Vascular Surgery Related Violations of the Emergency Medical Treatment and Labor Act.

OBJECTIVES: The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department (ED) receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services (CMS) and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues.

METHODS: EMTALA violations in the CMS publicly-available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality.

RESULTS: There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular-related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States (US) region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic-related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal/unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic labs or imaging (12.2%), and ancillary/nursing staff issues (7.1%). The overall mortality was 19.4% of which 31.6% died during the index ED visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%).

CONCLUSIONS: Although the frequency of vascular-related EMTALA violations was low, improvement in communication, awareness of vascular disease among staff, specialty staffing, and development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.