Journal Reviews

Tintinalli JE. Analysis of insurance payment denials using the prudent layperson standard. Ann Emerg Med 2000; 35:291-294.

Managed care organizations (MCOs) are denying payment for ED visits that meet the prudent layperson definition of an emergency, says this study from the University of North Carolina at Chapel Hill. The study reviewed 200 ED visits that were classified as "not a medical emergency" by two MCOs. One MCO denied 44 visits, of which 38 met the prudent layperson standard, and the other MCO denied 156 visits, of which 113 met the standard.

Part of the problem is that there is no explicit or consensus definition of the prudent layperson standard, says the researcher. The ED visits were analyzed for chief compliant and risk factors for morbidity. Any minor disorder lasting one day or more, with normal vital signs recorded, was considered not to meet the prudent layperson standard because a personal physician could have been contacted within that time frame.

The prudent layperson standard has been adopted for Medicare and Medicaid programs in most states. However, the study shows that federal and state prudent layperson legislation, although important for reimbursement of ED visits, does not ensure compliance. ICD-9-CM coding systems need to be expanded to include variables such as triage severity, chief complaint, comorbidities, and mechanism of injury to determine whether the prudent layperson standard is met, according to the study. In the future, compliance by MCOs will be affected by legislation, pressure from consumers and physicians, improvement in classification systems, and expanded chart review, says the researcher.


Husni ME, Linden JA, Tibbles C.Domestic violence and out-of-hospital providers: A potential resource to protect battered women. Acad Emerg Med2000; 7:243-248.

Out-of-hospital providers can be valuable resources to help victims of domestic violence, many of whom refuse transport to the hospital, according to this study from Beth Israel Deaconess Hospital in Boston, Boston University School of Medicine, and Hennepin County Hospital in Minneapolis.

Emergency medical services (EMS) personnel are important resources for domestic violence victims for the following reasons, say the researchers:

• As initial responders, they have an opportunity to intervene on behalf of the victims.

• They can observe the environment in which the violence occurred. They might detect violence that could otherwise go undetected, because they are able to observe the behavior of the batterer in the home.

• In many cases, victims might refuse to be transported to the hospital for a variety of reasons, including shame, fear of retaliation, fear of legal consequences for the batterer, and child care issues. Failure to transport prevents victims from obtaining hospital-based services such as social work or referrals to hotlines and emergency shelters. Educational programs should focus on improving recognition of abuse and competency in safety planning and documentation, the study suggests. For example, the EMS training curriculum might need to include topics not covered in current training modules, such as scene safety and evidence preservation.

Prehospital personnel should be trained to identify and document domestic violence, assess patient safety, offer timely resources, and empower victims to make choices, write the researchers. "Increased training and competence in assisting victims of domestic violence may allow earlier intervention, before the violence escalates and the woman is seriously harmed."


Blank FS, Keyes M. Thrombolytic therapy for patients with acute stroke in the ED setting. J Emerg Nurs 2000; 26:24-30.

EDs should develop practice guidelines to reflect the Stroke Council of the American Heart Association’s 1996 guidelines for thrombolytic therapy for acute stroke, according to this study from Baystate Medical Center in Springfield, MA. The ED implemented the guidelines, and the following challenges were noted:

• The logistics of arranging 24-hour, seven-day neurology coverage for the ED was difficult because of a paucity of neurologists in the area.

• The expertise and physical presence of a neurologist in the ED at the time of patient assessment is an essential component of the protocol for giving tissue plasminogen activator (t-PA) therapy to a person who has had an acute stroke.

• A neurologist must be present to confirm the diagnosis after the CT scan and to perform the assessment, including the National Institutes of Health Stroke Scale.

Because of the strict inclusion criteria, the use of t-PA therapy in the ED for stroke patients is very low, the authors note. However, quickly assessing patients who meet the inclusion criteria and initiating therapy for them without delay are critical, because there is only a three-hour window of opportunity from onset of symptoms to drug administration, they add.

The authors caution that the possibility of an intracranial bleed and/or death exists as a complication with any thrombolytic therapy. "The ED should have all the professional supports in place and the resources needed to manage complications before instituting new treatment modalities such as this one."