1. Facts
1.1. Parties
1.1.1. Plaintiffs: Joshua Beller, minor born at 34 weeks gestation, and Melissa Welch
1.1.2. Defendant: Health and Hospital Corporation of Marion County, Indiana d/b/a Wishard Memorial Hospital
1.2. What Happened
1.2.1. 6/14/2001: 34 weeks pregnant, Ms. Welch called 911 and a Wishard ambulance was dispatched to her home. Paramedics determined that her water broke and she had a prolapsed umbilical cord.
1.2.2. After consulting with her obstetrician's office it was determined that Ms. Welch needed to be transported to the NEAREST hospital.
1.2.3. She was then transported to St. Francis Beech Grove ER where she was examined and then transferred via the Wishward ambulance to St. Francis Hospital South.
1.2.4. Joshua Beller was delivered by Caesarean section but suffered from hypoxia causing severe brain damage.
1.3. Procedural History
1.3.1. The plaintiffs file suit against the defendant alleging that it violated Emergency Medical Treatment and Labor (EMTALA) by failing to stabilize Ms. Welch and her son during an emergency situation.
1.3.2. The district court granted summary judgement in favor of the defendant.
1.3.3. The plaintiffs appeal
2. Issue before the Court
2.1. Did the plaintiffs "come to the emergency room" of Wishard Memorial Hospital when they entered the ambulance?
2.2. As the events occurred in 2001, did the 2003 amendment to the definition of "comes to the emergency department" provide clarification or represent a substantive change to the definition?
2.2.1. The 2001 regulation stated that an individual is on hospital property when in an ambulance that is owned and operated by the hospital even when said ambulance is not on hospital grounds.
2.2.2. In 2003 the above was amended to included that an individual is not considered to have come to the ER of that hospital if the ambulance is operating under community-wide emergency medical service (EMS) protocols that direct transport to the nearest hospital.
3. Rule of Law
3.1. EMTALA
3.1.1. 42 U.S. Code § 1395dd - Examination and treatment for emergency medical conditions and women in labor
3.1.1.1. If a hospital has an ER and a request is made for treatment on an individual's behalf, the hospital must provide appropriate medical screening to determine whether or not an emergency situation exists.
3.1.1.2. If an individual has an emergency medical condition which has not been stabilized, the hospital cannot initiate transfer of the individual.
3.1.1.3. The hospital must provide informed consent for treatment, if the patient refuses written informed consent to refuse treatment should be documented.
3.1.1.4. The hospital must provide informed consent for transfer, if the patient refuses written informed consent to refuse transfer should be documented.
3.1.2. 42 CFR 489.24 - Special responsibilities of Medicare hospitals in emergency cases
3.1.2.1. Defines that an individual has "come to the emergency department" if the individual:
3.1.2.1.1. Presents to the ER or hospital property and makes a request for treatment or a request is made on his/her behalf.
3.1.2.1.2. Is in a ground or air ambulance owned and operated by the hospital, even if the ambulance is not on hospital ground.
4. Analysis
4.1. Violation of EMTALA
4.1.1. Ms. Welch's argument
4.1.1.1. Based on the 2001 definition of "comes to the emergency room," Ms. Welch feels that she arrived at Wishard Memorial Hospital when she was transported in the Wishard ambulance.
4.1.1.1.1. As she came to Wishard Memorial Hospital, the hospital failed in its duty to stabilize Ms. Welch's medical emergency, as the only way to stabilize her condition was to deliver her unborn son. This failure resulted in permanent physical and mental disabilities.
4.1.2. Hospital's defense
4.1.2.1. Ms. Welch did not "come to the emergency room" under the definition of EMTALA
4.1.2.1.1. Although the 2003 amendment was not in effect at the time of the events, Wishard contends that the standard practice was to “sidestep” this interpretation to avoid applying the definition of “comes to emergency department” to hospital owned ambulances that served as community-wide emergency response vehicles.
4.1.2.2. Wishard provided an appropriate medical screening of Ms. Welch's condition.
4.1.2.2.1. The plaintiff agrees that an appropriate screening was performed.
4.1.2.3. Wishard did not transfer Ms. Welch to Beech Grove, therefore, it did not have any duty to stabilize her condition.
4.1.2.3.1. The movement of Ms. Welch and her unborn son Joshua Beller were directed by her obstetrician, the physician at Beech Grove and the physician at St. Francis Hospital South.
4.1.3. The Court's reasoning
4.1.3.1. The Wishard ambulance was operating under EMS protocols at the time it transported the plaintiffs to Beech Grove. However, since the 2003 amendment occurred after the incident, can it be retroactively applied?
4.1.3.1.1. The Supreme Court previously ruled that an administrative agency cannot retroactively impose a rule unless given expressed authority by Congress. However, not all rules create substantive change and instead provide clarification.
5. Conclusion
5.1. The appellate court affirmed the summary judgement of the district court.
5.1.1. EMTALA
5.1.1.1. Both the 2001 and 2003 definitions are consistent in that an individual is considered to have come to the ER if that person is in an ambulance owned and operated by the hospital. In this case, however, the Wishard ambulance was operating under EMS protocols, therefore, under EMTALA the plaintiffs had not come to the Wishard ER.
6. Impact
6.1. Guardian v. Health and Hospital Corporation of Marion County WL 6822468, *5, S.D.Ind. (2016)
6.1.1. Alice Hatzell takes her adult, mentally handicapped daughter Cheryl Hatzell to the ER for evaluation after she is not feeling well and has not had a bowel movement or urinated in several days.
6.1.1.1. An abdominal x-ray is obtained which confirms Cheryl is constipated. A urinalysis is order but Cheryl is unable to provide a sample and no further actions are taken to obtain a urine sample. Alice voices her concern but is told by the doctor to follow up with her primary care manager (PCM).
6.1.1.1.1. The next day she falls down the stairs and is taken by EMS to the hospital where she is found to have a broken nose and states that she is tired. Alice informs the medical staff that Cheryl abdomen is distended, she has not urinated in several days and she is concerned Cheryl has a UTI. The doctor again instructs her to follow up with her PCM.
6.2. Gillispie v. Regional Care Hospital Partners, Inc. WL 12599597, *1, W.D.Pa. (2014)
6.2.1. The plaintiff, Ms. Gillispie was employed by the defendant for 13 years before her termination 11/1/2012. At the time of her termination she served as the Quality Project Coordinator and previously the Director of Acute Care Services.
6.2.1.1. Ms. Gillispie is terminated after voicing concerns that the care provided to four patients was in violation of federal and state laws and regulations. She also stated that her attempts to report said violations to the appropriate agencies was thwarted by the medical center's CEO, Cynthia Cowie.
6.2.1.1.1. Ms. Gillispie files suit against the defendant for unlawful retaliatory discharge in violation of EMTALA and wrongful termination in violation of various polices.
7. Importance
7.1. Why should health care professionals care about this ruling?
7.1.1. This ruling reinforces that a hospital cannot be held liable under EMTALA for the actions of its ambulances when they are acting under county-wide EMS protocols.
7.1.1.1. This could encourage more hospitals to invest in their own ambulances that will be able to provide a higher standard of care to patients due to more hospital oversight and training.
8. Influence
8.1. Policy
8.1.1. In 2008 the Department of Health and Human Services provided updates to EMTALA to clarify the meaning of "stabilize" and further determine when a hospital had met the requirements of EMTALA.
8.1.2. Hospitals are very diligent in ensuring that their policies concerning ambulance and emergency room procedures are consistent with EMTALA, many have spent hundreds of thousands of dollars to ensure compliance.