EMF-7 EMTALA: Two decades later

Abstract

Study objectives: We determine whether emergency departments (EDs) continue to willfully deny screening and stabilization in violation of the Emergency Medical Treatment and Active Labor Act (EMTALA) and to examine the evidence used to justify EMTALA violations. Methods: Under the Freedom of Information Act, the Centers for Medicare and Medicaid was petitioned for the 200 most recent EMTALA citations requiring a corrective plan of action. Each violation was classified into 1 of 3 primary categories: (1) to perform a screening examination or to stabilize; (2) possible to screen or stabilize; and (3) no evidence of to screen or stabilize. Citations were also classified into 10 additional subcategories, including actual or risk of harm to patient(s), screening or treatment decisions based on financial or insurance status, clinical judgment errors, procedural deficiencies, and documentation failures. Violations occurring in inpatient locations and not involving the ED were excluded. Three investigators independently reviewed a subset of data, and interrater reliability was computed (κ). Results: We received 206 records from the period from November 1999 to September 2001. Of these 206, 174 (84%) violations met inclusion criteria and 57 (33%) were category 1 (clear instances of EDs refusing to screen or stabilize), 43 (25%) were category 2 (possible refusal), and 74 (43%) were category 3 (no refusal). Subcategory classifications included harm to patient(s) (17 [10%] of 174), financial (7 [4%] of 174), clinical judgment (26 [15%] of 174), procedural (93 [53%] of 174), and documentation (137 [79%] of 174). The interrater reliability κ statistics for the refusal to screen/treat classifications (category 1 to 3) were 0.29 and 0.56 (fair to moderate agreement). Conclusion: Willful ED to screen or stabilize still occurs despite EMTALA regulation and enforcement. However, a substantial number of violations reviewed contained no evidence of deliberate denial of care.