turning non-emergent pts away

[Jennifer, RN]

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.

[RedERRN]

The ER I work in has a policy where all patients meeting triage levels of 4 or 5 (we use the 5-tiered ESI) are sent to "Quick Care" where they receive a MSE (Medical Screening Exam) by a physician. If their chief complaint is then deemed to be non-emergent, the patient is instructed by the physician (by scripted dialogue) that their condition is not an emergency. The patient is then given the option of #1) staying at our facility to receive treatment after paying either $150 cash or their entire non-emergent co-pay or #2) leaving our facility to seek care at one of the many urgent care facilities across town or with their private MD.

The reasoning for this policy is that soooo many patients present to the ER with non-emergent complaints. These patients contribute to the overcrowding and sluggish throughput. Unfortunately, we nurses can't legally tell them that they are not having an emergency and need to leave. According to EMTALA, all patients must receive a Medical Screening Exam by a physician. By following our policy we cover all the bases. It seems to work WONDERS...and word has spread pretty quick around town, too!

[Batman24]

The ER I work in has a policy where all patients meeting triage levels of 4 or 5 (we use the 5-tiered ESI) are sent to "Quick Care" where they receive a MSE (Medical Screening Exam) by a physician. If their chief complaint is then deemed to be non-emergent, the patient is instructed by the physician (by scripted dialogue) that their condition is not an emergency. The patient is then given the option of #1) staying at our facility to receive treatment after paying either $150 cash or their entire non-emergent co-pay or #2) leaving our facility to seek care at one of the many urgent care facilities across town or with their private MD.

The reasoning for this policy is that soooo many patients present to the ER with non-emergent complaints. These patients contribute to the overcrowding and sluggish throughput. Unfortunately, we nurses can't legally tell them that they are not having an emergency and need to leave. According to EMTALA, all patients must receive a Medical Screening Exam by a physician. By following our policy we cover all the bases. It seems to work WONDERS...and word has spread pretty quick around town, too!

That seems like the way to go. Butts are covered and no laws are broken. Have you seen a huge reduction in non-emergent patients as of yet?! Are non-emergent people in pain turned away if it is too late to get into a clinic for the day?! What happens with potential broken bones?! Do you do an x-ray?! I am just trying to leave as I am pre-nursing. Thanks.

[pkapple]

Just remember it is NOT the patients choice to leave once they present as one poster suggested. of course they can walk out, leave AMA refuse further care, etc. BUT if an employee even remotely implies the visit is inappropriate, and the patient leaves it was and is an EMTALA violation.

Ah for the really good old days when triage nurses sent those folks off to the office tomorrow or walk-in, or heaven forbid said you don't need stitches for that itty-bitty tiny little scrape on your knee.

If your triage allows you to send 4's and 5's to your fast-track type urgent care, be sure it is still considered an ER visit, until the medical provider says there is no emergency. If your facility runs a clinic type area, and a patient can present there independant of an er visit, you CAN NOT refer them there from triage-a provider must do that.

Telling pts to stay and pay once the nature of the emergency is established-again by a medical provider is legal, ethical and eventually practical. If you think about it-the time and paper work has been done-the xrays, labs etc would have been part of the medical screening, so the meds,scripts and discharge papers are all that you get to eliminate til payment.

Now if an earache presents and triage is able to have a provider take a quick look and that provider is comfortable saying this is not emergent, you may wait and pay etc etc per scripted dialogue that will save time--just remember to log the pt in your er record and document the MSE and result.

I hate EMTALA-not the intent-just the reality it has become

[ginger58, ASN, RN]

I believe the hospital that I just left is assigning a doc and nurse to triage and if the problem isn't emergent they are sent to the acute care facility.

[core0]

Umm If I am not mistaken it is illegal to turn down patients and I beleive it is an EMTALA violation especially without an assessment from a physician, as all patients have the right to that assessment before being refered to another facility or clinic.

