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Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I know an ER nurse who told me that at her hospital a patient can be assessed by the triage RN and then taken to the urgent care across the street if not in need of emergency care. A transporter walks or wheels the person for ingrown toenail, a cut the needs suturing, or a young person with upper respiratory symptoms and no chronic illness.

It is better for true emergencies and also better for the person who probably not have to wait while the critically ill and injured are seen.

She said they tell others so more people go to urgent care rather than the ER.

I have a question......is this urgent care across the street apart of that facilities ED?

I agree there are plenty of chronic conditions that are treated in the ED that should be treated else where and that getting them out of the ED is the best plan......however.....The problem with the triage RN is performing the MSE (medical screening exam)

EMTALA contains 2 basic requirements:

  • For any person who comes to a hospital emergency department, "the hospital must provide for an appropriate medical screening examination . . . to determine whether or not an emergency medical condition exists" (see 42 USC 1395dd[a]).[3]
  • If the screening examination reveals an emergency medical condition, the hospital must "stabilize the medical condition" before transferring or discharging the patient.

and turfing them to another facility is a dangerous path to be walking on a tightrope....and a violation of EMTALA.

If a patient presents to the ED with chest pain and the triage nurse feels it's Costochondritis and sends them to urgent care minus the MSE

Medical screening exam

Any person requesting emergency services, who presents to a facility that provides emergency services, must receive a medical screening exam (MSE). The purpose of the MSE is to identify whether an emergency medical condition (EMC) exists.

This request can come from the patient, someone accompanying the patient, a law enforcement officer bringing someone to the ED, or someone walking into the ED requesting a blood pressure check.

and the patient suffered a MI. The facility has violated EMTALA for not performing the MSE.

Everyone....EVERYONE presenting to the ED is required to have/be offered a MSE...as I explained earlier. Failure to provide this is a violation of EMTALA and it can't be offered by a triage nurse for they are not a "qualified provider".

The MSE must be performed by a qualified medical provider (QMP). Although the statute does not preclude a nurse or mid-level provider from performing the MSE, compliance generally is ensured if a physician evaluates the patient. In the case of a nurse or mid-level provider, the QMP must have a job description for this role, qualifications and competencies must be established, and a formal designation for approved individuals must be in their personnel file.
If that urgent care across the street is apart of the system...they are fine if not...that nurse is taking a huge risk and shouldering responsibility that she should not (unless specially trained and documented in personnel file).... but that is her choice.

Just because facilities are doing this doesn't mean that when something goes horribly wrong that they can't be held responsible....or they won't blame the nurse for acting out of scope.

I have been at this a long time and I even called my go to source. Either there are details that are not revealed here that would change my answer....or these facilities are taking a risk.

Specializes in Emergency & Trauma/Adult ICU.

I think the thread has veered far off course from the information the OP shared; however, I will chime in on the MSE point.

Firstly, although I certainly cannot speak for Blue Devil, DNP -- I strongly suspect that what she intended to convey was not that the hospital system to which she was referring violates EMTALA, but rather, as a matter of policy, does not tend to treat what an MSE provider has determined to be a nonemergent complaint. And this is not the first time I have seen this discussed on allnurses.com -- there have been a number of threads discussing nonemergent patients being asked for payment after the MSE but prior to treatment of a nonemergent condition.

Secondly, as Esme12's last post references, it is possible to have triage by a registered nurse serve as an MSE. I have worked in a hospital where this was practiced. Hospital policy spelled out this practice in writing, listed specific educational and experiential requirements for RNs to be assigned to triage, and listed very tight parameters on patient ages, medical histories, and vital signs. All patients falling outside those parameters were required to be seen by a provider. It can work.

Thirdly, one of my favorite docs is fond of saying "triage is a process -- not a place". If a nonemergent ED visit involving an ingrown nail can be wrapped up without the patient ever "going in the back" -- this is probably a good thing.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
You are right Altra we have veered off topic.....
Specializes in Going to Peds!.

I think my hospital's er is now collecting payment after the MSE reveals a non emergent condition that should receive medical treatment. Patients can choose to pay & be treated or leave.

Sent from my HTC One X using allnurses.com

I think the thread has veered far off course from the information the OP shared; however, I will chime in on the MSE point.

