The Emergency Medical Treatment and Active Labor Act ("EMTALA") was enacted in 1986 as part of the Consolidated Omnibus Budget Reconciliation Act ("COBRA")1. The statute is often referred to as the "anti-dumping statute," as it was enacted pursuant to legislative concern that hospital emergency departments were transferring unstable patients or refusing to provide emergency services based on the patient’s uninsured status or inability to pay for treatment.2
This article addresses the availability of relief for plaintiffs in federal court through establishing a cause of action under EMTALA, and through attaching appropriate state claims for medical malpractice, wrongful death, loss of consortium, and intentional or negligent infliction of emotional distress to the federal claim. This article focuses on two cases from the United States District Court for the Northern District of Illinois, where the court interpreted key components of EMTALA. There are no reported Seventh Circuit or Illinois state court cases addressing the scope of EMTALA. The lack of reported case law in Illinois indicates that Illinois plaintiffs could be missing an important opportunity to bring a cause of action in federal court under EMTALA.
Although EMTALA does not create a federal medical malpractice claim,3 it does provide plaintiffs with a private cause of action in federal court to "obtain those damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as is appropriate."4 The statute does not apply to claims against individual physicians, but only to hospitals.5 If a plaintiff can state a cause of action under EMTALA, relief may not only be available under the statute, but appropriate state law claims may be attached to the EMTALA claim and addressed by federal courts through supplemental jurisdiction.
EMTALA imposes two basic requirements on hospitals furnishing emergency services.6 When a patient comes to a hospital emergency department seeking treatment, EMTALA requires hospitals to:
1. Provide an appropriate medical screening examination, and
2. Provide necessary stabilizing treatment for emergency medical conditions.
Further, the statute requires that a hospital refrain from transferring an unstabilized patient unless the benefits of transfer outweigh the risks and the transfer is "appropriate." EMTALA requires the transferring as well as the receiving hospital to follow certain procedures in order for the transfer to be considered appropriate.
A. The Meaning of "Comes to" the Emergency Department
The Health Care Financing Administration ("HCFA"), the federal agency charged with the responsibility of administering EMTALA, has promulgated regulations giving an expansive meaning to the phrase "comes to the emergency department." According to the regulations, an individual patient has come to the emergency department when he or she is on hospital property.7 Hospital property, in turn, includes the following:8
1. The entire hospital campus, including the parking lot, sidewalk, driveway, and any areas or structures located within 250 yards of the main buildings;
2. Ambulances owned and operated by the hospital, even if the ambulance is not on hospital grounds;
3. Ambulances not owned by the hospital if they are on the hospital campus.
A few years ago, a Chicago incident captured national attention when a hospital’s emergency department personnel refused to assist a young gunshot victim who lay bleeding only 35 feet from the hospital’s doors. The staff members said that hospital policy would not allow them to leave the hospital to treat the victim, and the teenager died. The HCFA definition of hospital property set forth above should ensure that such incidents would not occur again, because the hospital would be in violation of EMTALA if it refuses to screen and stabilize a patient who is within 250 yards of the main hospital building.
Interestingly, the First Circuit has recently held that EMTALA applies to any hospital inpatient with an emergency medical condition, regardless of how that person enters the hospital or where within the hospital he is located at the time of onset of the emergency medical condition. In Lopez-Soto v. Hawayek,9 a woman in labor was admitted to the maternity ward, and gave birth to a baby boy by cesarean section. The physician noted that the newborn was suffering from severe respiratory distress, but transferred him to a neonatal intensive care unit at a different hospital without stabilizing him. The newborn died the next day, and the parents sued the hospital under EMTALA. The court held that the stabilization provisions of EMTALA applied under these facts, even though the mother had not come to the emergency room. The court noted that the Congressional intent in enacting EMTALA was not only to prohibit hospitals from turning away indigent patients but also to protect inpatients with emergency conditions from being improperly discharged or transferred in order to save costs.
