HEALTH POLICY/BRIEF RESEARCH REPORT
EMTALA and Patients With Psychiatric Emergencies: A Review of Relevant Case Law Rachel A. Lindor, JD; Ronna L. Campbell, MD, PhD; Jesse M. Pines, MD, MBA; Gabrielle J. Melin, MD; Agnes M. Schipper, JD; Deepi G. Goyal, MD; Annie T. Sadosty, MD
Study objective: Emergency department (ED) care for patients with psychiatric complaints has become increasingly challenging given recent nationwide declines in available inpatient psychiatric beds. This creates pressure to manage psychiatric patients in the ED or as outpatients and may place providers and institutions at risk for liability under the Emergency Medical Treatment and Labor Act (EMTALA). We describe the patient characteristics, disposition, and legal outcomes of EMTALA cases involving patients with psychiatric complaints. Methods: Jury verdicts, settlements, and other litigation involving alleged EMTALA violations related to psychiatric patients between the law’s enactment in 1986 and the end of 2012 were collected from 3 legal databases (Westlaw, Lexis, and Bloomberg Law). Details about the patient characteristics, disposition, and reasons for litigation were independently abstracted by 2 trained reviewers onto a standardized data form. Results: Thirty-three relevant cases were identified. Two cases were decided in favor of the plaintiffs, 4 cases were settled, 10 cases had an unknown outcome, and 17 were decided in favor of the defendant institutions. Most patients in these 33 cases were men, had past psychiatric diagnoses, were not evaluated by a psychiatrist, and eventually committed or attempted suicide. The most frequently successful defense used by institutions was to demonstrate that their providers used a standard screening examination and did not detect an emergency medical condition that required stabilization. Conclusion: Lawsuits involving alleged EMTALA violations in the care of ED patients with psychiatric complaints are uncommon and rarely successful. [Ann Emerg Med. 2014;-:1-6.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.01.005
INTRODUCTION Background The Emergency Medical Treatment and Labor Act (EMTALA) mandates that patients who present to emergency departments (EDs) be given appropriate screening examinations. If an emergency medical condition is found during that examination, the law requires that patients be stabilized before discharge or transfer. In the case of patients with psychiatric conditions, an emergency medical condition exists if the individuals are determined to be dangerous to themselves or others.1 If an ED does not have the ability to stabilize the patients, the law allows transfer of the patients and requires outside facilities to accept the transfers if they have the capacity and capability to treat the patients. EMTALA’s requirements apply to all patients, regardless of their ability to pay for their care. Importance Institutions and providers who violate EMTALA are at risk for civil monetary penalties and exclusion from the Medicare program. Institutions may also face lawsuits from private parties in civil court. These lawsuits may be brought separately or in addition to
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malpractice charges. Little is currently known about how EMTALA has been enforced in private lawsuits involving psychiatric patients.5 EMTALA’s requirements to screen and stabilize all patients may be particularly challenging in the care of patients with psychiatric conditions. Although psychiatric visits compose an increasing proportion of ED visits,2 there has been a concurrent nationwide reduction in inpatient psychiatric beds,3 often necessitating transfer of patients to outside facilities, prolonged ED boarding, or ED-based care for patients with psychiatric complaints.4 These factors may compel providers to choose between holding at-risk psychiatric patients in already crowded EDs or discharging them. ED directors have cited EMTALA as one of the main reasons they keep psychiatric patients within the ED for hours or days rather than discharging them.5 Goals of This Investigation This study seeks to characterize trends in the incidence, patient characteristics, and legal outcomes of private EMTALA cases involving psychiatric patients, with the goal of clarifying courts’ interpretations of providers’ EMTALA obligations when treating patients with psychiatric illness. Annals of Emergency Medicine 1
Lindor et al
EMTALA and Patients With Psychiatric Emergencies
Editor’s Capsule Summary
What is already known on this topic Emergency providers cite fears of Emergency Medical Treatment and Labor Act (EMTALA) violations when making disposition decisions for patients with psychiatric disorders. What question this study addressed This structured review of case decisions published in common legal databases describes the frequency and outcomes of psychiatric-related EMTALA claims in the 26 years since EMTALA’s enactment. What this study adds to our knowledge Only 33 psychiatric-related EMTALA case decisions have been published since 1986. Only 2 cases are known to have been decided against the provider. How this is relevant to clinical practice Physicians who practice good medicine should not be terribly concerned about EMTALA for psychiatric patients; however, the study did not examine medicolegal claims distinct from EMTALA.
information (3), yielding 33 unique cases that involved EMTALA allegations revolving around the care of patients with psychiatric complaints. The authors were provided with sample cases and met as a group to discuss what characteristics of the patients and ED courses could be reasonably obtained and would be relevant. Per Gilbert et al,7 a standardized data form was created to record details about characteristics of the patients, ED evaluation, and legal outcome. The 2 primary abstractors (R.A.L. and R.L.C.) independently abstracted 5 full cases and discussed any conflicts. Ambiguities in data categories were clarified with the full group before full data abstraction was performed. Two abstractors (R.A.L. and R.L.C.) independently reviewed and abstracted the information for all cases. Conflicting or ambiguous data were discussed, and a senior investigator (A.T.S.) adjudicated any disagreements.
RESULTS Characteristics of Study Subjects Table 1 summarizes characteristics of patient presentation, evaluation, disposition, and reasons for litigation. The mean age of patients involved in litigation was 31 years (range 17 to 52 years; median 28 years; interquartile range 22 to 40 years). The majority of patients were men, had a past psychiatric diagnosis, were not treated by psychiatrists or providers with dedicated psychiatric training, were discharged from the ED, and eventually committed or attempted suicide.
