From the Editor

Check the fine print in EMTALA’s proliferating regulations

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Did The Nurse Midwife Break An EMTALA Rule?

A 24-year-old gravida 1 para 0 at 39 weeks presents to obstetrical triage with contractions every 7 minutes. A certified nurse midwife examines the patient and finds the cervix 2 cm dilated and 40% effaced, with a fetal vertex presentation at –1 station. The fetal heart rate tracing is reactive with no decelerations. The patient is advised to walk about the labor floor to see if her cervix changes. Two hours later, contractions are every 9 minutes and the cervix is unchanged. The midwife discharges the patient home without discussing the case with a physician.

Few obstetrical care providers are well versed in every nuance of the Emergency Medical Treatment and Labor Act (EMTALA), the complex set of federal regulations that govern emergency care. Under EMTALA, physicians and other certified health-care personnel, including certified nurse midwives, are allowed to evaluate women who come to the hospital with contractions and a question of labor.

However, EMTALA regulation 42 CFR 489.24(b) states that “a woman experiencing contractions is in ’true labor’ unless a physician certifies that she is in false labor.” Thus, when qualified nonphysician personnel, such as nurse midwives, diagnose “false labor” (early labor), a physician must certify the diagnosis before the patient can be discharged.

In this case, the nurse midwife violated EMTALA by discharging the patient without a physician’s certification. To be technically compliant with the EMTALA regulations, the nurse midwife should have discussed the case with a physician before sending the patient home.

EMTALA regulations have other interesting features. Consider this case:

Did The Obstetrician Break An EMTALA Rule?

A 35-year-old gravida 1 para 0 at 37 weeks presents to labor and delivery at 2 AM with contractions every 5 minutes. A labor nurse evaluates the patient and notes that the cervix is long and closed. Ultrasound demonstrates a vertex presentation. Fetal heart rate monitoring demonstrates a reactive tracing with no decelerations. Two hours later, the labor nurse observes the cervix is 2 cm dilated and 40% effaced. The labor nurse calls the patient’s attending physician at home and relays the key clinical findings. The physician tells the nurse to discharge the patient and instruct her to return to the office or the labor floor in the morning.

To comply fully, the hospital governing body (typically the Board of Trustees) must formally approve a by-law that designates labor floor nurses as “qualified medical personnel” and recognizes that they are capable of evaluating and triaging patients in suspected labor. If the formal hospital by-laws have this provision and if the nurse’s notes in the medical record indicate that the case was discussed with a physician, then EMTALA regulations have probably been met. If the hospital governing body has not formally approved labor floor nurses to act as “qualified medical personnel,” the physician and hospital could be in violation.

Each EMTALA violation carries a fine of up to $50,000.

Rules Beget Rules

As federal mandates and regulations proliferate, we are challenged to stay abreast of the minutiae and nuances.

Our medical textbooks are often 1,000 pages in length. It is unfortunate that federal and state regulations governing how we provide medical care are likely to multiply into the tens of thousand pages.

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