Redirect nonurgent patients and comply with EMTALA

ED gives expedited MSE to 260 patients a month

Would you like to improve patient flow by decreasing the number of nonurgent patients waiting for care in your already crowded ED waiting room? At University of Colorado Hospital in Denver, physicians and specially trained ED nurses perform an expedited medical screening examination (MSE) after triage but before registration, and they report dramatic results.

"We screen and refer approximately 8% of our ED volume, about 260 patients per month," reports Kathleen Oman, RN, PhD, CNS, ED clinical nurse specialist and research nurse scientist.

Although the benefits of a less crowded waiting room speak for themselves, there also are potential problems related to expedited MSEs, she cautions. "There is the concern of bad public relations if the community, rightly or not, interprets us as denying care to the uninsured, and there are liability risks if a mistake is made," she notes.

Since the expedited MSEs were implemented, the ED has had to contend with an onslaught of bad publicity, such as frequent articles in the local newspaper with a negative slant, reporting on cases such as a man who drove a long distance to the ED seeking care for trauma to his jaw and after screening, was informed that he did not have an emergency. "In retrospect, we wished we would have anticipated this reaction and done some proactive work, such as sending out press releases explaining that we are trying to control wait times and overcrowding and educating patients about appropriate places to seek care," says Oman.

In addition, EDs are probably worried about possible violations of the Emergency Medical Treatment and Labor Act (EMTALA), says Oman. "We’ve had EMTALA violations alleged against us by both patients and other EDs, but investigations have supported our screening and decision-making process," she says.

Here are key steps in the MSE process:

  • The exam is given to patients triaged at Level 4 or 5.

If the patient is triaged as a Level 4, the nurse places the patient in a room for the physician to do the MSE. If the patient is a Level 5, a specially trained nurse completes the MSE. Triage nurses receive a three-hour training on the protocols, EMTALA issues, and customer service in order to perform the MSE, says Oman.

Training includes an overview of EMTALA and an explanation of why this is not violating federal regulations, says Oman. "Nurses are instructed that there is no discussion of insurance or finances/charges before screening exam," she says.

Many times, triage nurses are not allowed to perform the MSE as they have not completed the training, notes Amy Diesburg-Stanwood, RN, an ED triage nurse at the facility. "In that case, if a physician is not able to perform the MSE, the patient stays in the ED and does not receive an expedited screening exam." About 20 nurses have completed the voluntary training so far, comprising one-third of the ED nursing staff.

The nurse and physician complete an MSE form that is more detailed than the standard triage form. "It includes physical findings that the nurse and physician need to look for," says Diesburg-Stanwood. "This ensures that key findings, such as compromised circulation, are not missed."

  • Patients are asked for a deposit.

If patients are assessed not to have an emergency medical condition, a registration clerk asks for a deposit to continue care in the ED. "The copay depends on the insurance status of the patient and can range from $3 to $260," says Oman. Patients without insurance are asked for a $260 copay.

If no deposit is made, the patient is given community referrals such as primary care clinics, women’s health clinics, and dental resources. "Everyone has a choice, and care is not refused to anyone," says Diesburg-Stanwood. "If the patient pays their copay, they go back to the waiting room and wait behind the emergent patients."

  • Many patients choose to seek care elsewhere.

Most patients given the expedited MSE do not have emergency medical conditions, notes Oman. "Our preliminary data showed that 38% of patients sought care elsewhere," she adds.

Patient with a mole

Recently, Diesburg-Stanwood triaged a Level 5 patient who presented with a mole on his back. "I pulled out the MSE form, assessed his mole, and explained to the man that he did not have an emergent condition, and he agreed," she says.

Diesburg-Stanwood explained that if the patient had an emergent condition he would be seen regardless of his ability to pay, but nonemergent conditions required a copay that is applied toward the ED visit. "He made the decision to leave after I educated him on follow-up options in the community and important changes to his condition that might change the status, such as signs of infection," she says.

Without the expedited MSE, people with emergencies would wait longer, says Diesburg-Stanwood. "It also gives the patient an understanding of what the appropriate use of the ED is, so that a patient with abdominal pain is not waiting behind a patient with a mole who does not need care today," she says.


For more information on expedited medical screening examinations, contact:

  • Amy Diesburg-Stanwood, RN, Emergency Department, University of Colorado Hospital, 4200 E. Ninth Ave., Denver, CO 80262. E-mail:
  • Kathleen Oman, RN, PhD, CNS, Clinical Nurse Specialist, Emergency Department, University of Colorado Hospital, 4200 E. Ninth Ave., Denver, CO 80262. Telephone: (303) 372-5634. E-mail:

A patient education brochure, "What You Should Know about the Emergency Department," explains the problem of ED overcrowding and why some emergency patients experience long waits for care. Copies of the brochure can be downloaded at no charge on the American College of Emergency Physicians web site ( Click on "Health Information," "Brochures & Handouts," "What You Should Know about the Emergency Department — Four-color/Two-page version."