MATERIALS AND METHODS Study Design Three subscription legal databases (Westlaw, Lexis, and Bloomberg Law) were searched for all relevant court opinions, jury verdicts, and settlements, using the query terms “EMTALA,” “Emergency Medical Treatment and Active Labor Act,” “anti-dumping,” and “emergency department” and using a Boolean search including “suicide,” “psych,” “mental health,” “behavioral health,” and “mental illness.” These databases contain legal decisions that have been published by the courts, in addition to unpublished opinions and settlements electively published by each database. Although additional legal databases do exist and may contain a small number of additional unpublished opinions not included in this study, the 3 databases used contain a comprehensive catalog of the published opinions and thus provide a nearly comprehensive snapshot of the available information. All cases reported from 1986, the year EMTALA was enacted, through the end of 2012 were included in this study. No medical records were accessed for this research. This search strategy was similar to that used in previous legal case series and yielded 383 court opinions.6 Data Collection and Processing and Primary Data Analysis Of the 383 court opinions identified in the initial search, 244 cases were excluded because of duplication and 106 were excluded because they were unrelated to a psychiatric complaint (100), were unrelated to EMTALA (3), or had insufficient 2 Annals of Emergency Medicine
Main Results Table 2 summarizes the 33 cases involving alleged EMTALA violations related to the care of patients with psychiatric complaints. As shown in the Figure, the annual incidence of EMTALA cases reported to legal databases has varied from 0 to 4 cases per year. At least 25 (75%) of the EMTALA cases identified were litigated together with a malpractice claim based on the same incident. The outcome of the EMTALA claim was unknown in 10 cases (30%). The first relevant case was filed in 1988, 2 years after the enactment of EMTALA, and was decided in 1992, requiring 4 years to progress through the court system. The mean time between the incident prompting litigation and the final legal decision in the 33 cases was 3.8 years for all cases—4.5 years for cases ultimately decided against the providers and 3.7 years in cases decided in favor of the providers or with an unknown outcome. Among the 23 cases with a known outcome, the majority (N¼17; 74%) were decided in favor of the defendant providers. Two cases with a known outcome (9%) were decided in favor of the plaintiff, whereas 4 (17%) ended with settlement. In the 17 EMTALA cases known to be decided in favor of the providers, 4 cases were decided according to procedural issues (eg, claim filed outside the statute of limitations), and the rationale for 1 case was not provided in the report. Of the remaining 12 cases in which the EMTALA requirements were applicable and the courts found in favor of the Volume
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Table 1. Characteristics of patient presentation, ED evaluation, final disposition, and reasons for litigation. Patient Characteristics*
No. (%; 95% CI)
Male sex Past psychiatric diagnosis Previous suicide attempt Substance abuse at presentation Suicidal ideation at presentation Homicidal ideation at presentation Suicide attempt before presentation Other chief complaint (eg, acute psychosis, depression, anxiety) Reasons for litigation Suicide Suicide attempt Other (eg, homicide, assault, other injuries related to high risk behaviors) Characteristics of ED evaluation* Evaluated by emergency physician only Evaluated by psychiatrist Evaluated by nonphysician provider with dedicated psychiatric training (eg, a specially trained nurse, social worker, psychologist) Characteristics of ED disposition Discharge Transferred or admitted as inpatients Left without being seen Admitted to observation unit
25 18 8 10 14 4 6 9
(76; 59–87) (55; 38–70) (24; 13–41) (30; 17–47) (42; 27–59) (12; 4–27) (18; 8–34) (27; 15–44)
19 (58; 40–73) 5 (15; 6–31) 9 (27; 15–44)
18 (55; 38–70) 11 (33; 20–50) 4 (12; 5–27)
20 10 2 1
(61; 44–75) (30; 17–47) (6; 2–20) (3; 1–15)
*The numbers shown here represent the number of cases in which the presence or absence of each characteristic was specifically documented in the court report. The percentages reflect the frequency with which each characteristic is documented in all 33 cases, recognizing that the documentation provided in the court reports may be incomplete and underestimate the true prevalence of these characteristics. Patients who were evaluated by a psychiatrist or other provider with dedicated training may also have been treated by an emergency physician.
providers, 1 case was based on a court’s determination that a patient was properly stabilized. In the 11 remaining cases, courts determined that an appropriate medical screening examination was provided and no emergency medical conditions were found; therefore, the courts did not even consider whether the patients had been properly stabilized because this is a requirement only if an emergency medical condition is detected.
LIMITATIONS This study is based on court opinions reported by available legal databases. Most of these opinions are from appeals-level courts, which often make decisions on single issues within a case but do not decide the final outcome of the case. Instead, the final outcome is often decided by local trial courts, which do not publish most cases. As a result, the final outcome was not available in 10 of the 33 cases in this study. In addition, these databases do not contain records of cases dismissed before trial or settled out of court, except for a small number that are electively chosen by each database vendor. The databases also do not include most reports of jury trials. Therefore, the cases used in this study represent a subset of all relevant EMTALA cases. In the cases that are reported, the results are based on information available in the text of court opinions, which are Volume
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written by individual judges and contain various amounts of detail. As a result, the information presented here may underestimate the prevalence of certain factors or characteristics. For example, court opinions reported a past psychiatric diagnosis in 55% of cases, but many opinions simply did not reference past diagnoses, meaning the actual percentage may be higher than our results demonstrate. These cases represent claims of EMTALA violations, not claims of medical malpractice. EMTALA claims are based on allegations that providers failed to appropriately screen and stabilize patients as required by the EMTALA statute. In contrast, medical malpractice claims are based on allegations that providers practiced negligently. It is possible for providers to comply with EMTALA yet commit malpractice in the same patient encounter. To illustrate, the EMTALA statute requires that providers administer an “appropriate medical screening examination,” which has been interpreted as a duty to apply the same screening procedures to paying and nonpaying patients alike.8 In contrast, medical malpractice law requires providers to practice with “due care,” which has been defined by courts as a duty to practice non-negligently. A court can find that providers are screening all patients uniformly, thus meeting the requirements of EMTALA, and also find that the screening examination is negligently designed or performed, thus putting the providers at risk for medical malpractice claims. Because of the different standards for EMTALA and malpractice liability, the cases in this study illustrate institutions’ liability risks under EMTALA, but they do not provide insight into the corresponding liability risks under malpractice law, which may be enforced separately from or in addition to those of EMTALA.
