Question: If a triage nurse sees a patient and performs vital signs, then asks the patient to take a seat, is the nurse able to tell the patient how long the expected wait might be? In our ED, sometimes the wait for less acute patients is several hours. We do not want patients to leave without being seen or defer them away, but patients get very upset when they have to wait a long time and they were not informed of the wait time up front. What can the triage nurse do to communicate wait times and still comply with the Emergency Medical Treatment and Labor Act (EMTALA)?

Answer: You have every reason to be concerned, according to Jonathan D. Lawrence, MD, JD, FACEP, an ED physician and medical staff risk management liaison at St. Mary Medical Center in Long Beach, CA.

"We have all heard statements by enforcement officials that anything that discourages a patient from receiving a medical screening examination may be considered a potential EMTALA violation," he says. "That said, there are steps that can be taken to minimize the risk."

It goes without saying that emergent patients must be seen immediately and urgent patients as soon as space becomes available, adds Lawrence. Of the remaining nonurgent patients in the waiting room, he says that first and foremost, everyone must "be in the same boat.

"There can be no perception of preferential treatment because of ability to pay, race, age, gender, or any other identifying characteristic," he stresses.

The waiting time can be estimated and told to the patient without violating EMTALA, says Lawrence. He suggests saying something such as, "It looks like the waiting time will be two hours, but we’re trying to move patients through as quickly as possible."

Undoubtedly, this will cause some patients to leave, but that is their right, he adds. "EMTALA allows for patients to withdraw their request for a medical screening examination," Lawrence explains.

All EDs should have a form for the patients to sign should they intend to do so, says Lawrence. "The form should make it clear that the ED remains ready to see patients if they change their minds," he says. Consider this wording, Lawrence suggests:

"I recognize that under federal and state law, I have the right to a medical screening examination and stabilizing treatment for any emergency condition found. I hereby withdraw any request for such an examination and/or treatment for myself or for ________________ (relation) and hereby release the hospital from any obligations it has under the law to provide such examination and/or treatment."

Another important point is that patients in the waiting area should be re-evaluated periodically to be certain they haven’t deteriorated from nonurgent to a more urgent category, says Lawrence.

"From a customer service point of view, this additional contact is important," he says. "It also allows the triage nurse to keep the patient updated as to the ability to find a place for treatment in the ED proper."

However, Lawrence says that the ED has a more serious concern than just EMTALA. "If routine waits at a private facility are as long as is stated, a serious overhaul in the way business is being done is in order," he says. "A task force to see why throughput times are so long is a must."

You need to determine whether the problem is admitted patients taking up space in the ED, long turnaround times for laboratory and ancillary services, lack of physical space or personnel, or all of these, Lawrence says.

"A supportive administration should address these concerns," he emphasizes. "The possibility of EMTALA fines would be a gentle reminder that the problem can’t be ignored," he adds.

Resources

For more information, contact:

  • 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.