new to the ER with a question for you experts :)

cookienay · Jan 14, 2011

This is not an EMTALA violation per se that I am aware of. Ideally, these patients should be moved to a different facility that has the staff and space to properly care for them. There is increasing evidence to support what we have always known: outcomes suffer when inpatients are boarded in the ER. While it may not be an EMTALA violation necessarily, it is most definitely a patient safety issue. My advice: do search for articles/studies relating to ED boarding relating to patient safety. If your facility is big on customer service, there should be info available on that as well. Share these with your director and your QA/Safety director. Approach in the manner of wanting help find a solution, not just whine about the problem.

However, this will not change unless top leadership is on board. ED boarding was a huge issue before our VP got on board. It was a pain in the butt during the change (micromanaged to the nth degree!!), but well worth it as we almost never have any boarded patients anymore.

If it looks like the situation will not be changing, look for solutions that prevent things being missed or overlooked. We developed a checklist to keep things from getting missed (our processes were so different). YOu may want to develop that for your department.

This is a bad situation and one with no easy solution. Good luck!

instanthuman · Jan 14, 2011

thanks so much! that was a very good and thought provoking answer...i will definitely research those leads.

GreyGull · Jan 14, 2011

The ENA has posted several good articles and references including their White Paper on this topic. You can contact ENA through their website or your local/state chapter for a list of their references, views and what is being done at the state and national levels. I also believe ENA has a listserv where you can post your concerns for some feedback. Of course that may not give you anonymity but then no forum is truly anonymous.

Also, the American College of Emergency Physicians has some good material that can help you in your search.

American College of Emergency Physicians

BrnEyedGirl, BSN, MSN, RN, APRN · Jan 14, 2011

We've had record setting high cenus where I work. We've been boarding up to 20 pts who came to the ER, are admitted, then have no bed to go to upstairs. We have been approached about inpatient transfers to the ER for the very same reasons you mention. There was a big meeting, lots of shouting, but in the end it was decided that this would be an EMTALA violation, a transfer from inpatient to ER is considered a transfer to lower level of care and is a violation. So we now have a mini ICU in our ER.

Larry77, RN · Jan 14, 2011

We do not allow it in any situation. We have used the EMTALA argument, and the argument that the paper trail is impossible...for billing and charting. Luckily our Manager is very hard-headed and extremely vocal when this topic is brought up in meetings.

When we end up boarding it's usually d/t psych admits who don't have beds (especially kids, we only have adult in-patient psych).

instanthuman · Jan 14, 2011

thanks again for all of your replies. i really appreciate all of the information and opinions/experiences. what a great forum!

nurse2033, MSN, RN · Jan 14, 2011

EMTALA (Emergency Medical Transport and Active Labor Act) refers to transporting patients between facilities. I don't see how it applies to bringing someone downstairs. I agree that boarding patients sucks for everyone but I don't see how it is against the law. In the long term this should not be the default method that admin uses for overflow or changes in acuity, but in the short term it is the best thing to do. I think it is certainly safer than leaving a critical patient on a non critical unit.

EmergencyNrse · Jan 14, 2011

The same thing was happening back in '06.

Census was high and more and more critically ill

patients were being held in the ER.

Try coming in to work one morning after a day or two off

and getting assigned (x2) ICU patients that had been admitted

16-hrs before you got there. NOTHING had been addressed from

their admission orders:

-No meds administered from their MAR.

-No labs repeated.

-No radiology.

-No EKG.

It was the scariest thing I have ever encountered while being a nurse.

If something had gone wrong I would have been the one without a

chair when the music stopped. Prompted me to cross-train in ICU/CCU

so at least I would have a clue as to how to treat these patients.

If you are an ER nurse and haven't been up in the unit for awhile

(or not since nursing school) I recommend doing it. It really is a

different beast and you should be better prepared.

Esme12, ASN, BSN, RN · Jan 14, 2011

i have worked at many facilities......most consider a transfer form the floor to the ed as a patient is an emtala violation. since you do not have to self report emtala violations this problem is under reported. an inpatient is not an ed patient. the requirement for medical screening and treatment or transfer has been fullfilled and the care of the patient has been transferred to another md. you can technically utilize the ed monitors for an inpatient but the ed md bears no responsibility for the patient and all usual inpatient policies apply.

an inpatient can become an ed patient in disaster/emergent situations when such situations exist. in the event of a disaster there are guidelines and rules to address this like during 9/11 or hurricane katrina.

http://emedicine.medscape.com/article/790053-overview

in patients have been made ed patients in extenuating circumstances by discharging them as in inpatient and readmitting to the ed for trreatment for falls with injuries in the absence of obtaining other treatment. if it is the monitor that is needed it is a slippery slope to depend on the ed staff to not only care for the ed patients but the icu "transfer/boarder" is a slippery slope of increasing risk, declining quality, and skyrocketting liability.

boarders are an unfortunate reality and hospitals must figure creative ways to safely circumvent the problem. transfer is not always an option especially if it is not to a higher level of care, besides the loss of revenue. a facility where i worked we developed a "code census" which indicated that the hospital was instituting measures for saftey and quality. all direct "volunteer" elective admissions we placed on hold. if deemed necessary by the pcp admissions were sent to the ed for evaluation and disposition. md's we required to expidite discharges by 14:00. nurses were place on call for voluntary "float pool" to care for patients in other designated areas ie: medical day, surgical day, and pacu for alternative icu monitored areas and/or endo for patient care areas to keep the ed clear of boarders. there was also a cdu "clinical decision unit" developed by the emergency department the could accomodate boarders and long term psych placement issues away form the general ed population. voluntary cross training was encouraged which was an output of cash at first but paid off in the long run by having more nurses to pull as a resource and not count on deptartment overtime or agencies.

it is generally agreed that boarders cared by the ed staff is a risk due to the unpredicable nature of the ed patient volume. this all took some argueing and passionate persuasion to both staff and administration...but it ended up working very well. a separate "orientation" inservice was given to ed staff of general hospital policies and routines and were held accountable for tests and orders if they were the assigned nurse.

seems complicated but it worked and everyone felt in control and although not always thrilled......were glad to help out in a pinch! :twocents:

cookienay · Jan 15, 2011

Esme- good info. Would it still be considered EMTALA if they were under the care of the admitting inpatient physician and not the ED physician? They were just geographically in the ED area? This is where I was coming from in my initial response of it not being EMTALA.

Such an informative thread!

star77, MSN, RN · Jan 15, 2011

Once someone is admitted to ICU or if we anticipate someone is going to be admitted to ICU (ie it's OBVIOUS - hypotensive/septic or neuro issues...), we get an ICU float nurse, so we either split the ICU assignment OR they take the ICU patients and we take the ER patients. Lucky, I guess.