An EMTALA primer: the impact of changes in the emergency medicine landscape on EMTALA compliance and enforcement

Tiana Lee's article provides an overview and update on the latest in the Emergency Medical Treatment and Active Labor Act (EMTALA). Reviewing the history of the statute, explaining some of the relevant regulations, and exploring government enforcements efforts to date, Ms. Lee highlights the benefits and drawbacks of the statute and recommends ways to ameliorate EMTALA's weaknesses.     

EMTALA: reaching beyond the emergency room to expand hospital liability

The Office of the Inspector General and private plaintiffs are vigorously pursuing EMTALA violations. These efforts are particularly troubling to hospitals, who face difficult statutory interpretation and application questions, especially in light of managed care reimbursement requirements. Two recent cases, one of them from the United States Supreme Court, expand hospital liability under EMTALA. This Article reviews current EMTALA standards and regulations, and analyzes how the recent decisions, in the absence of congressional action, are likely to impose substantial burdens upon hospitals.     

Patient dumping in the hospital emergency department: renewed interest in an old problem

Alarm about the adverse effects of transferring emergency patients for economic reasons has resulted in federal legislation aimed at curbing the practice. We review the history of common law hospital liability for denial of emergency care and analyze the federal legislation designed to restrict the transfer of medically indigent patients with emergency problems. We conclude that the currently proposed solutions to patient dumping will have limited effectiveness without more specific incentives for the provision of health care to the medically indigent.     

Identifying pregnant women experiencing domestic violence in an urban emergency department

The article describes characteristics of pregnant women presenting to the Emergency Department (ED) who are experiencing current violence and presented a screening tool to identify pregnant women experiencing violence. Women completed an in-person interview regarding violence, sociodemo-graphic factors, health status, and drug use. Fifteen percent of women reported at least one episode of violence during the pregnancy. Young age (OR = 3.37, 95% CI: 1.79-6.36), current alcohol use (OR = 1.53, 95% CI: 1.06-2.19), current marijuana use (OR = 1.96, 95% CI: 1.32-2.92), less than a high school education (OR = 1.46, 95% CI: 1.01-2.12), and a prior diagnosis of trichomonas (OR = 1.81, 95% CI: 1.20-2.72) were significantly related to experiencing current violence. Screening patients using these five characteristics identified 8 out of 10 women reporting violence (sensitivity = 75.6%). These results identify a set of predictors that may be helpful in identifying pregnant women who are experiencing current domestic violence.     

Impact of emergency department intimate partner violence intervention

The objective of the study is to assess the impact of emergency department (ED) intimate partner violence (IPV) counseling and resource referrals on patient-perceived safety and safety planning. ED patients with risk factors were offered consultation with trained IPV advocacy counselors who completed safety assessments, provided resource referrals, and helped patients develop safety plans. Patients were contacted after ED intervention to assess progress and further assist in IPV counseling. Over 96% of patients perceived an increase in their safety after the intervention, and approximately 50% had completed a portion of their safety plan. Legal assistance and/or law enforcement were considered the most beneficial resource referrals. Although follow-up was limited, this study appears to demonstrate that an ED IPV intervention program may be useful in helping IPV victims achieve safer living environments and access local resources.     

Coming soon to the "genetic supermarket" near you

Recent medical studies have indicated that synthesized human growth hormone (hGH) may cosmetically enhance short, but otherwise perfectly healthy, individuals by adding inches to their final predicted height. In this note, Curtis Kin examines the legal and ethical implications of such a discovery, arguing that nontherapeutic hGH treatment is likely the first of many biotechnology and gene therapy enhancements that may be available to the public in a "genetic supermarket" of enhancement products. Mr. Kin finds that the current regulatory framework for biotechnology and gene therapy inadequately regulates unapproved uses of hGH and fails to address properly its implications for a genetic "race to perfection." He proposes changes to the current regulatory framework that will enforce a strict distinction between therapeutic and enhancement applications of biotechnology and gene therapy. These changes in the law, Mr. Kin reasons, will help to solve the social and ethical problems posed by these emerging developments in technology.     

