turning non-emergent pts away

mamalle · Jun 10, 2007

we just started doing something with our Tenet run ER.

MSE exams

triage nurse evaluates pt- determines it is not a medically necessity.

pt goes into a different room and waits for either the ER doc or PA to come in and evaluate him/her. If they decide it is not something that needs to be seen now- they will give them the option of staying and paying or refer out to the clinic. After the pa/ er doc goes in- then the financial person goes in and asks about insurance/ payment. etc. Its been in force for about 1.5 weeks so far. So far we have had return customers with worsening symptoms because they did not f/u with the clinic and more admissions. Today my PA was all pissed because a pt did not pay his copay since the registration people said its in their policy to not deny them since their insurance will pay the contracted amount. He felt like it could turn into a lawsuit since the ones that didnt have the money ie. insurance were being turned away and the ones that did have the insurance were given care. Its a big debate right now..

rph3664 · Jun 30, 2008

this sounds like a good first step toward fixing what is wrong with our health care system. if there are free clinics and urgent care facilities that the poor can use for their primary care providers, then let's ease them into doing so and away from clogging the er. telling them they must either pay up front or see a primary care provider still gives them choices -- and if they have the money for multiple piercings, tattoos and acrylic nails perhaps they do have the money for an er visit.

or, for that matter, a visit to a regular physician and the time to make the appointment.

TraumaNurseRN · Jun 30, 2008

I know you couldn't possibly have meant to this to sound the way it does

I'm not certain why you feel this way

MassED, BSN, RN · Jul 4, 2008

Do any of your ERs turn non-emergent pts away, like toothaches, lice, STDs, etc? Rumor has it that this week, we in triage are going to start handing out cards to the local free clinics to pts with minor complaints and telling them that this is an emergency room and their complaint is not emergent and they will not be seen here, to make an appt at the local health clinic. I can't see this working.

can that happen? Is it legal to turn someone away? I'm trying to find any sources that document the legality of this....

MassED, BSN, RN · Jul 4, 2008

As I understand, it is a violation of EMTALA to turn a patient away without a minimum of a medical assessment, if the patient insists. But I don't believe that there is anything wrong with informing the patient, based on his/her complaint, that the ER is not an appropriate place for treatment, and offering the option of other sources of care. Then it becomes the patient's decision to stay (and wait, and face a substantial bill) or go.
Regardless of the legalities, I believe that administration should staff your ER 24/7 for the first few weeks of this policy in order to address the concerns, complaints, and behaviors of patients who may be uncooperative. It should NOT fall on the nurses, docs, or techs to have to address unsatisfied patients and explain the financial ramifications of their choices in seeking care. That said, I'm sure administration will be nowhere near the ER!

some info on EMTALA, from http://www.emtala.com/oblig.txt

"What are the Obligations of Medicare-Participating Hospitals That Offer

Emergency Services to Individuals Seeking Such Services?

* The anti-dumping statute (section 1867 of the Social Security Act; 42

U.S.C. 1395dd) sets forth the Federally-mandated responsibilities of

Medicare-participating hospitals to individuals with potential

emergency medical conditions.

* Under the anti-dumping statute, a hospital must provide to any person

who comes seeking emergency services an appropriate medical screening

examination sufficient to determine whether he or she has an emergency

medical condition, as defined by statute. When appropriate, ancillary

services routinely available at the hospital must be provided as part

of the medical screening examination."

MassED, BSN, RN · Jul 4, 2008

Anyone work in an ER facility with ajoining walk-in clinic for the sore throats/ boo-boos, etc?

we had Urgent Care, but now they have a new system where triage is out - it's all PA's or NP's doing a quick "mini" assessment, putting the patient where they see fit (where the nurse then does the triage). They have a small screening room to (ha ha) accommodate for the Urgent Care that is now ED holding. This new system incorporates all of it - so they think it's better, when a sore throat will sit much longer if I have an active chest pain patient. Keeping the trivial stuff in another area is the better way. When you combine all of those patients, it's just not what's best for all of the patients or any of the staff.

justme1972 · Jul 4, 2008

They do this in the hospitals where I live.

When the triage nurse is done, anything even remotely heart/stroke related stays. Everything else like the famous "stumped toes" are sent back home. Pain patients also stay.

This used to be a major problem in our area, but there have been two clinics including the health department that has opened up that will see patients on a sliding income scale and take about any insurance that will pay them.

mwboswell · Jul 5, 2008

We have been doing this for several months now. The "bosses" and "bigwigs" had extensive meetings about this and hammered out a policy to guide what we'll do.

Right now, as it stands, if a pt meets specific, clear criteria (IE: chronic problems like toothaches, back pain etc) and they DO NOT meet other criteria (IE: under 18, over 55, medicare and a few others), then they are still triaged and put in a treatment room. Which ever ER attending doc sees the pt, they are informed that this pt meets "the critiera" and they go see the pt and do a "medical screening exam". Sometimes this is merely a history and pysical, sometimes it may include some lab or diagnostic testing. But when the MSE is done and it is established that no "Emergency Medical Condition" exsits, then the financial people come in and require the pt to pay their insurance dictated co-payment, or if no insurance, then some fee like 50$ I think.

