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Date: May 15th, 2019

Reference: Terp et al. Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. AEM May 2019

Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine.

Case: You are working in your emergency department at a hospital that has an on-site psychiatric unit. You are holding several patients in the department who have been placed on involuntary holds for suicidal ideation while a bed search occurs at facilities elsewhere in the region. Your charge nurse tells you that she has learned the psychiatric unit has open beds that currently aren’t being used.

Background: The Emergency Medical Treatment and Labor Act (EMTALA) was passed in 1986 to combat and prevent delayed, denied, or inadequate treatment of uninsured ED patients.

This federal US law mandates that patients who present to an emergency department must have a medical screening evaluation, stabilization of their emergent needs and arrange transfer to higher level of care if necessary.

There is also an obligation on the receiving hospital. They must accept these patients in transfer if they have a specialist on-call with the ability to manage the patient.

The Center for Medicare and Medicaid Services (CMS) has clarified that EMTALA applies to psychiatric emergencies.

CMS has terminated Medicare provider agreements to 12 hospitals, four of which were related to psychiatric emergencies. Civil monetary penalties may also be levied for EMTALA violations.

Clinical Question: What are the characteristics of civil monetary penalties related to EMTALA violations involving psychiatric emergencies compared to non-psychiatric emergencies?

Reference: Terp et al. Civil Monetary Penalties Resulting from Violations of the Emergency Medical Treatment and Labor Act (EMTALA) Involving Psychiatric Emergencies, 2002 to 2018. AEM May 2019

  • Population: All civil monetary penalty settlements between 2002 and December 11, 2018
  • Exposure: EMTALA violations related to psychiatric emergencies.
  • Comparison: EMTALA violations not involving psychiatric emergencies.
  • Outcome: Civil monetary penalties levied by the Office of the Inspector General (OIG).

Dr. Sophie Terp

This is an SGEMHOP episode which means we have the lead author on the show. Dr. Sophie Terp is an is an assistant professor of clinical emergency medicine in the Department of Emergency Medicine at the Keck School of Medicine of USC. Her research focuses primarily on access to emergency care for vulnerable populations and specifically on enforcement of the Emergency Medical Treatment and Labor Act (EMTALA).

Authors’ Conclusions: “Nearly one in five civil monetary penalties related to Emergency Medical Treatment and Labor Act violations involved psychiatric emergencies. Settlements related to psychiatric conditions concentrate in two of the 10 Centers for Medicare & Medicaid Services regions, with half of all settlements occurring in three states (Florida, North Carolina, and Missouri). Average financial penalties related to psychiatric emergencies were over twice as high as penalties for nonpsychiatric complaints. Recent large penalties related to violations of the Emergency Medical Treatment and Labor Act law underscore the importance of improving access to and quality of care for patients with psychiatric emergencies.”

Quality Checklist forObservational Study:

  1. Did the study address a clearly focused issue? Yes
  2. Did the authors use an appropriate method to answer their question? Yes
  3. Was the cohort recruited in an acceptable way? Yes
  4. Was the exposure accurately measured to minimize bias? Yes
  5. Was the outcome accurately measured to minimize bias? Yes
  6. Have the authors identified all-important confounding factors? Unsure
  7. Was the follow up of subjects complete enough? Unsure
  8. How precise are the results? Unsure
  9. Do you believe the results? Yes
  10. Can the results be applied to the local population? Yes
  11. Do the results of this study fit with other available evidence? Yes

Key Results: They searched 16 years and identified 230 civil monetary penalty settlements related to EMTALA violations. There were 222 (97%) penalties levied against facilities and 8 (3%) against individuals. A decline in settlements related to non-psychiatric emergencies was noted, with an increase in those related to psychiatric emergencies

One in five settlements involved psychiatric emergencies. The average psychiatric-related settlement was 2.6 times the average non-psychiatric settlement.

  • The settlements involving psychiatric patients were all against the hospital
  • Five (83%) of the six settlements more than $100,000 were for psychiatric complaints
  • The three largest settlements were $1,295,000; $260,000; and $200,000
  • Psychiatric Cases: Mean $85,488.64 (95% CI 25,766.07 – 145,211.20)
  • Non Psychiatric Cases: Mean $32,004.45 (95% CI 28,802.75 – 35,206.16)

Listen to the podcast on iTunes or Google Play to hear Sophie’s responses to our five nerdy questions.

  1. Medical Screening Evaluation (MSE): Failure to do an MSE was the most identified EMTALA violation for psychiatric patients (37/44 – 84%). Are we doing a poor job in screening these patients?
  2. Failure to Stabilize: This was the second most common identified EMTALA violation and the only one statistically different from the non-psychiatric settlements. Can you discuss what you think this specifically means, and provide some examples?
  3. Increasing Numbers: One-in-five settlements were for psychiatric cases and the number is rising. Any idea why this might be happening?
  4. Penalties: Can you speculate as to why penalties are higher for psychiatric vs non-psychiatric violations?
  5. Case Study: You presented a case study in your paper of an EMTALA violation involving a hospital in the southeast and boarding a psychiatric patient for 38 days in the ED. Can you briefly describe what happened?

Comment on the Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

SGEM Bottom Line: Civil monetary penalties for EMTALA violations involving psychiatric patients are increasing, and very expensive for hospitals. Institutions need to have protocols in place to avoid inadequate stabilization, screening, and inappropriate transfer of patients.

Case Resolution: You call on the on-call psychiatrist who arranges for nursing staff to open up the remaining beds in the psychiatric unit.

Dr. Corey Heitz

Clinical Application:  Do an appropriate medical screening exam on all ED patients including psychiatric patients.  Stabilize any emergent needs and arrange transfer of any patient to a higher level of care if necessary.

What Do I Tell My Patient?    You need emergency mental healthcare. We have a bed for you in our hospital and our great psychiatric team will take care of you.

Keener Kontest: Last weeks’ winner was Amy Makish from London, Ontario. She knew Amyand’s Hernia is an inguinal hernia when the appendix is included in the hernia sac and becomes incarcerated.

Listen to the podcast to hear this weeks’ trivia question. If you know the answer, send an email to TheSGEM@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize.

SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on EMTALA violations in psychiatric emergencies? Tweet your comments using #SGEMHOP. What questions do you have for Sophie and herteam? Ask them on the SGEM blog. The best social media feedback will be published in AEM.

Also, don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. We will put the process on the SGEM blog:

  • Go to the Wiley Health Learningwebsite
  • Register and create a log in
  • Search for Academic Emergency Medicine – “May”
  • Complete the five questions and submit your answers
  • Please email Corey (coreyheitzmd@gmail.com) with any questions or difficulties.

Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine.