If a patient isn't allowed to check back in, is it an EMTALA violation?

[doctorFred]

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Scenario 1: A 48 year old male is seen in the ED for headache. He is evaluated and discharged. While in the waiting room, he complains he has suddenly experienced significant back pain, and wishes to be evaluated again. The treating physician, however, decides not to let the patient check himself back in. Is this an EMTALA violation for not performing a "medical screening exam" on this new complaint?

Scenario 2: A 51 year old homeless male complains of chest pain, is evaluated, spends 24 hours in ED obs (including stress testing) and is discharged. Again, while in the waiting room, he wishes to check himself back in because his pain has worsened. The treating physician does not allow him to do so. If an adverse event occurs, has an EMTALA violation taken place?

I've had to consider both of these scenarios recently and was curious if anyone else had any insight. My gut instinct is a "no" for both.

 

[Birdstrike]

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[BJJVP]

I believe they are technically violations even if no bad outcome is found. But I'm not an EMTALA expert.

I've had them check back in hoping to see a different physician. I don't want to even give the appearance of an EMTALA violation. Therefore, I always let them check back in. But, I will tell the triage nurse to assign the pt to my team, see them right away and discharge them immediately.

 

[Socrates25]

I remember studying for the Texas medical jurisprudence exam on this issue, and their study materials imply that it is in fact an EMTALA violation to deny repeat check ins.

However, it also says that the "medical screening exam" doesnt necessarily have to be done by a physician. The actual EMTALA law is vague -- theoretically you could have a triage nurse do the medical screening exam and then send them on their way.

 

[alreadylernd]

I remember studying for the Texas medical jurisprudence exam on this issue, and their study materials imply that it is in fact an EMTALA violation to deny repeat check ins.

However, it also says that the "medical screening exam" doesnt necessarily have to be done by a physician. The actual EMTALA law is vague -- theoretically you could have a triage nurse do the medical screening exam and then send them on their way.

While the MSE (medical screening exam) doesn't need to necessarily be done by the physician, a triage nurse cannot de facto perform one - I believe the hospital must designate (in advance) who can perform the exam as part of its hospital policies. Triage does not necessarily equal MSE.

"Pain" can probably be deemed a symptom of an EMC thus necessitating a documented MSE. Also, I'm fairly certain that outcome/motive have no bearing on whether something is an EMTALA violation, therefore whether or not there was an adverse outcome is moot.

I agree with Birdstrike - both are likely violations.

 

[GeneralVeers]

I tell the nurse to put them in a chair. I walk up, greet them, maybe listen to their heart and lungs, and discharge them. Takes about one minute.

 

[EctopicFetus]

I tell the nurse to put them in a chair. I walk up, greet them, maybe listen to their heart and lungs, and discharge them. Takes about one minute.

This.. but yes I imagine both the scenarios would be violations. Without getting too much into the details why arent they allowed to check back in? A stress test is a mediocre test a neg stress and 3 neg trops dont mean the dude wont infarct while waiting for his cab ride home.

 

[GeneralVeers]

This.. but yes I imagine both the scenarios would be violations. Without getting too much into the details why arent they allowed to check back in? A stress test is a mediocre test a neg stress and 3 neg trops dont mean the dude wont infarct while waiting for his cab ride home.

According to the "Cockroach Theory" it is statistically impossible for the drunk, malingering, loser to actually die from anything. The mere fact that they live to torment us and make our lives miserable confers a poorly understood protective effect.

 

[jbar]

I tell the nurse to put them in a chair. I walk up, greet them, maybe listen to their heart and lungs, and discharge them. Takes about one minute.

Anything different in your charting of the repeat visit? Can you say "exam unchanged from previous visit"? I feel like the time suck in something like this isn't the seeing the patient again, it's charting it.

 

[GeneralVeers]

Anything different in your charting of the repeat visit? Can you say "exam unchanged from previous visit"? I feel like the time suck in something like this isn't the seeing the patient again, it's charting it.