DISCUSSION Despite being cited as a common concern among ED directors, our study suggests that private lawsuits alleging EMTALA violations during the care of psychiatric patients are rare and infrequently successful. In the majority of cases with a known outcome, the courts found there was no violation because the providers performed appropriate screening examinations, did not detect any emergency medical conditions, and therefore had no further duty to stabilize the patients. This finding is consistent with a previous report demonstrating that most EMTALA claims are decided according to courts’ determinations that an appropriate screening examination was provided, whereas few decisions are made according to whether stabilization was medically achieved.9 In accordance with the limited number of cases available, we did not determine whether the incidence of relevant EMTALA lawsuits has changed in recent years. Because judges are able to dismiss cases at an early stage if they determine that there is no feasible claim, many claims never make it to litigation. The cases that pass the first hurdle to litigation, such as those included in this study’s data, therefore represent scenarios that pose the highest risk of being judged as an actual EMTALA violation. Despite their low success rate, these cases still represent Annals of Emergency Medicine 3
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EMTALA and Patients With Psychiatric Emergencies Table 2. Outcomes of private EMTALA cases involving patients with psychiatric issues. Year Reported
State of Incident
Patient Outcome
1992 1992 1993 1995 1995 1995 1996 2000 2001 2001 2002 2002 2003
Tennessee West Virginia Missouri Ohio Kansas Maryland California Texas North Carolina California Illinois New Mexico Illinois
2004 2005 2005 2006 2006 2006 2006 2007 2008 2009 2009 2010 2010 2011 2011 2011 2012 2012 2012 2012
Illinois New Hampshire Vermont Florida California Tennessee Michigan Louisiana Texas Michigan California Tennessee California Nebraska Virginia Nevada Michigan Massachusetts Michigan Missouri
Suicide attempt Medical death Suicide Suicide Suicide Suicide attempt Suicide Suicide Suicide Suicide Suicide Suicide Worsening of psychiatric illness—death (MVA) Incarceration Incarceration Suicide Victim of assault Suicide attempt Suicide attempt Victim of assault Suicide Suicide Homicide Suicide Suicide Suicide attempt Suicide Worsening of psychiatric illness Suicide Suicide Suicide Suicide Victim of assault
EMTALA Lawsuit Outcome No violation No violation Unknown No violation No violation No violation No violation Settlement No violation No violation No violation Settlement Unknown Unknown Violation Settlement No violation No violation Unknown Unknown Unknown Violation No violation No violation No violation Unknown Unknown No violation Unknown No violation Settlement Unknown No violation
Associated Malpractice Suit
Amount, $
Yes Unk* Yes Yes Yes Unk Unk Yes Unk Yes Yes Yes Unk
Confidential
Confidential
Yes Yes Yes Unk Yes Yes Yes Yes Yes Yes Yes Unk Yes Yes Yes Yes Yes Unk Yes Yes
150,000 Confidential
0†
20,000
Unk, Unknown; MVA, motor vehicle accident. *Elements of these cases were heard in appeals court and therefore reported in the legal databases used for this study, but the final disposition of the cases was decided later in trial courts, which are less frequently reported in the databases. † Damages in trial were awarded as part of a civil liability claim, which was later reversed on appeal rather than as part of the EMTALA violation, which was not challenged on appeal.
significant burdens for the litigants, with an average length of time between the incident in controversy and the ultimate decision of almost 4 years. Among these cases, the most prevalent characteristics of patients included male sex, a history of a psychiatric diagnosis, and ongoing suicidal ideation. In addition, most patients were not evaluated by a psychiatrist, were discharged directly from the ED, and eventually committed suicide. We are unable to determine whether the risk of an EMTALA claim is higher when no psychiatric consultation is performed. However, the fact that the majority of claims involved evaluation by nonpsychiatrists only, particularly in cases in which suicidal ideation was present, should be carefully considered. No common themes were identified in the 2 cases that resulted in a finding of an EMTALA violation. The first case, which occurred in 2000 and was reported by the courts in 2005, involved a female patient with a history of alcohol abuse and depression who presented to the ED intoxicated and with suicidal ideation. 4 Annals of Emergency Medicine
She was treated by an emergency physician who suggested that she speak with a guidance counselor in the ED, but the woman refused to talk to the counselor. The emergency physician subsequently committed her to police protective custody, and she filed an EMTALA claim after she was detained in a jail overnight with no psychiatric care. The second case, which occurred in 1997 and was decided in 2001, involved an uninsured patient with a history of depression and previous suicide attempts who presented to the ED after inflicting shallow cuts on his wrist. He was treated by a psychiatric nurse who had him fill out a contract in which he agreed to stay in the company of friends and family until an outpatient psychiatry appointment could be scheduled. An emergency physician cosigned the safety contract but never formally assessed the patient. The patient was subsequently discharged from the hospital and hanged himself the next day. Courts frequently consider screening examinations to be appropriate for the purposes of EMTALA even if the Volume
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EMTALA and Patients With Psychiatric Emergencies were applied relatively uniformly and did not detect any emergency medical conditions that required stabilization. Questions about whether the screening examinations were performed adequately are generally the purview of malpractice law rather than EMTALA. Though clinicians have cited fear of EMTALA liability as a factor in their disposition choices for psychiatric patients,5 this review suggests that the threat of liability under EMTALA is small. Documenting adherence to a uniform screening procedure may make that liability threat even smaller. Supervising editors: Megan L. Ranney, MD, MPH; Debra E. Houry, MD, MPH
Figure. Number of EMTALA cases involving psychiatric patients published per year. The cases are shown here in the year they were decided rather than the year that the inciting event occurred or the year the cases were filed. The average time between the inciting event and the final decision was nearly 4 years because of the time it takes for a case to progress through the court system.