Firstly, although I certainly cannot speak for Blue Devil, DNP -- I strongly suspect that what she intended to convey was not that the hospital system to which she was referring violates EMTALA, but rather, as a matter of policy, does not tend to treat what an MSE provider has determined to be a nonemergent complaint. And this is not the first time I have seen this discussed on allnurses.com -- there have been a number of threads discussing nonemergent patients being asked for payment after the MSE but prior to treatment of a nonemergent condition.

Secondly, as Esme12's last post references, it is possible to have triage by a registered nurse serve as an MSE. I have worked in a hospital where this was practiced. Hospital policy spelled out this practice in writing, listed specific educational and experiential requirements for RNs to be assigned to triage, and listed very tight parameters on patient ages, medical histories, and vital signs. All patients falling outside those parameters were required to be seen by a provider. It can work.

Thirdly, one of my favorite docs is fond of saying "triage is a process -- not a place". If a nonemergent ED visit involving an ingrown nail can be wrapped up without the patient ever "going in the back" -- this is probably a good thing.

Yes, the thread has veered a little off course, but not a large amount. The OP was posting concerning the rollout of PPACA and the discussion that has followed has been one based on beliefs regarding how the rollout of PPACA will effect the ER (the veering has come in the form of what is and is not an acceptable and/or legal way to deal with a patient that really does not need an ER practitioner).

With regards to BlueDevilDNP's comments the concern I had was the callous manner in which the patient is told "tough luck". There is a right way and a wrong way to go about this. Regardless of whether or not the facility kicks them out prior to an MSE or after (and there was no mention, as you point out, in that post of when the "kick out" occurs) there is NEVER, and I repeat NEVER, any excuse for ANY health professional being rude to a patient. The patient who walks into a podiatrist office complaining of stomach pain is clearly in the wrong place, BUT it would be inappropriate for the staff at the podiatrist office, or even the Podiatrist themself, to tell the patient "hey stupid you came to the wrong place for this now get out of my office and go to the correct place". For what it's worth IF BlueDevilDNP's name reflects a location in North Carolina then this would put the facilities, possibly, in the Research Triangle Area of North Carolina. I just do not believe that facilities in this area, or most any area really, are being this rude to people, especially prior to an MSE, and are not (or have not been) facing a lawsuit from someone. With absolutely no disrespect meant it was the manner in which this was presented (i.e. that being rude in this manner was perfectly acceptable) that seemed, and still seems, very very wrong to me.

As you, and others, have pointed out asking for payment after the MSE is done in many many places. Being rude, and harassing the person over not having the money (such as the "save up" response) is not only uncalled for but is most assuredly ample grounds to sue over harassment if not also discrimination. A person has a right to expect to receive competent medical care in a hospital free from discrimination or harassment for any reason. The "save up" line does not meet this expectation, and, as I am sure you are aware, it is this that can, and does, lead to litigation.

I think most of us would agree that the ingrown toenail can better be dealt with somewhere other than an ER. This, as I say, should be presented to the patient in a way that "sells" them on the reason it is not best to do it here. One of the easiest is to point out the cost savings to them, the patient, by having the ingrown removed in an office, urgent care, walk in clinic, etc. over the ER. A $120 out of pocket PCP office procedure or a $600 out of pocket ER procedure is a no brainer to most people. Then if the patient really seems intent on paying the $600 out of pocket on the spot . . . well the ER has just brought in a little extra cashflow for the hospital tonight (and immediately too not after 6 months to a year of back and forths with the insurance company). If the patient expresses concerns that they cannot afford either option then "tough luck" is NEVER an acceptable response. Refer the patient to the local free clinic (many areas have one), or ask the patient to wait in the lobby, notify the Social Worker on duty, and have them work with the patient (this is part of their job after all).

Once again this is not meant to ruffle feathers, but remember guys, right or wrong, emergent or not, we are dealing with PEOPLE here in a MEDICAL environment. We are not working on an assembly line, and we are not some sort of "ER Police" whose task it is to do away with all patients who do not fit the mold or image of a "correct" patient. Remember that just as with 911 people are told by numerous sources to go to the ER if they need medical treatment. Some, but by all means not most, of the patients may know they have arrived at the ER for a reason that does not require an ER (just like there are people who call 911 because McDonald's miscooked the hamburger but most people who call 911 for a non-emergency have a real reason they need police, fire, etc. it is just not an active emergency).

