EMTALA claim for failure to provide medical screening dismissed, claim for failure to stabilize medical condition proceeds

Medical screening claims under the Emergency Medical Treatment and Active Labor Act (EMTALA) must assert a failure to screen or improper screening, a district court in Missouri held, granting in part and denying in mart a hospital’s motion to dismiss EMTALA claims. The case was allowed to proceed on the patient’s claim for failure to stabilize her medical condition in violation of EMTALA. The patient’s claims for failure to provide appropriate medical screening in violation of EMTALA and medical malpractice were dismissed (Pennington-Thurman v. Christian Hospital Northeast, October 22, 2019, Cohen, P.).

Procedural history

A patient arrived at the hospital’s emergency department with severe leg cramps, received narcotic pain medication, vomited, and objected to being discharged because she felt ill. The patient was nonetheless discharged and left in the wheelchair in the waiting room. The patient filed a complaint against the hospital and its physician seeking monetary relief for alleged violations of the EMTALA (42 U.S.C. §1395dd) and claims of medical malpractice. The patient claimed the hospital violated EMTALA by failing to: (1) provide appropriate medical screening because they believed the patient lacked health insurance; and (2) stabilize the patient prior to discharge.

EMTALA claims

The hospital moved for dismissal of the patient’s EMTALA claims because the patient failed to plead factual allegations suggesting: (1) she received no screening; (2) she received improper screening for a discriminatory purpose; (3) she received screening that was different from other patients with charley-horse cramps; and (4) she had an emergent condition that the hospital failed to stabilize.

Failure to screen

The hospital argued that the patient’s complaint failed to state a claim for any of the three categories of failure to screen: (1) failure to screen at all; (2) improper screening of patients for a discriminatory reason; (3) and screening a patient differently from other patients perceived to have the same condition. The court held that the patient did not allege that the hospital failed to screen her at all since the complaint’s factual allegations established that the hospital’s nursing staff and physician examined her, performed blood work, and treated her pain. Regarding the second and third categories, the court held that the patient did not allege that patients perceived to have insurance and the same medical condition were screened or treated differently than she was. Moreover, the patient failed to state how the hospital allegedly deviated from its normal screening process. Therefore, the court found that she did not plead facts to support a claim either that the hospital screened her differently from other patients with similar conditions or failed to appropriately screen her for a discriminatory reason. As a result, the court dismissed the patient’s claim that the hospital failed to provide appropriate medical screening in violation of EMTALA.

Failure to stabilize

The hospital argued that the patient failed to state a claim under EMTALA for failure to stabilize her medical condition because the complaint established that the patient treated her emergency medical condition with pain medication and resolved her pain prior to discharge. The court declined to find on a motion to dismiss either that: (1) a reaction to medication that includes vomiting is not an emergent medical condition; or (2) a patient who vomits and feels ill while in the emergency department is stabilized and therefore fails to state a claim under EMTALA. Accepting the allegations in the complaint as true and drawing all reasonable inferences in favor of the nonmoving party, the court found that the patient sufficiently alleged that she had an emergent medical condition and the hospital failed to stabilize her condition prior to discharge. As a result, the court denied the hospital’s motion to dismiss the patient’s failure to stabilize claim.

No relief; EMTALA doesn’t cover medical malpractice claims

A U.S. District Court in Alabama has dismissed a claim brought by a patient against the Health Care Authority of the City of Huntsville (the Hospital). The patient, a woman who came to the emergency room, alleged the hospital violated EMTALA by failing to conduct an appropriate screening exam and stabilize her after her admission to the hospital. The hospital moved to dismiss the lawsuit claiming they screened her appropriately and stabilized her after she arrived. The court held that the hospital met EMTALA requirements and granted motion to dismiss under Federal Rules of Civil Procedure 12(b)(6) (Baker v Health Care Authority of the City of Huntsville, July 9, 2019, Kallon, A.).

The court looked to the EMTALA requirements to determine whether the patient stated a claim for which relief could be granted. The court noted that congress enacted EMTALA to prevent hospitals from turning away or transferring indigent patients without evaluation or treatment. The court noted that to prevail on the patients EMTALA claim she must plead facts showing that the hospital violated the appropriate medical screening or stabilization requirements.

Screening requirement

EMTALA requires that when a person goes to the emergency room for an exam or treatment, the hospital must provide for an appropriate medical screening exam. The screening must be within the capability of the emergency room to determine whether or not an emergency medical condition exists. It also requires that indigent patients receive similar care to anyone else that would be screened in the emergency room with similar symptoms.

Under the facts of this case, the woman was given four screenings within an hour of arrival in the emergency room. She was diagnosed with a hypertensive emergency and admitted to the hospital. Several hours later she was examined again and properly diagnosed with a stroke. The woman argues that because she was not diagnosed with a stroke earlier, the hospital did not conduct a proper screening. The woman did not allege any facts to show that she was screened differently from any other patient. The court held that as long as the hospital screened her similarly to any other patient with the same symptoms there is no liability under EMTALA.

Stabilization requirement

Under EMTALA the stabilization requirement has to do with transferring the patient to another facility. The statute requires that the hospital treat the emergency condition as necessary to assure with reasonable medical probability that no material deterioration of the condition occurs during transfer of the patient. The court found that the EMTALA obligation to stabilize ends when the patient is admitted to the hospital and not transferred. In this case the woman was admitted to the Huntsville Hospital and therefore the woman would have had to plead facts to show that the hospital admitted her with intention to subterfuge to avoid EMTALA liability. Since she did not allege any facts to support that allegation the court holds that she has not alleged a plausible claim for violations of EMTALA’s stabilization requirement.

