Federal district court judge DJ Hellman has thrown out EMTALA allegations against Milford Regional Medical Center in Massachusetts on pretrial motions for summary judgment filed by the hospital.
Case facts:
Plaintiff alleges that on October 19, 2009 she presented to the hospital via ambulance complaining of severe pain in her abdomen and shooting pains in her back. She was 34+ weeks pregnant and had a history of the gastric bypass. She had been in the hospital with similar complaints 4 times over the preceding two months.
Plaintiff was transported to the labor and delivery area where she was examined by two obstetricians. The decision was made to transfer to a tertiary care facility after the patient’s condition worsened. The hospital did not have an NICU and did not have surgeons capable of handling complications that might result due to the gastric bypass. At the time of the certification for transfer, the physician’s notes indicate the patient and her fetus had stable vital signs, and there was no evidence of rupture of the membranes.
The patient was accepted at UMass Memorial, the patient signed consent to transfer, and was transferred by ALS ambulance to the tertiary care facility, where she arrived in critical condition and fetal heart rate was noted at 60 to 70 bpm. She was transferred to the operating room for emergency C-section, where the child was delivered with no detectable heartbeat or respiration and died 11 days later. Cause of death was indicated as cardiorespiratory failure, hypoxic ischemic encephalopathy, and intracranial hemorrhage.
Prior to transfer the record reflects that the plaintiff began vomiting blood.
[The court record does not indicate whether that development occurred prior or subsequent to the certification for transfer, but CMS rulings in the language of the statute indicate that the transfer certification must be based on the patient’s condition at the time of the physical transfer. If not addressed, citations have been issued for failing to update the risk/benefits and notify the receiving facility.]– Editor
Plaintiff filed suit alleging that the defendant hospital violated EMTALA by failing to stabilize her emergency condition and failing to properly stabilize her before transferring her to another hospital.
Rulings:
The hospital for sought to bar the EMTALA claim alleging that the patient was seen in the labor and delivery area not the emergency department. While not citing specific language of EMTALA law and regulations that definitively protect women in labor and consider labor and delivery area is part of the dedicated emergency department of the hospital, the court relied on other cases that hold presentations for the labor and delivery area to be covered by EMTALA.
Hospital then sought to bar the EMTALA claim by alleging that the plaintiff did not have an emergency medical condition under EMTALA. The court likewise correctly rejected that position.
The hospital argued that the patient had been admitted to the hospital for inpatient care and therefore EMTALA did not apply. The court again correctly rejected that argument, citing a variety of other court cases.
[The court did not consider, nor was it apparently argued, that the CMS regulation subsequently adopted to terminate EMTALA for admitted patients applies to patients who are “admitted” under the “one midnight rule”. The court probably chose to avoid this issue due to the split of authority between Circuit Courts over whether CMS had the authority to issue the rule which contravenes the direct language of the statute.] — Editor
The final issue was whether the patient was appropriately transferred under EMTALA. On that score, the court found that the plaintiff received treatment for nausea and vomiting and back pain, was monitored together with her baby, was appropriately examined, and was transferred pursuant to the signed authorization for transfer by the physician who had considered all of the circumstances and German plaintiff needed to be transferred because of the benefits of having an ICU and gastroenterologist available outweighed the dangers of transportation. The patient had consented to transfer. The transfer itself was accomplished with appropriate personnel and equipment. On that basis, the court ruled the hospital had complied with EMTALA in the transfer process..
The court retained the remaining state malpractice actions for further trial and refused the hospital’s requested that the case be sent back to state court.
Additional comments:
While the court dismissed the case on EMTALA elements, the reader is reminded the CMS regulatory enforcement looks into the quality of the care and documentation, and applies the site review guidelines in determining whether compliance is present. It appears in this case documentation was thorough enough for court purposes, but CMS often looks for much higher standard documentation.
The most conspicuous potential difference in the case between CMS and the court is totally unaddressed in the decision. Specifically, the opinion does not detail what risks were specifically listed on the consent to transfer form. CMS would look carefully at whether the potential risk of death to the patient or to the fetus was among the potential risks disclose to the patient. If it was not, CMS would cite the transfer for failure to adequately disclose risks and benefits.
As this did not come up in the court litigation, the presumption for the hospital would appear to be that was properly documented in this case. But, as a ward of warning, numerous other cases of high risk OB transfers have been cited for risks that were entirely lacking or grossly under-stated in the consent to transfer documents.
See Bryson v. Milford Reg’l Med. Ctr., (D. Mass. Mar. 27, 2014.)