13 October 2008

Screen 'em and Street 'em

The title of this post is a play on the old ER maxim, "Treat' em and street em." Rapid turnover in the ER is our friend, and we all want to get the minimally ill and worried well out ASAP so we can focus on the truly ill and the unknowns in the waiting room and hallway beds. So we do our best to churn and burn through the cases where we can to free up scarce resources.

My recent post about the odd little things you see in the ER produced a few interesting comments on this topic, the gist being the not-unheard-of solution of performing an EMTALA screen and immediately discharging those who are determined not to have an "Emergency Medical Condition." As a manager of a practice which is highly motivated to capitalize on every possible efficiency, I can tell you that we have considered this practice at various times over the years, and we have never pursued it. There are a number factors which we considered to be adverse or prohibitive:

  • EMTALA itself represents a major obstacle and potential liability. The statute requires a medical screening examination (MSE), but does not define exactly what an adequate screening exam consists of. Can a PA do it? How about an RN? What are the minimum acceptable components? The statute is silent on these topics, and case law is all over the map as to what constitutes a valid MSE. Each institution is left to set their own standards. If you choose to screen and street, and this practice ever comes under close scrutiny by a court or regulatory body, your procedures best be bullet-proof and followed to a "T" every single time, because this practice is generally viewed with extreme hostility. If you are found to be deficient in this practice, you may be in for the proverbial world of hurt. Most hospital adminstrators (nor practice administrators) will not have the intestinal fortitude to take this sort of risk.
  • EMTALA also represents a poorly-recognized malpractice liability. Though this is not authorized in the statute, and case law expressly argues against the practice, many Medicare Quality Improvement Organizations (QIOs) have come to use EMTALA as a proxy for medical malpractice. In short, if you treat someone, and they proceed to have a bad outcome, the QIOs have been known to step in and allege an improper MSE and levy fines as well as other penalties. These fines are not covered by your Med Mal policy. Worse, once the door is opened, the QIO has carte blanche to review large numbers of cases and practices and can be very unfriendly in their approach and the exercise of their broad powers. Don't ask me how I know this because I cannot tell you. You do have the option of fighting this to an administrative law judge, but your case had better be strong, and if you were screening and streeting, I would not want to defend you. Remember that although EMTALA was intended to prevent improper treatment of poor/uninsured patients, no improper financial motivation is required to show a violation occurred.
  • Then there's the simple Med Mal perspective. Never mind the Feds -- if you street someone, they will make a very sympathetic plaintiff (or, to be clear, you will make a very unsympathetic defendant).
  • To undertake such a practice, you will need the approval and cooperation of your hospital. There are some well-designed programs out there that generally involve screening non-urgent patients and redirecting them to a hospital-owned urgent care clinic or something of the sort. If your patients do have access to something of this sort, then this practice can indeed serve as an essential pressure relief valve to your ER. Absent some alternative avenue of care, it's hard to see a hospital administrator signing off on such a plan. Many hospitals have core values, whether religiously-derived or simply a committment to community service, that involves providing charitable care to those who cannot get it elsewhere. To me it seems like telling patients to "piss off" without providing some care plan would be a very tough sell to your CEO.
  • Most screening MSE programs would be of limited efficacy. In my experience, the most challenging cases, and the ones that are most consistent with "abuse" of the ER, are ones which you could not turn away from triage. I'm talking about the chronic recurrent abdominal pains, headaches, low back pains, febrile toddlers, etc. None of these can be dismissed as non-emergent without at least a physician performing an H&P on them -- there are potential life-threatening causes of each. So if the physican has to take the time to see and evaluate these folks, well, you've already provided the time-consuming portion of the service so you might as well finish off the job! Ditto for the uncommon/odd minor things. It's not clear to me that a policy could be crafted which would allow an RN to justifiably and defensibly turn them away from triage. It takes the judgement of a physician to know that there's no emergency, and that requires the doc to take the time to see them. Since these are the simple cases, it would probably take less time to reassure and discharge them (perhaps with a prescription) than it would to kick them out.
  • Even a well-designed and operated MSE program is likely to be a money-loser. Understand that you would have to be consistent in the application of the policy with all your patients, even the well-insured ones. There is no ER case which is more profitable than the insured minor orthopedic injury. Quick, easy, and lucrative. (Don't blame me if the rules don't make a bit of sense; I just work here.) If you send away all your minor sprains and nondisplaced fractures, you are sending away a significant fraction of your revenue, and the easiest money at that.
  • There's no way to generate more pissed-off patients and more complaints for your hospital than to block access to the ER. If you are in a competitive market: i.e., there are some insured patients, and they have treatment options, this will not go over well with your administration, less because of the cost than because of the negative publicity. The blowback may also have negative consequences for staff morale. Nobody likes feeling like a dick and blocking access to care.
Ultimately, the last point is really the deal-killer. Refusing someone's request for care -- or even just for an assessment -- is a crappy thing to do, socially, and a hard thing to justify morally. It just feels wrong, and for many of us who work in the ER, it seems to run counter to our mission. I take a lot of pride in the fact that we take all comers. Sure, it's frustrating when "all comers" includes those who didn't really need me. But some of those people surprise me, once you get the full story. Who doesn't have the story about the completely unexpected MI they once saw? And in this health care system, when people do not have funding for or access to a PCP, it's that much harder to justify the screen n' street. The practice seems counter to our fundamental role as society's ultimate safety net, which is why in the end, this practice has never really caught on in any large measure.


