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Legal Case Review: Case Summary: (Anne Marie Nolen v. Boca Raton Community Hospital, Inc. Et al., 373 F.3d 1151 (11th Cir. 2004)

Cris Palacio, Esq.
1-1-4 The patient’s cervix was found to be neither dilated nor thinned and culture results were negative. Fetal monitoring for more than an hour revealed only one conclusive episodic contraction. After almost two hours of testing and observation, the physician determined the patient was not in labor and discharged the patient to follow up with a scheduled appointment with her perinatologist the next day. After leaving the hospital, the patient began having cramps but did not contact the hospital or her OB physician. The next day, her perinatologist concluded, following examination that the patient may have been entering pre-term labor at that time but that she could not have been in pre-term labor at the time she was in the hospital.  The patient was admitted to suppress her pre-term labor, however, this was unsuccessful and the first baby was stillborn and the other two babies did not survive for more than a few weeks.   Allegation: The patient sued the hospital and both physicians alleging that the hospital did not provide an initial adequate medical screening examination; did not stabilize her labor condition adequately and discharged her in violation of the EMTALA.   Analysis: First, the court addressed the patient’s contention that EMTALA requires a hospital to have a written screening procedure. Relying on a previous decision by an 8 Circuit Court on the same issue, and based on the language of the statute itself, the Court found that there is no requirement under EMTALA that a facility have a written procedure for Medical Screening Examinations. In reviewing the facts of the case, the Court found that the hospital nurse performed exactly the type of screening that would have been given to any other patient in that position.  In fact, the Court found that the patient received “superior” care from the hospital, in that the nurse summoned the physician to perform an in-person exam, which was done in only 6% of the patients under similar conditions. (Note that the Court did evaluate statistics related to care provided to similar patients!) The Court held that, so long as the patient received the same quality screening that a similarly situated patient would have received, the hospital satisfied its EMTALA obligations.   This decision is consistent with an earlier decision by the 11th Circuit Court in Holcomb v. Monoham (30 F.3d 116, 1994), where the Court found that Humana Hospital-Montgomery had provided the patient with an “appropriate” MSE. In that case, the court stated that EMTALA “is not designed to redress a negligent diagnosis by the hospital…as long as a hospital applies the same screening procedures to indigent patients which it applies to paying patients, the hospital does not violate…the Act.”   This pediatric nurse presented to the above hospital on May 4, 2000 for a labor check.  The patient was 22 weeks pregnant with triplets and was complaining of cramping and mucous discharge. A hospital nurse took the patient’s vital signs and medical history, listened to fetal heartbeats, put the patient on a fetal monitor, performed an initial abdominal exam and paged her physician. The physician performed a cervical exam, a vaginal culture and an ultrasound to evaluate each of the three fetal heart rates.   The U.S. District Court for the Northern District of Florida came to the same conclusion when addressing the issue of what constitutes an “appropriate” MSE under EMTALA in Rose Lane v Calhoun Liberty County Hospital Association, Inc. 846. Supp. 5432 (1994). In Rose Lane, the Court states that the important question is whether the hospital conforms to its “standard screening procedures,” holding that there is no EMTALA liability if there is consistency, “even if those procedures are deficient under state medical malpractice law.”   Risk Reduction Strategies: To avoid allegations of inappropriate medical screening exams, it is important that patient’s presenting with the same or similar symptoms are provided the same quality medical screening exam.  This can best be demonstrated by thorough and timely chart documentation and assuring that existing policies, protocols and procedures are up to date and reflect your department’s actual practice.   It is recommended that Emergency Room Departments conduct periodic self-assessments to determine compliance with all EMTALA regulations.