At my shop, esophageal food impactions generally get observation status. GI is quite busy and getting an urgent but not emergent endoscopy case can take several hours.
EMTALA 100% applies to observation patients. Admitted patients
usually (but not always) don't have EMTALA obligations unless CMS can show that the patient was admitted instead of observation status to avoid EMTALA implications.
If you admit a patient with an esophageal food impaction, they aspirate or have a complication, and if the patient or family so pursues, you'll find yourself staring down an EMTALA violation that has precedent.
In one EMTALA fine, a hospital didn't have a GI doc on call to perform an EGD for an elderly lady with an esophageal food impaction. So the ER did what any of us would've done: they transferred the patient to a facility that did have a GI on call and ability to do the EGD. The patient aspirated in the ambulance, became profoundly hypoxemic, suffered an asystolic cardiac arrest, and ultimately died. The transferring hospital and ED physician were both found to be in violation of EMTALA because the
ENT on call at that facility had credentials to perform an EGD even though he had not done one in >10 years and wasn't even contacted during this case. CMS and OIG viewed that because there was a specialist credentialed to do the EGD, the EGD should have been done at the referring facility and the patient never transferred. After the EMTALA violation, all of the nitty gritty became discoverable because the hospital was put on a 23-day fast track to losing ability to participate in Medicare. This resulted in a large settlement for the patient's family. CMS will get 50-100 charts they identify of similar cases (to see if it's your usual practice), nursing staffing rosters for the prior 90 days, physician staffing rosters for the prior 30 days, and the on-call schedules for the prior 30 days. They will look at credentialing of multiple specialities if it's relevant. This is how they found that the ENT's core credentials included EGD (which was in place not really to perform an EGD, but in place to allow an EGD to be performed during trach procedures).
CMS views stabilization as within a reasonable degree of medical certainty, no material deterioration should occur during a transfer or while the patient is in observation status. Sometimes stabilization requires days to weeks, and the general consensus that a true inpatient admission voids EMTALA obligations has been challenged recently. There's even been cases where patients were deemed unstable because they had "significant pain" upon discharge from the emergency department. How many of our patients wanting Dilaudid IV or oxycodone prescriptions say they're in 10/10 pain while walking, chewing gum, and texting simultaneously? CMS could -- and has sometimes in the past -- viewed that as not stabilizing the patient. Granted, these cases involve people with bad outcomes that generate the EMTALA investigation.
For anyone who normally delays EGD in these patients when you have capacity to perform them, you are subjecting yourself to possible EMTALA violations and litigation. I would advocate strongly that your hospital changes its policies and/or culture so that these patients get an EGD from the ER and are subsequently discharged (or then admitted if they so choose). I've provided expert witness EMTALA opinion before and would be happy to do so if you want to take up this issue with your gastroenterologists or hospital administrators.
