'Urgent care' after triage not easy decision to make

Use these criteria, expert advises

One of the EMTALA-related questions he hears most frequently from providers is whether it is permissible to send patients to an urgent care setting following triage in the emergency department (ED), says Stephen Frew, JD, a web site publisher (www.medlaw.com) who specializes in interpreting the Emergency Medical Treatment and Labor Act.

The answer, Frew says, depends on several things, as he explains below:

Is the urgent care owned and operated by the hospital where the patient presented?

If the answer is no, the patient may not be triaged to urgent care.

Is the urgent care facility classified as a rural health clinic (RHC)?

If the answer is yes, the patient may not be triaged to the urgent care RHC.

Is the urgent care facility on the campus of the hospital where the patient presented?

If the answer is no, the patient may not be triaged to urgent care.

If the provider's urgent care question survives those three filters, Frew continues, it's time to consider these rules:

  • All patients of similar condition, complaint, and acuity must go to the same location. The purpose of this is to prevent unequal treatment ("disparate" treatment in court terminology) and "cherry picking" of cases based on insurance or revenue issues.
  • There must be a valid medical reason for moving the patient. This means that patients must not be moved to the urgent care area for discriminatory reasons, revenue-related reasons, or for physician convenience.
  • The patient must be escorted to the area, not sent there. This is to prevent patients from being sent out of the ED before assessment without any medical management between locations.

If the patient refuses to go to the urgent care setting and wants to be seen in the ED, the situation enters a "gray zone," Frew says. "From an EMTALA perspective, the patient came to the ED, and the ED is still an available option. On the other hand, the patient does not have an adequate basis to determine where he or she is best seen."

In such a case, Frew adds, he recommends advising the patient that the urgent care option is quicker and is just as reliable. Threatening patients with long waits, however, could be viewed as intimidation, he points out. "If the patient persists in wanting to be seen in the ED, by all means see the patient in the ED," Frew says. "Be polite. Remember, the alternative is that the patient may leave without being seen, which could lead to an EMTALA complaint or an adverse outcome with resulting malpractice issues."

While patients can be "unreasonable and manipulative," he adds, arguing with them is not worth the time, energy, lower customer satisfaction scores and risk that could result. Frew also notes that urgent care areas must follow all the same rules for compliance as the ED.

"Many urgent care [areas] are covered with co-payment signs, insurance requirements, and upfront registration procedures that are not EMTALA compliant," he says. "If you are using the urgent care for medical screening exams of presenting patients, then it is officially a 'designated emergency department' and must operate just like the ED for EMTALA compliance purposes."