Opinion ID: 1713706
Heading Depth: 1
Heading Rank: 2

Heading: Preston's Claim

Text: ¶ 51. The claim at issue here is Preston's claim against Meriter under the screening requirement of EMTALA, 42 U.S.C. 1395dd(a). That provision states: Medical screening requirement. In the case of a hospital that has a hospital emergency department, if any individual (whether or not eligible for benefits under this subchapter [42 USCS §§ 1395 et seq.]) comes to the emergency department and a request is made on the individual's behalf for examination or treatment for a medical condition, the hospital must provide for an appropriate medical screening examination within the capability of the hospital's emergency department, including ancillary services routinely available to the emergency department, to determine whether or not an emergency medical condition (within the meaning of subsection (e)(1)) exists. ¶ 52. The majority's discussion of the screening requirement is focused on the meaning of the language comes to the emergency department found in 42 U.S.C. 1395dd(a). The majority concludes that: the proper interpretation of comes to the emergency department in this case imposes a duty upon a hospital to provide a medical screening examination to a newborn who (1) presents to the emergency room of the hospital or (2) is born in the birthing center of the hospital and meets the conditions set forth in 42 C.F.R. § 489.24(b) (1999). Majority op., ¶ 38. The majority further explains that in 42 C.F.R. § 489.24(b), the Department of Health and Human Services (DHHS) has consistently defined the phrase comes to the emergency department to include all hospital property. Majority op., ¶ 35. While I agree with the majority's conclusion about the meaning of emergency department, the majority overlooks the dispositive issue in the present case, which is whether EMTALA applies to inpatients. Because, as I explain below, Bridon was an inpatient rather than someone who comes to the hospital, I conclude Preston's claim regarding Bridon falls outside the scope of EMTALA and instead sounds in Wisconsin's medical malpractice law. ¶ 53. There have been no prior decisions directly addressing whether EMTALA's screening requirement applies to inpatients. However, it is only EMTALA's screening requirement that is before us on this review. The dearth of cases is not surprising considering that most EMTALA claims do not implicate the unique attributes present in pregnancies, where essentially a patient with a patient arrives at the hospital, the expectant mother carrying the unborn child. However, court decisions and federal regulation [4] regarding EMTALA's stabilization and transfer requirements, 42 U.S.C. 1395dd(b)-(c), [5] shed light on the relation of EMTALA to inpatients. ¶ 54. Before the implementation of the DHHS regulation, jurisdictions were split as to whether the stabilization and transfer provisions of EMTALA applied to a patient once he or she was admitted to a hospital. In Thornton v. Southwest Detroit Hospital, 895 F.2d 1131, 1132 (6th Cir. 1990), a patient suffered a stroke, arrived at the hospital's emergency room and spent 10 days in the hospital's intensive care unit and 11 more days in regular inpatient care before being discharged to her sister's home for basic nursing care. The patient brought an action under the stabilization requirement of EMTALA, alleging that the hospital failed to stabilize her before discharging her. Id. The hospital argued that the stabilization requirement did not apply once a patient was admitted to the hospital. Id. at 1135. The Sixth Circuit Court of Appeals disagreed, stating: Although emergency care often occurs, and almost invariably begins, in an emergency room, emergency care does not always stop when a patient is wheeled from the emergency room into the main hospital. Hospitals may not circumvent the requirements of the Act merely by admitting an emergency room patient to the hospital, then immediately discharging that patient. Emergency care must be given until the patient's emergency medical condition is stabilized. Id. ¶ 55. In Lopez-Soto v. Hawayek, 175 F.3d 170, 171 (1st Cir. 1999), the patient arrived at the hospital with normal labor pains. The patient was examined and admitted to the maternity ward, where the doctor ordered a cesarean section. Id. The patient gave birth to a baby boy who emerged with severe respiratory and pulmonary problems. Id. The infant was transferred to a hospital with a functioning neonatal intensive care unit without first being stabilized, and he later died. Id. The patient brought an action under the stabilization and transfer provisions of EMTALA, arguing that the hospital did not stabilize the infant before transferring him, but the district court dismissed the claim on the ground that the newborn had come to the hospital via the operating room, and EMTALA applied only to entries via the emergency room. Id. at 172. The First Circuit Court of Appeals reversed, concluding that the stabilization and transfer requirements were not limited to entries via the emergency room: Congress obviously had a horizon broader than the emergency room in mind when it enacted EMTALA. The statute explicitly embraces women in labor, see 42 U.S.C. § 1395dd(e)(1)(B) (defining emergency medical condition)yet most gravid women go to maternity wards, not emergency rooms, when they are ready to give birth. ... Congress's preoccupation with patient dumping is served, not undermined, by forbidding the dumping of any hospital patient with a known, unstabilized, emergency condition. After all, patient dumping is not a practice that is limited to emergency rooms. If a hospital determines that a patient on a ward has developed an emergency medical condition, it may fear that the costs of treatment will outstrip the patient's resources, and seek to move the patient elsewhere. That strain of patient dumping is equally as pernicious as what occurs in emergency departments, and we are unprepared to say that Congress did not seek to curb it. Id. at 176-77. ¶ 56. However, other jurisdictions concluded that EMTALA's stabilization requirement did not apply to inpatients. In Bryant v. Adventist Health System/West, 289 F.3d 1162, 1164 (9th Cir. 2002), a patient sought care at a hospital's emergency room after coughing up blood, and the doctor failed to detect a large lung