The many faces of access: reasons for medically nonurgent emergency department visits

Investigating why people use the hospital emergency department (ED) for visits considered medically nonurgent can enhance our understanding of people's expectations of health care services, of their conceptions of prudent lay judgment, and of difficulties in negotiating the logistics of primary care services. This study identified reasons for such ED use from users' perspectives in both pediatric and adult visits. Respondents were asked to explain what brought them to the ED and to define an emergency. The study was conducted in two northeastern U.S. hospital EDs. The analysis drew on a convenience sample of 408 (331 pediatric, 77 adult users) face-to-face interviews that employed both open- and closed-ended questions. Findings indicate most patients had medical insurance and a regular place of care and most arrived by car or taxi. Twelve main themes emerged under three main categories: conceptions of needs, appropriateness, and preference for the ED. The findings indicate that various reasons for ED use may be construed as access issues. These include beliefs regarding limited availability of after-hour consultation services and of timely appointments at one's primary care site. Drawing on the findings, a typology that distinguishes between groups of users according to their preference for the ED, a level of congruence between their own reason and their definition of an emergency was developed. The typology suggests that people's concerns that influence their decision to come to the ED cannot be solved simply by expanding primary care services or by educational interventions. Its application yields recommendations for services and interventions.     

Consumer beliefs and health plan performance: it's not whether you are in an HMO but whether you think you are

Surveys that rate how persons enrolled in HMOs and other types of health coverage feel about their health care are used to bolster claims that HMOs provide inferior quality care, providing justification for patient protection legislation. This research illustrates that the conventional wisdom regarding inferior care in HMOs may color how people assess their health care in surveys, resulting in survey findings biased toward showing HMOs provide inferior care and reinforcing existing stereotypes. Using merged data from the Community Tracking Study Household and Insurance Followback surveys, we identify privately insured persons who correctly and incorrectly know what kind of health plan they are covered by. Nearly a quarter misidentified their type of health coverage. Differences between responses by HMO and non-HMO enrollees to questions covering satisfaction with health care and physician choice, the quality of the last physician's visit, and patient trust in their physician shrink or disappear when we control for beliefs about what type of plan they are covered by. Results suggest that researchers and policy makers should be cautious about using consumer surveys to assess the relative quality of care provided under different types of health insurance.     

Support for emergency department screening for intimate partner violence depends on perceived risk

Emergency department (ED) screening for intimate partner violence (IPV) faces logistic difficulties and has uncertain efficacy. We surveyed 146 ED visitors and 108 ED care providers to compare their support for ED IPV screening in three hypothetical scenarios of varying IPV risk. Visitor support for screening was 5 times higher for the high-risk (86%) than for the low-risk (17%) scenario. Providers showed significantly more support for the need for ED IPV screening than visitors. Controlling for confounding by gender, race, experience with IPV, hospital, and marital status did not affect comparisons between groups. These responses indicate greater support for IPV screening in the ED for high-risk than for low-risk cases, particularly among visitors.     

Tell us how you Really Feel: Validating an Inmate Social Climate Survey

Correctional facilities have a discernible social climate, or collection of contextual properties that derive in part from the perceptions of inmates. These properties include the physical, organizational, social, and emotional characteristics of correctional institutions. Social climate directly influences the attitudes and behavior of inmates, their well-being, and prison management. The present study describes the results of an applied research project conducted in association with a government agency that audits Ohio’s prisons and youth facilities through site inspection visits and survey data. The agency’s questionnaires, as well as the procedures used to sample inmates and administer the instruments, were evaluated to determine the degree to which they accurately reflected the perceptions of inmates and the social climate of the correctional institutions. We identified several problems related to survey construction and administration. The results suggest that the surveys are at least to some degree not measuring several important dimensions of the correctional environment and the experiences of inmates as intended.