Sweetooth

Actually this is incorrect. I would depend on your state BON. EMTALA does not prohibit nurses from doing the medical screening exam. Here is the link from the Texas BON:

http://www.bne.state.tx.us/practice/faq-emtala.html

Note the nurse must have adequate knowledge and skills as well as necessary support.

David Carpenter, PA-C

[AnnieOaklyRN, BSN, RN, EMT-P]

Actually this is incorrect. I would depend on your state BON. EMTALA does not prohibit nurses from doing the medical screening exam. Here is the link from the Texas BON:

http://www.bne.state.tx.us/practice/faq-emtala.html

Note the nurse must have adequate knowledge and skills as well as necessary support.

David Carpenter, PA-C

I took this streight from the EMTALA site and it specifically states nurses should not do medical screening exams as it would not stand up in court. Also the nurse would be responsible for filling out a transfer form and according to EMTALA a nurse or other qualified personel can only do this if a physician is not present. In addition the patient cannot be referred to another facility based on a triage exam. Here is the quote:

"It is important to remember this crucial point: Triage is not the same as a medical screening examination. Triage is a process which determines when a patient is seen by a physician, not whether he is seen.

3. Does the medical screening examination need to be done by a physician?

The short answer is that any assessment which is done by any person other than a physician has a much higher risk of being found insufficient under EMTALA. As noted in sections 4 and 12 above, the regulations provide thatthe hospital must make a designation of who is considered to be a qualified medical person for purposes of (1) performing the medical screening examination and (2) the certifying signature in support of transfer in the event that a physician is not available. It is doubtful, however, that CMS or the courts would give hospitals unfettered discretion to specify who can be regarded as a "qualified medical person" as provided in the regulations. It is very unlikely, for example, that an attempt to simply designate all nurses as "qualified medical persons" would be found to comply. On the other hand, tailoring the provisions to particular areas of nursing specialty, such as permitting OB nurses to examine patients who may be in labor, would probably be found reasonable.

Designating appropriate "physician substitutes" such as physicians' assistants or nurse-midwives is often reasonable, but it is recommended that the bylaws provide for phone consultation with the supervising physician and also identify the situations in which the supervising physician must come in to see the patient personally. (Note also the provision in the regulations, buried in the definitions section, requiring that a physician certify, after a reasonable period of observation, a diagnosis of false labor. The amendments to the regulations adopted in August 2006 have relaxed this requirement, declaring that such a certification may properly be made by physician surrogates such as nurse midwives.)

It is possible that a court, faced with a decision in a case in which a person other than a physician has done an emergency room evaluation and has determined that the patient may be sent home rather than being admitted, and a serious complication has arisen, would use this regulation to support a conclusion that a direct consultation with a physician was required in that circumstance. Judges are human, and subject to some of the same prejudices that affect juries, including a tendency to view cases in light of medical hindsight."

Reference: http://www.emtala.com/faq

Sweetooth

[Ruby Vee, BSN]

the er i work in has a policy where all patients meeting triage levels of 4 or 5 (we use the 5-tiered esi) are sent to "quick care" where they receive a mse (medical screening exam) by a physician. if their chief complaint is then deemed to be non-emergent, the patient is instructed by the physician (by scripted dialogue) that their condition is not an emergency. the patient is then given the option of #1) staying at our facility to receive treatment after paying either $150 cash or their entire non-emergent co-pay or #2) leaving our facility to seek care at one of the many urgent care facilities across town or with their private md.

the reasoning for this policy is that soooo many patients present to the er with non-emergent complaints. these patients contribute to the overcrowding and sluggish throughput. unfortunately, we nurses can't legally tell them that they are not having an emergency and need to leave. according to emtala, all patients must receive a medical screening exam by a physician. by following our policy we cover all the bases. it seems to work wonders...and word has spread pretty quick around town, too!

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.

