A US Federal District Court in Puerto Rico has ruled that the 2003 CMS regulation that interpreted EMTALA not to apply to in-patients does not have the "force and effect of law" and held that a mother could continue with her suit against the hospital that transferred her neonate child while allegedly in a profoundly unstable condition without providing stabilizing care.

According to the court's opinion, the mother gave birth by Cesarean section at Hospital San Pablo del Este (HSPE) and was originally taken to the hospital's newborn unit. The child developed emergency conditions, including upper gastrointestinal bleeding and was vomiting blood.

The following day, the physician at HSPE ordered the infant transferred to Hospital Interamericano de Medicina Avanzada where the child was described on arrival as being "critically ill r/o sepsis". The medical records showed that the infant left HSPE "totally unstable...with active upper gastro- intestinal bleeding", the court noted. The child died two days later.

The hospital moved to dismiss the case on the grounds that under the 2003 CMS regulations, the hospital was not bound by the stabilization and transfer rules of EMTALA because the infant was an in-patient.

The court ruled that the Lopez-Soto case had previously held that EMTALA did apply in almost identical circumstances, and emphasized that EMTALA's clear language is not limited to hospital emergency departments. The Lopez-Soto case is the only significant court of appeals case to interpret the Supreme Court ruling on EMTALA in the 1999 Roberts case (full text on the www.medlaw.com site).

The Judge refused to through out the case because of the CMS interpretation as not being binding on the court and would not apply in any case because the interpretation was issued after the child's death. The court noted retro-active applications are not favored by the law.

The Lima-Rivera decision allows the mother to proceed to trial, but she still must prove her allegations and that the conduct did violate EMTALA. Further appeal of the ruling is not likely to be allowed until a final verdict has been rendered in the case.

The judicial finding that the regulation is only an interpretation has the potential to bring the issue up on
appeal in this or other cases and perhaps ultimately return EMTALA to the Supreme Court for further clarification.

The original Roberts court clearly felt that EMTALA was not affected by what door the patient entered or what their status in the hospital was, and applied it to an in-patient discharge situation. The interpretation that EMTALA sections are to be read separately is also critical to the building debate over whether the CMS interpretation that "EMTALA does not apply to inpatients" alters the requirements for hospitals with specialized capabilities to accept transfers under EMTALA.