Hospital’s primary care center relieves ED logjam

New policy complies with EMTALA?

Is it an extremely creative solution to one of emergency medicine’s most nagging problems, or a violation of the Emergency Medical Treatment and Labor Act (EMTALA)? We may never know the complete answer unless the issue winds up in court someday, but for now, Flagler Hospital in St. Augustine, FL, is successfully easing the pressure on its ED by directing some patients to a county-funded primary care center just down the hall.

Flagler had opened a new ED, and the first winter season brought a change to their caseload, reports Jennifer Arguilla, RN, BSN, MBA/HCM, LNC, director of Flagler’s Emergency Center Care. "We saw a dramatic increase in self-pays, which is difficult for a single, not-for-profit hospital," she says. "We looked at the majority of our patients and what they came in for, and what part of the ED they used most."

Arguilla found that most of the patients were fast-track cases of nonepisodic, nonacute care.

Hoping to reduce $28 million a year in unpaid bills, St. Johns County’s only hospital made a policy change in early January to direct some ED patients to the county center. "We were trying to find ways we could buffer the business we have," Arguilla explains.

The hospital started the county-run primary care center two years ago, reports Peter Bacon, a hospital spokesman. "Its purpose is to provide a primary care doctor for people who don’t have one or who don’t have insurance," he says.

These patients present to the ED with a cold or a headache, and they need to see a physician, Bacon says. "What we initiated in January is designed to direct them to the more appropriate, long-range wellness care they really need."

How the system works

Under this new arrangement, when a patient signs in, the triage nurse follows normal ED protocols and does her initial assessment. Then, she calls the physician at the primary care center and does a person-to-person referral, says Arguilla. "After that, they either send the patient over, or the doctor says they need more labs," she says. "Also, if the patient is in the clinic and the physician finds something, they will send them back to the main facility."

The physician at the primary care center is trained in emergency medicine and family practice, notes Arguilla. "He works under the same physician group that has our ED," she says. "So, we are still doing appropriate medical screening by an actual physician."

Since the program was begun only recently, there is not a lot of data available on its effectiveness. "We’re averaging at least five patients [transferred] a day," says Arguilla. "It’s mainly impacting my fast-track population. but it cuts everyone’s wait time, so everybody’s happy."

There’s another benefit for the patients: "People who come here and don’t have a physician now have a home," says Arguilla. "And, since we’re hooked up with the county, we have social workers, prescription assistance programs, and so forth." She doesn’t see why other facilities couldn’t do what Flagler has done, but notes that "we are the only hospital serving this county; that’s why we have full county support."

What would EMTALA say?

Naturally, Flagler ran the plan by its general counsel and received a green light in terms of EMTALA. "We made sure our bylaws did not violate EMTALA," says Arguilla. "My comfort level is that we are using an emergency physician. I wouldn’t be comfortable otherwise."

But for Alan Steinberg, Esq., an attorney with the law firm of Horty Springer in Pittsburgh, the situation is not that black and white. "If a patient presents and receives a true screening exam, and it is not an emergency medical condition, then EMTALA is done," he says. "The patients certainly are getting screened and seen by a physician."

However, he adds, "in a really strict review, there may be a problem, because under EMTALA you have to treat all the people presenting with symptoms the same way. If you send one patient over [to the county center] and keep another in the ED, are you making a distinction?"

In other words, he says, on the one hand Flagler may be compliant because both patients are being screened by a physician, but because some patients leave the ED before screening, there could be a problem. "It is a well thought-through plan, and its intent is good," he summarizes, "but you would need to [demonstrate] rigorous compliance language if there were ever legal questions raised."


For more information on in-house transfers, contact:

  • Jennifer Arguilla, RN, BSN, MBA/HCM, LNC, Emergency Center Care Director, Flagler Hospital, 400 Health Park Blvd., St. Augustine, FL 32086. Phone: (904) 819-5155. Fax: (904) 819-4472.
  • Alan Steinberg, Esq., Horty, Springer & Mattern, 4614 Fifth Ave., Pittsburgh, PA 15213. Phone: (412) 687-7677. Fax: (412) 687-7692. E-mail: