When a surge of patients at a Harris Health System emergency department (ED) keeps patients in the waiting room for a long time, physicians and advanced practice providers (APPs) may come see them there. If their vital signs have changed or they report worsening pain, the patients will have a medical screening exam (MSE) in a private area of the waiting room.

That’s one of the Texas health system’s strategies to prevent violations of the Emergency Medical Treatment and Labor Act (EMTALA), said Carolynn Jones, chief compliance and risk officer at Harris Health, which has two hospitals—a level one and level three trauma centers.

“Both our emergency centers are extremely busy,” she said (EDs are called emergency centers, or ECs, there). “When you get oversaturated, the wait times are extended, and it presents a very real danger of patients coming into your emergency centers and sometimes you’re not even recognizing they’re there. We create ways to keep a close eye based on severity and acuity.” It’s a compliance challenge that requires a lot of work with clinical and operations teams in and out of the emergency room. “There’s a misconception that EMTALA compliance is an EC-only issue,” Jones said. “It has to be the focus of everyone in the hospital.”

Under EMTALA, hospitals must give all patients who show up at the emergency room a medical screening exam (MSE) regardless of their ability to pay and stabilize them if they have an emergency medical condition (EMC). Patients may be transferred if hospitals lack the capacity or capability to treat them, and receiving hospitals must accept transfers unless they lack the capacity or capability. In January, two hospitals—in Florida and Kentucky—settled civil monetary penalty cases with the HHS Office of Inspector General (OIG) over alleged EMTALA violations, including allegations involving a patient with COVID-19 and another with an ectopic pregnancy—a reminder of the persistent compliance perils in this area (see below).