Avoid COBRA’s bite with careful triage and documentation procedures

Incomplete entries in patient logs and inconsistent triage procedures are red flags for HCFA investigators

The intent of the COBRA/EMTALA (Consolidated Omnibus Budget Reconciliation Act/Emergency Medical Treatment and Active Labor Act) regulations sound harmless enough: no patient should be refused care because of lack of insurance. Yet COBRA can indeed strike well-meaning caregivers like a snake.

ED nurses often interpret COBRA regulations incorrectly, at great peril. "HCFA (the Health Care Financing Administration) has reported an increasing number of violations in this area," reports Charlotte Yeh, MD, FACEP, chief of emergency medicine at New England Medical Center in Boston, and a member of HCFA’s task force on EMTALA. Over the past two years, over 500 facilities have been investigated for patient dumping.

One thing is clear: COBRA has created a lot of confusion, especially as regional differences and conflicting managed care requirements come into play. (See the related article on managed care and COBRA on this page.) It’s important to realize that ED personnel don’t have to refuse care, or have bad patient outcomes, to violate COBRA, says Yeh. In some cases, the mere mention of insurance—even by the patient—can cause problems.

"It’s not like we’re out there denying anybody care, but the little innocuous things that nurses do are still potentially risky," says Kathleen Conboy, RN, BS, CEN, unit coordinator at United Health Care Services in Binghamton, NY, and member of an Emergency Nurses Association (ENA) committee on COBRA. "As hard as we prepare nurses for trauma and pediatrics, we need to work just as hard at understanding COBRA."

Not surprisingly, consultants advise ED nurses to do everything possible to avoid an investigation. Here are some common COBRA/EMTALA violations ED nurses should be on the lookout for:

Triage nurses referring patients outside the ED without a thorough medical screening exam. Although it happens all the time, it’s a clear COBRA violation for triage nurses to confuse triage with a medical screening. "Triage is not a medical screening examination," emphasizes Yeh. "Triage determines the order patients are seen, not whether they do or don’t have an emergency medical condition." A medical screening exam is the process required to determine the presence or absence of an emergency medical condition. That may include ancillary services such as CAT scans or MRIs. "A triage exam doesn’t constitute a medical screening exam, unless the staff doing triage has been trained to look for emergency conditions," Yeh explains.

Incomplete entries in patient logs. Patient logs are the first place investigators look, so be careful to complete all entries. Every single patient that walks in needs to be logged, warns Steven A. Frew, a Rockford, IL-based health care attorney and consultant. "If investigators come in and find a gap, that file is automatically going to be pulled," he says. "If there are a bunch of incompletes, they will probably pull a significantly larger sample than they would otherwise."

Altered records are major red flags. "There’s only one thing worse than an incomplete record, and that’s a record with whiteout," he says. "Investigators will descend on that like a vulture."

Transferring patients to a lower or similar level of care. A medical screening exam must be completed before any transfer takes place in order to determine whether a patient has an emergency medical condition, says Yeh. "You must be confident and able to substantiate that the patient does not have an emergency medical condition," she adds. "If they do, you would not want to transfer that patient unless you can demonstrate that the medical benefits [of transfer] clearly outweigh the risks."

Refusing patient transfers. It’s a risky move for an ED nurse to refuse to accept any patient—especially if the ED provides a higher level of care than the facility from which the patient was transferred. Turning down requests for transfer is getting a lot of scrutiny, reports Frew. "Often a nurse will say, We can’t take any more patients,’ but technically that’s incorrect," he says. "They have to go through their internal processes for opening beds if they have any capacity, or downgrade some patients to lower levels of care to make openings for them."

To ensure COBRA regulations are adhered to, the ED at Promina’s Northwest Health System in Atlanta developed an interfacility transfer form. (See form on page 44.) Four separate transfer documents (Patient Refusal of Transfer, Patient Request for Transfer, Physician Certification for Transfer, and Interhospital Transfer forms) are combined on a single page.

Nurses no longer need to worry about using the correct form, and documentation of essential information has improved. "It also cuts down on inappropriate information—any mention of insurance on a patient transfer form is a potential COBRA violation," says Lorene Newberry, RN, clinical nurse specialist in emergency trauma at the hospital. "Because it’s a preprinted form, no one has to guess about what information to include."

Referring potentially suicidal or belligerent patients out of the ED. COBRA views these patients as unstable, and has issued several citations to EDs that have referred such patients to social services, says Frew. "The standard for medical screening requires these people to have an exam that rules out any metabolic causes," he explains.