Ummmm..are they ALLOWED to do that?

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OK, I have worked in about 5-6 different ERS, both as staff and agency an I have never experienced this. Right now I am doing a contract in a dinky little community non-teaching hospital. The ER is understaffed and bursting at seams because they admit everyone who rolls in the freaking door. Well the other night nursing supervisor called to say that she was sending the ER a patient from med surg with a positive troponin because ICU was full. Ummm can they do that? We only had 4 nurses first of all(no secretary, no tech), with almost every bed full most of them in a holding pattern. And the patient was going to be MINE. I already had 7 patients, ALL of them holds. Its like I am not even an ER nurse anymore. But can they do that....just turf pts from the floors BACK down to ER, especially when WE are already overwhelmed? The ER nurses say it is done all the time and when they threatned to complain they were told by supervisor that " Go ahead and when we get shut down we will all be out of a job" So there are 12 ICU beds with 6 nurses and 30 ER beds, with 4 nurses? How is that fair?

you can also put a crash cart and a vent and a cc rn anywhere, even in a m/s room.

you can not send them back to the "emergency" department. it is a federal violation of emtala and your hospital could lose its medicare and medicaid reimbursement.

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I have researched Emtala quite a bit for some problems we were having. No where did it address this issue. The patient is not "dumped" on the ER. They keep their same doctor and their same orders. The ER doctor is not involved. It is similar to sending a M/S patient to the ICU. I really do not understand how you think this is an Emtala violation. If it is, please send me the references, because we sure need to know this if it's true.

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The answer is yes and no... it really depends on your hospital's and emerg's policies.

Unfortunately, many administrators don't see a problem with making the ED a dumping ground for all of the hospital's problems... so, not only do you get sick patients coming in off the street but you get them internally too. This is just wrong on many levels (interrupts ED patient flow, increases ED overcrowding, no privacy for the 'in-patient', noisy environment=no rest ((your pt was a post MI :eek: it's just not a good situation for the pt at all)) etc etc). They tried this at my hospital and we have a fantastic ED Chairman who jumped on it quickly. In the past they've also tried to make us have the hospital code bed one night because ICU was full:eek: .

We now have a policy that states once the patient becomes an in-patient they never return to the ED. If a patient deteriorates on the floor and the ICU is full, the ICU must find a way to accommodate the patient (transfer a patient out etc.) It is an internal problem NOT an ED problem.

One solution to this issue is the recovery room. They have all of the monitoring equipment and if the recovery room nurses aren't capable/comfortable looking after this type of patient, an ICU/CCU nurse should be called in.

Another thought... don't the ED attendings have a say in this? Afterall, another service is coming and occupying a valuable ED bed reducing ED resources that should be available to the ED. In our hospital, the ED physician can trump the nursing supervisor.

Personally, I think the nursing supervisor made a very bad decision.

This sounds like the best answer. Use Recovery Room. I guess it works as long as the staff there aren't already overwhelmed by recovering patients. It is really terrifying the state of health care for the masses in America.

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I have researched Emtala quite a bit for some problems we were having. No where did it address this issue. The patient is not "dumped" on the ER. They keep their same doctor and their same orders. The ER doctor is not involved. It is similar to sending a M/S patient to the ICU. I really do not understand how you think this is an Emtala violation. If it is, please send me the references, because we sure need to know this if it's true.

sending a M/S pt to the ICU is an upgrade, and appropriate for a higher level of care...

I went to an EMTALA conference and in the Q&A part of the seminar, this question was asked, and the answer was that it's a violation...Not sure if I can find any written reference...

I've been doing ER nursing for 12 years, (in Phoenix) and I've never heard of this practice of dumping back to the ER...

Let's clarify though...Housing a true M/S pt in the ICU for example (d/t MS bed shortage - not a status upgrade) can only happen if you can prove that your MS beds are full...You are then in overcapacity mode...In AZ, the state licenses EVERY bed in the hospital for a specific "type" or level of care...You just can't put a tele pt in an ICU bed for the heck of it...

I think the distinction for me is checking a pt back into the ED...Sometimes @ 0200, the floor wants to send a MS pt down to the ED for sutures or a nosebleed...THAT'S an EMTALA violation, as you are now required to sign that pt in as an ED pt...A huge no no for an inpt...You wouldn't take a transfer from another hospital (of an inpt) to your ER...It's the same thing...

Housing an inpt in the ER d/t space constraints (ran out of ICU beds) is NOT a good use of your resources, but likely legal...

The house sup dropped the ball, I believe, as the ED needs all of the space it has, and putting an inpt there (are you sending the nurse? NOT) is lame, as now an ED nurse has MORE work...He/she should have come up w/ a better plan than to overburden the ED...

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Specializes in Tele, Acute.

That pt was sent to ER from MS because they were poss. having an MI? That means the pt needed to be 1:1 or 2:1, giving you this pt would have been extremely dangerous!

