Emergency Medical Treatment and Active Labor Act and trauma triage.

The Emergency Medical Treatment and Active Labor Act (EMTALA) was conceived as a means to ensure that patients with emergent conditions would receive stabilizing care and to avert the potentially dangerous, economically driven, interhospital transfer of patients. This legislation and its subsequent application arrived near the time that regional and statewide trauma systems were established. Trauma systems were developed to guide optimal resource use for the injured patient regardless of the patient's ability to pay. Unfortunately, when coupled with current economic and litigation threats to community emergency and surgical practitioners, EMTALA represents a threat to the continuation of the trauma system concept. Trauma systems are dependent on a tiered hospital network where severely injured patients are taken to a hospital with resources aligned to manage the worst of injuries. When primary triage from the field cannot accomplish this task, secondary triage from a nondesignated or lower-level hospital to the higher-level trauma center is needed. EMTALA has served as a driver to change the priority for secondary triage from addressing the needs of the severely injured patient to filling community hospital surgical specialist emergency department on-call coverage gaps for less severely injured patients. Further, legal action associated with claims of EMTALA violations has needlessly extended medical examination and "stabilization" efforts at community emergency departments prior to needed secondary triage. Higher-level trauma centers will benefit from codifying system-wide emergency medical services practices related to primary and secondary triage, establishing trauma center capacity and divert practices, and initiating "transfer center" operations that control transfer of patients to these centers.