Ummmm..are they ALLOWED to do that? - page 6

OK, I have worked in about 5-6 different ERS, both as staff and agency an I have never experienced this. Right now I am doing a contract in a dinky little community non-teaching hospital. The ER is... Read More

  1. by   CritterLover
    Quote from hogan4736
    good question...i anticipated it after i posted...

    emtala seems to distinguish the er as an almost separate entity...

    the pt that codes in the er will use the ed pyxis, the ed staff, and is in the ed...i think emtala could have something to say here...

    i'd be curious to hear any other thoughts...

    quick story:

    we xferred a guy out of our ed (via chopper)...they got to the chopper, but the pt wouldn't fit inside (too tall)...the flight crew brought the pt back in, but the pt was maintained under the flight crew's care...

    my thought was,at the time, what if he coded while under their care, but in our er?

    so we signed him back in, care was xferred back to us, and we grounded him to his destination...kind of a similar situation...

    there may not be an answer, as it is a murky topic

    yeah, there are definatly many murky areas.

    imo, the murky areas would show up less often if administration would realize that patients get much better care when they don't try to push the staffing guidelines to the limit.

    i was just talking with a good friend of mine who is a nm of our er. she said while it is most certainly not an emtala violation, because emtala ends once the patient is admitted. however, she said it does violate some jcaho standards because you have to have a plan for this situation, and the staff to care for the patients. sending the patient back to the er might be the plan, but then additional staff has to be brought in to take care of the patient. she said the same is true for the holdovers -- hospitals that do not staff appropriatly for holdovers, such as the op's case -- are going to be in trouble with jcaho when they are surveyed.


    i hope i'm translating what she told me correctly.



    about the chopper story:

    they always ask for a weight, but i've never been asked for a height before. i can see why it would be a problem, though. i helped load a guy on one a few weeks ago....i never realized how small those things are! i always thought i'd like to be a flight nurse at some point. haven't pursued it because i get so motion sick. but wow, i think i'm too clausterphobic to work out of one of those!
    Last edit by CritterLover on Mar 17, '07
  2. by   wooh
    Quote from hogan4736
    Right,

    however, one scenario...

    you bring down an ICU pt d/t no room upstairs, you even send a nurse with the pt ...you don't check the pt into the ED, and maintain the inpt orders, and the pt's assigned doc...everything is going well, then the pt codes...

    do you think the ER doc won't step in? of course he will...now you HAVE to check the pt in, as he is in your ED...

    EMTALA violation
    Why would you check the patient in just because the ED physician sees them? At my last facility, the ED physician was part of the code team. So she stepped in even if the code was on the floor. Codes on the floor didn't get checked back in just because the ED physician came and intubated.

    I'm not saying it's a good idea. (Although when hospital is full to capacity, I don't think we're looking for a good idea, rather a lesser of many evils idea.) But I just don't see how it's an EMTALA violation. Sending them down for sutures (and as such treatment by the ED doc) is entirely different than housing an inpatient in the ED with treatment from the admitting the doc.
  3. by   wooh
    ....emtala violation....jcaho standards...
    i was thinking earlier in this thread that it's starting to sound like the er manager's answer to everything is "it's an emtala violation" where the floor manager's answer to everything is "it violates jcaho standards."

    (begin dreamworld) if only we could simply think, "what is best for this patient at this moment?" instead of arguing over regulations and standards... heck, we'd probably get our patients cared for and out the door so fast that we wouldn't have to worry about overflow anymore.... (end dreamworld)
  4. by   hogan4736
    I agree wooh...

    The distinction is clear...

    I'm looking for definitives here, when likely, none exist...

    Would EMTALA see a difference between coding an inpatient that had been sent back to the ER, versus the ER doc going up to the floor...I believe so...

    You mentioned "lesser of many evils"

    Housing an inpt back down to the ER, is the highest (IMO) of all evils
    Last edit by hogan4736 on Mar 17, '07
  5. by   traumalover
    Wow. First post. Was inspired to join and post because I have been an icu nurse for 2 years. Also prn in the er and on the floor and have been floated to ms. everybody works hard, in different ways. In our Icu, we take everything from balloon pumps, open hearts, traumas, everything but transplants. sometimes we are full and no shuffle can be done. Why? So we can send an unstable pt to the floor, increasing that nurse's workload, and the pt can come back down later with people shaking their head saying we shouldn't have done that? Also, our unit responds to level 1 and 2 traumas, all codes, and are responsible for the rapid response team. er responds to codes and traumas as well. ms work their butts off as does post surg. Our hospital has people stacked in the er too. we do divert but only in last case scenarios, especially since all our neighbors are own diversion too. everyone's job seems to be getting harder and harder, but the teamwork I have with some er and floor nurses makes it a lot easier. One thing that makes it harder is anger. I will listen to anyone vent but I don't appreciate being blamed. Maybe (and please no one get angry) a committee (I hear the boos) formed of representatives from icu, er, tele, and bed coordination should meet and discuss various options. good luck and remember pt care first! If you feel unsafe say so!
  6. by   CritterLover
    Quote from wooh
    i was thinking earlier in this thread that it's starting to sound like the er manager's answer to everything is "it's an emtala violation" where the floor manager's answer to everything is "it violates jcaho standards."

