Complying with the Emergency Medical Treatment and Labor Act (EMTALA): Challenges and solutions.
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SUBMITTER: Hsuan C
PROVIDER: S-EPMC8340543 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:INTRODUCTION:The Emergency Medical Treatment and Labor Act (EMTALA) was intended to prevent inadequate, delayed, or denied treatment of emergent conditions by emergency departments (ED). While controversies exist regarding the scope of the law, there is no question that EMTALA applies to active labor, a key tenet of the statute and the only medical condition - labor - specifically included in the title of the law. In light of rising maternal mortality rates in the United States, further exploration into the state of emergency obstetrical (OB) care is warranted. Understanding civil monetary penalty settlements levied by the Office of the Inspector General (OIG) related to EMTALA violations involving labor and other OB emergencies will help to inform the current state of access to and quality of OB emergency care. METHODS:We reviewed descriptions of all EMTALA-related OIG civil monetary penalty settlements from 2002-2018. OB-related cases were identified using keywords in settlement descriptions. We described characteristics of settlements including the nature of the allegation and compared them with non-OB settlements. RESULTS:Of 232 EMTALA-related OIG settlements during the study period, 39 (17%) involved active labor and other OB emergencies. Between 2002 and 2018 the proportion of settlements involving OB emergencies increased from 17% to 40%. Seven (18%) of these settlements involved a pregnant minor. Most OB cases involved failure to provide screening exam (82%) and/or stabilizing treatment (51%). Failure to arrange appropriate transfer was more common for OB (36%) compared with non-OB settlements (21%) (p = 0.041). Fifteen (38%) involved a provider specifically directing a pregnant woman to proceed to another hospital, typically by private vehicle. CONCLUSION:Despite inclusion of the term "labor" in the law's title, one in six settlements related to EMTALA violations involved OB emergencies. One in five settlements involved a pregnant minor, indicating that providers may benefit from education regarding obligations to evaluate and stabilize minors absent parental consent. Failure to arrange appropriate transfer was more common among OB settlements. Findings suggesting need for providers to understand EMTALA-specific requirements for appropriate transfer and for EDs at hospitals without dedicated OB services to implement policies for evaluation of active labor and protocols for transfer when indicated.
| S-EPMC7081879 | biostudies-literature
Project description:ObjectivesThe Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation.Materials and methodsA retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year.ResultsAmong 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals.ConclusionsFor-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.
| S-EPMC8630639 | biostudies-literature
Project description:IntroductionThe Emergency Medical Treatment and Labor Act (EMTALA) of 1986 was enacted to prevent hospitals from "dumping" or refusing service to patients for financial reasons. The statute prohibits discrimination of emergency department (ED) patients for any reason. The Office of the Inspector General (OIG) of the Department of Health and Human Services enforces the statute. The objective of this study is to determine the scope, cost, frequency and most common allegations leading to monetary settlement against hospitals and physicians for patient dumping.MethodsReview of OIG investigation archives in May 2015, including cases settled from 2002-2015 ( https://oig.hhs.gov/fraud/enforcement/cmp/patient_dumping.asp ).ResultsThere were 192 settlements (14 per year average for 4000+ hospitals in the USA). Fines against hospitals and physicians totaled $6,357,000 (averages $33,435 and $25,625 respectively); 184/192 (95.8%, $6,152,000) settlements were against hospitals and eight against physicians ($205,000). Most common settlements were for failing to screen 144/192 (75%) and stabilize 82/192 (42.7%) for emergency medical conditions (EMC). There were 22 (11.5%) cases of inappropriate transfer and 22 (11.5%) more where the hospital failed to transfer. Hospitals failed to accept an appropriate transfer in 25 (13.0%) cases. Patients were turned away from hospitals for insurance/financial status in 30 (15.6%) cases. There were 13 (6.8%) violations for patients in active labor. In 12 (6.3%) cases, the on-call physician refused to see the patient, and in 28 (14.6%) cases the patient was inappropriately discharged. Although loss of Medicare/Medicaid funding is an additional possible penalty, there were no disclosures of exclusion of hospitals from federal funding. There were 6,035 CMS investigations during this time period, with 2,436 found to have merit as EMTALA violations (40.4%). However, only 192/6,035 (3.2%) actually resulted in OIG settlements. The proportion of CMS-certified EMTALA violations that resulted in OIG settlements was 7.9% (192/2,436).ConclusionOf 192 hospital and physician settlements with the OIG from 2002-15, most were for failing to provide screening (75%) and stabilization (42%) to patients with EMCs. The reason for patient "dumping" was due to insurance or financial status in 15.6% of settlements. The vast majority of penalties were to hospitals (95% of cases and 97% of payments). Forty percent of investigations found EMTALA violations, but only 3% of investigations triggered fines.
