[Editor’s Note: This column is part of an ongoing series that will address reader questions about the Emergency Medical Treatment and Labor Act (EMTALA). If you have a question you’d like answered, contact Staci Kusterbeck, Editor, ED Management, 280 Nassau Road, Huntington, NY 11743. Telephone: (631) 425-9760. Fax: (631) 271-1603. E-mail: StaciKusterbeck@aol.com.]

Question: I work in a rural emergency department (ED) that increasingly has been treating patients without seeing an ED physician. Patients are being sent from clinics to get intravenous therapy, palliative medications, and lab tests at a scheduled time. The ED is being utilized as an outpatient department, and no medical screening examination (MSE) is given. Is this a violation of EMTALA?

Answer: The statute states that everyone who "comes to the hospital for examination or treatment" needs an MSE, says Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA. However, Lawrence notes that recent regulations specify that patients coming to the hospital for regularly scheduled appointments do not need the screening exam. "The problem in this scenario is that they are coming to the ED for their regularly scheduled treatment," he explains.

Have the medical staff amend the rules on who may perform a screening exam to allow for nurse screening on these patients, he suggests. As long as all patients in the same or similar circumstances are treated the same way, EMTALA screening regulations will have been met, he explains.

Under EMTALA, any unscheduled patient is deemed to have an emergency medical condition and therefore requires an MSE, according to John D. Lipson, MD, MBA, principal of Columbus, IN-based Medical Staff Support Services, which assists medical staff leaders and administrators with EMTALA compliance. In the above scenario, the ED is being used to give scheduled treatment that normally would be done in another outpatient setting in other hospitals, Lipson says.

Address these issues

Therefore, there are two questions you need to address to understand how to handle the individual patient, he says. "First, is the patient truly a scheduled visit?" he asks. For instance, an asymptomatic patient getting a series of rabies shots is a scheduled patient, as is a patient who routinely receives a monthly blood transfusion for chronic anemia. However, a patient sent from a doctor’s office to receive a narcotic injection for pain is an unscheduled patient, and therefore requires an MSE by the ED physician before the injection is given, Lipson says.

Likewise, a patient sent from a nursing home with fever to receive IV antibiotics is an emergency patient and therefore requires an MSE, he says. All patients must be registered, and the registration book should clearly indicate the patient is being seen for a scheduled appointment, he adds.

Lipson says that the second question to answer is: Does the scheduled patient have signs or symptoms that, to a layperson, might indicate the possibility of an emergency medical condition? Have a nurse screen the patients and take a simple history and a set of vital signs, Lawrence suggests. "If either revealed a change in condition from that for which the patient was sent to the ED, then a more extensive physician screen would be indicated."

Hospital policy must indicate that if the ED nurse, in doing the nursing assessment, finds a condition such as pain, fever, abnormal vital signs or new patient complaints, an MSE will be performed by a physician, Lipson advises. "If the ED is being used for chemotherapy, patients who have a change in condition, fever, pain, nausea, or out-of-bounds laboratory studies also should be evaluated by a physician and receive an MSE," he says.

Although these patients have not made the traditional request for examination and treatment of a medical condition by a qualified medical person, they are coming to the ED with the request for treatment, points out Denise Casaubon, RN, owner and president of DNR Consultants, a Fountain Hills, AZ-based company specializing in health care corporate compliance.

What should be considered is the nature of the procedures being performed, Casaubon says, and she recommends that protocols define the necessary terms (such as what constitutes an outpatient) and address what to do in the event of an adverse outcome. "If issues such as these are not clearly addressed, the hospital is exposing itself to increased liability," she says.

Sources

For more information about the Emergency Medical Treatment and Labor Act, contact:

Denise Casaubon, RN, DNR Consultants, 16217 Balsam Drive, Fountain Hills, AZ 85268. Telephone: (480) 816-6695. Fax: (480) 836-8185. E-mail: Dcasaubon@msn.com.

Jonathan D. Lawrence, MD, JD, FACEP, Emergency Department, St. Mary Medical Center, 1050 Linden Ave., Long Beach, CA 30813. Telephone: (562) 491-9090. E-mail: jdl28@cornell.edu.

John D. Lipson, MD, MBA, Medical Staff Support Services, 6043 Chinkapin Drive, Columbus, IN 47201. Telephone: (812) 342-2658. E-mail: lipsonj@medstaff.net. Web: www.medstaff.net.