[core0]

I took this streight from the EMTALA site and it specifically states nurses should not do medical screening exams as it would not stand up in court. Also the nurse would be responsible for filling out a transfer form and according to EMTALA a nurse or other qualified personel can only do this if a physician is not present. In addition the patient cannot be referred to another facility based on a triage exam. Here is the quote:

"It is important to remember this crucial point: Triage is not the same as a medical screening examination. Triage is a process which determines when a patient is seen by a physician, not whether he is seen.

3. Does the medical screening examination need to be done by a physician?

The short answer is that any assessment which is done by any person other than a physician has a much higher risk of being found insufficient under EMTALA. As noted in sections 4 and 12 above, the regulations provide thatthe hospital must make a designation of who is considered to be a qualified medical person for purposes of (1) performing the medical screening examination and (2) the certifying signature in support of transfer in the event that a physician is not available. It is doubtful, however, that CMS or the courts would give hospitals unfettered discretion to specify who can be regarded as a "qualified medical person" as provided in the regulations. It is very unlikely, for example, that an attempt to simply designate all nurses as "qualified medical persons" would be found to comply. On the other hand, tailoring the provisions to particular areas of nursing specialty, such as permitting OB nurses to examine patients who may be in labor, would probably be found reasonable.

Designating appropriate "physician substitutes" such as physicians' assistants or nurse-midwives is often reasonable, but it is recommended that the bylaws provide for phone consultation with the supervising physician and also identify the situations in which the supervising physician must come in to see the patient personally. (Note also the provision in the regulations, buried in the definitions section, requiring that a physician certify, after a reasonable period of observation, a diagnosis of false labor. The amendments to the regulations adopted in August 2006 have relaxed this requirement, declaring that such a certification may properly be made by physician surrogates such as nurse midwives.)

It is possible that a court, faced with a decision in a case in which a person other than a physician has done an emergency room evaluation and has determined that the patient may be sent home rather than being admitted, and a serious complication has arisen, would use this regulation to support a conclusion that a direct consultation with a physician was required in that circumstance. Judges are human, and subject to some of the same prejudices that affect juries, including a tendency to view cases in light of medical hindsight."

Reference: www.emtala.com/faq

Sweetooth

Two points. One I really can't tell what emtala.com is but I would go directly to the source or more authoratative sites generally. Second, no where does this say that nurses can't do screening exams. In fact it specifically states that some type of nurses can do exams (OB is an example here). The points it makes are the same the Texas board makes which are the nurse must have adequate knowledge and skills and there must be backup. The backup can be telephonic and there has to be a provision for another provider to come and physically examine the patient if necessary. PT transfer is a whole different oprah.

There are resources that you can get for screening exams (essentially algorithms). As the article states you couldn't get away with saying all nurses are eligible. You could design an educational program and a proficency checklist and designate certain nurses as capable of doing medical screening exams. Just as you don't have any nurse doing triage, similarly you don't have any nurse doing screening exam. There are quite a few hospitals using RN's to do screening exams. These hospitals have carefully examined the issues. I'm not saying that it is a good idea or not, just stating it happens. It also depends on wether the BON defines this as medicine or not. Texas says not, other states may vary.

Here is the appropriate quote from the federal regulation from what we are discussing here:

"Use of dedicated emergency department for nonemergency services. If an individual comes to a hospital’s dedicated emergency department and a request is made on his or her behalf for examination or treatment for a medical condition, but the nature of the request makes it clear that the medical condition is not of an emergency nature, the hospital is required only to perform such screening as would be appropriate for any individual presenting in that manner, to determine that the individual does not have an emergency medical condition."

So if you show up and say you have a cold, the screening exam just needs to make sure that you have no urgent or life threatening medical conditions. Well within the capability of most ER nurses that I know. Now if you are talking about determining wether to transport a patient to a higher level of care or almost anything involving pregnant women I would definitely want a higher level of evaluation.

