If an ER patient is Not Sick, are we still supposed to treat?

[ernoc333]

Under EMTALA, we're required to Triage, Provide a Medical Screening Examination and Stablize. Once a patient is deemed medically stable, we have fulfilled our EMTALA requirement. Although I know that doesn't end our obligation. What if after the Medical Sceening Exam it's determined that the patient is NOT SICK? Are we in terms of Civil and Ethical Practice basis required to provide care for them?

Here's my real world example. A patient's chief complaint was Fever 98.9 degrees and Rhinitis for 30 minutes prior to arrival, no history, no medications, no other complaints, no other symptoms, no recent travel, no sick exposures. Just was worried that he or she was coming down with the Swine Flu that had been in the Media. The CDC recommends that we only do Viral Swabs for H1N1 if the patient is very symptomatic, very sick and will be admitted to the Hospital, we are not to do a swab on every single person who is concerned about H1N1. We get these presentations constantly, I believe due to the Media coverage of the Swine Flu.

This is one doctor's regular approach: Viral Swab for Influenza, IV, IV fluids 1 Liter, Labs- CBC, Chem Panel and Urinalysis and Tylenol orally, then repeat vital signs per protocol (for him, it's every 15-30 minutes). Prescription home for Sudafed, Motrin and Tylenol.

Another doctor sees this as a Not Sick patient, and will discharge this patient home with the recommendation of Tylenol and Ibuprofen if a Fever does start, and to see the Primary Doctor in a few days just for follow up.

Which doctor's treatment is Right? I say doctor #2's treatment was more Ethical as the patient was Not Sick and hence, we should not treat someone who is Not Sick, that is part of our obligation. Although Doctor#1 would never be sued due to he covered every possible base imaginable, while doctor #2 could have complaints from people who didn't feel enough was done. Are we obliged to do, or should we do Diagnostics, Medications and Prescripations for Not Sick people? Is Legal Medical Practice, ie: what was done by doctor #1, where a doctor is so worried about a Lawsuit that his or her orders, even if not clinically indicated, will cover ever possible Legal Base, Right?

[emtb2rn, BSN, RN, EMT-B]

We only have 1 doc that takes the # approach. All the others go with #2.

Overall, I don't think GOMER (git outta my er) therapy is applied as often as it's called for....

[sissiesmama, ASN, RN]

That's what our ER docs do also. It's been more than 4 yrs since I saw one of the docs treating one of the pts in question as no. 1 above, thankfully. I did get called in to talk with my ER NM and "state" reps after a patient's mom had called that we "just sent them home". They read my charting and interviewed me after the ER doc and we both gave the same answers - it hadn't been too long, and we did still remember mom and child. (Mom wasn't a very happy camper even just arriving that am.)

In my doc, I had covered myself quite well, thankfully. When mom complained, she left out the part about "see your PCP today" and also "return to the ER if needed and if condition worsens". They always get those "see the PCP ..." and return to the ER if ..." instructions verbally and written on the d/c sheet, so the state people were happy with us.

Anne, RNC

[whichone'spink, BSN, RN]

If a patient does not have insurance to get a primary care provider, then some of the doctors in my ED refer them to a local community clinic. That's more ethical than just discharging them with no more than canned instructions. Also helps to cover their behinds if they get complaints from these patients later. Just my .02

[rjflyn, ASN, RN]

Sorry but in the example given 98.9 is NOT a fever as far as I am concerned. Most doctors I work with I would probably not order Tylenol or Motrin for this either. Most likely the pt would be told they have a cold and to see their PCP or referred to the teaching service affiliated with our hospital. They would then be given d/c instructions by nurse and shown to discharge.

[Be_Moore]

Doctor #1 is practicing what we call "defensive medicine" and is running a total CYA show. He can't be sued because he did everything he needed to do. Defensive medicine is estimated to be around 6-10% of our current healthcare costs.

Unfortunately, we live in a lawsuit happy society and #1 did the right thing from a CYA perspective. But it's very expensive. Doctor #2 did the right thing from a cost perspective, but it can be costly depending on tort reforms laws in the state. But no, if you are "Not Sick" we have no obligation to treat you at all. Honestly, more doctors need to tell the "not sick" patients "This is not an emergency and you do not require emergency care. Follow up with your PCP."

[morte, LPN, LVN]

is doc #1 familiar with the term "insurance fraud"?.....

[sissiesmama, ASN, RN]

If a patient does not have insurance to get a primary care provider, then some of the doctors in my ED refer them to a local community clinic. That's more ethical than just discharging them with no more than canned instructions. Also helps to cover their behinds if they get complaints from these patients later. Just my .02

Yes, that's what the facility my dh and I work for do. It is a very large Catholic facility that was the first in our city, I think. We are just a block or so from the Salvation Army shelter and 2 or 3 halfway houses. We are in an area where most of our clientele (sp??) are lower income families and don't have insurance. They use us as their PCP at times.

