Improper patient transfer: EMTALA case study

This case study describes the application of EMTALA (the Emergency Medical Treatment and Active Labor Act) to a clinical situation.The events in this case took place in late 1986, and this was the first case in which a physician was fined for violating EMTALA. ¹

Please see related article "EMTALA: Requirements for on-call physicians"

Presentation

A pregnant woman arrived in the emergency department (ED) at Hospital A at 4 p.m. She was at or near term with her sixth child. She was experiencing one-minute, moderate contractions every three minutes and her membranes had ruptured.

Two obstetrical nurses examined the patient and found she was in labor and had high blood pressure. The patient had received no prenatal care, did not have a physician, and did not have health insurance.

Physician action

The obstetrical nurse called Ob-gyn A, who was on-call to treat unassigned obstetrics patients. When Ob-gyn A was told of the patient's history and condition, he told the nurse that he “didn't want to take care of this lady.” He asked the nurse to prepare the patient for transfer to Hospital B, which was 170 miles away. Ob-gyn A said he would call back in five to 10 minutes.

The obstetrical nurses told the nursing supervisor and hospital administrator of their belief that it would be unsafe to transfer the patient. When Ob-gyn A called back, the nurse told him that according to hospital regulations and federal law, Ob-gyn A would have to examine the patient and arrange for Hospital B to receive her before she could be legally transferred.

The nurse also asked for permission to start magnesium sulfate. Ob-gyn A told the nurse to begin administering the medication only if the patient could be transported by ambulance.

Ob-gyn A arrived at 4:50 p.m. and examined the patient. The examination revealed that the patient had ruptured membranes, was dilated 3 cm, and the fetus was "smaller than usual."

Her blood pressure was 210/130 mm Hg and the physician was concerned the patient had been hypertensive throughout her pregnancy.

He arranged for the patient's transfer to Hospital B, which was better equipped to handle any complications that might occur as a result of the mother's hypertension. The nurse was ordered to begin magnesium sulfate and have the patient transferred by ambulance.

At 5 p.m., the nurse showed Ob-gyn A the hospital's EMTALA guidelines, but he refused to read them. He told the nurse that the patient represented more risk than he was willing to accept from a malpractice standpoint.

The nurse explained that the patient could not be transferred unless Ob-gyn A signed a hospital form titled "Physician's Certificate Authorizing Transfer." Ob-gyn A signed the form, but did not complete the certificate. He told the nurse that until the hospital “pays my malpractice insurance, I will pick and choose those patients that I want to treat.”

Ob-gyn A went to care for another unassigned patient and the nurses arranged for the transfer. The patient’s blood pressure was 173/105 mm Hg at 5:30 p.m.; 178/103 mm Hg at 5:45 p.m.; 186/107 at 6 p.m.; and 190/110 mm Hg at 6:50 p.m.

At 6:50 p.m., the patient was wheeled to the ambulance. Ob-gyn A did not re-examine her before she was taken to the ambulance and he did not order any medication or life support equipment for the patient during transfer. An obstetrical nurse and two emergency medical technicians accompanied the patient.

Approximately 40 miles into the 170-mile trip to Hospital B, the nurse delivered the baby in the ambulance. She directed the driver to a nearby hospital to obtain pitocin. While at that hospital, the delivering nurse called Ob-gyn A, who ordered her to continue to Hospital B despite the birth.

In accordance with the patient's wishes, the ambulance returned her to Hospital A where Ob-gyn A refused to treat her. He ordered that the patient be discharged if she was stable and not bleeding excessively. Another ob-gyn examined and admitted the patient. Three days later, the patient and her baby were discharged in good health.

Legal implications

As a result of the events in this case, HHS determined that Ob-gyn A violated EMTALA by ordering a woman with hypertension and in active labor with ruptured membranes transferred from the ED of one hospital to the ED of another hospital 170 miles away.

The physician was assessed a penalty of $25,000. Ob-Gyn A appealed the decision, claiming that the patient received all the care that she was due under EMTALA because he stabilized her hypertension sufficiently for transfer and she was not in active labor when she left the hospital in the ambulance.

An administrative law judge (ALJ) upheld the fine, but reduced it to $20,000. The HHS appeals board affirmed the ALJ and the United States Court of Appeals for the Fifth Circuit affirmed the HHS appeals board decision.

Based on a review of the expert testimony heard by the ALJ and the appeals board, the court found that the record showed “substantive, if not conclusive evidence” that the patient’s hypertension was an “emergency medical condition” as defined by EMTALA. Therefore, the patient required stabilization before transfer. The court found that the evidence supported the determination that Ob-gyn A did not provide stabilizing treatment and violated EMTALA.

The court also focused on Ob-gyn A's decision to authorize the transfer. Accordingly, there were two reasons why the transfer was inappropriate. First, Ob-gyn A did not weigh the risks and benefits of the transfer, making the decision to transfer inappropriate. “Every reasonable adult, let alone physician, understands that labor evolves to delivery, that high blood pressure is dangerous, and that the desirability of transferring a patient with these conditions could well change over a two-hour period. [The physician's] indifference to [the patient's] condition for the two hours after he conducted his single examination demonstrates not that he unreasonably weighed the medical risks and benefits of transfer, but that he never made such a judgment.” ²

The second reason the transfer was considered inappropriate was because the accompanying personnel were only fully qualified to deliver the baby in the absence of complications. The nurses and EMTs were not qualified to perform a cesarean delivery or treat other complications from the patient’s hypertension that could have developed. Additionally, Ob-gyn A did not order a fetal heart monitor or other specialized neonatal equipment for the ambulance. ²

Source

1. Institute of Medicine. Hospital-Based Emergency Care: At the Breaking Point. 2007. Washington, DC: The National Academies Press. Available at https://doi.org/10.17226/11621. Accessed December 8, 2021.

2. Burditt v. U.S. Dept. of Health, 934 F.2d 1362 (5th Cir. 1991). Available at https://casetext.com/case/burditt-v-us-dept-of-health. Accessed December 9, 2021.