If they don't or can't pay this fee, then they are discharged and given referrals to the local free clinic, free dental clinic or urgent care etc.

If they do or if they can pay, then the treatment continues; whatever that may be.

Overall, when you look at our specific criteria, it actually isn't being used that much at all. Too many people fall out of the criteria in some way, AND our list of allowable complaints is limited to only 3-4 things.

But I feel that it is a step in the right direction,

I also feel it gets back to what the original intent of EMTALA was,

and I think it starts to send a message.

northshore08 · Jul 7, 2008

A local "for-profit" facility's free-standing ED did the "triage-MSE-pay $150" deal, and it did lower their routine pt load. So we got them instead. I asked some of the patients why they came to us. The responses were the same ones I am sure you all get--don't want to wait, can't pay their ED fee, etc.

But...the scenario increased our customer service scores in the local area, and many of our patients said "If I can't afford the ED fee they want, what makes them think I can pay the doctor up front tomorrow?" Also heard "My doctor won't see me anymore in the office because I owe a bill." And the up front fees demanded by the orthos in our area were horrendous.

Local free clinics take a month to do an assessment and financial evaluation, if you can get an appt.

Looks like we are all tied in a knot--patients and EDs both.

So...do you want the stumped toe now to treat, or do you want it a week from now with cellulitis/sepsis? Do you want the sore throat now, or when the peritonsillar abscess has developed and there is nobody to care for the kids when she is admitted? You pick it.

We are damned if we do, but also damned if we don't. At lest we can give them a list of what to watch for.

LMPhilbric · Jul 8, 2008

Under EMTALA, ERs are required to screen and stabilize. If the screening shows that an emergency medical condition does not exist, happy trails. So, the foot fungus x 1 year that is screened by a provider and determined not to be an emergency, does not have to be treated. So, yes, you can definitely ask for a fee up front after the MSE is done, and I think it's a great idea. You just have to get everyone on board. I had a lady the other night that showed up in my ER 4 hours after she left our sister hospital with pink eye. She was given antibiotic gtts but they weren't working fast enough. (Oh, Sweet Jesus, what did I do to deserve triage tonight?) I brought the doc out to screen her and get rid of her, and he figured it was just easier to see her AGAIN and give her the Tobradex gtts that she wanted. He figured if she wanted to pay for a 2nd ER visit in 4 hours, more power to her. I'm here to tell you that we are not going to see dime one of either one of those visits. Now if $250 up front won't discourage that kind of nonsense, nothing will.

mwboswell · Jul 9, 2008

A local "for-profit" facility's free-standing ED did the "triage-MSE-pay $150" deal, and it did lower their routine pt load. So we got them instead. I asked some of the patients why they came to us. The responses were the same ones I am sure you all get--don't want to wait, can't pay their ED fee, etc.
But...the scenario increased our customer service scores in the local area, and many of our patients said "If I can't afford the ED fee they want, what makes them think I can pay the doctor up front tomorrow?" Also heard "My doctor won't see me anymore in the office because I owe a bill." And the up front fees demanded by the orthos in our area were horrendous.
Local free clinics take a month to do an assessment and financial evaluation, if you can get an appt.
Looks like we are all tied in a knot--patients and EDs both.
So...do you want the stumped toe now to treat, or do you want it a week from now with cellulitis/sepsis? Do you want the sore throat now, or when the peritonsillar abscess has developed and there is nobody to care for the kids when she is admitted? You pick it.
We are damned if we do, but also damned if we don't. At lest we can give them a list of what to watch for.

I agree it does create a round-n-round flow and I think that's why it's essential to try and get all the providers in the local area on board, AND, see what can be done to strengthen the Free Clinic system or those willing to at least do some "pro bono" follow ups.

our "triage-mse-pay-to-stay" (TeMPTS) only included a specific set of presenting complaints which were felt to be "recurrent" and it also specifically stated about chronic conditions. In this case a toe with cellulitis wouldn't have met the definition....

...that being said, even if the pt doesn't have one of our "select" complaints that requires payment up front, prior to discharge, ALL patients are asked "what can you pay today" towards their co-payment and/or any outstanding prior ER bills.

Through a lot of people's good nature, we have actually had a fair amount of income this way!!!!

FlightRN422 · Jul 10, 2008

I have just created a policy concerning this. The posts are correct it is a EMTALA violation to turn a non emergency (or any patient for that matter) away prior to a MSE (medical screening exam). RN's in most cases are not legally allowed to perform a medical screening. The way our ED does this is:

Patient is triaged as normal (ESI 5 tier triage). The chart is them flagged for the MD. If we are busy we place the patient in a our waiting room inside the ER, used as family room or second triage room if needed. The MD then goes in to perform a MSE. The patient is then informed that their condition is not an emergency. The patient then is given the option of paying a monetary value (different depending on hosptial population and insurance) Ours is 50 for self pay and co-pays for insurance. If the patient decided not to pay then they are given referrals to primary care MD's and clinics in the area. We do have a policy and the criteria is strict such as no one under 5 or over 65. They have to have a complaint that basically can be taken care of in a MD office, normal VS and truthfully not an extensive past medical history. Script refills are a perfect scenerio. So far this is working well. There has to be strong education on clerks, ED staff and MD's to be successful and stay within the legal guidelines. Hope this helps all.