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Leaders of US emergency departments (EDs) must be aware of and responsive to the authorities that accredit and regulate the practice of emergency medicine. The key to a high-efficiency ED that delivers safe, high-quality patient care is an ED nurse director and a medical director who take joint ownership of the department. The goal of this collaborative relationship is to create an efficient patient-centered ED that is simultaneously a nurturing workplace for staff. All hospital departments float on a sea of culture: medical, administrative, and legal. In regard to regulation, the best course is the one that keeps the department off the rocks. Navigating through proactive compliance is facilitated by a map and the purpose of this chapter is to provide one.

Legislative bodies, state and federal, regulate emergency medicine practice by way of statute. Other bodies, in particular those that oversee the spending of government money, regulate EDs by way of controlling reimbursement and the ever-present threat of the charges and penalties of so-called fraud and abuse. The Centers for Medicare and Medicaid Services (CMS) is the preeminent example of such an entity. Private accrediting organizations, such as the not-for-profit The Joint Commission (TJC) and competing alternative accrediting entities also regulate various aspects of ED operation. Finally, various professional associations such as the Emergency Nurses Association (ENA) and the American College of Emergency Physicians (ACEP) promulgate best practices and other recommendations that may carry the weight of the law in malpractice actions if the department does not comply with them.

The statutory regulation at the federal level embodied in the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Health Insurance Portability and Accountability Act (HIPAA) as it regards electronic medical records, the Core Measures-Quality Check and Accountability Measures of CMS and the TJC accreditation requirements for Medication Reconciliation (MedRec) will be the focus of attention for this chapter.

Emergency Medical Treatment and Labor Act

Few government acronyms can engender visceral reactions in emergency physicians like the incantation of EMTALA (Emergency Medical Treatment and Labor Act). EMTALA was enacted by Congress in 1986 as an “antidumping” law.1,2 EMTALA is explored in greater depth in Chapter 89. However, in this chapter, EMTALA will be briefly introduced to give the necessary context to our discussion of emergency medicine's current regulatory environment.

EMTALA is federal law requiring hospitals with EDs to provide a medical screening exam (MSE) and to treat the emergency medical conditions of patients in a nondiscriminatory manner, regardless of a patient's ability to pay, insurance status, national origin, race, creed, or color. EMTALA also legislates that receiving hospitals able to provide a necessary and higher level of care must do so.

EMTALA's enforcement power lies in the Medicare dollars that participating hospitals receive. Most hospitals rely on Medicare dollars and could not function without them. Few hospitals can afford, therefore, to eschew CMS ...

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