EMTALA, two decades later: a descriptive review of fiscal year 2000 violations.

Purpose: To determine to what extent cases sanctioned under the Emergency Medical Treatment and Active Labor Act (EMTALA) reflect willful refusal of screening or stabilization.

Basic Procedures: The Centers for Medicare and Medicaid Services were petitioned for all confirmed EMTALA citations from year 2000. Each citation was classified into one of three categories: (1) willful refusal to perform a screening exam or to stabilize; (2) possible refusal to screen or stabilize; or (3) no evidence of refusal to screen or stabilize. Citations were reviewed to determine the presence of 10 other characteristics. Three investigators independently reviewed a subset of data to verify acceptable inter-rater reliability.

Findings: We received 157 (53%) of the 294 records requested. Of the 131 involving ED personnel, 44 (34%) demonstrated willful refusal of screening or stabilization. Thirty-two (24%) were possible refusals of service, and 55 (42%) contained no evidence of refusal.

Principal Conclusion: Emergency department willful refusal of screening and stabilization still occurs despite enforcement of EMTALA.