  1. You've got to be a woman ---- this post is based totally on split-tail logic. You obviously feel the need to invaginate the entire world and all of its ills. Problems don't get solved that way -- that behavior only makes them worse. You are potentiating a bad situation - you are part of the problem.

    A man (a leader) looks at a situation dispassionately and makes judgments that will serve the greater good. Did MacArthur or Patton worry about being perceived as 'dicks' by the troops? They did not. You don't see that type of leadership in the post Benjamin Spock world.

    Get rid of blinders (the tunnel vision) and look at the big picture. Every time you do something that is expedient / inappropriate (ex: treat non-traumatic finger pain x 5min in an EMERGENCY ROOM), while it might make you 'feel good', it contributes to the demise of the system.

  2. You may not realize this, but when you lead with "You've got to be a woman," (clearly intended as an insult) you're not exactly doing much to enhance your credibility. Thanks for playing, though.

  3. I try to avoid like hell going to an ER. The problem is, around here there isn't such a thing as a 24-hour urgent care clinic that could deal with the febrile toddlers and ramped up middle-of-the-night UTIs and groin pain that has been getting steadily worse all during the job that night.

    I wish there was, because their bill would probably be way less than the ER bill, and we're self-pay. ER bills are painful when you don't have private insurance.

  4. variation on a theme, 4 phases of EM (obviously after the MSE):


  5. symtym:

    Ha ha. You forgot "repeat 'em!"


  6. You've got to love the sheer irony of one who leads with "you've got to be a woman," indirectly asserts his manhood, alludes to MacArthur and Patton, and sign his missive with "anonymous." One thing I know about reading both MacArthur's and Patton's autobios is they never signed anything anonymously. I think the blog posting reflects very well the state of EM and the practice of EPs -- not our doing, but by so many failings of having any semblance of a national healthcare policy (not to be construed as gov/single payer). The system anonymous refers to has been destroyed and we're the safety net.

  7. "I think the blog posting reflects very well the state of EM and the practice of EPs -- not our doing, but by so many failings of having any semblance of a national healthcare policy (not to be construed as gov/single payer). The system anonymous refers to has been destroyed and we're the safety net."

    The 'system' was brought down as a result of the creation of the 'safety net'. Our country was damaged in the same way by LBJ's 'Great Society'. The CRA (Community Reinvestment Act) destroyed the banking industry. Are you seeing the pattern yet? The unintended consequences of these 'programs' have yielded a nation of government dependent weaklings ---- without the government tit most folks wouldn't survive!

