Discharging patients on the board

I had a charge who would discharge patients without telling the nurse and the patient would still be in the room. It's to keep the discharge times

If management did this, I would notify not only the union, but CMS as well.

I don't worry about that ^ too much. Anything could happen whether I discharge them myself or someone else does. That's different than someone sitting in an office doing something electronically that closes out the visit prior to ordered care having been rendered; in the case described there were still medication orders.

We haven't had any clarification from the OP, so, generally:

• Patient discharged/signed out with a plan for the patient to stay in the room for a prolonged time awaiting transportation: Fine, but it's management's deal at that point
  

• Patient moved from room/stretcher to hall/chair before course of care complete (so that another patient can utilize room/stretcher) but not discharged/signed out: Also fine, as long as the patient's location is also changed electronically. Course of care will be completed in the new location.
  
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• Patient discharged/signed out by another RN because course of care is complete even though it may take a few more minutes for them to get out of the room: Fine.
  

• Patient electronically removed from room to another location when the patient's physical location has changed: Fine.
  

• Patient electronically removed from tracker/board and/or visit ended electronically before ED course of care is complete and there are still orders intended to be completed before discharge and the patient has neither eloped nor signed out AMA: NO. These tools are there to serve us and the patient, and this is quite the bastardization of their usefulness. If this were okay, might as well have programmed EMR rules that automatically discharge sore throats after 15 minutes and prescription refills after 5 minutes, etc., and let the staff in a huge busy ED knock themselves out keeping track of it all.
  

Completely disagree with the antibiotic pt point. There very well could be a reason to watch for a reaction you are not aware of. Plus, if the doctor ordered the patient to be watched, then they should not be discharged until they are monitored as ordered.

I don't think it's appropriate to keep a discharged patient in a room for 3 hours to wait for a ride. Patients aren't taken off our board unless they are out of the department. I did work at a place that had a discharge lounge. We would put patients in there who needed to have discharge instructions explained if we needed a room for another patient, or in the case of waiting for a ride. The patient was kept on the board though because a real discharge means that someone leaves the department. We keep deceased patients on the board too, until they are taken to the morgue or the coroner gets the body.

I had a charge who would discharge patients without telling the nurse and the patient would still be in the room. It's to keep the discharge times

If management did this, I would notify not only the union, but CMS as well.

If something happens before they physically leave then it would be no different than if they had just showed up with that problem. Once the MSE (medical screening exam as required by EMTALA) has been completed then the legal obligation has ended, the patient's physical location does not determine whether the MSE has been completed.

I don't see the logic behind removing pts who are still physically there, though. There's totally a more sane way around that issue. We use Epic and all we do is move them to one of the urgent care locations that's designated as a chair. Then when they're actually gone we then discharge them.

It's falsification of documentation. Documenting that a patient is discharged when they are not. Seems pretty cut and dry here. I'm sure CMS, TJC, and your State Board of Nursing would love to here about this...

As someone who deals directly with CMS, TJC, state board and etc I can tell you that they don't care if you don't follow them after the regulatory requirements of a MSE have been met, since that's all that defines what a "discharge" is from their point of view, although they do take issue with nurses who don't understand that differentiation since that means they should be reviewed for whether or not they should continue to have a license.

If a patient who has meet the regulatory criteria for dishcharge (they have no criteria that establishes an ongoing need for nursing care) then there is no justification for ongoing care which would establish a need for nursing staff to keep track of the patient's whereabouts.

I'm not clear what justification those who oppose this criteria are using, but I'm curious what that criteria might be. Feel free to share what that criteria is.

Muno,

Are you saying that we're all playing these stupid throughput games for no reason at all? You know I believe you, but I need some clarification.

My understanding of what you're saying is that care that is being provided such as that in the OP (an antibiotic that has been ordered and the patient still needs to receive) is beyond the official EMTALA obligation for MSE. I can understand that. Therefore, the patient can rightfully be discharged (without evoking the concern of CMS) because the MSE is complete. I would agree except for two things: 1) I'm pretty sure that under usual circumstances hospital administrators are not qualified to independently discharge patients; that is a function of the provider. No provider has discharged this patient. 2) Additional care has been undertaken and is in progress. If the visit is ended electronically, appropriate documentation cannot occur and chaos would eventually ensue d/t trying to keep track of patients who remain in the department off-record. I would think it to be really unsafe, generally-speaking.

Hosptials have always had the option of screening and immediately discharging non-urgent patients. They have their reasons for not writing policies with this in mind. I really don't think it's kosher for them to 1) Not screen and discharge patients the way EMTALA officially allows them to, but then 2) allow an administrator to end the visit while the care they told the patient they wanted to provide is still taking place.

I think the previous poster was wondering if CMS would care that this practice being described in the OP is solely for the purpose of falsifying throughput times. The OP quality measure (OP-18) calls for measure of time from arrival to departure for discharged patients. The practice of electronically discharging a patient who is still present and still completing ordered treatment (whether it is EMTALA-required "stabilizing" treatment or not) serves no other purpose than to attempt to falsely represent a patient's departure. I'm not a reporter of much of anything (ever), so I personally don't care whether CMS cares about this or not. But I do think it's feasible that they might care about purposeful attempts to falsify quality reporting data. Could one assume that they would've written OP-18 using different verbiage if the length of time they meant to measure was "arrival to completion of MSE" rather than "arrival to departure"? I kind of think so....