B. Appropriate Medical Screening Examination
EMTALA requires that a hospital with emergency department provide an appropriate medical screening examination to patients who come to the hospital seeking treatment.10 The medical screening examination is undertaken to determine whether or not an emergency medical condition exists. If the patient is unconscious, a request for treatment can be made on the patient’s behalf.11
EMTALA does not define what constitutes an appropriate medical screening examination; however, both the HCFA and the United States District Court for the Northern District of Illinois have indicated that uniformity is the litmus test to determine if an appropriate medical screening examination has been conducted. HCFA has stated that a hospital has met its obligations under EMTALA if it applies, in a nondiscriminatory manner, a screening process that is reasonably calculated to determine whether an emergency medical condition exists.12
Both the plain language of the statute and the HCFA guidelines set forth in the Medicare/Medicaid State Operations Manual, indicate that an appropriate medical screening exam may range from a simple procedure, involving only the physician taking the patient’s history and conducting a routine physical examination, to complex procedures involving the use of a hospital’s ancillary services, laboratory tests, and other clinical services.13 EMTALA is not designed to address the appropriateness or thoroughness of the medical screening exam, but only to insure that the exam is applied uniformly regardless of a patient’s ability to pay.14
The United States District Court for the Northern District of Illinois has also focused on a standard of uniformity in order to determine if a hospital has violated the screening requirement of EMTALA. In Woessner v. Freeport Memorial Hospital, the court addressed the definition of an appropriate medical screening examination under EMTALA.15 In Woessner, the plaintiff arrived at the defendant’s emergency department, suffering from a high fever and pain in his left thigh.16 He was admitted to the hospital and tests were performed. Eventually, a doctor examined the blood test results and suggested that the plaintiff be transferred to another hospital for further evaluation. After the plaintiff was transferred, his condition deteriorated, and he nearly died after arriving at the second hospital. He also suffered additional complications requiring surgery, and eventually had to have his left leg amputated.17
At the outset, the defendant hospital argued that EMTALA was not applicable under those facts, as the statute was enacted to prevent hospitals from refusing to treat indigent or uninsured patients. Because the Woessner plaintiff did not establish his inability to pay, the hospital argued, EMTALA did not apply.18 The court rejected this argument, noting that EMTALA unambiguously refers to "any individual," and that although application of the statute’s plain language may result in a broader application than was originally intended, it does not produce unjust or absurd results.19
The plaintiff in Woessner alleged that the defendant hospital violated two provisions of EMTALA by failing to provide an appropriate medical screening examination when the plaintiff presented himself to the emergency room, and by failing to stabilize him prior to transfer. The hospital argued that the plaintiff failed to state a cause of action under EMTALA and urged the district court to apply the standard set by the Sixth Circuit in Gatewood v. Washington Healthcare Corp.20 as to both the screening and stabilization provisions of the statute.
Gatewood was a case involving the appropriateness of the medical screening examination given to the plaintiff, and the Sixth Circuit began by noting that in enacting EMTALA, Congress did not intend to enact a sweeping federal negligence or malpractice cause of action. According to the Gatewood court, the key inquiry under EMTALA is not whether a person received a correct diagnosis, but whether he was afforded the same level of treatment that was regularly provided to other patients in similar medical circumstances. The Woessner court concurred with that analysis, stating that "[t]he issue [was] not whether the hospital conformed to a standard of care as recognized under state negligence law, but whether the hospital conformed to its own standard emergency room procedures for treating similarly situated patients."21 Therefore, a hospital that is found to have conformed to its customary screening procedures is not liable under EMTALA, even though those standards may violate state negligence law.22 The Woessner court rejected the plaintiff’s argument that this approach would make hospitals immune to a lawsuit if it treated all patients poorly. The court reasoned that if a hospital treated all patients poorly, it would become subject not only to numerous negligence and malpractice actions, but that in theory, it could be held liable under EMTALA if its standards were so low as to amount to no appropriate medical screening at all.23
C. Necessary Stabilizing Treatment
The defendant in Woessner further urged the court to extend the Gatewood reasoning to the stabilization requirement of EMTALA as well, but the court refused to do so. Instead, the court noted that EMTALA contains a definition of stabilization, and therefore, there was no need to look further than the plain language of the statute.24
EMTALA defines "to stabilize," as "[t]o provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from the facility."25 The Woessner court reasoned that the definition of stabilization requires that medical treatment and discharge of a patient be reasonable under the circumstances, and that, therefore, the statutory requirement to provide stabilization does not hinge on whether or not the treatment is administered uniformly to similarly situated patients.26 Because the court was addressing the merits of a motion to dismiss, it did not discuss whether or not the hospital did in fact stabilize the plaintiff, but, rather, held that whether or not the plaintiff had been stabilized as required by EMTALA was a factual question that could not be decided at the dismissal stage.