Someone needs to go above the House Super to report this. If they don't, it will continue to happen. Your lic is on the line. I would even write it up. The threat of the hospital closing down should be reported also.

Please think about finding another job. I have a feeling the complaint will fall on deaf ears.:angryfire :angryfire :angryfire :angryfire :angryfire :angryfire :angryfire :angryfire

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sending a M/S pt to the ICU is an upgrade, and appropriate for a higher level of care...

I went to an EMTALA conference and in the Q&A part of the seminar, this question was asked, and the answer was that it's a violation...Not sure if I can find any written reference...

I've been doing ER nursing for 12 years, (in Phoenix) and I've never heard of this practice of dumping back to the ER...

Let's clarify though...Housing a true M/S pt in the ICU for example (d/t MS bed shortage - not a status upgrade) can only happen if you can prove that your MS beds are full...You are then in overcapacity mode...In AZ, the state licenses EVERY bed in the hospital for a specific "type" or level of care...You just can't put a tele pt in an ICU bed for the heck of it...

I think the distinction for me is checking a pt back into the ED...Sometimes @ 0200, the floor wants to send a MS pt down to the ED for sutures or a nosebleed...THAT'S an EMTALA violation, as you are now required to sign that pt in as an ED pt...A huge no no for an inpt...You wouldn't take a transfer from another hospital (of an inpt) to your ER...It's the same thing...

Housing an inpt in the ER d/t space constraints (ran out of ICU beds) is NOT a good use of your resources, but likely legal...

The house sup dropped the ball, I believe, as the ED needs all of the space it has, and putting an inpt there (are you sending the nurse? NOT) is lame, as now an ED nurse has MORE work...He/she should have come up w/ a better plan than to overburden the ED...

check out this publication:

http://www.ena.org/government/emtala/SC-06-21-EMTALAPtparking.pdf

i emailed ms. smith to help clarify this.

the above poster said it well, you can not just put pts in any old bed because you want to. beds are licensed for certain use. if a pt is a med surg pt, you can not just admit them to icu if you have no beds.

once a pt is admitted and has had the initial evaluation in the ed, the hospital accepts responsibility for the pt as an in patient. when the pt leaves, the receiving unit is now responsible for care. not the ed. to send a pt back to the ed is like the hospital saying "well, now we can't care for them." imagine if this was done on a regular basis?! the hospital is dumping poeple they all of a sudden can't handle, back on the ems system.

if a woman falls in icu and sustains head trauma with a bleed you can't send her BACK to the ed! if you don't have the resources to deal with head trauma, the pt needs to be transfered to an accepting facility with an accepting dr. they are to be held there until the transfer can occur.

if a pt is on med surg and develops cp they can not go back to the ed if there are no tele beds. they either have to stay where they are with resources brought to that unit, or again, transfered out.

once a pt is accepted and admitted to a unit, it becomes a one way street for them. once a pt presents to the ed, it is also a one way street. let's say all beds are full in the ed of nonurgent kind of things.... level 3 or 4s. then a medic roles in and there's no place to put them. you can not make an accepted pt go back to triage or go to the waiting room.

look at it this way too, the er is not "just" another place in the hospital, it is part of the ems system and sending people back to the er, after admission, affects the entire ems community. the er exists for new pts, NOT established pts. the *hospital* is required to provide care once they accept the admission, not the er.

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...the above poster said it well, you can not just put pts in any old bed because you want to. beds are licensed for certain use. if a pt is a med surg pt, you can not just admit them to icu if you have no beds...

Thanks tridil, nice post...

Just to clarify (refer to my post): Hospitals can admit a MS pt to an ICU bed, IF and only IF, all MS/tele beds are full, and you have a tracking tool for overcapacity...

Each shift, as the house sup, I log in our bed status (green, yellow I and II, and red)...When we are in red status (no MS/tele beds, and ER holds (MS/tele) then we CAN admit a tele pt to an ICU bed, as long as it's not the LAST ICU bed...

You nailed it about transferring...If you are thinking about housing an ICU (overflow) pt in the ER, IT'S TIME TO TRANSFER! As a house sup, I would find resources to care for the pt in his assigned room (even if I have to take care of him) until a transfer is arranged...

EMTALA allows for transfers d/t overcapacity...

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Specializes in PICU, surgical post-op.
Thanks tridil, nice post...

Just to clarify (refer to my post): Hospitals can admit a MS pt to an ICU bed, IF and only IF, all MS/tele beds are full, and you have a tracking tool for overcapacity...

Each shift, as the house sup, I log in our bed status (green, yellow I and II, and red)...When we are in red status (no MS/tele beds, and ER holds (MS/tele) then we CAN admit a tele pt to an ICU bed, as long as it's not the LAST ICU bed...

