Compliance with the Emergency Medical Treatment and Labor Act (EMTALA) during a disaster is the subject of a May 7, 2018, updated fact sheet from ASPR TRACIE (the Technical Resources, Assistance Center, and Information Exchange, Office of the Assistant Secretary for Preparedness & Response). The document reiterates EMTALA requirements, including the need to perform a medical screening exam (MSE) for all patients coming to the emergency department (ED), but notes that protocols can be adjusted according to the nature of the disaster and patients' presenting signs and symptoms. EMTALA can be waived only if all of the following apply: the U.S. president and the secretary of Health and Human Services (HHS) have both declared a national emergency and HHS has authorized EMTALA waivers; the Centers for Medicare and Medicaid Services (CMS) has notified covered entities that waivers are available and the facility then applies for the waiver (unless waivers are granted for an entire geographic region); and both the facility and the state have activated their emergency operations plans or pandemic plans. A waiver will normally last for 72 hours and can be applied retroactively only back to the time the emergency was declared. ASPR TRACIE advises hospitals to work in advance with emergency medical services (EMS) to set in place diversion criteria for patients arriving by EMS and to develop ED "saturation plans" and public communication campaigns in advance, working with local healthcare coalitions and emergency management authorities. For instance, three hospitals in a geographic area might determine in advance that hospitals A, B, and C could each accept 50 critical, 100 immediate, and 300 "walking wounded" patients; on-site EMS and providers at the hospital would complete MSEs, redirect, and transfer these patients, without clinicians at the transferring and receiving hospitals having to speak to one another directly for each patient. Regardless of diversion plans, once a patient arrives at an ED, EMTALA applies; injured patients who walk in or arrive in their own cars may not be diverted. The document also links to tips for no-notice incidents, derived from conversations with healthcare personnel after the October 2017 Las Vegas shooting. A wealth of practical advice includes keeping vehicle entrance points clear while ensuring other entrances to the facility are carefully controlled in case the hospital itself is targeted in a "multiscene" attack; reviewing the facility's "trauma alias" process to avoid duplicated names; and maintaining patient flow (one facility that treated the Las Vegas victims, the tip sheet says, had 500 patients prior to the shooting, 184 of whom they discharged within 15 hours). Other tip sheets relevant to no-notice events are available on topics such as media management, expanding traditional provider roles to meet patient surge, and family assistance.

HRC Recommends: Healthcare organizations should review and update their emergency operations management plans, disaster preparedness plans, and pandemic management plans, partnering in advance of disasters with local EMS and other concerned entities, emergency management authorities, and regional healthcare coalitions. Disaster planning may also affect a facility's risk assessment program. Emergency medicine is a high-risk specialty for malpractice litigation, and disaster medicine presents new and emerging clinical and other liability risks for the ED. Risk managers should ensure that the disaster management team is knowledgeable about EMTALA statutory and regulatory requirements; facilitate distribution of updated guidance for ED handling of disasters and mass casualty events; and ensure that EMTALA policies and procedures are reviewed on an ongoing basis.