Author affiliations: From the Mayo Medical School (Lindor), Department of Emergency Medicine (Campbell, Goyal, Sadosty), Department of Psychiatry and Psychology (Melin), and Legal Department (Schipper), Mayo Clinic College of Medicine, Rochester, MN; and the Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC (Pines).
examinations fail to detect an emergency medical condition when one appeared to be present in retrospect. In this study, this was most often observed in cases in which patients presented with suicidal ideation, were found not to have an emergency medical condition on screening, were discharged, and committed or attempted suicide soon thereafter. In these cases, many plaintiffs alleged that the patients’ emergency medical conditions were so obvious that the providers should have detected them on their screening examinations and therefore had a duty to stabilize the patients. However, for the purposes of EMTALA, the courts consistently emphasized that as long as the screening examinations were applied uniformly, the EMTALA duty was met, and allegations about the adequacy of the screening examinations were more properly heard as medical malpractice claims. Nearly a third of cases involved patients who were admitted as inpatients. All but 2 of these cases represented patient encounters that occurred before 2003, when the government issued regulations clarifying that EMTALA obligations end on admission unless there is evidence that the admission was made in bad faith, such as for the purpose of evading EMTALA obligations.10 Since this clarification, courts generally hear EMTALA cases involving inpatient admissions only if there is reason to believe that the patient was admitted by the hospital simply so it could avoid its EMTALA obligations. This may occur, for example, if a patient is admitted from the ED and is promptly discharged from the hospital without further care. Since 2003, courts appear to be following the regulations about the applicability of EMTALA to inpatients and heard significantly fewer claims involving these patients. In summary, private lawsuits alleging EMTALA violations arising from the care of psychiatric patients are rare and infrequently successful. In most cases, courts determine, according to the patients’ or families’ inability to demonstrate otherwise, that the screening examinations performed in EDs
Author contributions: RAL and ATS conceived the study. All authors participated in trial design. RAL, RLC, and ATS conducted data collection, and all authors participated in data analysis. RAL drafted the article, and all authors contributed substantially to its revision. ATS takes responsibility for the paper as a whole.
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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Publication dates: Received for publication June 26, 2013. Revisions received November 23, 2013, and December 16, 2013. Accepted for publication January 7, 2014. Presented as an abstract at the American College of Emergency Physicians Research Forum, Seattle, WA, October 14-17, 2013. Address for correspondence: Annie T. Sadosty, MD, E-mail [email protected].
REFERENCES 1. Centers for Medicare & Medicaid Services. State operations manual: appendix V—interpretive guidelines—responsibilities of Medicare participating hospitals in emergency cases. Rev. 60, July 16, 2010 [cited June 25, 2013]. Available at: http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_v_emerg. pdf. Accessed January 14, 2014. 2. Owens PL, Mutter R, Stocks C; Agency for Healthcare Research and Quality. Mental health and substance abuse related emergency department visits among adults in 2007. HCUP Statistical Brief. 2010;92:1-12. 3. Torrey EF, Fuller DA, Geller J, et al; Treatment Advocacy Center. No room at the inn: trends and consequences of closing public psychiatric hospitals. July 19, 2012 [cited June 25, 2013]. Available at: http:// tacreports.org/storage/documents/no_room_at_the_inn-2012.pdf. Accessed January 14, 2014. 4. Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room “boarding” of psychiatric patients. Health Aff (Millwood). 2010;29:1637-1642.
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EMTALA and Patients With Psychiatric Emergencies 5. Bender D, Pande N, Ludwig M; US Department of Health and Human Services. Psychiatric boarding interview summary [Internet]. January 9, 2009 [cited April 10, 2013]. Available at: http://aspe.hhs. gov/daltcp/reports/2009/PsyBdInt.htm. Accessed January 14, 2014. 6. Liang BA, Zivin JA. Empirical characteristics of litigation involving tissue plasminogen activator and ischemic stroke. Ann Emerg Med. 2008;52:160-164. 7. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305-308.
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8. See, eg, Baber v. Hospital Corp. of America, 977 F.2d 872 (4th Cir 1992). 9. Richards NS. Judicial resolution of EMTALA screening claims at summary judgment. NY Univ Law Rev. 2012;87:591-636. 10. Centers for Medicare & Medicaid Services; US Department of Health and Human Services. Medicare program: clarifying policies related to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions, final rule. Fed Reg. 2003;68:53222-53264.