| S-EPMC4899053 | biostudies-literature
Project description:OBJECTIVE:The objective was to describe characteristics of civil monetary penalties levied by the Office of the Inspector General (OIG) related to violations of the Emergency Medical Treatment and Labor Act (EMTALA) involving psychiatric emergencies. METHODS:Descriptions of EMTALA-related civil monetary penalty settlements from 2002 to 2018 were obtained from the OIG. Cases related to psychiatric emergencies were identified by inclusion of key words in settlement descriptions. Characteristics of settlements involving EMTALA violations related to psychiatric emergencies including date, amount, and nature of the allegation were described and compared with settlements not involving psychiatric emergencies. RESULTS:Of 230 civil monetary penalty settlements related to EMTALA during the study period, 44 (19%) were related to psychiatric emergencies. The average settlement for psychiatric-related cases was $85,488, compared with $32,004 for non-psychiatric-related cases (p < 0.001). Five (83%) of the six largest settlements during the study period were related to cases involving psychiatric emergencies. The most commonly cited deficiencies for settlements involving psychiatric patients were failure to provide appropriate medical screening examination (84%) or stabilizing treatment (68%) or arrange appropriate transfer (30%). Failure to provide stabilizing treatment was more common among cases involving psychiatric emergencies (68% vs. 51%, p = 0.041). Among psychiatric-related settlements, 18 (41%) occurred in CMS Region IV (Southeast) and nine (20%) in Region VII (Central). CONCLUSIONS:Nearly one in five civil monetary penalty settlements related to EMTALA violations involved psychiatric emergencies. Settlements related to psychiatric emergencies were more costly and more often associated with failure to stabilize than for nonpsychiatric emergencies. Administrators should evaluate and strengthen policies and procedures related to psychiatric screening examinations, stabilizing care of psychiatric patients boarding in EDs, and transfer policies. Recent large, notable settlements related to EMTALA violations suggest that there is considerable room to improve access to and quality of care for patients with psychiatric emergencies.
| S-EPMC7237063 | biostudies-literature
Project description:OBJECTIVE:The objective was to describe characteristics of civil monetary penalty settlements levied by the Office of the Inspector General (OIG) against individual physicians related to violation of the Emergency Medical Treatment and Labor Act (EMTALA). METHODS:Descriptions of all civil monetary penalty settlements between 2002 and 2015 were obtained from the OIG. Characteristics of settlements against individual physicians related to EMTALA violations were described including settlement date, location, amount, whether there was an associated hospital settlement, the medical specialty of the physician involved, and the nature of the allegation. RESULTS:Of 196 OIG civil monetary penalty settlements related to EMTALA, eight (4%) were levied against individual physicians, and 188 (96%) against facilities. Seven of the eight penalties against individual physicians were imposed upon on-call specialists, including six who failed to respond to evaluate and treat a patient in the emergency department (ED), and one who failed to accept appropriate transfer of a patient requiring higher level of care. The only penalty imposed on an emergency physician involved a case where a provider repeatedly failed to provide a medical screening examination to a pregnant teen based on the erroneous belief that a minor could not be evaluated or treated absent parental consent. Four of eight penalties against individual physicians were levied within the first 3 years of the 14-year study period. Half of all physician settlements were associated with a separate hospital civil monetary penalty settlement. CONCLUSIONS:For emergency physicians, a civil monetary penalty is a feared consequence of EMTALA enforcement, as a physician can be held individually liable for fine of up to $50,000 not covered by malpractice insurance. Although EMTALA is an actively enforced law, and violation of the EMTALA statute often results in hospital citations and fines, and occasionally facility closure, we found that individual physicians are rarely penalized by the OIG following EMTALA violation. Individual physician penalties are far less common than hospital citations or fines related to EMTALA or malpractice claims or payments. The majority of penalties against individual physicians were levied upon on-call specialists who refused to evaluate and treat ED patients. Only one emergency physician was fined during the study period for a clear violation of the EMTALA statute. Physicians should be diligent to ensure appropriate patient care and that facilities are compliant with the EMTALA statute, but should be aware that settlements against individual physicians are a rare consequence of EMTALA enforcement.
| S-EPMC7237064 | biostudies-literature
Project description:Prurigo nodualris (PN) is a chronic condition with highly pruritic, hyperkeratotic papules or nodules arising in the setting of chronic pruritus. While PN may serve as a phenotypic presentation of several underlying conditions such as atopic dermatitis, chronic kidney disease-related pruritus, and neurological diseases, it represents a distinct clinical entity that may persist despite the removal of the underlying cause, if one is identified. Neuronal proliferation, eosinophils, mast cells, and small-fiber neuropathy play a role in the production of pruritus in PN, although the exact mechanism has not yet been established. Identifying an underlying cause, if present, is essential to prevent recurrence of PN. Due to often present comorbidities, treatment is typically multimodal with utilization of topical and systemic therapies. We performed a PubMed/MEDLINE search for PN and present a review of recent developments in the treatment of PN. Treatment typically relies on the use of topical or intralesional steroids, though more severe or recalcitrant cases often necessitate the use of phototherapy or systemic immunosuppressives. Thalidomide and lenalidomide can both be used in severe cases; however, their toxicity profile makes them less favorable. Opioid receptor antagonists and neurokinin-1 receptor antagonists represent two novel families of therapeutic agents which may effectively treat PN with a lower toxicity profile than thalidomide or lenalidomide.