My two cents worth . . .

Just because facilities are doing this doesn't mean that when something goes horribly wrong that they can't be held responsible....or they won't blame the nurse for acting out of scope.

I have been at this a long time and I even called my go to source. Either there are details that are not revealed here that would change my answer....or these facilities are taking a risk.

Just wanted to supply a personal story that sheds light on what you are talking about here. My wife has been being treated for hypertension for years even though she is not yet 30. Her father actually had a kidney transplant due to kidney failure that resulted from asymptomatic, and thusly undiagnosed, hypertension. About 4 years ago now we were in Florida and my wife began to feel really really bad. We stopped off at a Walgreens Clinic and were promptly told by the NP on site that either 1) I needed to take her to the closest ER or 2) she (the NP) would call an ambulance to transport her due to how high her blood pressure was at the time. I decided to drive her because we were very close to the ER. Upon our arrival my wife told the person at check in that she was having chest pains, a severe headache, had a history of hypertension, and had been sent over from a walk in clinic. This person immediately put her in a wheelchair and rolled her into a room where the triage nurse proceeded to take her BP, performed an EKG, and then promptly told my wife that 1) her BP was only high because she was "nervous" over being in the ER and that 2) "chest pains on a person of your age is NEVER a reason to come to the ER". She then suggested that we "go to a walk in clinic" later if it "keeps up". When my wife told her this was unacceptable we were told "well I will put you in a room, but you will sit there for hours probably waiting on a doctor". She also informed us that "no competent physician would diagnose a patient in their twenties with hypertension or place them on medicine" (even though my wife was taking medicine for hypertension). Well to make a long story somewhat shorter we did NOT wait for hours to be seen. After they hooked her up to the monitor in the room the ER physician came in saw that her systolic BP was now over 200 and that she was having an arrythmia and promptly started care and arranged for her to go upstairs to the monitored unit. The hospital treatment, stay, etc. was well over $7,000. We didn't pay a penny. Why? Well I had a discussion with the hospital administration who agreed, along with the internist who saw my wife in the hospital, that the triage nurse had been in error (I was also reassured, as I already knew, that no one should ignore chest pains ever). I was actually told by the ER Medical Director that 1) the initial EKG performed by the triage nurse showed an "obvious" arrythmia, and that 2) the nurse in question would be removed from the ER until such time that she could show basic competence in the interpretation of an EKG. The implication was obviously that they would cover all charges, and we, in turn, would not sue.

So, needless to say I am a big proponent of doing things the right way NOT the way that might be the easiest to the facility or staff.

Specializes in Emergency & Trauma/Adult ICU.
Yes, the thread has veered a little off course, but not a large amount. The OP was posting concerning the rollout of PPACA and the discussion that has followed has been one based on beliefs regarding how the rollout of PPACA will effect the ER (the veering has come in the form of what is and is not an acceptable and/or legal way to deal with a patient that really does not need an ER practitioner).

With regards to BlueDevilDNP's comments the concern I had was the callous manner in which the patient is told "tough luck". There is a right way and a wrong way to go about this. Regardless of whether or not the facility kicks them out prior to an MSE or after (and there was no mention, as you point out, in that post of when the "kick out" occurs) there is NEVER, and I repeat NEVER, any excuse for ANY health professional being rude to a patient. The patient who walks into a podiatrist office complaining of stomach pain is clearly in the wrong place, BUT it would be inappropriate for the staff at the podiatrist office, or even the Podiatrist themself, to tell the patient "hey stupid you came to the wrong place for this now get out of my office and go to the correct place". For what it's worth IF BlueDevilDNP's name reflects a location in North Carolina then this would put the facilities, possibly, in the Research Triangle Area of North Carolina. I just do not believe that facilities in this area, or most any area really, are being this rude to people, especially prior to an MSE, and are not (or have not been) facing a lawsuit from someone. With absolutely no disrespect meant it was the manner in which this was presented (i.e. that being rude in this manner was perfectly acceptable) that seemed, and still seems, very very wrong to me.