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EMTALA and Patients With Psychiatric Emergencies: A Review of Relevant Case Law Rachel A. Lindor, JD; Ronna L. Campbell, MD, PhD; Jesse M. Pines, MD, MBA; Gabrielle J. Melin, MD; Agnes M. Schipper, JD; Deepi G. Goyal, MD; Annie T. Sadosty, MD
Study objective: Emergency department (ED) care for patients with psychiatric complaints has become increasingly challenging given recent nationwide declines in available inpatient psychiatric beds. This creates pressure to manage psychiatric patients in the ED or as outpatients and may place providers and institutions at risk for liability under the Emergency Medical Treatment and Labor Act (EMTALA). We describe the patient characteristics, disposition, and legal outcomes of EMTALA cases involving patients with psychiatric complaints. Methods: Jury verdicts, settlements, and other litigation involving alleged EMTALA violations related to psychiatric patients between the law’s enactment in 1986 and the end of 2012 were collected from 3 legal databases (Westlaw, Lexis, and Bloomberg Law). Details about the patient characteristics, disposition, and reasons for litigation were independently abstracted by 2 trained reviewers onto a standardized data form. Results: Thirty-three relevant cases were identified. Two cases were decided in favor of the plaintiffs, 4 cases were settled, 10 cases had an unknown outcome, and 17 were decided in favor of the defendant institutions. Most patients in these 33 cases were men, had past psychiatric diagnoses, were not evaluated by a psychiatrist, and eventually committed or attempted suicide. The most frequently successful defense used by institutions was to demonstrate that their providers used a standard screening examination and did not detect an emergency medical condition that required stabilization. Conclusion: Lawsuits involving alleged EMTALA violations in the care of ED patients with psychiatric complaints are uncommon and rarely successful. [Ann Emerg Med. 2014;-:1-6.] Please see page XX for the Editor’s Capsule Summary of this article. 0196-0644/$-see front matter Copyright © 2014 by the American College of Emergency Physicians. http://dx.doi.org/10.1016/j.annemergmed.2014.01.005
INTRODUCTION Background The Emergency Medical Treatment and Labor Act (EMTALA) mandates that patients who present to emergency departments (EDs) be given appropriate screening examinations. If an emergency medical condition is found during that examination, the law requires that patients be stabilized before discharge or transfer. In the case of patients with psychiatric conditions, an emergency medical condition exists if the individuals are determined to be dangerous to themselves or others.1 If an ED does not have the ability to stabilize the patients, the law allows transfer of the patients and requires outside facilities to accept the transfers if they have the capacity and capability to treat the patients. EMTALA’s requirements apply to all patients, regardless of their ability to pay for their care. Importance Institutions and providers who violate EMTALA are at risk for civil monetary penalties and exclusion from the Medicare program. Institutions may also face lawsuits from private parties in civil court. These lawsuits may be brought separately or in addition to
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malpractice charges. Little is currently known about how EMTALA has been enforced in private lawsuits involving psychiatric patients.5 EMTALA’s requirements to screen and stabilize all patients may be particularly challenging in the care of patients with psychiatric conditions. Although psychiatric visits compose an increasing proportion of ED visits,2 there has been a concurrent nationwide reduction in inpatient psychiatric beds,3 often necessitating transfer of patients to outside facilities, prolonged ED boarding, or ED-based care for patients with psychiatric complaints.4 These factors may compel providers to choose between holding at-risk psychiatric patients in already crowded EDs or discharging them. ED directors have cited EMTALA as one of the main reasons they keep psychiatric patients within the ED for hours or days rather than discharging them.5 Goals of This Investigation This study seeks to characterize trends in the incidence, patient characteristics, and legal outcomes of private EMTALA cases involving psychiatric patients, with the goal of clarifying courts’ interpretations of providers’ EMTALA obligations when treating patients with psychiatric illness. Annals of Emergency Medicine 1
Lindor et al
EMTALA and Patients With Psychiatric Emergencies
Editor’s Capsule Summary
What is already known on this topic Emergency providers cite fears of Emergency Medical Treatment and Labor Act (EMTALA) violations when making disposition decisions for patients with psychiatric disorders. What question this study addressed This structured review of case decisions published in common legal databases describes the frequency and outcomes of psychiatric-related EMTALA claims in the 26 years since EMTALA’s enactment. What this study adds to our knowledge Only 33 psychiatric-related EMTALA case decisions have been published since 1986. Only 2 cases are known to have been decided against the provider. How this is relevant to clinical practice Physicians who practice good medicine should not be terribly concerned about EMTALA for psychiatric patients; however, the study did not examine medicolegal claims distinct from EMTALA.
information (3), yielding 33 unique cases that involved EMTALA allegations revolving around the care of patients with psychiatric complaints. The authors were provided with sample cases and met as a group to discuss what characteristics of the patients and ED courses could be reasonably obtained and would be relevant. Per Gilbert et al,7 a standardized data form was created to record details about characteristics of the patients, ED evaluation, and legal outcome. The 2 primary abstractors (R.A.L. and R.L.C.) independently abstracted 5 full cases and discussed any conflicts. Ambiguities in data categories were clarified with the full group before full data abstraction was performed. Two abstractors (R.A.L. and R.L.C.) independently reviewed and abstracted the information for all cases. Conflicting or ambiguous data were discussed, and a senior investigator (A.T.S.) adjudicated any disagreements.
RESULTS Characteristics of Study Subjects Table 1 summarizes characteristics of patient presentation, evaluation, disposition, and reasons for litigation. The mean age of patients involved in litigation was 31 years (range 17 to 52 years; median 28 years; interquartile range 22 to 40 years). The majority of patients were men, had a past psychiatric diagnosis, were not treated by psychiatrists or providers with dedicated psychiatric training, were discharged from the ED, and eventually committed or attempted suicide.