abscess. The patient was discharged after being diagnosed with pneumonia and asthma, and the doctor requested he return the next day for further treatment. Id. The patient returned the following day, the lung abscess was detected and he was admitted to the hospital. Id. Within three days, the patient's condition declined rapidly, and he was transferred to another hospital, where he had surgery. Id. He later returned home and appeared to be improving, but died suddenly within 10 days of being discharged. Id. The patient's heirs filed an action alleging EMTALA violations concerning both the initial emergency room visit and the subsequent inpatient care. Id. Regarding the inpatient care, the Ninth Circuit Court of Appeals held that the stabilization requirement normally ends when a patient is admitted for inpatient care. Id. at 1167. The court stated: The stabilization requirement is ... defined entirely in connection with a possible transfer and without any reference to the patient's long-term care within the system. It seems manifest to us that the stabilization requirement was intended to regulate the hospital's care of the patient only in the immediate aftermath of the act of admitting her for emergency treatment and while it considered whether it would undertake longer-term full treatment or instead transfer the patient to a hospital that could and would undertake that treatment. It cannot plausibly be interpreted to regulate medical and ethical decisions outside that narrow context. Id. (quoting Bryan v. Rectors & Visitors of the Univ. of Va., 95 F.3d 349, 352 (4th Cir. 1996). The court discussed the Thornton and Lopez-Soto cases, but noted that because Congress enacted EMTALA `to create a new cause of action, generally unavailable under state tort law, for what amounts to failure to treat' and not to `duplicate preexisting legal protections' and that state tort law provided for negligent medical care for inpatients, EMTALA should not apply. Id. at 1168-69 (quoting Gatewood v. Washington Healthcare Corp., 933 F.2d 1037, 1041 (D.C. Cir. 1991). The court concluded, If EMTALA liability extended to inpatient care, EMTALA would be `converted ... into a federal malpractice statute, something it was never intended to be.' Id. at 1169 (quoting Hussain v. Kaiser Found. Health Plan, 914 F. Supp. 1331, 1335 (E.D. Va. 1996). ¶ 57. The Bryant court also addressed the concern in Thornton that hospitals might be able to avoid liability under EMTALA by admitting and then refusing to treat patients. See Thornton, 895 F.2d at 1135. The court stated: We agree with the [ Thornton court] that a hospital cannot escape liability under EMTALA by ostensibly admitting a patient, with no intention of treating the patient, and then discharging or transferring the patient without having met the stabilization requirement. In general, however, a hospital admits a patient to provide inpatient care. We will not assume that hospitals use the admission process as a subterfuge to circumvent the stabilization requirement of EMTALA. If a patient demonstrates in a particular case that inpatient admission was a ruse to avoid EMTALA's requirements, then liability under EMTALA may attach. Bryant, 289 F.3d at 1169. ¶ 58. Similarly, the court in Dollard v. Allen, 260 F. Supp. 2d 1127, 1135 (D. Wyo. 2003), ruled that the stabilization and transfer provisions of EMTALA do not apply to individuals admitted for inpatient care. In that case, the patient periodically visited her doctor for lower back pain and numbness in her buttocks. Id. at 1129. The problems continued and the patient was admitted to the hospital for pain management and rest. Id. After reporting that the back pain was not as severe, but the numbness had increased, the doctor discharged the patient. Id. at 1130. The next morning the patient began experiencing excruciating pain in her stomach and was unable to urinate. Id. She called the hospital and was readmitted under the care of a new doctor, who determined that the patient had a large ruptured disc in her back, as well as a rare neurological disorder affecting the lower end of the spinal cord. Id. The patient underwent lower-back surgery the day after she was admitted for the second time. Id. The patient filed suit alleging that the hospital violated the screening and stabilization before transfer requirements of EMTALA upon her first admission to the hospital. Id. at 1134. The court granted summary judgment to the hospital on the stabilization and transfer claim on two grounds, one being that the hospital did not violate EMTALA's stabilization before transfer requirement because that provision does not apply to individuals that have been admitted to the hospital for in-patient care. Id. at 1135. The court stated that allowing EMTALA claims in inpatient situations, where state tort law applied, would render[] the Act's preemption subsection superfluous. Id. The preemption provision, 42 U.S.C. 1395dd(f), states, The provisions of this section do not preempt any State or local law requirement, except to the extent that the requirement directly conflicts with a requirement of this section. The court reasoned that because EMTALA's purpose is to eliminate `patient-dumping' and not to `federalize medical malpractice,' EMTALA does not apply in inpatient situations, where state tort law applies. Dollard, 260 F. Supp. 2d at 1135 (quoting Ingram v. Muskogee Reg'l Med. Ctr., 235 F.3d 550, 552 (10th Cir. 2000). ¶ 59. In 2003, as a response to the questions raised by cases such as these, DHHS promulgated a rule interpreting hospital obligations under EMTALA as ending once the individuals are admitted to the hospital inpatient care. Medicare Program; Clarifying Policies Related to the Responsibilities of Medicare-Participating Hospitals in Treating Individuals With Emergency Medical Conditions, 68 Fed. Reg. 53222, 53244-45 (September 9, 2003) [hereinafter Clarifying Medicare Policies]. The rule set out in 42 C.F.R. § 489.24 now states: Exception: Application to inpatients. (i) If a hospital has screened an individual under paragraph (a) of this section and found the individual to have an emergency medical condition, and admits that individual as an inpatient in good faith in order to stabilize the emergency medical condition, the hospital has satisfied its special responsibilities under this section with respect to that individual.