    Here's an example of the problem (below) --- our society is a bunch of self-centered, immediate gratification oriented, no independent thought having A-holes --

    'I try to avoid like hell going to an ER. The problem is, around here there isn't such a thing as a 24-hour urgent care clinic that could deal with the febrile toddlers and ramped up middle-of-the-night UTIs and groin pain that has been getting steadily worse all during the job that night.'

    40-50 years ago folks would have handled this crap on their own --- toddle w/ fever --- come on --- today they need a board certified ER doc to administer the tylenol.

    Its not the system that's broken --- its the society !!!! You can't effectively treat the illness until you correctly identify the problem.

  8. I both see and live the problem every shift, as does shadowfax. Do you have a horse in this race or is sexism and bellicosity your lounge chair existence. We can argue about causality and harken back prior to the "Great Society" but how is that constructive to the problems we both appear to see. You seem to have a great deal of animus towards physicians that are in the trench actually dealing with this problem daily. There are federal laws that limits what we do (EMTALA: MSE, EMC). There are financial contraints that also limit, where our reimbursement is linked to satisfaction scores. Ever hear of Press Ganey, P4P, etc.? Bloviating in the comments of a blog is about as effective as a hair wagging a tail wagging a dog. What have you done to alleviate this? If society is broken (and I’m not arguing that it isn’t), then what have you done? Talk is cheap and the internet only cheapens it more. Your second comment is a great opinion piece -- where’s your blog? Classic dilemma here for you, do you harm the patient to spite the government (or society)? I think not!

  9. My only animus is toward stupid people -- those among us who are either unable or unwilling to think for themselves.

    Symtym acknowledges that there is 'a problem', but she seems reticent to share her thoughts on possible solutions -- it appears that she is content to wait for Moses to come down from the mountain with new instructions. 'We can't act because the system (the rules) prevent us from doing anything outside the box' --- balderdash I say !!! Were you one of the band members on the Titanic ?

    My point is simple -- don't use an F-16 for mail runs --- use the right tool for the job ---- 'fit for purpose' -- delivering primary care in the ER is a lose-lose situation. The more mission creep you allow the more you will have to tolerate as 'standard practice'. If folks were unable to get primary care in ERs it would force the hand of the idiots in government to develop a solution -- not a great alternative --- but there are no easy answers to this mess. In case you haven't noticed --- most modern leaders are reactionary not proactive --- they are not bold --- they are not visionary --- they are risk adverse --- they are concerned only with protecting their own asses ----. You can man the bilge pump 24/7, but this system -- as it is -- is not sustainable ---

  10. Anon,

    You're great with the fiery rhetoric and colorful metaphors, but sadly clueless when it comes to, you know, reality. You have a great fantasy about how AWESOME it would be if we just all said "no," and everybody realized we were right and fixed everything and there would be a parade. But clearly you haven't visited the real world recently.

    You have this notion that physicians stride across the healthcare world like a colossus, and what we say, goes. Have you ever sat down with a hospital CEO and negotiated a contract? You do realize that he is the one who gives us our jobs and if he doesn't like what we do there'll be another group here so fast it'll make your head spin. Have you ever sat down with the administrator of your local QIO to discuss the EMTALA violation he has concluded that you committed? Have you ever held a position of leadership within a healthcare organization? I suspect not, since you seem wildly unrealistic about the amount of control that we have over our work environment.

    Yes, you and I agree that the ER is not the place to deliver primary care. Duh. But just locking the doors of the ER is not going to suddenly generate 12,000 new family practitioners to care for everybody, nor is it going to create an insurance program for them all. I'm doing my bit to change things both by writing on this blog and by working within ACEP.

    What're you up to?