MATERIALS AND METHODS Study Design Three subscription legal databases (Westlaw, Lexis, and Bloomberg Law) were searched for all relevant court opinions, jury verdicts, and settlements, using the query terms “EMTALA,” “Emergency Medical Treatment and Active Labor Act,” “anti-dumping,” and “emergency department” and using a Boolean search including “suicide,” “psych,” “mental health,” “behavioral health,” and “mental illness.” These databases contain legal decisions that have been published by the courts, in addition to unpublished opinions and settlements electively published by each database. Although additional legal databases do exist and may contain a small number of additional unpublished opinions not included in this study, the 3 databases used contain a comprehensive catalog of the published opinions and thus provide a nearly comprehensive snapshot of the available information. All cases reported from 1986, the year EMTALA was enacted, through the end of 2012 were included in this study. No medical records were accessed for this research. This search strategy was similar to that used in previous legal case series and yielded 383 court opinions.6 Data Collection and Processing and Primary Data Analysis Of the 383 court opinions identified in the initial search, 244 cases were excluded because of duplication and 106 were excluded because they were unrelated to a psychiatric complaint (100), were unrelated to EMTALA (3), or had insufficient 2 Annals of Emergency Medicine
Main Results Table 2 summarizes the 33 cases involving alleged EMTALA violations related to the care of patients with psychiatric complaints. As shown in the Figure, the annual incidence of EMTALA cases reported to legal databases has varied from 0 to 4 cases per year. At least 25 (75%) of the EMTALA cases identified were litigated together with a malpractice claim based on the same incident. The outcome of the EMTALA claim was unknown in 10 cases (30%). The first relevant case was filed in 1988, 2 years after the enactment of EMTALA, and was decided in 1992, requiring 4 years to progress through the court system. The mean time between the incident prompting litigation and the final legal decision in the 33 cases was 3.8 years for all cases—4.5 years for cases ultimately decided against the providers and 3.7 years in cases decided in favor of the providers or with an unknown outcome. Among the 23 cases with a known outcome, the majority (N¼17; 74%) were decided in favor of the defendant providers. Two cases with a known outcome (9%) were decided in favor of the plaintiff, whereas 4 (17%) ended with settlement. In the 17 EMTALA cases known to be decided in favor of the providers, 4 cases were decided according to procedural issues (eg, claim filed outside the statute of limitations), and the rationale for 1 case was not provided in the report. Of the remaining 12 cases in which the EMTALA requirements were applicable and the courts found in favor of the Volume
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Table 1. Characteristics of patient presentation, ED evaluation, final disposition, and reasons for litigation. Patient Characteristics*
No. (%; 95% CI)
Male sex Past psychiatric diagnosis Previous suicide attempt Substance abuse at presentation Suicidal ideation at presentation Homicidal ideation at presentation Suicide attempt before presentation Other chief complaint (eg, acute psychosis, depression, anxiety) Reasons for litigation Suicide Suicide attempt Other (eg, homicide, assault, other injuries related to high risk behaviors) Characteristics of ED evaluation* Evaluated by emergency physician only Evaluated by psychiatrist Evaluated by nonphysician provider with dedicated psychiatric training (eg, a specially trained nurse, social worker, psychologist) Characteristics of ED disposition Discharge Transferred or admitted as inpatients Left without being seen Admitted to observation unit
25 18 8 10 14 4 6 9
(76; 59–87) (55; 38–70) (24; 13–41) (30; 17–47) (42; 27–59) (12; 4–27) (18; 8–34) (27; 15–44)
19 (58; 40–73) 5 (15; 6–31) 9 (27; 15–44)
18 (55; 38–70) 11 (33; 20–50) 4 (12; 5–27)
20 10 2 1
(61; 44–75) (30; 17–47) (6; 2–20) (3; 1–15)
*The numbers shown here represent the number of cases in which the presence or absence of each characteristic was specifically documented in the court report. The percentages reflect the frequency with which each characteristic is documented in all 33 cases, recognizing that the documentation provided in the court reports may be incomplete and underestimate the true prevalence of these characteristics. Patients who were evaluated by a psychiatrist or other provider with dedicated training may also have been treated by an emergency physician.
providers, 1 case was based on a court’s determination that a patient was properly stabilized. In the 11 remaining cases, courts determined that an appropriate medical screening examination was provided and no emergency medical conditions were found; therefore, the courts did not even consider whether the patients had been properly stabilized because this is a requirement only if an emergency medical condition is detected.
LIMITATIONS This study is based on court opinions reported by available legal databases. Most of these opinions are from appeals-level courts, which often make decisions on single issues within a case but do not decide the final outcome of the case. Instead, the final outcome is often decided by local trial courts, which do not publish most cases. As a result, the final outcome was not available in 10 of the 33 cases in this study. In addition, these databases do not contain records of cases dismissed before trial or settled out of court, except for a small number that are electively chosen by each database vendor. The databases also do not include most reports of jury trials. Therefore, the cases used in this study represent a subset of all relevant EMTALA cases. In the cases that are reported, the results are based on information available in the text of court opinions, which are Volume
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written by individual judges and contain various amounts of detail. As a result, the information presented here may underestimate the prevalence of certain factors or characteristics. For example, court opinions reported a past psychiatric diagnosis in 55% of cases, but many opinions simply did not reference past diagnoses, meaning the actual percentage may be higher than our results demonstrate. These cases represent claims of EMTALA violations, not claims of medical malpractice. EMTALA claims are based on allegations that providers failed to appropriately screen and stabilize patients as required by the EMTALA statute. In contrast, medical malpractice claims are based on allegations that providers practiced negligently. It is possible for providers to comply with EMTALA yet commit malpractice in the same patient encounter. To illustrate, the EMTALA statute requires that providers administer an “appropriate medical screening examination,” which has been interpreted as a duty to apply the same screening procedures to paying and nonpaying patients alike.8 In contrast, medical malpractice law requires providers to practice with “due care,” which has been defined by courts as a duty to practice non-negligently. A court can find that providers are screening all patients uniformly, thus meeting the requirements of EMTALA, and also find that the screening examination is negligently designed or performed, thus putting the providers at risk for medical malpractice claims. Because of the different standards for EMTALA and malpractice liability, the cases in this study illustrate institutions’ liability risks under EMTALA, but they do not provide insight into the corresponding liability risks under malpractice law, which may be enforced separately from or in addition to those of EMTALA.