David Carpenter, PA-C

[TRAMA1RN]

The people who abuse the ER are only going to increase in numbers, and no amount of public education is going to change this. One thing that may hlp would be to automatically deduct co-pays from the next automatic deposit on their welfare debit cards. Once the amount started to reflect the cost they may think twice before abusing the system.

[TazziRN, RN]

The ER I work in has a policy where all patients meeting triage levels of 4 or 5 (we use the 5-tiered ESI) are sent to "Quick Care" where they receive a MSE (Medical Screening Exam) by a physician. If their chief complaint is then deemed to be non-emergent, the patient is instructed by the physician (by scripted dialogue) that their condition is not an emergency. The patient is then given the option of #1) staying at our facility to receive treatment after paying either $150 cash or their entire non-emergent co-pay or #2) leaving our facility to seek care at one of the many urgent care facilities across town or with their private MD.

The reasoning for this policy is that soooo many patients present to the ER with non-emergent complaints. These patients contribute to the overcrowding and sluggish throughput. Unfortunately, we nurses can't legally tell them that they are not having an emergency and need to leave. According to EMTALA, all patients must receive a Medical Screening Exam by a physician. By following our policy we cover all the bases. It seems to work WONDERS...and word has spread pretty quick around town, too!

Our nurse manager tried to institute this a while ago but the ER medical chief is too soft-hearted. He can't turn anyone away, his thinking is "They're already here, so we might as well treat them."

We do not have a fast-track in the ER, but we have a hospital-owned clinic right next door and an urgent care clinic right next to that. Do people go there? Of course not! The urgent care I can understand, they don't take Medi-Cal and a very large part of our population has Medi-Cal. The clinic, though......if people with acute illnesses can't get an appt that very same day (sometimes that very same morning!), they come to the ER because they're "too sick to wait." We once had a man with back pain that was seen and medicated the night before, told to see his own doc and was able to get an appt for 0930, showed up in the ER again at 0900 and said he couldn't take the pain. By the time he was seen by the ER doc it was after 0930.

[TazziRN, RN]

Two points. One I really can't tell what emtala.com is but I would go directly to the source or more authoratative sites generally.

emtala.com is the authoritative source. And even EMTALA recommends that nurses not do medical screening exams. OB is a whole 'nuther ballgame, the pt almost always has an NST done to determine if there is an OB emergency/urgency, and NSTs take at least 15-30 minutes if not longer. ER triage nurses must do that based solely on questioning and VS.

Just curious, David, do you work ER? Anyone who works ER should know EMTALA, and recognize emtala.com.

[CritterLover, BSN, RN]

our nurse manager tried to institute this a while ago but the er medical chief is too soft-hearted. he can't turn anyone away, his thinking is "they're already here, so we might as well treat them."quote]

wow, this is a bad day for me and lost posts.......

anyway, back to what i said earlier, that got lost:

tazzi, this is exactly the reason why this sort of thing will never work in the er where i do some occasionial shifts.

well, not because the cheif is so soft-hearted, he's a j******. but some of our docs are very, very sweet, and have this kind of attitude.

it doesn't help that the er is located in the "poor" section of town, and even if we tell them to follow up, and they say they will; most won't.

what is a "non-emergency" today (uti) can become an emergency (urosepsis) next week if follow-up care isn't received (and rx's arn't filled).

so we treat many, many, many "non-urgent" (triage 4 or 5's ) a day.

that said, i don't see an ethical problem with what the op's facility is doing, as long as they do it withing the emtala guidlines, such as having a mid-level in triage.

as far a rns doing the mse goes, i've always assumed that was for rural facilities. emtala certainly does seem to "frown" upon it, other then certain situations (like ob), even though they allow it.

"reading between the lines," it sounds to me as though the provision is there, but emtala expects that rns doing the mse will be the "exception," rather then the "rule."

as another poster said -- i'd hate to be the rn doing the mse. too much responsibility, too much liability.