2002 proposal	2003 final regulation
Adding a new concept of the "dedicated emergency department" (DED), including such areas as Labor and Delivery as well as the emergency room, and clarifying that EMTALA will not typically apply to a scheduled visit to a non-dedicated department.	Carried forward pretty much intact. The most significant clarification is that the statute and regulations do apply to ambulatory care centers operated by hospitals. Because the EMTALA scheme does not apply to non-hospital facilities, there is no change as it applies to self-standing ACFs.
Approving a "quick screen" [our words, not those of CMS] approach for persons presenting to a DED where an emergency medical condition is unlikely to be involved and the person is not requesting emergency services.	For a patient presenting at the emergency room for treatment other than emergency care, the screening requirement may be met by a more attenuated process, so long as it is applied to all patients. The requirement may be satisfied by having the patient verify that he is not seeking emergency services and having a qualified medical person ask him a few questions. (Note the emphasized language. Questioning by a triage nurse will not suffice.) A significant addition is a comment that a person coming solely for the dispensation of medication at the direction of his physician will trigger the full EMTALA requirements, because they "may involve medical conditions". This will provide additional reasons to discourage this questionable practice.
Clarifying the 250-yard rule to exclude non-medical locations such as restaurants and shops, and (most importantly) to exclude physicians' offices and other medical facilities that are separate Medicare participants. The proposal provides that a new emergency medical condition which develops while outpatient services are being received does not invoke EMTALA responsibilities for the emergency room.	The 250-yard rule continues to operate, and the proposed exclusion is included in the Final Rule. The standard that applies to presentations on hospital property outside the Dedicated Emergency Departments is whether the patient is requesting emergency services, or the patient would appear to a normal prudent layperson to be in need of emergency treatment, based on his appearance or behavior. Thus, requests for treatment other than for emergency services as so defined, including most outpatient treatment, do not trigger EMTALA obligations.
Somewhat similarly, clarifying that a new emergency medical condition which arises in a previously stable inpatient is not governed by EMTALA.	Adopted. The EMTALA obligations end when the patient is admitted as an inpatient and the original emergency medical condition is stabilized. A new EMC arising thereafter does not trigger EMTALA obligations.
Eliminating any EMTALA obligation for off-campus facilities, whether or not they are provider-based under the Medicare regulations, unless they regularly provide emergency services.	Carried forward as proposed. The rule does permit the off-campus emergency facility to be operated under conditions that would not typically apply to the full-fledged emergency department, such as limited hours and staffing. Somewhat curiously, the rules state that these obligations will be enforced under the Medicare COP and not "under EMTALA".
Adopting a general "rule of reason" approach for on-call obligations, and explicitly disavowing any numerical rule of thumb.	Adopted. The hospital is not required to have 24 hour coverage in all specialties if it cannot reasonably do so. The hospital must adopt written standards to govern situations in which a particular specialty is not available. A very significant addition is the fact that some specialty coverage may now be provided by means other than the specialist coming to the emergency room. Thus, for the first time, referral to the specialist's office (if expressly provided in the written protocols) may be appropriate for certain hospitals with limited specialty coverage.
Eliminating special rules for hospital-owned ambulances.	Adopted. All ambulances, regardless of ownership, may comply with local EMS standards regarding the proper destination hospital. The effect is that an ambulance owned by Hospital A will no longer be required to transport patients to Hospital A, but may transport them to the nearest appropriate facility if it is directed to do so by a community EMS protocol or by a physician not affiliated with Hospital A.