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    Court Clarifies ED Rule (February 1996)

    by Attorney Frank E. Reardon

    February 1996

    Healthcare Law, Litigation & Public Policy   Medical Licensure & Discipline ♦ Employment Board of Registration

    Does EMT ALA require hospitals to provide an appropriate screening for all patients who appear in their emergency rooms, or only those patients who demonstrate that they are actively suffering from an emergency condition upon arrival? A recent decision by the First Circuit Court of Appeals suggests that, under EMT ALA, participating hospitals must provide appropriate screening to all who enter their emergency rooms.

    In Correa v. Hospital San Francisco, the court also found that a hospital's reason for its failure to screen a particular patient is irrelevant.

    On the morning of September 6, 1991, Canneo Figueroa was experiencing chills, cold sweat, dizziness, and chest pains. The 65-year-old widow asked her son to take her to the emergency department at the Hospital San Francisco, which is located in Puerto Rico. While it is unclear what the receptionist was told in the ED, Figueroa was assigned a number and told to wait. After waiting between an hour and an hour and a half, she was driven by her daughter to the office of Dr. Acadia Rojas Davis, the director of a clinic, arriving there between 3:00 and 3:30 p.m.

    Dr. Rojas Davis testified that at 1:00 he was notified by a nurse at Hospital San Francisco that Figueroa would be coming. The call from the hospital to the doctor's office was made shortly after the patient arrived in the hospital ED. The court noted that this testimony indicated the hospital's plan to dump the care of this patient after having seen her insurance card. By the time the patient was seen by Dr. Rojas, her blood pressure was only 60/90 and she began vomiting. Dr. Rojas administered IV fluids, but her condition continued to worsen. Figueroa died at 4:30 p.m., while Dr. Rojas was trying to secure an ambulance to transfer her to Heto Ray Community Hospital. The patient's death was attributed to hypovolemic shock.


    The family of Figueroa then brought suit against the Hospital San Francisco, alleging two violations of EMTALA: (1) that it had participated in inappropriate screening, and (2) for improper transfer. At trial, the policy statement of the hospital, introduced without objection, illustrated the hospital's commitment to ensure compliance with EMTALA, so the jury had a reasonable inference that the hospital considered itself covered by EMTALA. The jury in the lower court proceeding found in favor of the plaintiffs and awarded $200,000 on behalf of the decedent and a half million dollars for the pain, suffering, and mental anguish of the survivors.

    During the appeal to the First Circuit, the court focused on the fact that in passing EMTALA, Congress was concerned with reports that hospital emergency rooms were refusing to accept or treat patients without insurance. The law requires hospitals to provide an appropriate screening to anyone who enters an emergency department.

    The plaintiff’s burden in proving a violation of EMTALA is, first, to demonstrate that the hospital is covered by the regulations. Second, the plaintiff must prove that the patient arrived seeking treatment, and third, that the hospital dismissed the patient without stabilizing the emergency medical condition.

    The hospital argued that it did not deny treatment to Figueroa; it just issued her a waiting number. But the court found this inaction tantamount to a deliberate denial of screening. Hospital San Francisco also argued that a hospital can only be liable for a violation of EMTALA if economic concerns, such as inability to pay, motivate the hospital's actions. The First Circuit Court, however, pointed out that every Court of Appeals that has considered this issue has determined that EMTALA does not consider motive.

    The court then ruled that EMTALA covers all patients who enter a hospital's emergency room. and requires an appropriate screening of patients, and stabilization of their condition, regardless of insurance status. The First Circuit upheld the lower court's verdict and award of damages to the plaintiffs.

    EMTALA is a federal regulatory statute. However, plaintiffs have, with increasing frequency, used EMTALA as an avenue to pursue claims for medical negligence in federal, rather than state courts. For the most part, arguments that EMTALA should not apply in the malpractice setting have been unsuccessful. Therefore, emergency department staff must adhere to strict documentation requirements. Triage decisions regarding a patient must be carefully and clearly set forth in the written record. These notes must include the initial assessment and diagnostic differentials.

    Prior to transfer or discharge of a patient, the discharge diagnosis and treatment plan must be carefully transcribed as well as a statement of the patient's condition upon leaving the emergency department. Such documentation, written all the time, will be the best defense to future charges that the patient was “dumped” for financial rather than for appropriate medical reasons.