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.
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.”
| 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. |
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.
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 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.”
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”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 costYour 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 transportWhich documentation is specifically required for EMTALA-compliant transfer of an unstable patient at patient request?
A. Managed care case numberA 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 prohibited
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?
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