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?

[ernoc333]

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.

You missed the whole point entirely. You are on a whole other tangent.

[morte, LPN, LVN]

You missed the whole point entirely. You are on a whole other tangent.

ah, you saved me a post.....that i had been ruminating on for a while....

[Guest219794]

Back to the question"

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?

Short answer- No.

The examples you give are pretty black and white. I frequently find myself in the same situation, but much grayer areas. For example, narcs to a drug seeker, oe abx for a cold. Neither is in the pt's best interest, and both are in fact detrimental.

I have considered refusing to do it, but just don't feel like dealing with the hassle.

But, if I give a medication I know is not indicated, I am doing the wrong thing. Legally, morally, and ethically. I'll probably do it on my next shift.

[mwboswell]

You missed the whole point entirely. You are on a whole other tangent.

Nope, I am just giving you the background.

There is no "yes" or "no" answer.

You have to find your definition of "supposed to treat"....

Is there a legal requirement -NO

Is there an ethical/humanitarian imperative -YES

Does it make good PR sense -YES

Is it economically feasaible - NO

Is it sometimes not in the pt's best interest -YES

My point (you call tangent) was an attempt to explain why there are many different ways to answer your question.

[mwboswell]

Back to the question"

The examples you give are pretty black and white. I frequently find myself in the same situation, but much grayer areas. For example, narcs to a drug seeker, oe abx for a cold. Neither is in the pt's best interest, and both are in fact detrimental.

I have considered refusing to do it, but just don't feel like dealing with the hassle.

But, if I give a medication I know is not indicated, I am doing the wrong thing. Legally, morally, and ethically. I'll probably do it on my next shift.

Doing something detrimental can put you in just as much hot water as something that isn't indicated.

[mwboswell]

Yes exactly my concern. Thanks.

It's only insurance fraud if you're billing for something you didn't treat/diagnose.

If the charting/record supports the diagnosis and treatment then it's not fraudulent.

Question: What if they don't have insurance? Can it still be insurance fraud?

[ernoc333]

Back to the question"

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?

Short answer- No.

The examples you give are pretty black and white. I frequently find myself in the same situation, but much grayer areas. For example, narcs to a drug seeker, oe abx for a cold. Neither is in the pt's best interest, and both are in fact detrimental.

I have considered refusing to do it, but just don't feel like dealing with the hassle.

But, if I give a medication I know is not indicated, I am doing the wrong thing. Legally, morally, and ethically. I'll probably do it on my next shift.

True....antibiotics for simple URI are detrimental, the doctors always explain this, but with patients' insistence, will write for antibiotics anyway. And most if not all of us Nurses will give it to the patients anyway as well. Sometimes I feel a little guilty about that, knowingly doing something for a patient that is detrimental due to if I dont I'll lose my job.

Same as the Hypochondriac who has 60+ negative workups, X Rays, CT's...one day that patient will end up with a positive CT from all of the Radiation Exposure! It's like we hesitate to advocate the other way for the patient due to it's not the status quo, it's so much easier just to run a ton of the same diagnostics on the same patient over and over again.

[Guest219794]

Doing something detrimental can put you in just as much hot water as something that isn't indicated.

I agree. My point is that even though I know this, I do it. And, I believe alot of nurses do. I give medications that I don't believe are beneficial. Every drug has a risk/benefit ratio. I give medications that neither, I, nor the provider, would allow for our own family. ABX for a URI is a good example.

I don't blindly give every medication ordered. I frequently question orders, and get them changed. Most of my coworkers would consider me a good patient advocate. After I have worked with a given provider for a while, they generally consider my opinion worth hearing.

That being said, I pick my battles. I can't imagine actually questioning every order I believe innapropriate, or outright refusing. I know I am not alone in this.

I would love to work in an ER where everything I give is really appropriate. Where the providers take the time to educate patients, or, God forbid, simply refuse to give in and risk nasty feedback.

