EMTALA: New Providence process and three case studies

By Jeremy Lynn, M.D., medical director, emergency services, Providence Oregon
David Corman, M.D., medical director, Providence Transfer Center

Despite widespread education for ED providers and on-call specialists about the Emergency Medical Treatment and Labor Act (EMTALA), Providence continued to see situations with significant EMTALA risk. 

It became clear that a more organized structure was needed to provide access to emergency medical care for all who need it, as well as to decrease the EMTALA risk to our providers and hospitals. There can be hefty fines for both individual providers and hospitals per EMTALA violation.

Regional EMTALA Discernment Team

Chartered in 2020, the Regional EMTALA Discernment Team brings together experts to review potential EMTALA violations within one to two days of the event. The team is led by Julia Florea, RN, regional director of accreditation. When an EMTALA risk is identified, a thorough investigation is completed, and the team is called together to review the case and make a recommendation for next steps, up to and including filing a report with the Oregon Health Authority.

Transfer center EMTALA risk mitigation strategy

In 2020 we also worked to strengthen the first line of defense against EMTALA violations during patient transfers. Our transfer center team has been trained to recognize situations that might pose an EMTALA risk. A two-step strategy was developed to help intervene in real time:

  1. A script is used to remind providers on the phone of EMTALA obligations during transfer requests.
  2. If the issue is still unresolved, it will be escalated in real time to a call group consisting of hospital chief medical officers, the transfer center medical director and other medical staff leaders. We have successfully prevented several EMTALA violations with this strategy. 

Three EMTALA case studies

Each situation reviewed by the discernment team represents a learning opportunity for everyone involved. Below is a small sampling of cases reviewed in 2020:

Case #1: COVID patient

A COVID-positive patient was seen in one of Providence’s mid-sized EDs and was determined to need hospital admission. Providence Oregon has been sending most COVID-positive patients to our two large campuses, Providence Portland and Providence St. Vincent medical centers. Unfortunately, both large facilities were at capacity with no available beds. The sending provider initiated a transfer to another local non-Providence hospital, citing the lack of available COVID beds. The receiving hospital accepted the patient and later raised concerns about a possible EMTALA violation. Our new discernment team reviewed the case and determined that the patient should have been cared for at the original facility until an appropriate bed became available at Providence Portland or Providence St. Vincent.


Case #2: prior relationship

A patient presented to a non-Providence ED with a cold foot and was diagnosed with a complete arterial occlusion. The patient had undergone vascular surgery for peripheral artery disease a year previously at a Providence facility. The sending facility did not have capability to care for the patient and initiated transfer to a nearby non-Providence hospital. That hospital refused to accept the patient, citing that the original procedure was provided elsewhere. The patient eventually was accepted for transfer at Providence Portland, leading to several hours of delay. Our discernment team reviewed the case and determined the first receiving non-Providence provider violated EMTALA, since the law does not allow refusal of transfer because of a prior relationship. 


Case #3: private vehicle transfer

A young child was struck in the abdomen by a baseball while at a baseball game. The patient was seen at a Providence hospital that does not admit pediatric patients. An ultrasound revealed a collection of fluid in the abdomen, and the patient required transfer to a trauma center. The sending provider told the parents they could drive the child in their own vehicle. EMTALA requires that a transferring patient must be transported by qualified personnel with appropriate equipment. If the parents insisted on providing the transportation themselves, the provider is required to discuss the risks with them and get a written refusal of ambulance service.


Meeting EMTALA requirements is a joint responsibility of the hospital and medical staff. Many potential EMTALA scenarios are nuanced, complex and unique. Providence’s new resources help all of us navigate these complicated waters.

If you’re involved in a case you believe may have potential EMTALA risk, please complete a Datix report and mark the event type as admission/discharge/transfer and the event category as EMTALA. This will directly notify the discernment team, and the process will be started to support you in your decision-making. Thank you for everything you do for our patients needing emergency care.

About the Author

The Pulse content team focuses on bringing you the latest in clinical news from our world-class medical providers and physician leaders.

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