  11. I wouldn't really want to do a MSE even though I can tell with almost spot-on accuracy who is and is not sick, but I think there should be more legal protection for nurses who want to offer advice to patients in triage to, for instance, go to their clinic or take tylenol for their dry cough and fever x 1 day and only come back for shortness of breath etc. Obviously if I said any of that, that would be an EMTALA violation. Like, "you can stay if you want, but this condition does not appear to be serious nor life-threatening".

  12. 'I'm doing my bit to change things both by writing on this blog and by working within ACEP.'

    Well, as long as the ACEP is on the case our problems are all but solved. Let's see, the ACEP was established in '68, and since that time the ER 'situation' has become progressively worse !!! But hey ---- I'm all for doing the same thing over and over, and hoping for a different result.

    Why do you think primary care is delivered in ERs ---- its much more costly than providing it in the appropriate venue --- its markedly less effective (disease management / prevention / etc) ---

    The answer is that the delivery of primary care in ERs puts money in the 'right' pockets. The whole debacle happened on the ACEP's watch --- they are complicit !!! Give me one good reason why we couldn't stop the madness immediately if we wanted to --- we put a man on the moon, but we can't get some primary care clinics online ---- it would pay for itself (with all the money 'we' would save) - right? The rub is that while 'we' would save money and improve the quality of care -- the 'right' pockets would not get lined --- so we press on with the status quo.

  13. Maybe if we had put a woman on the moon instead, the whole health care problem would have been solved by now. :)

  14. Anon 1011: LOL


    I kind of agree with you. I think the *good* nurses should be able to give advice or answer questions. But many's the time I've heard a member of the "B team" on the phone with a member of the public, and I've wanted to leap across the counter screaming "Noooooo!" and snatch the phone from his/her hand. it's actually not an EMTALA violation to give patients the option to check in or not. But it is a liability concern for straight-up malpractice, which I think is why 99% of hospitals don't allow the practice.

  15. 'Maybe if we had put a woman on the moon'

    Right. Here's what happens when you select a lesser qualified candidate because she is the 'right' gender --- so you can look 'progressive' ... so you can feel all warm and fuzzy ---- affirmative action is a failure on earth and in space.

    This shit never happened with the Mercury 7 !!!

    ORLANDO, Fla. — A NASA astronaut accused of trying to kidnap a romantic rival for a space shuttle pilot's affections was charged with attempted first-degree murder Tuesday as her lawyer sparred with prosecutors to effort her release.

    Nowak raced from Houston to Orlando wearing diapers in the car so she wouldn't have to stop to go to the bathroom, authorities said. Astronauts wear diapers during launch and re-entry.

  16. Where do you start with so many misconceptions? Perhaps with neither shadowfax nor I are shes (how do you miss that on this blog is beyond me). It's hard to follow any logic in your missive anonymous. You are advocating action, what is the action that can be done in the real world. From your rhetoric I'm presuming you don't work for any large EM groups or hospitals systems. Do you even work in EM?

  17. The system is dysfunctional --- that's a fact. The change that is required (in this case) is not going to come from the establishment because from their perspective --- there is no problem. The 'right' folks are getting very rich so there is no motivation to try anything new. The number of ER physicians / ERs are steadily growing ---- the ACEP is pushing this agenda --- there is strength / power in numbers --- compensation, career opportunities, lifestyle, status all increase as the ER 'system' expands. In cash rich markets (government money -- stolen taxpayer dollars) there is far more ER capacity than is required to handle their 'emergencies' ---- in cash strapped areas (poor white regions without Jesse Jacksonotypal extortionists) there is a conspicuous absence of emergency services. Its all about money, power, and status. Governments, churches, and special interest groups (ACEP) are very much like bacteria ---- they will continue to grow until the food supply is exhausted.

    Has the ACEP ever published a study which called for emergency services to be cut back in an over-served area? Did they then suggest that those ER dollars be redirected to clinics in order to better serve the community?