You nailed it about transferring...If you are thinking about housing an ICU (overflow) pt in the ER, IT'S TIME TO TRANSFER! As a house sup, I would find resources to care for the pt in his assigned room (even if I have to take care of him) until a transfer is arranged...

EMTALA allows for transfers d/t overcapacity...

We dealt with this just last week ... our entire children's hospital was full, we had the only open bed (and already had 7 peds overflow kids). We got reamed out by the peds HN for refusing to accept another peds admision into our last PICU bed. Thankfully the sup get involved and we kept our bed. (Until later that night when we had a double trauma, but that's a story for another day...)

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Specializes in ER, ICU, Infusion, peds, informatics.

so then is sending a floor patient back to the er (while waiting on an icu bed) an emtala violation because it ties up resources that should be taking care of er patients (stretcher, nurse)?

i guess this makes some sense. i just can't see, though, how it is that much different than holding icu/med-surg patients in the er for a length of time while waiting on a floor bed. i realize the difference is that they have left the er, but that seems like a minor distinction when looking at the big picture (tying up resources).

i see a clear distinction between what hogan was talking about regarding checking in the med/surg patient for sutures in the middle of the night and sending a patient who needs a higher level of care to the er while waiting on an icu bed. to me, it is easy to see how the first is an emtala violation. but returning an inpatient to the er, under inpatient status, with a physician (meaning the er doc doesn't need to see the patient unless he/she codes) is different.

this really isn't something i've every had to deal with. it is against my hospital's policy for patients to return to the er once they have gotten to a floor bed, though occasionaly the supervisor has tried. the last time i remember it happening, she (the supervisor) ended up taking the patient, on the med/surg floor, on a lifepack monitor while waiting for an icu bed to open up. (this was several hours). i don't remember the patient requiring intubation, i'm pretty sure it was a bradycardia issue. however, it is important to note that not all hospital rooms can accomidate a ventilator. while i don't know about our inpatient rooms, i know for certain that all of our er slots cannot.

using recovery room does make some sense, at leat during the day (that is our code bed if icu is full), but at night there is no recovery nurse. i"m not even sure if there is one on-call. the or team is on-call for emergency surgeries (no one in-house) but they may have the circulator stay and recover after hours, rather than pay a second nurse to be on-call. i'm not sure, since i'm never on the receiving end of those patients.

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We dealt with this just last week ... our entire children's hospital was full, we had the only open bed (and already had 7 peds overflow kids). We got reamed out by the peds HN for refusing to accept another peds admision into our last PICU bed. Thankfully the sup get involved and we kept our bed. (Until later that night when we had a double trauma, but that's a story for another day...)

good for your house sup...

having been an ER sup in a 600 bed facility, you have to, as an ED charge nurse, respect each ICU's need to keep a code bed open...

an ED bed CANNOT be a code bed for an inpt, it has to be an ICU bed...

7 overflows means that you had 7 floor kiddos in your PICU...As the house sup it's a tough thing to deal with that, as the peds ward was likely full...

ouch...

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...But returning an inpatient to the ER, under inpatient status, with a physician (meaning the ER doc doesn't need to see the patient unless he/she codes) is different

exactly...

this is NOT an EMTALA violation (my apolgies for not making the distinction earlier in the thread)...

BUT, it is NOT a good plan...As tridil stated, the ER doors should be ONE WAY only, as bringing an inpt down to the ED burdens th ED (one less bed with a full WR), burdens the ED nurse, and can back up the EMS system...

shame on the house sup for not taking care of the pt (though not always feasible when she herself is slammed, but it is a better option)

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Specializes in ER, ICU, Infusion, peds, informatics.
exactly...

this is not an emtala violation (my apolgies for not making the distinction earlier in the thread)...

but, it is not a good plan...as tridil stated, the er doors should be one way only, as bringing an inpt down to the ed burdens th ed (one less bed with a full wr), burdens the ed nurse, and can back up the ems system...

shame on the house sup for not taking care of the pt (though not always feasible when she herself is slammed, but it is a better option)

so, then, the answer to the op's question is that yes, they are allowed to do that, provided hospital policy allows for it?

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[color=#483d8b]of course it is a bad idea, but i can see where there are times when you don't have a good option.

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[color=#483d8b]transferring is a nice thought, but when one local hospital is full to capacity, the rest usually are, as well. it is tough enough finding an accepting facility when we have an er patient that has out-of-network insurance but needs to be admitted. it has to be close to a nightmare to find one when the patient needs icu level care (and the house supervisor is trying to take care of the patient and make the transfer arrangements).

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...typical MS units do not have telemetry equipment or nurses able to read EKGs or push cardiac meds.

This is a common misconception...

If you are an RN without ACLS, you CAN push the same meds as an ACLS RN...

your hospital may have a policy that trumps this, but an RN is an RN is an RN

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