Key takeaway: Under EMTALA, an unstable patient may be transferred only if the patient requests it after informed discussion or if a physician certifies the medical benefits of transfer outweigh the risks and an appropriate transfer is executed.
Question – EMTALA Transfer of Unstable Patients
A 47-year-old woman presents to the emergency department for evaluation of chest pain. Electrocardiography reveals ST elevation myocardial infarction. The patient requests transfer to her "usual hospital" where her records are located for cardiac catherization.
Which statement is correct regarding the transfer of unstable patients under the rules of the Emergency Medical Treatment and Active Labor Act (EMTALA)?
Answer Options:
A. Unstable patients may be transferred at the request of a managed care organization.
B. It is never acceptable to transfer unstable patients.
C. Unstable patients may be transferred at a competent adult patient’s request.
D. Unstable patients may be transferred due to insurance status.
Correct: C
Under EMTALA, the stabilization and transfer rules apply to patients with an emergency medical condition who are unstable. Transfer is permissible in only two scenarios: (1) the patient or legally responsible person requests transfer after being informed of the risks and benefits, or (2) the physician certifies that the medical benefits of transfer reasonably outweigh the risks, and the transfer is performed appropriately (accepting facility agrees, qualified transport, necessary records, and stabilization to the extent possible). Managed care directives or insurance status can never drive transfer decisions (Centers for Medicare & Medicaid Services [CMS] State Operations Manual, Appendix V, 2019; American College of Emergency Physicians [ACEP] EMTALA resource, 2021; Rosen’s Emergency Medicine, 10th ed., 2022).
Examinees often miss this item because they overgeneralize “never transfer the unstable patient” or assume payer/plan preferences can influence disposition. The boards expect you to recognize the narrow, rule-bound circumstances in which an unstable patient may be transferred and to recall the elements of an “appropriate transfer.”
Why This Emergency Medicine Question Is Often Missed
- Examinees conflate “unstable” with “nontransferable,” forgetting EMTALA’s two explicit allowances: patient request or physician risk–benefit certification with appropriate transfer steps.
- Managed care noise: learners incorrectly think plan requirements, network status, or facility preference can dictate transfers.
- In STEMI scenarios, the urgency of reperfusion can distract from EMTALA process requirements (accepting facility agreement, qualified transport, documentation), leading to the wrong rationale.
What the Distractors Indicate
| Option | What It Tests / Implies | Why It’s Wrong Here |
|---|---|---|
| Unstable patients may be transferred at the request of a managed care organization. | Belief that payers/managed care can direct EMTALA transfers | EMTALA prohibits transfer decisions based on insurance/plan directives; care cannot be delayed for financial considerations. |
| It is never acceptable to transfer unstable patients. | Overgeneralization that unstable patients can never be transferred | EMTALA permits transfer at patient request or when physician certifies benefits > risks, with appropriate transfer elements. |
| Unstable patients may be transferred due to insurance status. | Misconception that insurance/network status justifies transfer | Insurance status/network is explicitly not a lawful basis for transfer under EMTALA. |
High-Yield Pearl for ABEM Exam Prep
For an unstable patient, EMTALA allows transfer only for patient-requested transfer or physician-certified benefit>risk transfer—and only as an appropriate transfer with accepting facility agreement, qualified transport, and complete documentation.
Core Learning Objectives
1. Identify when EMTALA permits transfer of an unstable patient and the required elements of an appropriate transfer.
2. Recognize prohibited motivations and common process errors in EMTALA transfers (insurance status, managed care pressure, delays for authorization).
The Exam Trick at Play
The stem pressures you with a high-stakes condition (STEMI) and a patient preference; the trick is to ignore payer/network issues and recall the two legal pathways for transfer and the need for an appropriate transfer, not a blanket “never transfer.”
Additional Practice Questions and Remediation for EMTALA Transfers
Emergency Medicine Practice Question 1 — Patient-requested transfer
A hemodynamically unstable GI bleed patient requests transfer to a hospital where their gastroenterologist practices. What makes the transfer EMTALA-compliant?
A. Verbal agreement from EMS to “go quickly”B. Written approval from the patient’s insurance plan
C. Physician documents risks/benefits, patient signs request, accepting physician agrees, appropriate transport arranged, records sent
D. Sending hospital documents that beds are tight
E. Transfer after initial fluids without notifying the receiving facility
Emergency Medicine Practice Question 2 — Insurance pressure
A managed care representative urges transfer of an unstable septic patient to an in-network facility. The ED has ICU capability. Under EMTALA, the appropriate response is:
A. Transfer because in-network facilities lower costB. Keep patient and stabilize; ignore plan directives in EMTALA decisions
C. Delay care until authorization obtained
D. Transfer if the patient’s spouse requests it without informing risks
E. Discharge and have patient self-present to in-network hospital
Emergency Medicine Practice Question 3 — Risk–benefit certification
Your ED lacks PCI capability. A STEMI patient is hypotensive on pressors. Under EMTALA, appropriate action is:
A. Begin stabilization and transfer only after physician documents that benefits of PCI-capable transfer outweigh risks, with accepting facility and qualified transportB. Keep patient until fully hemodynamically normal, then transfer
C. Transfer immediately without calling the receiving facility
D. Wait for insurance authorization for transfer
E. Ask patient to sign AMA to allow transfer
Emergency Medicine Practice Question 4 — Documentation elements
Which documentation is specifically required for EMTALA-compliant transfer of an unstable patient at patient request?
A. Managed care case numberB. Patient’s signed request acknowledging risks/benefits discussed
C. Proof that transport is cheapest available
D. A notation that ED is busy
E. Social worker note of patient preference only
Emergency Medicine Practice Question 5 — Active labor scenario
A term pregnant patient in active labor with nonreassuring fetal tracing presents to a Critical Access Hospital without obstetrics. Under EMTALA, transfer is permissible if:
A. The patient is unstable, so transfer is categorically prohibitedB. The patient requests transfer after risks/benefits explained, or physician certifies benefits > risks, and an appropriate transfer is arranged
C. The insurer prefers a tertiary center
D. The nurse arranges transfer without physician involvement
E. The patient signs AMA and leaves by private car
Mini Case Discussion Prompt
Compare the EMTALA steps and documentation when an unstable patient requests transfer versus when the physician certifies benefits outweigh risks. How do accepting facility agreement, transport level, and risk–benefit framing differ in STEMI versus active labor cases?
Mini-FAQ - EMTALA Transfers
- Does EMTALA ever allow transfer of an unstable patient? Yes—either at the informed request of the patient (or legal representative) or when the physician documents that benefits of transfer outweigh the risks, with an appropriate transfer. Boards test both pathways.
- Can insurance/network status influence EMTALA transfer decisions? No. ABEM/ABIM-style questions expect you to reject payer influence; decisions must be clinical and compliant with EMTALA process.
- Must you get receiving facility acceptance before transferring? Yes. An accepting physician/facility agreement is a core element of an “appropriate transfer” on exams.
- Can the medical screening exam or stabilization be delayed for prior authorization? No. Exams frequently flag delays for authorization as EMTALA violations.
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