DISCUSSION Despite being cited as a common concern among ED directors, our study suggests that private lawsuits alleging EMTALA violations during the care of psychiatric patients are rare and infrequently successful. In the majority of cases with a known outcome, the courts found there was no violation because the providers performed appropriate screening examinations, did not detect any emergency medical conditions, and therefore had no further duty to stabilize the patients. This finding is consistent with a previous report demonstrating that most EMTALA claims are decided according to courts’ determinations that an appropriate screening examination was provided, whereas few decisions are made according to whether stabilization was medically achieved.9 In accordance with the limited number of cases available, we did not determine whether the incidence of relevant EMTALA lawsuits has changed in recent years. Because judges are able to dismiss cases at an early stage if they determine that there is no feasible claim, many claims never make it to litigation. The cases that pass the first hurdle to litigation, such as those included in this study’s data, therefore represent scenarios that pose the highest risk of being judged as an actual EMTALA violation. Despite their low success rate, these cases still represent Annals of Emergency Medicine 3
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EMTALA and Patients With Psychiatric Emergencies Table 2. Outcomes of private EMTALA cases involving patients with psychiatric issues. Year Reported
State of Incident
Patient Outcome
1992 1992 1993 1995 1995 1995 1996 2000 2001 2001 2002 2002 2003
Tennessee West Virginia Missouri Ohio Kansas Maryland California Texas North Carolina California Illinois New Mexico Illinois
2004 2005 2005 2006 2006 2006 2006 2007 2008 2009 2009 2010 2010 2011 2011 2011 2012 2012 2012 2012
Illinois New Hampshire Vermont Florida California Tennessee Michigan Louisiana Texas Michigan California Tennessee California Nebraska Virginia Nevada Michigan Massachusetts Michigan Missouri
Suicide attempt Medical death Suicide Suicide Suicide Suicide attempt Suicide Suicide Suicide Suicide Suicide Suicide Worsening of psychiatric illness—death (MVA) Incarceration Incarceration Suicide Victim of assault Suicide attempt Suicide attempt Victim of assault Suicide Suicide Homicide Suicide Suicide Suicide attempt Suicide Worsening of psychiatric illness Suicide Suicide Suicide Suicide Victim of assault
EMTALA Lawsuit Outcome No violation No violation Unknown No violation No violation No violation No violation Settlement No violation No violation No violation Settlement Unknown Unknown Violation Settlement No violation No violation Unknown Unknown Unknown Violation No violation No violation No violation Unknown Unknown No violation Unknown No violation Settlement Unknown No violation
Associated Malpractice Suit
Amount, $
Yes Unk* Yes Yes Yes Unk Unk Yes Unk Yes Yes Yes Unk
Confidential
Confidential
Yes Yes Yes Unk Yes Yes Yes Yes Yes Yes Yes Unk Yes Yes Yes Yes Yes Unk Yes Yes
150,000 Confidential
0†
20,000
Unk, Unknown; MVA, motor vehicle accident. *Elements of these cases were heard in appeals court and therefore reported in the legal databases used for this study, but the final disposition of the cases was decided later in trial courts, which are less frequently reported in the databases. † Damages in trial were awarded as part of a civil liability claim, which was later reversed on appeal rather than as part of the EMTALA violation, which was not challenged on appeal.
significant burdens for the litigants, with an average length of time between the incident in controversy and the ultimate decision of almost 4 years. Among these cases, the most prevalent characteristics of patients included male sex, a history of a psychiatric diagnosis, and ongoing suicidal ideation. In addition, most patients were not evaluated by a psychiatrist, were discharged directly from the ED, and eventually committed suicide. We are unable to determine whether the risk of an EMTALA claim is higher when no psychiatric consultation is performed. However, the fact that the majority of claims involved evaluation by nonpsychiatrists only, particularly in cases in which suicidal ideation was present, should be carefully considered. No common themes were identified in the 2 cases that resulted in a finding of an EMTALA violation. The first case, which occurred in 2000 and was reported by the courts in 2005, involved a female patient with a history of alcohol abuse and depression who presented to the ED intoxicated and with suicidal ideation. 4 Annals of Emergency Medicine
She was treated by an emergency physician who suggested that she speak with a guidance counselor in the ED, but the woman refused to talk to the counselor. The emergency physician subsequently committed her to police protective custody, and she filed an EMTALA claim after she was detained in a jail overnight with no psychiatric care. The second case, which occurred in 1997 and was decided in 2001, involved an uninsured patient with a history of depression and previous suicide attempts who presented to the ED after inflicting shallow cuts on his wrist. He was treated by a psychiatric nurse who had him fill out a contract in which he agreed to stay in the company of friends and family until an outpatient psychiatry appointment could be scheduled. An emergency physician cosigned the safety contract but never formally assessed the patient. The patient was subsequently discharged from the hospital and hanged himself the next day. Courts frequently consider screening examinations to be appropriate for the purposes of EMTALA even if the Volume
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EMTALA and Patients With Psychiatric Emergencies were applied relatively uniformly and did not detect any emergency medical conditions that required stabilization. Questions about whether the screening examinations were performed adequately are generally the purview of malpractice law rather than EMTALA. Though clinicians have cited fear of EMTALA liability as a factor in their disposition choices for psychiatric patients,5 this review suggests that the threat of liability under EMTALA is small. Documenting adherence to a uniform screening procedure may make that liability threat even smaller. Supervising editors: Megan L. Ranney, MD, MPH; Debra E. Houry, MD, MPH
Figure. Number of EMTALA cases involving psychiatric patients published per year. The cases are shown here in the year they were decided rather than the year that the inciting event occurred or the year the cases were filed. The average time between the inciting event and the final decision was nearly 4 years because of the time it takes for a case to progress through the court system.