In Williams v. County of Cook,27 the United States District Court for the Northern District of Illinois dealt, once again, with both the screening and stabilization requirements of EMTALA. Though the facts of the case are rather gruesome, it illustrates how careful courts are to avoid any appearance of entwining a state medical malpractice claim with a federal EMTALA claim.
In Williams, the plaintiff came to the defendant hospital’s emergency room in active labor. She alleged that the attending physicians did not examine, assess, screen, diagnose, or otherwise treat her, but instead proposed to transfer her to another hospital and told her to wait in the lobby. Williams waited in the lobby of the hospital for three hours before eventually receiving treatment after her baby’s feet began to protrude from her birth canal. During delivery, the baby’s head was decapitated, and only the torso was delivered. However, the attending physicians did not inform Williams that the baby’s head remained inside her. She was left alone, and while attempting to use the bathroom, expelled the decapitated head of her baby onto the bathroom floor.
Two hours later, she was admitted to the hospital to deliver what she was told was the placenta of her baby. Labor was induced, and Williams delivered the placenta of her first baby, along with a second baby, who Williams claimed was "viable, undiagnosed and born alive."28 According to her, the attending physicians abandoned the second baby, who died later that day. Williams was discharged the next day without knowing the whereabouts of either of her two babies or the circumstances surrounding their deaths.
In addressing Williams’ EMTALA claims, the court held that the defendant hospital did not violate EMTALA’s requirement that, if an emergency medical condition exists, a hospital must ordinarily stabilize the medical condition before transferring or discharging a patient.29 The court held that Williams had not been transferred or discharged before the emergency medical condition was stabilized, and that in fact, she was eventually treated.
Interestingly, the Williams court did not address whether the defendant’s treatment of Williams was consistent with the treatment of other patients, but rather, concluded that because treatment occurred and the plaintiff was not transferred to another facility, the stabilization requirement of EMTALA was satisfied. The court held, further, that most of the other allegations were relevant only to state law claims of malpractice.
However, the court did reject the hospital’s argument that because the attending physicians proposed to transfer the plaintiff to another hospital, a screening examination must necessarily have taken place. According to the court, whether or not a screening examination had taken place was a question of fact, and that, therefore, the issue could not be decided on a motion to dismiss.30
Unlike the court in Woessner, the Williams court seemed to apply a flat standard to the stabilization requirement, holding that if any treatment occurs and there is no transfer of the patient, EMTALA is satisfied, regardless of whether or not that treatment is uniform between patients able to pay for the care received and indigent or uninsured patients.
The Seventh Circuit has no published decisions interpreting the stabilization provisions of EMTALA. However, in a recent case, the Sixth Circuit has used a flexible standard of reasonableness in determining whether the stabilization and transfer provisions of EMTALA have been met in a particular case. In Cherukuri v. Shalala,31 two people who were seriously injured in an auto accident were taken to a rural hospital without trauma capabilities. Because the victims had head injuries in addition to internal bleeding, and the emergency room physician decided that they needed surgery before they were transferred to a different hospital that had a trauma unit. The anesthesiologist on call advised against surgery because the hospital lacked the equipment to monitor the effects of anesthesia on the pressure in the brain. The physician transferred the patients to another hospital, and he was subsequently assessed a civil monetary penalty of $100,000 on the ground that he had violated the stabilization requirement of EMTALA by failing to stop the internal bleeding before transferring the patients. The Sixth Circuit, applying a flexible standard of reasonableness, held that the facts did not show that the physician knew or should have known that the risks of transfer outweighed the benefits. The decision shows that physicians who use their best medical judgment with regard to patient transfers in emergency situations need not have anything to fear from EMTALA.
D. Transfers to Other Facilities
In some instances, it may be to a patient’s advantage to be transferred before stabilization. EMTALA requires that a physician sign a certification stating that based on the information available at the time of the transfer, the benefit of transferring the individual to another facility outweigh the risks involved in the transfer.32 The certification should also contain a summary of the risks and benefits upon which it is based.
Under EMTALA, a transfer is considered appropriate if the transferring hospital provides medical treatment within its capacity to minimize the risk to the individual or to the unborn child. There are certain procedures that must also be followed in effecting the transfer.