    My point is don't wait around for a top-down solution ----- don't kid yourselves -- even if Jesus2 (Barry) gets elected -- its not going to happen --- a grass-roots effort is needed here ---- a bottom-up approach --- SMALL coordinated actions by many can change the course ..... or --- you can just wait for the ACEP to fix it ----- they've had 40 years already ...... perhaps they're just getting warmed up :)

  18. I think your characterizations of ACEP and EM groups to be more true than not. We are a specialty that is a victim of its own "success." It is not the specialty I chose in medical school. It is not the specialty of my residency (EMTALA had just come out). However, I disagree with your 3rd paragraph -- those that have taken that approach become unemployable in EM. EM is what it is, right or wrong, because it is a specialty first and foremost defined by constituency politics. We have EMTALA, because of sufficient political ire raised by patient dumping practices in the early 1980s. We have primary care displaced to the ER, because of insufficient creation/retention of primary care specialist, capitation (moving the cost to a another cost center), the disenfranchised from healthcare (under/non-insured), etc. And then there is the hospital competition industry which the leaders of EM have totally bought into. We have become a specialty consumed with metrics and evaluation/treatment by “guidelines” and “worse-case scenarios. Perhaps 20y ago your 3rd paragraph approach would have legs, it has none today. You offer lots of rhetoric, but no examples of real world change.

  19. 'You offer lots of rhetoric, but no examples of real world change.'

    Right. You have a better chance of being abducted by EBEs than seeing an individual, a group, or a government agency prioritize the 'greater good' above their own self interest.

    Our world is all about immediate gratification, self actualization at any cost, and the elimination of any 'inconveniences'. Ben Spock and our liberal leaders have worked assiduously to ensure that there are no consequences for bad behavior ----- anything goes ---- we can't be judgmental ---- don't encourage responsible behavior --- just install abortion clinics on every corner --- if you don't make the grade no problem -- we'll just 'gender norm' or get you in w/ affirmative action -- in the name of 'progressive politics' we'll force the nation to accept abnormal behavior (queers) as normal --- why should kids have to work / save to buy anything ---- get it now on credit ---- don't worry about paying off your debts ---- the 'rich white men' will be happy to give up their savings so that every ghetto shack can have a wide-screen TV.

    Our healthcare woes are merely a symptom of a much larger disease process. I don't think that we can turn the tide this late in the game. The only chance for a positive outcome here is for the last remaining sentient individuals to take SMALL steps in the right direction. 'The odds are against us and the situation is grim.' I wish that I had better news --- but the wheels have already come off our wagon --- we are just skidding to a stop at this point.

  20. Thank you for providing that clear and logical explanation of why screening the patient and turning them away is impractical.

  21. Ah ---- the mental midget has elected to weigh-in ---

    'Thank you for providing that clear and logical explanation of why screening the patient and turning them away is impractical.'

    Your ability to distort, warp, and twist the meaning of words never ceases to amaze me. Allow me to reorient you to reality --- it is impractical to provide primary care in emergency departments --- true to form your mind has flipped the truth 180 degrees in order to accommodate its liberal agenda.

    It is practical to provide primary care in primary care clinics --- that's the truth ---. All thinking individuals should support changing the system to this end, and they should do everything within the limit of the law to achieve the goal.

  22. Anonymous,

    All thinking individuals should behave the way you want them to. I suppose that would satisfy your craving for instant gratification.

    I still think that SF did an excellent job of explaining why this is impractical. All you did was throw a tantrum. If anything, you will convince people that the system should not be changed.
    I have not stated that the system should not be changed.

  23. FYI 20+ years before EMTALA ED's were bursting at the seams and a lot worse than they are today. Studies as early as the 1960's showed that. This was largely as a result of your Patton's troops coming home, starting families, increasing the unemployment rate (which was so low during the war that wage and price freezes were enacted, resulting in health insurance on a wide scale for the first time).
    Furthermore, Patton's troops would have never had a chance in hell if Rosie the riveter and all the other working women had not jumped in to do the jobs all those men wouldn't let them do just a few years earlier. It always scares me to think such angry and sexist people may actually be charged with the care of sick and vulnerable people.


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