On dictation it would take me less than 1 minute to dictate the repeat visit note.

 

[Hamhock]

A stress test is a mediocre test a neg stress and 3 neg trops dont mean the dude wont infarct while waiting for his cab ride home.

This was my thought after reading the original post.

EMTALA would not be on my mind when a guy who was just discharged for chest pain returns complaining of increased chest pain.

I'm only thinking of what was missed or how big the infarction is.

HH

 

[WilcoWorld]

This was my thought after reading the original post.

EMTALA would not be on my mind when a guy who was just discharged for chest pain returns complaining of increased chest pain.

I'm only thinking of what was missed or how big the infarction is.

HH

Agreed. On each and every one of my discharge instructions I say something like "If your symptoms worsen, or if you develop new concerning symptoms return to the ER for reevaluation."

 

[GeneralVeers]

This was my thought after reading the original post.

EMTALA would not be on my mind when a guy who was just discharged for chest pain returns complaining of increased chest pain.

I'm only thinking of what was missed or how big the infarction is.

HH

We're not talking about normal, responsible human beings. I think any of us would have no problem with them being seen again if something changed. We are talking about denying check-in to the malingering abusers.

 

[Hamhock]

We're not talking about normal, responsible human beings. I think any of us would have no problem with them being seen again if something changed. We are talking about denying check-in to the malingering abusers.

I am not talking about "normal, responsible human beings" or "malingering abusers"... I am just talking about a recent chest pain who turns around after discharge and tells me or the triage nurse that his chest pain has returned and is worse.

They are all a missed diagnoses or developing ischemia/infarction in my mind until proven otherwise....especially based on the original post.

Indeed, that is kind of my point: to focus so much on EMTALA can easily lead to lack of focus on what sounds like a possible true emergency.

HH

 

[EctopicFetus]

I mean I imagine each shop has the 50 something year old chest painer with 4 stents, a CABG, who comes in 2x per week. usually we come up with a plan of care, no narcs (citing that duke study), and then theye go off to torture some other ED.

Again.. the scenarios arent clear. I think everyone here has the bs pts. I had a guy who I dc'ed who then attacked the police/our security. He has some vague complaint afterwards. I exained the guy and dc'ed him to the police.

 

[alreadylernd]

http://www.boston.com/lifestyle/hea...of_patients_in_emergency_rooms/?p1=News_links

These 3 cases in Mass aren't identical to the hypothetical ones you presented, but I was curious about what everyone else thought about them. The surgeon not coming in, and the ER turning away a patient (Lahey case) seem pretty cut and dry, but the transfer case of the patient in respiratory distress doesn't make sense - the patient was requesting transfer and it sounds like was accepted at the other hospital. Doesn't that eliminate EMTALA?

 

[Birdstrike]

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[doctorFred]

I didn't clarify in my original post, but Veers is correct - these were both individuals of the 40-50 ED visit/year variety.

 

[NinerNiner999]

They are both EMTALA violations and technically a MSE should have been performed.

 

[Xerxes1729]

The point they're trying to make is that the condition deteriorated after the request for transfer occurred. Patient was stable, requested transfer. Okay, no problem.

Patient deteriorates after first doc leaves, may be too unstable to transport: the issues have changed. The patient needs to be informed they are too unstable for transfer by the doc assuming care. If they still demand transfer it becomes an AMA issue, not an EMTALA issue. They may need to be stabilized THEN transferred.

It's complicated.

I think the key is that condition changed after the discussion with the first doc AND shows the known bump in risk at the time of hand off from one physician to another.

Be careful out there.

It's also worth noting that apparently the medics did not feel comfortable transferring the patient.

 

[Roguelyn]

I agree with what's been said; we're forced to reevaluate.

 

[Birdstrike]

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[Zebra Hunter]

I agree with what's been said; we're forced to reevaluate.