As you, and others, have pointed out asking for payment after the MSE is done in many many places. Being rude, and harassing the person over not having the money (such as the "save up" response) is not only uncalled for but is most assuredly ample grounds to sue over harassment if not also discrimination. A person has a right to expect to receive competent medical care in a hospital free from discrimination or harassment for any reason. The "save up" line does not meet this expectation, and, as I am sure you are aware, it is this that can, and does, lead to litigation.

. . .

Well, this is where we differ. I in no way, shape, or form interpreted those comments as being LITERALLY what is said to patients.

Nor would I derail a thread on discussion of the ACA with a treatise on perceived rudeness.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
Just wanted to supply a personal story that sheds light on what you are talking about here. My wife has been being treated for hypertension for years even though she is not yet 30. Her father actually had a kidney transplant due to kidney failure that resulted from asymptomatic, and thusly undiagnosed, hypertension. About 4 years ago now we were in Florida and my wife began to feel really really bad. We stopped off at a Walgreens Clinic and were promptly told by the NP on site that either 1) I needed to take her to the closest ER or 2) she (the NP) would call an ambulance to transport her due to how high her blood pressure was at the time. I decided to drive her because we were very close to the ER. Upon our arrival my wife told the person at check in that she was having chest pains, a severe headache, had a history of hypertension, and had been sent over from a walk in clinic. This person immediately put her in a wheelchair and rolled her into a room where the triage nurse proceeded to take her BP, performed an EKG, and then promptly told my wife that 1) her BP was only high because she was "nervous" over being in the ER and that 2) "chest pains on a person of your age is NEVER a reason to come to the ER". She then suggested that we "go to a walk in clinic" later if it "keeps up". When my wife told her this was unacceptable we were told "well I will put you in a room, but you will sit there for hours probably waiting on a doctor". She also informed us that "no competent physician would diagnose a patient in their twenties with hypertension or place them on medicine" (even though my wife was taking medicine for hypertension). Well to make a long story somewhat shorter we did NOT wait for hours to be seen. After they hooked her up to the monitor in the room the ER physician came in saw that her systolic BP was now over 200 and that she was having an arrythmia and promptly started care and arranged for her to go upstairs to the monitored unit. The hospital treatment, stay, etc. was well over $7,000. We didn't pay a penny. Why? Well I had a discussion with the hospital administration who agreed, along with the internist who saw my wife in the hospital, that the triage nurse had been in error (I was also reassured, as I already knew, that no one should ignore chest pains ever). I was actually told by the ER Medical Director that 1) the initial EKG performed by the triage nurse showed an "obvious" arrythmia, and that 2) the nurse in question would be removed from the ER until such time that she could show basic competence in the interpretation of an EKG. The implication was obviously that they would cover all charges, and we, in turn, would not sue.

So, needless to say I am a big proponent of doing things the right way NOT the way that might be the easiest to the facility or staff.

I am sorry you experienced this...there are bad nurses everywhere......you wife's story, by ALL accepted triage standards, is triage to acute side monitored bed with probability for admission...level 2 acuity.

I am glad your wife is better.

Specializes in Critical care, tele, Medical-Surgical.
I have a question......is this urgent care across the street apart of that facilities ED?

I agree there are plenty of chronic conditions that are treated in the ED that should be treated else where and that getting them out of the ED is the best plan......however.....The problem with the triage RN is performing the MSE (medical screening exam) and turfing them to another facility is a dangerous path to be walking on a tightrope....and a violation of EMTALA.

If a patient presents to the ED with chest pain and the triage nurse feels it's Costochondritis and sends them to urgent care minus the MSE and the patient suffered a MI. The facility has violated EMTALA for not performing the MSE.

Everyone....EVERYONE presenting to the ED is required to have/be offered a MSE...as I explained earlier. Failure to provide this is a violation of EMTALA and it can't be offered by a triage nurse for they are not a "qualified provider". If that urgent care across the street is apart of the system...they are fine if not...that nurse is taking a huge risk and shouldering responsibility that she should not (unless specially trained and documented in personnel file).... but that is her choice.

Just because facilities are doing this doesn't mean that when something goes horribly wrong that they can't be held responsible....or they won't blame the nurse for acting out of scope.