We do now have some of the local community income based clinics, and we refer them to those clinics if they wish. We have a hospital run clinic next to the ER where they can be seen for a 5 dollar co pay,or free if they need it.

Don't get me wrong, our docs are for the most part very sympathetic and will see the "not sick" patients that would normally be just medically screened. They will give rxs when they are being screened, that kind of thing.

It's usually the patients with 5 or 6 kids in tow and wanting guest trays for all of them, and answer their cell phones - 5 or 6 calls repeatedly to "visit" with their friends, ect. They say they have no $$$ for rxs or MD visits to see their PCP, but their nails are manicured to perfection, and their clothes they have on cost a lot more than mine do and I worked full time. They pull up in their expensive SUVs, or whatever, and haul booty. The mamas are wearing a boatload of nice jewelry, ect.

I'm not judging, I'm just saying... if it makes any sense.

There's a big difference between the parents who CAN'T work or are disabled, and the ones who sit at home and just don't contribute. Just my .02.

Anne, RNC

[sissiesmama, ASN, RN]

Sorry but in the example given 98.9 is NOT a fever as far as I am concerned. Most doctors I work with I would probably not order Tylenol or Motrin for this either. Most likely the pt would be told they have a cold and to see their PCP or referred to the teaching service affiliated with our hospital. They would then be given d/c instructions by nurse and shown to discharge.

Right, that's what we do too. We hate to get the ones that come in with their children and say "Well, no we couldn't afford a thermometer, and we didn't give any Tylenol or anything so you could actually see that baby does have a fever of 99 degrees.

Of course, baby is at that time playful and doesn't look sick at med screening. They "can't" afford a thermometer, but they arrive in a high dollar ride and have the state of the art cell phone, which they stay on quite a bit of the time while we are doing our thing.

We would do what you described and not medicate for that temp, but give mama verbal and written instructions on temp management and antipyretic administration for approp. temps, and see the PCP or local clinic that is based on income. Of course, most of them just roll their eyes then, because they don't want to have to wait at the clinic.

We have had parents call 911 for a child that has a temp of 99 or so, thinking if they came in by rig, they wouldn't have to wait, just go straight back to a room.

Anne, RNC

[sissiesmama, ASN, RN]

To the OP, thanks for starting this thread. This is something that really gets "under my skin" at times when our facility stays so busy with GSWs, stabbings, traumas, codes, ect. Thanks!! I'm glad to talk about it.

Anne, RNC

[mwboswell]

Hi all, interesting posts here.

Here's my take...

#1) NEWS FLASH - unless you were under a rock for the last 10 years, the ED has become a walk-in clinic for a lot of things. Obviously lots of what we do is not "emergency".

#2) That being said, everyone currently working in an ED should KNOW that we are doing walk-in/urgent care most often and thus, I believe, inherited an obligation to treat everybody.

#3) If you don't agree with treating everybody and doing some real compassionate care for those who "have not" - then you need to get out of EM

#4) If you're still clinging to the idea that "I only signed on to treat emergencies", then you need to get out of this business

#5) Hospitals have now realized that a LARGE percent of it's visibility and community reputation is garnered through it's ED. A hospital's reputation for excellence and competency is often linked to it's community perception of their ED - so guess what, now hospitals are shifting their customer service focus to the ED

#6) While trying to "tweak up" the ED perspective to those customers, does it mean that we will be asked to do a lot of "non-Emergency" stuff for pt's - YES!

#7) Do you realize that with on the national average, over 60% of your ED patients have insurance and are "paying customers"? Remember this includes: medicare, medicaid, auto Liability Insurance, victim's insurance AND of course blue cross and the others. That means 6 out of 10 patients have a third party plan that pays our bills and keeps us employed!

#8) Your hospital WANTS that business! So they're going to do what they can to drive you to provide good customer service which "may" include sometimes, giving more treatment than you would normally expect for simple problems.

is this right? I don't know.

I guess you have to put yourself in your patient's shoes and figure what they "perceive" as "good care"...remember it's all about perceptions!

I can see, treat and discharge a patient with no IV's,/tests or meds and no Rx's and if I take the time to explain to them their condition,t reament and explain why no workup is needed and answer all their questions - they will still likely rate me VERY HIGH on the cusomer satisfaction surveys. It's all how you present it. If you just BRUSH them off with 'go home, take tylenol and res' AND make them feel stupid or belittled - no matter how competent or hi-tech the care, they will have a higher chance of rating you unfavorably.

Some MD/NP/PAs who don't know how to talk to their patients and explain things will act more like Dr #1 thus the pt believes you did "everything". those MD/NP/PAs that are good "people" persons and who can sit down and talk with their pt's, will not have to to labs and tx's just to prove they know what they are doing....

My 2 cents.

[ernoc333]

is doc #1 familiar with the term "insurance fraud"?.....

Yes exactly my concern. Thanks.