| S-EPMC6400231 | biostudies-literature
Project description:Triple-negative breast cancers (TNBCs) are defined by the absence of estrogen and progesterone receptors and the absence of HER2 overexpression. These cancers represent a heterogeneous breast cancer subtype with a poor prognosis. Few systemic treatment options exist besides the use of chemotherapy (CT). The heterogeneity of the disease has limited the successful development of targeted therapy in unselected patient populations. Currently, there are no approved targeted therapies for TNBC. However, intense research is ongoing to identify specific targets and develop additional and better systemic treatment options. Standard adjuvant and neoadjuvant regimens include anthracyclines, cyclophosphamide, and taxanes. Platinum-based CT has been proposed as another CT option of interest in TNBC. We review the role of this therapy in general, and particularly in patients carrying BRCA germ-line mutations. Available data concerning the role of platinum-based CT in TNBC were acquired primarily in the neoadjuvant setting. The routine use of platinum-based CT is not yet recommended by available guidelines. Many studies have reported the molecular characterization of TNBCs. Several actionable targets have been identified. Novel therapeutic strategies are currently being tested in clinical trials based on promising results observed in preclinical studies. These targets include androgen receptor, EGFR, PARP, FGFR, and the angiogenic pathway. We review the recent data on experimental drugs in this field. We also discuss the recent data concerning immunologic checkpoint inhibitors.
| S-EPMC4881925 | biostudies-literature
Project description:A painless presentation of aortic dissection is rare in about 5% of cases. A few case reports discussed about involvement of coronary arteries causing bradycardia. In our case, we are presenting a rare presentation of aortic dissection with initial presentation as bradycardia without involvement of coronary arteries and without cardiac symptoms. A 56-year-old man with history of hypertension presented with acute onset of altered mental status and right hand numbness. Initial vital signs were remarkable for bradycardia with heart rate 36/min. Physical exam was only significant for decreased sensation for light touch on right hand. Electrocardiogram showing marked sinus bradycardia. Initial computed tomography (CT) head did not show any acute abnormalities. On Day 2, patient complained of new weakness in left upper extremity. On exam, he had dysmetria, left upper extremity drift and cold to touch. Blood pressure was significantly different in both arms with 141/83 mmHg on right and 44/23 mmHg on left. He underwent immediate CT angiography chest showing Type 1 aortic dissection with extension into the brachiocephalic artery and right common carotid artery (RCCA) with thrombosis in RCCA. Patient was emergently taken for surgical repair of aortic dissection and resuspension of aortic valve. In our case, the initial presentation of aortic dissection included isolated sinus bradycardia without cardiac symptoms and no evidence for atrioventricular block. The mechanism may have been involvement in the arterial supply of the carotid body receptors. Patients with coexisting symptoms such as bradycardia and neurological deficits should be evaluated for aortic dissection.
| S-EPMC6601170 | biostudies-literature
Project description:IntroductionNon-US international medical graduates (IMG) represent a gradually increasing portion of emergency medicine (EM) residents in the United States. Yet there are no previous studies that explore the needs of this learner population. We conducted a qualitative study to examine non-US IMGs' perceptions of challenges they face specifically regarding team dynamics during their first year of an EM residency.MethodNine non-US IMGs in EM from all over the US participated in anonymous, semi-structured phone interviews lasting 45-60 minutes. We then coded and analyzed the interviews to identify axes and themes using an inductive approach informed by grounded theory. Focused coding and member checking were employed.ResultsNon-US IMGs' perceptions of challenges regarding team dynamics during their first year of an EM residency coalesced into two themes: system-based challenges, such as a new power dynamic and understanding the local hospital system, and interpersonal challenges, such as establishing rapport and articulation of critical thinking.ConclusionNon-US IMGs perceived several unique challenges regarding team dynamics during their first year of an EM residency, whether system-based or interpersonal-based. We propose solutions such as a transitional curriculum (as suggested by the participants as well) and cultural-competence training for academic leadership.
| S-EPMC9897247 | biostudies-literature
Project description:The accelerated growth of proteomics data presents both opportunities and challenges. Large-scale proteomic profiling of biological samples such as cells, organelles or biological fluids has led to discovery of numerous key and novel proteins involved in many biological/disease processes including cancers, as well as to the identification of novel disease biomarkers and potential therapeutic targets. While proteomic data analysis has been greatly assisted by the many bioinformatics tools developed in recent years, a careful analysis of the major steps and flow of data in a typical highthroughput analysis reveals a few gaps that still need to be filled to fully realize the value of the data. To facilitate functional and pathway discovery for large-scale proteomic data, we have developed an integrated proteomic expression analysis system, iProXpress, which facilitates protein identification using a comprehensive sequence library and functional interpretation using integrated data. With its modular design, iProXpress complements and can be integrated with other software in a proteomic data analysis pipeline. This novel approach to complex biological questions involves the interrogation of multiple data sources, thereby facilitating hypothesis generation and knowledge discovery from the genomic-scale studies and fostering disease diagnosis and drug development.
| S-EPMC2474689 | biostudies-literature