I have been at this a long time and I even called my go to source. Either there are details that are not revealed here that would change my answer....or these facilities are taking a risk.

The urgent care clinis is associated with the same hospital as the ER. There are certified emergency physicians, LVNs, MAs and and NPs.

I would not want the responsibility of the triage RN, but from what I know it has been OK so far.

I think they are very cautious. They are certified triage RNs.

My friends son is a young man who cut his hand on a broken plate while washing dishes. He immediately applied pressure with a clean undershirt and drove himself to that ER. He said the triage nurse looked at his hand, took his vital signs, listened to his heart, lungs and abdomen. After asking many questions had a transporter walk him to urgent care.

hey gave him a tetorifice shot, sutured his hand, drew blood, and the NP told him to return there or to his doctor for any signs of infections and to have the sutures removed in a week.

It IS a huge responsibility for the triage RN.

Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
The urgent care clinis is associated with the same hospital as the ER. There are certified emergency physicians, LVNs, MAs and and NPs.

I would not want the responsibility of the triage RN, but from what I know it has been OK so far.

I think they are very cautious. They are certified triage RNs.

My friends son is a young man who cut his hand on a broken plate while washing dishes. He immediately applied pressure with a clean undershirt and drove himself to that ER. He said the triage nurse looked at his hand, took his vital signs, listened to his heart, lungs and abdomen. After asking many questions had a transporter walk him to urgent care.

hey gave him a tetorifice shot, sutured his hand, drew blood, and the NP told him to return there or to his doctor for any signs of infections and to have the sutures removed in a week.

It IS a huge responsibility for the triage RN.

Thanks...that makes sense then...technically no because they are referring to another area of their hospital...even if it is across the street...they provide "transportation"...even if it is a wheelchair. They are not "technically "discharged" from the system.

Triage nurses do this all the time. I worked for a facility that had 2 Emergency departments. Acute and Urgent care. Under specific training and specific protocols the triage nurse would decide triage level, assign a department, order appropriate x-rays/labs when indicated....best run department I have ever seen.

My issue is triage doing the MSE, training or not and discharging them with go find CVS. I am sure it is perfectly legal...but I would not work triage under those conditions. I am good enough to do that however, I am NOT paid enough for that responsibility.

Specializes in Pediatric Pulmonology and Allergy.
My state has welcomed the ACA. Open enrollment is going to be interesting and we are counting down! My company estimates we will get as many as 18,000 new primary care patients. Medicaid reimbursement is reasonable here, and they pay promptly 100% of the time, keeping collections up. We are going to need trucks to haul the tons of money we are going to rake in, patients are going to be taken care of in a far more cost effective way than the ED. All of us are opening up our panels to prepare. I'm reserving 4 appointment slots a day strictly for new ACA patients, in addition to my 4 frozen slots for emergencies, which will likely end up being ACAs if none of my other patients needs a last minute appt. That's 1/3 of my patient day! Most of my colleagues are doing something similar.

Somehow I don't think the point of the aca was to help providers rake in ever greater sums of money.

Specializes in Nephrology, Cardiology, ER, ICU.

And getting back to the topic at hand, APNs will cont to play a vital role in the implementation of the ACA:

Nursing Graduate Medical Education Demonstration Program—ACA Section 5509

Section 5509 of the ACA establishes up to five hospital-based graduate nurse education demonstration projects for the clinical training of advanced practice registered nurses (APRNs). The statute mandates that all training programs must occur in, and be administered by, a hospital organization. Yet, there is a concern among APRN educators that relying only on hospital-based training may promote more specialized medical training that contradicts efforts to increase the number of primary care providers who are trained and educated to meet the needs of rural patients. Advanced practice nurses will play a key role in meeting the emerging primary care needs of this country, particularly in rural communities. This demonstration project provides an opportunity to design a training methodology that emphasizes community-oriented primary care training experiences, but only if the funding flows to the community-based sites. The Committee recommends that the Secretary require any programs funded under the Nursing Graduate Medical Education Demonstration Program include significant training and allocation of training dollars for community-based ambulatory training sites and that preferences be given to applicants that include rural community-based training sites.

http://www.hrsa.gov/.../wpacaprimarycareprovisions092011.pdf

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