Or, Imagine this: Pt comes in with a pain complaint without objective findings. Provider checks the state registry to find the prescription hx. Provider asks if anything has ever worked for this pain in the past. "Oh, vicodin seems to help? When is the last time you had vicodin prescribed?" If the patient give misleading information, have the pt arrested and taken out in cuffs. I have seen this done, and that patient never came back.

If I ever have the opportunity to work in an ER that operates on principle rather than expediency, I'll sign up. I would really love to work in a department that does only evidence based best practices. Not an option where I live.

[ernoc333]

Right. Exactly my point. I'm so glad there are others who have the same observation. It does seem like it would be extremely difficult to stand up for the ideal principles all of the time. My fear is that given the current Legal Environment, we are eventually going to get into trouble for doing these common practices- it will get turned around on us. Ie: "If you knew I was misusing/abusing the Opiates, why did you continue to give them to me, you fed my addiction, ruined my life and caused me Pain and Suffering."

Doing something detrimental can put you in just as much hot water as something that isn't indicated.

I agree. My point is that even though I know this, I do it. And, I believe alot of nurses do. I give medications that I don't believe are beneficial. Every drug has a risk/benefit ratio. I give medications that neither, I, nor the provider, would allow for our own family. ABX for a URI is a good example.

I don't blindly give every medication ordered. I frequently question orders, and get them changed. Most of my coworkers would consider me a good patient advocate. After I have worked with a given provider for a while, they generally consider my opinion worth hearing.

That being said, I pick my battles. I can't imagine actually questioning every order I believe innapropriate, or outright refusing. I know I am not alone in this.

I would love to work in an ER where everything I give is really appropriate. Where the providers take the time to educate patients, or, God forbid, simply refuse to give in and risk nasty feedback.

Or, Imagine this: Pt comes in with a pain complaint without objective findings. Provider checks the state registry to find the prescription hx. Provider asks if anything has ever worked for this pain in the past. "Oh, vicodin seems to help? When is the last time you had vicodin prescribed?" If the patient give misleading information, have the pt arrested and taken out in cuffs. I have seen this done, and that patient never came back.

If I ever have the opportunity to work in an ER that operates on principle rather than expediency, I'll sign up. I would really love to work in a department that does only evidence based best practices. Not an option where I live.

[mwboswell]

Or, Imagine this: Pt comes in with a pain complaint without objective findings. Provider checks the state registry to find the prescription hx. Provider asks if anything has ever worked for this pain in the past. "Oh, vicodin seems to help? When is the last time you had vicodin prescribed?" If the patient give misleading information, have the pt arrested and taken out in cuffs. I have seen this done, and that patient never came back.

I'm just interested here...please clarify;

The pt was arrested for what charge?

Patients lie all the time, what justifies arresting them?

[Guest219794]

It is a little OT, but I found the statute. I gave that as an example, because I think it is a common example of a nurse administering a medication that is not indicated.

17-A MRSA sec 1108, copies provided here, makes it illegal for a person to

obtain or exercise control over a prescription for a scheduled drug as a result of

deception. "Deception" includes:

"Failure by a person, after having been asked by a prescribing health care

provider or a person acting under the direction or supervision of a prescribing health

care provider, to disclose the particulars of every narcotic drug or prescription for a

narcotic drug issued to that person by a different health care provider within the

preceding 30 days; or

Furnishing a false name or address to a prescribing health care provider or a

person acting under the direction or supervision of a prescribing health care provider."

This criminal statute also abrogates the privilege for communications made to a

health care provider in an effort to obtain drugs by deception. And the statute allows a

health care provider to report a suspected violation to a law enforcement agency, with

immunity for good faith reporting.

[Lunah, MSN, RN]

The only person I've seen arrested in the ED was a frequent flyer who stole a prescription pad and went to town with it. LOL. She came in by rescue a few weeks later, and someone (not sure who, exactly) called the police, and they came in and arrested her. She had also tried to call narcotics scrips in over the phone, saying she was one of our docs. Unreal!!

Anyway, back to the topic ...

Most of our providers are of the style of doc #2, but some still do the #1 maneuver, and totally admit it's defensive medicine.