New EMTALA Ruling makes Ambulance Diversion Rules More Confusing

New EMTALA Ruling makes Ambulance Diversion Rules More Confusing

Just when all the medical directors and Emergency Departments thought they were starting to understand the scope and boundaries of the Emergency Medical Treatment and Labor Act (EMTALA) when setting policy about ambulance diversions the 9th U.S. Circuit Court of Appeals has reversed the dismissal of the 1998 Arrington v. Wong complaint on January 22, 2001. The far-reaching decision by the 9th Circuit Court of Appeals said that the redirection of a patient to another hospital via telemetry contact between the paramedic and a physician violated EMTALA. The Court said that EMTALA applies and it is concerned that patients be protected from "telemetry schemes that may result in patient dumping." The hospital's best bet is to have a clearly written and well-communicated policy and alerting method to indicate when it is on diversionary status - as it is the only clear protection in this type of case.

The majority opinion reinstated a 1998 lawsuit filed by the family of a Hawaii man. Harold Arrington had a heart attack on his way to work and died soon after getting to a hospital. The ambulance taking him to the nearest hospital, Queen's Medical Center, radioed the emergency room but was diverted by a doctor there to Tripler Army Medical Center, a more distant hospital where Arrington had been a patient. The ambulance was not owned by the Queen's Medical Center and the court ruled in 1998 that the case be dismissed. The case was dismissed in 1998 when the presiding Judge ruled that the EMTALA did not apply since the patient was not on "hospital property" nor did the patient "come to" the ED.

However in Monday's opinion by Judge Stephen Reinhardt of Los Angeles, the 9th Circuit opinion that overturned Arrington v. Wong he said such a patient is covered by EMTALA. An excerpt from the opinion states, "A hospital may not prevent a non-hospital owned ambulance from coming to the hospital unless it has a valid treatment-related reason for doing so. Moreover, even if the hospital is in diversionary status, where the ambulance comes to the hospital in spite of an instruction to take the patient elsewhere, that ambulance "comes to" the hospital and emergency treatment of that patient must be provided." The Judge spoke to the Court's belief that EMTALA's scope exists to also protect patients from telemetry schemes that may result in patient dumping.

Dissenting, Judge Ferdinand Fernandez of Pasadena said that for the law to apply, "a person must be at the hospital physically." An excerpt from his dissenting opinion states, "In addition to a request for services, the person must come to the hospital's emergency department. The plain meaning of that requirement is that the person must be at the hospital physically. It will not to do for him to be in contact through electronic connection, or for him or someone else to hold a hope that he can get there. It surely does not mean "move toward;" it clearly means "to arrive" at the place in question." The Judge drew examples to substantiate his opinion that included a hypothetical patient who called the ED via telephone and never "came to" the ED as being similar to telemetry contact by ambulance.

The regulations and the court decision makes these regulations binding in California and eight other Western states. The case may be appealed to the US Supreme Court or stayed until further action is taken by Congress. We'll just have to wait and see how this issue finally settles. In the meantime, confusion results.

Handling ambulance diversions and making policy is difficult enough simply because of the inconsistencies of policies and procedures between hospitals, communications agencies and EMS systems, but now the EMTALA throws us for another loop! Now, once again, hospitals and medical directors are unclear on how the EMTALA (1986 Patient Anti-Dumping Act) law should be interpreted when making ambulance diversion policy decisions.

Where did The EMTALA come from?

The Emergency Medical Treatment and Labor Act (EMTALA) (also referred to as the "1986 Patient Anti-Dumping Act") was enacted by Congress in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act (COBRA) of 1985 (42 U.S.C. §1395dd). It was designed to prevent hospitals from refusing to treat patients or transferring them to charity hospitals or county hospitals because they are unable to pay or are covered by the Medicaid program. In effect, EMTALA designated emergency departments as one of America's most important health care "safety nets."

Enacted by Congress to address widespread reports of denials of emergency care to the poor and uninsured, the statute created a right to screening and emergency treatment if a patient "comes to the emergency department." EMTALA essentially is viewed as an "unfunded mandate" by many health care agencies.

What Role Does EMTALA Play in Ambulance Diversion Policy?

EMTALA does makes a provision for ambulance diversions, and its intention was thought to be fairly clear since EMTALA does state that the policy for diversion must be clearly communicated and any diversion must be documented. The 1998 Arrington vs. Wong court case held that under EMTALA a hospital may divert an ambulance that has contacted its ED and is on the way to that hospital so long as the hospital is in diversionary status. It has been commonly interpreted that as long as the hospital does not own the ambulance it is expected that the scope of EMTALA's "comes to" the ED language does not apply that the hospital has an obligation to the patient under EMTALA. However, the Arrington v. Wong 1998 lawsuit decision reversed this Monday has resulted in ambiguity once again in how the law applies. The question that now must be decided by Arrington v. Wong court case, perhaps in a Supreme Court appeal, is whether or not contacting a hospital vie a telemetry system means that the patient has in fact "come to" the hospital and invokes EMTALA - even if the ambulance is not owned by the hospital.

When does EMTALA apply? Basically, EMTALA applies to individuals on "hospital property", - not just in the hospital's emergency department. EMTALA also applies to any patient who "comes to" the ED. The "hospital property" definition includes the entire main campus of the hospital, including the physical area immediately adjacent to a hospital's main buildings; other areas and structures not strictly contiguous to the main buildings, but within 250 yards of the main buildings; and other areas that may be specified by HCFA regional offices. Hospital property also includes parking lots; sidewalks; driveways; hospital-owned ambulances, regardless of their location; and ambulances not owned by a hospital if they're on the hospital's campus. And, clinics or other hospital departments off the main-campus have recently been included in the "hospital property" definition. "Comes to" the ED means "physically present" - at least until the 9th Circuit's decision Monday.

The 1998 dismissal of the Arrington v. Wong complaint had supposedly interpreted unclear language in the 1986 Patient Anti-Dumping Act. While the "hospital property" and the "comes to" the hospital definitions sounds clear, the ruling this past week has simply served to confuse us all. The federal appeals court ruling now means that, except in rare circumstances, hospitals cannot turn away ambulances en route with emergency patients. The reversal of Arrington v. Wong means that ambulance diversion policies are going to be even more confusing until this court battle is decided.

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References

EMTALA

Healthcare Legal Update
COBRA Patient Anti-Dumping Law
Update on Ambulance Diversion Case
January 1993

Final word from government on EMTALA means trouble

Arrington v. Wong, M.D. D. Hawaii 1998 Ruling

9th U.S District Court of Appeals Reversal of Arrington v. Wong

Don't divert ambulances, hospitals told