Author affiliations: From the Mayo Medical School (Lindor), Department of Emergency Medicine (Campbell, Goyal, Sadosty), Department of Psychiatry and Psychology (Melin), and Legal Department (Schipper), Mayo Clinic College of Medicine, Rochester, MN; and the Departments of Emergency Medicine and Health Policy, George Washington University, Washington, DC (Pines).
examinations fail to detect an emergency medical condition when one appeared to be present in retrospect. In this study, this was most often observed in cases in which patients presented with suicidal ideation, were found not to have an emergency medical condition on screening, were discharged, and committed or attempted suicide soon thereafter. In these cases, many plaintiffs alleged that the patients’ emergency medical conditions were so obvious that the providers should have detected them on their screening examinations and therefore had a duty to stabilize the patients. However, for the purposes of EMTALA, the courts consistently emphasized that as long as the screening examinations were applied uniformly, the EMTALA duty was met, and allegations about the adequacy of the screening examinations were more properly heard as medical malpractice claims. Nearly a third of cases involved patients who were admitted as inpatients. All but 2 of these cases represented patient encounters that occurred before 2003, when the government issued regulations clarifying that EMTALA obligations end on admission unless there is evidence that the admission was made in bad faith, such as for the purpose of evading EMTALA obligations.10 Since this clarification, courts generally hear EMTALA cases involving inpatient admissions only if there is reason to believe that the patient was admitted by the hospital simply so it could avoid its EMTALA obligations. This may occur, for example, if a patient is admitted from the ED and is promptly discharged from the hospital without further care. Since 2003, courts appear to be following the regulations about the applicability of EMTALA to inpatients and heard significantly fewer claims involving these patients. In summary, private lawsuits alleging EMTALA violations arising from the care of psychiatric patients are rare and infrequently successful. In most cases, courts determine, according to the patients’ or families’ inability to demonstrate otherwise, that the screening examinations performed in EDs
Author contributions: RAL and ATS conceived the study. All authors participated in trial design. RAL, RLC, and ATS conducted data collection, and all authors participated in data analysis. RAL drafted the article, and all authors contributed substantially to its revision. ATS takes responsibility for the paper as a whole.
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Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article as per ICMJE conflict of interest guidelines (see www.icmje.org). The authors have stated that no such relationships exist. Publication dates: Received for publication June 26, 2013. Revisions received November 23, 2013, and December 16, 2013. Accepted for publication January 7, 2014. Presented as an abstract at the American College of Emergency Physicians Research Forum, Seattle, WA, October 14-17, 2013. Address for correspondence: Annie T. Sadosty, MD, E-mail [email protected].
REFERENCES 1. Centers for Medicare & Medicaid Services. State operations manual: appendix V—interpretive guidelines—responsibilities of Medicare participating hospitals in emergency cases. Rev. 60, July 16, 2010 [cited June 25, 2013]. Available at: http://www.cms.gov/Regulationsand-Guidance/Guidance/Manuals/downloads/som107ap_v_emerg. pdf. Accessed January 14, 2014. 2. Owens PL, Mutter R, Stocks C; Agency for Healthcare Research and Quality. Mental health and substance abuse related emergency department visits among adults in 2007. HCUP Statistical Brief. 2010;92:1-12. 3. Torrey EF, Fuller DA, Geller J, et al; Treatment Advocacy Center. No room at the inn: trends and consequences of closing public psychiatric hospitals. July 19, 2012 [cited June 25, 2013]. Available at: http:// tacreports.org/storage/documents/no_room_at_the_inn-2012.pdf. Accessed January 14, 2014. 4. Alakeson V, Pande N, Ludwig M. A plan to reduce emergency room “boarding” of psychiatric patients. Health Aff (Millwood). 2010;29:1637-1642.
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EMTALA and Patients With Psychiatric Emergencies 5. Bender D, Pande N, Ludwig M; US Department of Health and Human Services. Psychiatric boarding interview summary [Internet]. January 9, 2009 [cited April 10, 2013]. Available at: http://aspe.hhs. gov/daltcp/reports/2009/PsyBdInt.htm. Accessed January 14, 2014. 6. Liang BA, Zivin JA. Empirical characteristics of litigation involving tissue plasminogen activator and ischemic stroke. Ann Emerg Med. 2008;52:160-164. 7. Gilbert EH, Lowenstein SR, Koziol-McLain J, et al. Chart reviews in emergency medicine research: where are the methods? Ann Emerg Med. 1996;27:305-308.
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8. See, eg, Baber v. Hospital Corp. of America, 977 F.2d 872 (4th Cir 1992). 9. Richards NS. Judicial resolution of EMTALA screening claims at summary judgment. NY Univ Law Rev. 2012;87:591-636. 10. Centers for Medicare & Medicaid Services; US Department of Health and Human Services. Medicare program: clarifying policies related to the responsibilities of Medicare-participating hospitals in treating individuals with emergency medical conditions, final rule. Fed Reg. 2003;68:53222-53264.
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