E. Appropriate State Law Claims
Although it may be possible to attach related state claims to an EMTALA claim, the statute can not be used to adjudicate claims for medical negligence or other state law claims relating to medical malpractice. It is important to keep state law claims and federal EMTALA claims isolated for purposes of establishing a cause of action under each. EMTALA claims are subject to a two-year statute of limitations33, but any notice requirements under state law may also apply to EMTALA claims.34 Although the state law claims will likely arise out of the same transaction or occurrence as a plaintiff’s EMTALA claim, the facts must support all the elements of each cause of action. For example, violation of EMTALA cannot be used to establish a cause of action for a state claim of medical malpractice.35
Federal courts in Illinois have recognized that when a plaintiff brings a claim under EMTALA, a federal court may have appropriate supplemental jurisdiction for negligence36, loss of consortium37, intentional or negligent infliction of emotional distress38, and wrongful death39. As stated above, a successful plaintiff must plead each of the elements of these causes of action separately from any claim arising under EMTALA.
E. Damages Available Under EMTALA
A hospital that participates in the Medicare program and violates EMTALA is subject to a civil money penalty of up to $50,000 ($25,000 if the hospital has less than 100 beds) for each violation.40 The hospital is also subject to the termination of its Medicare provider agreement. Further, physicians who violate EMTALA may be liable for a civil money penalty of up to $50,000, as well as face possible exclusion from federal healthcare programs.
EMTALA allows plaintiffs to sue hospitals and recover damages available for personal injury under the law of the State in which the hospital is located, and such equitable relief as appropriate.41 It should be remembered, however, that under EMTALA, a private cause of action may be brought only against a hospital, and not against an individual physician.
F. Public Entities Not Immune
Finally, the United States District Court for the Northern District of Illinois has held that local public entities are not immune from suit under EMTALA.42 Although the Illinois Tort Immunity Act states that local public entities are not liable for injury resulting from the failure to make a physical or mental examination, the failure to diagnose or treat a person, or the failure to admit a person to a medical facility,43 EMTALA preempts state or local law requirements that directly conflict with its requirements. EMTALA’s requirement for hospitals to provide emergency room patients with appropriate medical screenings and stabilization of emergency conditions before discharge or transfer, are in direct conflict with the Illinois Tort Immunity Act, and the Illinois law is therefore preempted.44
Although EMTALA can provide plaintiffs with an entry into federal court, federal district courts in Illinois have been careful not to allow state law issues to bleed into EMTALA claims. If a plaintiff has a distinct and viable claim under the EMTALA, a separate state law claim arising out of the same circumstances may be appropriately attached for review by a federal court.
1. 42 U.S.C. §1355dd (1999).
2. Office of the Inspector General, U.S. Department of Health and Human Services, Patient Dumping (Aug. 1, 1998).
3. See e.g., Williams v. County of Cook, 1997 WL 428534 (N.D.Ill.); Eberhardt v. City of Los Angeles, 62 F.3d 1253 (9th Cir.1995); Repp v. Anadarko Municipal Hosp., 43 F.3d 519 (10th Cir.1994); Holcomb v. Monahan, 30 F.3d 116 (11th Cir.1994).
4. 42 U.S.C. §1395dd(d)(2)(A) (1999).
5. 42 U.S.C. §1395dd(d)(2)(A) (1999); Williams, 1997 WL 428534, at *4 (adopting the position taken by the Aoverwhelming majority", and holding that plaintiffs can not bring a private cause of action against a physician). The Williams court expressly rejected the holding in Sorrells v. Babcock, 733 F.Supp. 1189 (N.D.Ill.1990), which held that a private cause of action could be brought against an individual physician under EMTALA, noting that the decision reached in Sorrells had been severely criticized.
6. EMTALA and Medicare conditions of participation for hospitals do not require hospitals to provide emergency services. It is only when emergency services are provided that a hospital will be subject to EMTALA and Medicare conditions of participation with respect to emergency services. See 42 U.S.C. §1355dd(a); 42 C.F.R. §482.12(f)(1). However, many states, including Illinois, do require that a hospital provide some basic form of emergency services in order to be licensed as a hospital. At minimum, Illinois requires hospitals to provide Standby Emergency Services in order to be licensed (77 Ill.Admin.Code tit. 77, §250.710 (c)). This provision mandates that a licensed physician be on call to the emergency department at all times. Courts have held that EMTALA imposes obligations upon physicians who serve in an on-call capacity at a participating hospital, whether or not those physician services are compensated. See e.g., Union of American Physicians and Dentists v. County of Santa Clara, 196 Cal. Rptr. 602 (Cal. App. 1983).