    (begin dreamworld) if only we could simply think, "what is best for this patient at this moment?" instead of arguing over regulations and standards... heck, we'd probably get our patients cared for and out the door so fast that we wouldn't have to worry about overflow anymore.... (end dreamworld)

    yeah, it does seem that way sometimes. thing is, emtala usually goes against what it easier for the er. the other thing is that emtala violations come with huge fines.

    i really do believe that most good nursing superviors do try to do what is best for the patients. they may be wrong in the end, but i think most will do what appears to be best for the patients at that particular time, with the imformation they are given at the time. i think the problem comes in when one unit perceives that they are being "dumped on."

    i worked in a unit like that once. it was a sicu. the hospital had several other icus, so we really were supposed to take just surgeries. but come the weekend, there wern't as many surgeries, our patients would get txf to the floor/stepdown units, and we would have empty beds. of course, the other icus would be full, the er would get full, and they would try to send us the icu holds from the er. oh boy. you just can't imagine the fits that were thrown. i'm still astonished that the unit got away with that for so long.
  7. by   veetach
    In our hospital we have a policy that no one goes from inpatient status to outpatient status. The solution to this problem would have been to transfer this patient out to a facility who could care for him.
  8. by   ERERER
    you cannot transfer a patient to another facility if you have the ability to care for them. this does not mean bedspace, it means specialties (burns, neuro, etc). i've been doing this a long time. you would never find a physician to accept an established pt just due to "bed problems". THAT would be an emtala violation. Emtala addresses inappropriate transfers, started out as an "anti-dumping" legislation to prevent sending self-pays to other facilities. For example: we send out all our OB's because we do not offer, or have OB physicians on staff. This would be even if the entire hospital was empty. the closest facility that offers OB and has bed space is obligated to take the pt, insurance or not. THAT is emtala in a nutshell. Someone above said it "emtala ends when the pt leaves the ER". It does not cover in house patients at all. If the powers to be think that the pt would be safest in the ER, then that's where they go, like it or not. The patient still has their admitting orders, physicians, etc the same. The only way the ER doc gets involved is if the pt codes. Which would be the same if the patient was upstairs.
  9. by   grammyr
    As a supervisor in a small rural hospital, I do what is best for the patient. If it means physically putting them in the ED then so be it. If a patient on the floor goes bad and ICU is full, to the ED they will go, not because the nurses on the floor are not capable of taking care of the patient, but because if that patient is going south I need a crash cart, drugs,etc handy and the ED is the next best place. if there is no space in ICU. This would be a short term solution until a space in ICU could be made available or the patient gets transferred to a tertiary care hospital.
  10. by   hogan4736
    Quote from ERERER
    you cannot transfer a patient to another facility if you have the ability to care for them. this does not mean bedspace, it means specialties (burns, neuro, etc). i've been doing this a long time. you would never find a physician to accept an established pt just due to "bed problems". THAT would be an emtala violation. Emtala addresses inappropriate transfers, started out as an "anti-dumping" legislation to prevent sending self-pays to other facilities. ..
    you most certainly can transfer d/t lack of bedspace...if you have documented overcapacity...even the big city hospitals to it...

    you can also transfer d/t equipment failure (i.e. vents)
    we are a small hospital, and we have 3 vents...one was on a pt, the other two failed...I transferred the pt...
  11. by   hogan4736
    Quote from grammyr
    As a supervisor in a small rural hospital, I do what is best for the patient. If it means physically putting them in the ED then so be it. If a patient on the floor goes bad and ICU is full, to the ED they will go, not because the nurses on the floor are not capable of taking care of the patient, but because if that patient is going south I need a crash cart, drugs,etc handy and the ED is the next best place. if there is no space in ICU. This would be a short term solution until a space in ICU could be made available or the patient gets transferred to a tertiary care hospital.

    I am also a house sup in a small rural hospital, and you are doing the wrong thing by placing the pt in the ER...do your tele floor and PACU not have crash carts, and do you not have ACLS??

    No OR/PACU call?
    no ICU director/clin coordinator to come in?
  12. by   UM Review RN
    Quote from hogan4736
    This is a common misconception...


    If you are an RN without ACLS, you CAN push the same meds as an ACLS RN...



    your hospital may have a policy that trumps this, but an RN is an RN is an RN
    You're right; hospital policy does trump this. And IMHO, it should. No one without the proper training or equipment should be pushing certain meds.

    I could probably also be floated over to OB or Pedes, but frankly, it'd be quite dangerous for the patients for me to do that.
  13. by   hogan4736
    I respectfully disagree (See Braselow Tape)

    In a code situation, with several ACLS RNs around (I am in a small hospital - I am okay w/ ANY RN pushing epi), there is plenty of help...

    Things I have given once (IV) in 12 years (IN THE BIG CITY EDs):

    Pitocin (in an emergent situation...we need OBLS!!!!)
    Colchisine
    Vasopressin
    Aramine (didn't have ACLS current for this one...a RARE vasopressor-WOW)
    levophed

    NEVER given:

    TPA
    Ampho
    Streptokinase

    Nobody killed yet...

    If you don't know, look it up...if it's crazy, ask...

    One exception:Chemo...I need the class

    Let's get real...There are 2 reasons EVERYONE passes ACLS and PALS these days (hospital RNs only...does NOT include medics and CC transport RNs):

    1) How many codes has an RN run (alone) in the hospital?
    2) mean instructors (the old school ACLS ones) suck - intimidation is not conducive to learning
    Last edit by hogan4736 on Mar 20, '07

close