About a third of U.S. hospitals over the past decade violated federal standards for providing emergency department (ED) care, according to an investigation by WebMD and Georgia Health News.

Here are the 15 tactics to reduce avoidable ED utilization

Investigation details

For the eight-month investigation, WebMD and Georgia Health News examined whether U.S. hospitals followed ED care standards established under the Emergency Medical Treatment and Labor Act (EMTALA)—a federal law designed to ensure patients are not turned away from EDs when they are unable to pay for care. Physicians and hospitals that violate EMTALA can face up to $104,826 in fines for each violation.

WebMD and Georgia Health News under the Freedom of Information Act obtained a list from CMS of all EMTALA violations reported from March 2008 to March 2018. The investigators requested full reports for the most recent 27 violations and partnered with the geographic information systems company Esri to analyze the CMS data.

Findings

According to WebMD and Georgia Health News, there were more than 4,300 EMTALA violations from March 2008 to March 2018 at 1,682 of the approximately 5,500 hospitals in the United States. The investigation found EMTALA violations were more likely to occur at hospitals with fewer than 100 beds when compared with larger hospitals. According to the investigation, hospitals with fewer than 100 beds accounted for 1,488 of the more than 4,300 violations.

The investigation also found EMTALA violations were more likely to occur at hospitals in the Southeast region of the United States when compared with any other region of the United States. According to the investigation, hospitals located in the Southeast accounted for 1,175 out of the more than 4,300 violations.

WebMD and Georgia Health News found that the most common EMTALA violations were for failing to conduct thorough medical screening exams, accounting for more than 1,300 of the violations. Hospitals had nearly twice as many violations for failing to conduct thorough medical screening exams as they did for transferring patients inappropriately, which was the second-most common violation, the investigation found.

According to the investigation, EMTALA violations from January 2016 to March 2018 were associated with the deaths of at least 34 patients. WebMD and Georgia Health News found the underlying medical conditions often cited in those violations included pregnancy and mental health crises.

However, WebMD and Georgia Health News found that the likelihood an ED visit would result in a documented violation was very low. For example, the investigation found that out of 142.6 million ED visits in 2016, CMS investigators identified just 459 EMTALA violations.

Expand the role of patient navigation in the ED

Reasons for EMTALA violations

Experts have said both small and large EMTALA violations often result from inadequate hospital resources.

Boykin Robinson—an ED physician who manages Core Clinical Partners, which provides staff for EDs—said, "An EMTALA [violation] usually implies you don't have the resources to take care of the patient at your facility. Smaller hospitals have fewer resources."

Ryan Kerr—a former nurse and who now is an attorney with Arnall Golden Gregory, which consults with hospitals—noted hospitals with fewer resources typically do not have the equipment needed to fully evaluate or stabilize patients, which under law means patients must be transferred. "Each of these transfers create an opportunity for the hospital to inadvertently violate EMTALA if the hospital could have stabilized the patient or the hospital committed an error in the transfer process," he said.

Jay Bhatt, senior vice president and CMO at the American Hospital Association, said hospitals take EMTALA "very seriously." He continued, "Hospitals strive to stabilize and treat all patients with emergent medical needs. When a hospital does not have an available bed or does not offer the treatment a patient needs, it will transfer the patient to another hospital that does have the capability."

Some call for stronger enforcement

Experts have said the statistics on EMTALA violations do not accurately represent the full scope of such violations because cases are only counted when an individual—usually a doctor, hospital administrator, or a nurse—files a report.

Howie Mell, an ED physician in Chicago and a spokesperson for the American College of Emergency Physicians, said when an individual from one hospital files a complaint about an event at another hospital, both hospitals are subject to an investigation. He said, "That system of going after both sides really discourages people from complaining."

Cheryl Fish-Parcham, director of access initiatives for Families USA, suggested there's a need for greater enforcement. "I think it's really important that there be strong enforcement of this law because consumers are not in a position to enforce this themselves," she said.

CMS said the agency is seeking to improve its enforcement of EMTALA requirements. Richard Wild, a regional CMO at CMS, said, "EMTALA is fundamentally the Golden Rule of emergency care, codified by Congress. Every hospital should strive to provide every person who presents symptoms in an emergency department with the best care. There should be one standard of care—their best care (Goodman/Miller, WebMD/Georgia Health News, 11/29; Goodman/Miller, WebMD, 11/29; Baker, "Vitals," Axios, 11/30).

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For organizations assuming population health risk, top priorities include reducing the rates of avoidable ED visits, avoidable admissions, and readmissions. But most organizations don't have all the staff they need to engage patients and support robust care management.

Our infographic explains how community paramedics can help extend the care team to achieve these system goals.

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