7. 42 C.F.R. §489.24(b); See also 42 C.F.R. §489.24 (i)(1) (stating that off-campus departments of the main hospital are subject to EMTALA requirements). Further, the capability of the hospital to provide treatment includes that of the hospital as a whole, and not just the capability of the off-campus department.
8 42 C.F.R. §489.24(b); see also 42 C.F.R. §413.65(a)(2) (defining hospital campus as including areas and structures that are not contiguous to the main buildings but are located within 250 yards of the main buildings).
9 175 F.3d 170 (1st Cir. 1999). The United States Supreme Court has also intimated that EMTALA applies to a situation where a patient was improperly transferred after receiving approximately six weeks of inpatient treatment. Roberts v. Galen of Virginia, Inc., 525 U.S. 249 (1999) (per curiam).
10. 42. U.S.C. §1399dd (1999).
13. 42 U.S.C. §1395dd (1999); Medicare/Medicaid State Operations Manual, Appendix V, Interpretive Guidelines and Investigative Procedures for Responsibilities of Medicare participating Hospitals in Emergency Cases, at 19.
14. Medicare/Medicaid State Operations Manual, Appendix V at 19 (stating that a medical screening examination is the process required to reach with reasonable clinical confidence, the point at which it can be determined whether a medical emergency does or does not exist.)
15. Woessner v. Freeport Memorial Hosp., 1993 WL 6983 (N.D.Ill.).
19. Woessner, 1993 WL 6983, at *2.
20. Gatewood v. Washington Healthcare Corp., 933 F.2d 266 (6th Cir. 1990).
21. Woessner, 1993 WL 6983, at *2.
22. Id.; see also Baber v. Hospital Corp. of Am., 977 F.2d 872, 879-80 (4th Cir.1992) (rejecting the argument that the EMTALA imposes a national standard of care on hospitals in screening patients; rather, a hospital must design its own screening procedures, then apply them uniformly to all patients with similar complaints).
23. Woessner, 1993 WL 6983, at *3.
24. Woessner, 1993 WL 6983, at *2.
25. 42.U.S.C. §1395dd(e)(3)(A), cited by Woessner, 1993 WL 6983, at *3 (emphasis added).
26. Woessner, 1993 WL 6983 at *3.
27. Williams, 1997 WL 428534 (N.D. Ill.).
28. Williams, 1997 WL 428534, at *4.
30. This type of factual circumstance is precisely what the court in Woessner envisioned, when it surmised that if a screening process did not take place, or if it was so inadequate that it did not constitute an actual examination, it would in fact violate EMTALA.
31. 175 F.3d 446 (6th Cir. 1999).
32. 42 U.S.C. §1395dd(c).
33. 42 U.S.C. §1395dd(d)(2)(C).
34. See e.g., Baucom v. DePaul Health Ctr., 918 F. Supp. 288 (E.D. Mo. 1996) (holding that an EMTALA claim can be time-barred because the hospital was not notified of the wrongful death claim within one year of the death, as required by state law).
35. See Woessner, supra; see also Holcomb v. Monahan, 30 F.3d 116 (11th Cir.1994).
36. See Woessner, supra.
38. See Williams, supra. It should be noted, however, that the father of the two babies whose deaths during childbirth were the impetus of the parents’ claim of infliction of emotional distress, was dismissed from the claim, as he was not found to be in the "zone of danger".
40. 42 U.S.C. §1395dd(d)(1)(A).
41. 42 U.S.C. §1395dd(d)(2)(A). In states with medical malpractice statutes limiting damages, damages arising from an EMTALA claim will be limited in accordance with state law. See Power v. Arlington Hosp. Ass’n, 42 F.3d 851 (4th Cir. 1994).
A discussion of sovereign immunity issues involved in suing state hospitals (as opposed to hospitals run by local public entities) under EMTALA is beyond the scope of this article.
42. See Williams, supra.
43. 745 ILCS §§10/6-105, 10/6-106, 10/6-109.
44. Williams, 1997 WL 428534, at *5.
Nicole E. Eitmann received her J.D. with distinction/special honors from the University of Iowa in 1998. She is an Illinois attorney concentrating in health care law.