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[Editor’s note: This column addresses reader questions about the Emergency Medical
Treatment and Labor Act (EMTALA). If you have a question you’d like answered, contact
Greg Freeman, Editor, ED Management,
3185 Bywater Trail, Roswell, GA
30075. Telephone: (770) 998-8455. E-mail: Free6060@
Question: Is it OK to have someone very quickly screen incoming patients at the door to catch those who clearly do not have an emergency condition — such as the woman who just wants a pregnancy test — and send them away to a public clinic or more appropriate provider? Even if it is technically compliant with EMTALA, would this be a risky way to clear our overcrowded ED?
Answer: If done correctly, this strategy can be entirely compliant with EMTALA and an effective way to relieve the burden of clearly nonemergent patients, says Daniel J. Sullivan, MD, JD, FACEP, president of the Sullivan Group, a consulting company in Oak Brook, IL, that specializes in EMTALA interpretation.
Sullivan spoke on the topic recently at the meeting of the American Society for Healthcare Risk Management (ASHRM) in Nashville, TN.
The rule does not require a medical screening examination (MSE) for people who clearly do not have an emergency condition and who are not requesting emergency care. As far as EMTALA is concerned, Sullivan says the key is who does this quick screen at the door.
The final EMTALA rule specifies that some medical decisions must be made by a "qualified medical professional," so not just anyone can make the decision to turn the patient away.
Spell out who is qualified to screen
Hospitals are free to make their own determination of exactly who is qualified, but the EMTALA rule is clear that such decisions should be made by someone with substantial medical training. That means that you might not be able to use just any nurse, but a registered nurse often will qualify, Sullivan says.
The triage nurses may not be considered qualified medical personnel unless your hospital policies spell that out, he says.
"The hospital board must determine what makes someone qualified medical personnel and implement bylaws designating those triage nurses as such," adds Sullivan.
Once you determine who can make that call, screening at the door can be an effective way to reduce overcrowding, he explains.
"You can determine with a few questions that the patient has no emergency condition and is not requesting emergency care," he says. "You can tell them We don’t do routine blood pressure checks,’ and give them a list of public clinics."
Of course, the reason why the patient wants a blood pressure check can be germane, Sullivan says. You don’t want to turn away a patient who is feeling lightheaded and might be suffering from severe hypertension. But if the patient simply wants a routine blood pressure check, that is a different situation.
The goal of the screening at that point is to weed out those who clearly have no emergency condition and don’t even think they do, he says.
The Centers for Medicare and Medicaid Services (CMS) stated in the final EMTALA rule that the law is triggered when the patient has an emergency condition or is requesting emergency care, so there can be some disagreement when screening at the door.
If the screener determines there is no emergency condition but the patient insists he needs emergency care, the more prudent course may be to let that patient through and into the ED to be triaged normally, points out Sullivan.
Though ED managers may be reluctant to screen patients at the door like an exclusive nightclub, he says you would not be pushing the limits of EMTALA by doing so.
A velvet rope and bouncer at the door might be too much, but otherwise, CMS expects you to perform this type of screening, Sullivan continues.
"CMS says it’s OK and even encourages it as a way to address overcrowding," he says.
That interpretation is borne out by more guidance issued recently by CMS after the final rule was released.
Explaining the final EMTALA rule to surveyors, the memo stated, "The rule clarifies that when an individual comes to the dedicated ED for nonemergency services, and from the nature of his or her request, it is clear that the individual is not making a request or having a request made on his or her behalf for examination or treatment for an [emergency medical condition], the hospital is not obligated to conduct a comprehensive MSE. An example is an individual who presents to the dedicated ED for a minor medical complaint such as suture removal."
The memo noted that the preamble to the regulation "contemplates that a registered nurse could conduct a relatively basic MSE in this instance and direct the patient to another location other than the dedicated ED for the suture removal.
"Implicit in this guidance is the notion that it is permissible for a registered nurse to conduct the MSE, as long as the nurse is considered to be qualified medical personnel by the hospital and is acting within the scope of his/her license," it added.
For more information, contact:
• Daniel J. Sullivan , MD, JD, FACEP, The Sullivan Group, 2000 Spring Road, Suite 200 Oak Brook, IL 60523. Phone: (630) 990-9700. Web: www.thesullivangroup.com.