In 1986, concerned that indigent and uninsured patients were not receiving proper emergency treatment, Congress enacted the Emergency Medical Treatment and Active Labor Act (EMTALA), designed to prevent hospitals from “patient dumping.” To determine when the statute applies, federal courts have had to interpret what constitutes an “emergency medical condition,” and ascertain the category of individuals protected by the act.

In Torretti v. Main Line Hospitals Inc., the 3rd U.S. Circuit Court of Appeals confronted these issues for the first time.

EMTALA sets forth two requirements for hospitals that participate in Medicare and provide emergency care. First, hospitals must provide appropriate medical screening to determine if an emergency medical condition exists for any individual who presents to an emergency department.

Second, if an emergent condition is apparent, treatment must be provided to “stabilize” the patient. Accordingly, one of the primary objectives of EMTALA is to remedy the problem of inappropriate hospital transfers. If arrangements are made to transfer an individual to another medical facility, the patient must be stabilized prior to transfer. EMTALA does not create a federal claim for malpractice, but is determined independent of any such claims which are typically adjudicated in state courts.

The contours of EMTALA are defined, in part, by the Department of Health and Human Services Centers for Medicare and Medicaid Services (CMS) which has Congressional authority to promulgate rules interpreting Medicare-related statutes. CMS regulations trigger EMTALA’s provisions whenever “an individual comes to the emergency department” seeking treatment. Consequently, outpatients are not covered since they are presumably receiving hospital care. Although, not all federal courts accept CMS’s determination that once an individual is admitted as an inpatient, the hospital’s obligation under EMTALA ends, as seen in Moses v. Providence Hospital and Medical Centers Inc.

The statute defines emergency medical condition as:

“A medical condition manifesting itself by acute symptoms of sufficient severity … such that the absence of immediate medical attention could reasonably be expected to result in … placing the health of the individual … in serious jeopardy.”

In Torretti, Honey Torretti gave birth to an infant with severe brain damage. The plaintiff was an insulin-dependent diabetic, a known pregnancy risk, and had experienced preterm labor during the third trimester. She was referred to the Pennsylvania-based Paoli Hospital Perinatal Testing Center for monitoring throughout the pregnancy. At 34 weeks, plaintiff presented for a routine ultrasound and fetal nonstress test.

Plaintiff informed the on-staff perinatologist, Dr. Andrew Gerson, about recent discomfort due to large abdomen size and reported decreased fetal movement. The non-stress test demonstrated decreased fetal heart rate variability. Additionally, 16 contractions occurred during 28 minutes of fetal monitoring. Gerson noted that the abdominal circumference was “off the charts” with an 11-pound fetus.

Due to the aforementioned test results, the patient’s diabetic condition, and following consultation with the primary care physician, Gerson directed plaintiff to Lankenau Hospital for further monitoring. The Torrettis arrived at Lankenau approximately 45 minutes after leaving Paoli. While plaintiff’s condition appeared unchanged upon arrival, it “worsened very quickly” once fetal monitoring commenced. The brain damaged infant was subsequently delivered via Cesarean section.

Plaintiffs filed suit against Paoli and several other health care providers, along with a federal EMTALA claim. While other circuits have confirmed that EMTALA only applies to hospitals and not individual physicians, this particular issue was not raised in the Torretti holding.

In dismissing the claim, the U.S. District Court for the Eastern District of Pennsylvania found insufficient evidence that defendants knew of an emergent condition. Further, the plaintiff was an outpatient who visited Paoli for a scheduled appointment.

On appeal, the plaintiffs contended that, due to the high-risk pregnancy, Torretti always presented with a “potential” emergency medical condition regardless of whether plaintiff was a “patient” as defined by the statute. Moreover, the plaintiffs allege that defendants failed to properly stabilize Torretti prior to transfer.

Upholding the district court’s ruling, the 3rd Circuit found that the proofs did not indicate an emergent condition until after monitoring began at Lankenau. Gerson testified that the ultrasound showed some fetal movement and excess fluid around the infant, leading to the conclusion that immediate delivery was not required. Further, the court explicitly rejected the plaintiffs’ contention that every routine visit qualified as a potential medical emergency due to high-risk pregnancy.

The 3rd Circuit endorsed CMS’s chapter and verse that EMTALA does not apply to outpatients, even if “they are later found to have an emergency medical condition … [and] are transported to the hospital’s dedicated emergency department.” In addition, the court approvingly cites the 4th Circuit’s finding in Vickers v. Nash General Hospital Inc. that”the [EMTALA] Act does not hold hospitals accountable for failing to stabilize conditions of which they are not aware, or even conditions of which they should have been aware.”

Consistent with the holdings of other circuits, this confirms that knowledge of an emergent condition is a key element in activating the statute’s provisions. The 3rd Circuit emphasized the district court’s finding that there was “no evidence” that Gerson or the hospital staff at Paoli knew the plaintiff’s condition was emergent prior to the Lankenau transfer.

The 4th Circuit’s quoted dictum “even conditions of which they should have been aware” underscores that the knowledge requirement does not impose a specific standard of care. As the district court observed, “The question is not whether the hospital should have detected an emergency medical condition, but whether the hospital had actual knowledge of the emergency. A reasonableness standard does not apply.”

Similarly, other circuits, including the 1st Circuit in Fraticelli-Torres v. Hosp. Hermanos, have found that the EMTALA duty to stabilize “does not impose a standard of care prescribing how physicians must treat a critical patient’s condition while he remains in the hospital, but merely prescribes a precondition the hospital must satisfy before it may undertake to transfer the patient.” This exemplifies the understanding that EMTALA does not create a malpractice claim, but is targeted strictly to address patient dumping.

Both the facts and findings in Torretti are instructive, since hospital transfer is where the risk of patient dumping often arises. The 3rd Circuit accepts CMS’s more restrictive application to outpatients, even for individuals with high-risk medical conditions. Further, the decision suggests that the subjective belief of the health care provider as to the existence of an emergent condition, even if erroneous, is dispositive. The holding reflects the federal judicial trend limiting the scope of EMTALA and the challenges claimants face advocating for more expansive interpretations.

Douglas M. Singleterry is an associate with Dughi & Hewit in Cranford. This article originally appeared in the New Jersey Law Journal, a Legal affiliate. •