Holding

The court found that the woman’s allegations against the hospital for failure to provide her with timely and necessary treatment may support a malpractice claim but do not fall under a violation of the EMTALA statute. The woman would have had to show that the hospital treated her differently than other patients who presented with similar symptoms. The claim was dismissed under Rule 12(b)(6) and the court declined to exercise supplemental jurisdiction over her state law claims.

Addressing the challenges behavioral health patients present when in crisis

Access to proper treatment for patients with behavioral and mental health issues has become a major issue in the United States and has received attention from the public and Congress. But, there are unique issues when a behavioral health patient appears at a hospital emergency room and the hospital must abide by the Emergency Medical Treatment and Active Labor Act (EMTALA) (42 U.S.C. §1396dd). Catherine M. Greaves, counsel, and Kristin M. Roshelli of King & Spaulding, LLC addressed the challenges hospitals face in emergency situations with behavior health patients in a Health Care Compliance Association webinar held on July 25, 2017.

The behavioral health patient and EMTALA

When a patient comes to the hospital’s emergency department (ED) with a behavioral health condition and requests emergency treatment, the patient (1) may be a danger themselves or to others, (2) may lack orientation, which is interfering with his or her ability to meet basic needs such as nutrition or safety, or (3) may have an underlying mental illness. Patients may be suicidal or homicidal, assaultive or combative, delusional or psychotic, or experiencing withdrawal from drugs or alcohol.

Hospitals must ensure that EMTALA requirements are met, including conducting a medical screening as well as a psychiatric evaluation, properly stabilizing the behavioral health patient if a n emergency medical condition (EMC) exists, and addressing transfer issues, including the vehicle used to transfer have been addressed. In addition, the hospital must have policies and procedures that adequately reflect EMTALA requirements and must provide education and training on serving behavioral health patients for the ED and other hospital staff, including security. If the hospital is in a state that has laws requiring mental health patients to be evaluated and treated at designated facilities may clash with or be more stringent than EMTALA. Hospitals must not disregard EMTALA requirements.

Concerns specific to behavioral health patients

Greaves said that EDs have become the “de facto dumping grounds for psychiatric patients.” One out of 8 ED visits are for mental health disorders or substance abuse, which represents a large percentage when compared to the population as a whole. In addition, she pointed out a 2008 survey conducted by the American College of Emergency Physicians that found that 99 percent of emergency physicians reported admitting behavioral health patients daily. According to Greaves, much of this is due to the lack of available designated psychiatric hospital beds and the decrease in state facilities for behavioral health patients. Currently, there are only 14 beds available per 100,000 people, which represents a decrease of 90 percent since the 1990’s, and is the number of beds available in 1850. The optimal number of beds is 50 per 100,000.

MSE for behavioral health patients

MSE for behavioral health patients consists of two steps, an initial medical screening to rule out underlying medical/organic causes for symptoms followed by a psychiatric review once medical clearance has been determined. Greaves stressed the importance of conducting the medical screening examination before doing a psychiatric evaluation to rule out medical conditions that can trigger behavioral symptoms. As examples, she noted that drugs and alcohol can mask underlying medical conditions and infections, especially in the elderly, can trigger psychiatric behavior. She also emphasized that appropriate hospital personnel conduct screening.

Stabilization

Greaves noted that patients with behavioral health conditions are not quickly stabilized. Patients must be stabilized enough to tolerate a transfer or be discharged. Hospitals should consider whether the patient is protected and prevented from injuring or harming self or others; when using chemical or physical restraints, and is the underlying EMC stabilized. Although some patients refuse treatment, suicidal patients may not refuse medical and psychiatric evaluations and stabilizing treatment. If the patient is being transferred with restraint for stabilization, how long will the stability last and how long is the trip.

If the ED decides to transfer a patient that is not stable, the physician must explain the reason for the transfer and certify that the benefits outweigh the risk. The transfer, however, must comply with all of the other EMTALA regulations. Within the hospital’s capabilities, treatment must be provided to minimize the risk of harm, the receiving facility that agrees to accept the transfer must be contacted, and appropriate information must be sent to the receiving facility.

Transfer challenges

Behavioral health patients are transferred at higher rates than nonpsychiatric patients with much longer wait times for the transfer because of issues locating an available bed in a national shortage, insurance acceptance and prior authorization delays, and arranging transportation. When it comes to choosing the vehicle to transport behavioral health patients, there is no single method that is full proof. Hospitals should balance minimal interference with the patient’s dignity and self-respect, reduce the likelihood of harm to self or others, and prevent the transport experience from being perceived as a traumatic event.

Options for transportation include ambulance, police care, private vehicle, and a hybrid, but all present problems. An ambulance may not be a good choice because it is filled with objects that can be utilized to harm self or others and there is no barrier to protect the driver. A police car may traumatize the patient, a support person is not allowed, there is no established protocol for safe transport of behavioral health patients, and there is limited ability to intervene if a medical emergency occurs during transport. In addition, both ambulances and police vehicles brings a public cost. Private vehicles should not be used because family are generally not capable of providing appropriate care. Some states laws allow variations that make up a hybrid that may include the involvement of Mental Health Crisis Teams or unmarked police vehicles.