expedite your being seen by a physician. Please let us know if your condition gets worse while you are waiting."

EMTALA investigations have become a "major heartbreak" for hospitals, particularly when they are unfounded, says Rowse. "However, taking the right steps from the get-go and showing compassion will go a long way to preventing complaints being filed."


For more information, contact:

  • Pamela S. Rowse, RN, Quality/Risk Consultant, Emergency Department, Saint Rose Dominican Hospital-Rose de Lima Campus, Henderson, NV. Telephone: (702) 616-5548. E-mail: wownurse@aol.com.
  • Jeff Strickler, RN, MA, Clinical Director, Emergency Services, University of North Carolina Hospitals, Chapel Hill. Telephone: (919) 966-0068. E-mail: JCStrick@unch.unc.edu.