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Bringing Inpatients to the Emergency Department

February 6, 2011

A friend wrote me an e-mail asking about a hospital’s EMTALA liability for bringing an admitted patient to the emergency department. In his case, a patient with a condition needing emergent care was wheeled from the ICU to the emergency department. Unfortunately, the emergency department was full when the patient arrived and no rooms were available.

What does EMTALA say about inpatients?

Bob Bitterman of Bitterman Health Law Consulting Group is one of the most knowledgeable EMTALA experts in the nation. I posed the question to him. Here was his response:

According to CMS, EMTALA only applies to ‘any individual not a patient‘ presenting to the ED.
CMS defines ‘patient’ to include anyone admitted as an ‘inpatient’.
Therefore, EMTALA does not apply to the care of the patient on the floor, it does not apply to the transfer of the patient to the ED, and it does not apply to the patient once brought down to the ED.
Thus, the screening examination and stabilization duties do not apply to any inpatient brought to the ED, even once they are in the ED.

Technically, since EMTALA doesn’t apply to inpatients brought to the emergency department, the emergency physician isn’t bound to treat the patient once the patient arrives. If attempting to treat an admitted patient jeopardizes the health of emergency department patients (to whom the emergency physician does have an EMTALA duty) the emergency physician has a responsibility to treat the emergency department patients first. When there is no room available in the emergency department, the floor staff may need to bring the patient back to the floor and have the attending physician come to see the patient.

Other issues arise aside from EMTALA problems.

The emergency department is considered an outpatient setting. Taking a patient from an inpatient setting to the emergency department is like taking a patient from an inpatient setting to a physician’s office or clinic. How often have you seen inpatients being transported by ambulance to doctor’s offices? With inpatient medicine, the physicians come to see the patients, not vice-versa.

That raises another issue. Few emergency physicians are credentialed to treat inpatients. Suppose there was a bad outcome and a lawsuit occurred. A plaintiff attorney familiar with the distinction between inpatient and outpatient and aware of the credentialing issues involved could easily file a claim that the hospital allowed the emergency physician to practice inpatient medicine without proper training or credentialing.

There also may be billing issues regarding the services the patient received and in what venue the patient received them (.pdf file) although those issues should be secondary to proper patient care.

Ideally, hospitals should have a policy about situations like this. Most contracts that I have reviewed – especially in rural hospitals where the emergency physician is sometimes the only physician in-house – have contingencies for managing inpatient emergencies.

Rather than surprising an overcrowded emergency department with a crashing patient when more resources are available in the intensive care unit, it is much more reasonable to call the ED physician to the floor in an emergency — provided that there are no critically ill patients requiring the physician’s attention in the emergency department.

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