I know this is an old thread, but I had a question on this scenario. Obviously we are required to re-evaluate, but can this exam be done without registering the patient in for a second or third time? As in, perform an MSE without the patient being checked in, meaning no documentation. To my knowledge, EMTALA does not require documentation of MSE, just simply that an MSE be performed, but maybe I am misinterpreting it.

 

[Franzd'Epinay]

I know this is an old thread, but I had a question on this scenario. Obviously we are required to re-evaluate, but can this exam be done without registering the patient in for a second or third time? As in, perform an MSE without the patient being checked in, meaning no documentation. To my knowledge, EMTALA does not require documentation of MSE, just simply that an MSE be performed, but maybe I am misinterpreting it.

"If you didn't document it, it didn't happen."

 

[Groove]

Both are EMTALA violations. I don't know if the documentation is technically required but it covers your ass. You definitely want to have documented the second MSE.

A hospital in my state was fined EMTALA for preventing a homeless, psych patient back into the ED. They were technically prevented by security.

It's definitely a frustrating loophole but something to always consider when you have triage nurse coming to you about Pt X who is well known to the department and checks in daily and has been discharged 3 times in the past 24 hours wants to check back in for a different complaint. I don't honestly know the best way to deal with these patients but EMTALA requires an MSE at the very least so you technically can't kick them out without performing one. I usually don't really mind these working for a CMG because it allows me to pick up an entirely new patient that is well known to me and discharge them immediately, copying and pasting elements from my last note and reduces all my times and increasing pph. I let them check back in as many times as they want.

 

[The Knife & Gun Club]

I know this is an old thread, but I had a question on this scenario. Obviously we are required to re-evaluate, but can this exam be done without registering the patient in for a second or third time? As in, perform an MSE without the patient being checked in, meaning no documentation. To my knowledge, EMTALA does not require documentation of MSE, just simply that an MSE be performed, but maybe I am misinterpreting it.

I’d imagine you need to document something. From a pure EMTALA point of view though a single like free text note of “an MSE was performed, no emergency condition exists at this time, patient will be discharged, see prior ED note from time X for plan of care, which is unchanged.”

Although the hospital or risk people probably want another full note.

 

[RoyBasch]

As far as I know not seeing them is a violation. So I just keep seeing them. I know nothing is wrong, so I just do an h&p, typical dc orders. No investigations ordered. Takes 2 minutes. They check back in, I’ll do it again. It’s great. I get multiple encounters counting towards my metrics with turbo low LOS juicing my metrics for the shift.

Usually after the 3rd visit the patient gets bored/frustrated with me and leaves for good. The one key to this strategy is if you are not a single coverage shop you need to tell triage to always room the patient in your box/pod. If a different doc picks up the patient and actually orders stuff (meds, labs, etc.) it gives the patient what they want and feeds the bear.

 

[turkeyjerky]

As far as I know not seeing them is a violation. So I just keep seeing them. I know nothing is wrong, so I just do an h&p, typical dc orders. No investigations ordered. Takes 2 minutes. They check back in, I’ll do it again. It’s great. I get multiple encounters counting towards my metrics with turbo low LOS juicing my metrics for the shift.

Usually after the 3rd visit the patient gets bored/frustrated with me and leaves for good. The one key to this strategy is if you are not a single coverage shop you need to tell triage to always room the patient in your box/pod. If a different doc picks up the patient and actually orders stuff (meds, labs, etc.) it gives the patient what they want and feeds the bear.

Even better if you discharge them from the triage room. Immediately. Without even touching them.

 

[RoyBasch]

Even better if you discharge them from the triage room. Immediately. Without even touching them.

Yep, I put the dc order in as soon as I see them reappear on the EMR tracker, I have had 35 second LOS, the overlords love it.

 

[gamerEMdoc]

100% a violation. Would just as much time to do a quick screening exam in triage and dc the patient than argue with them about not checking in.