[Editor’s note: This column is part of an ongoing series that addresses reader questions about the Emergency Medical Treatment and Labor Act (EMTALA). If you have a question you’d like answered, contact Greg Freeman, Editor, ED Management, 3185 Bywater Trail, Roswell, GA 30075. Telephone: (770) 998-8455. E-mail: [email protected].]
Question: In the May 2003 issue of EDM, the answer in the EMTALA Q&A suggested that it was OK for the triage nurse to give patients an estimate of the waiting time. Are you sure that’s right?
A realistic estimate isn’t possible because of all the unexpected events in an ED, and if the patient is given a time frame, he or she may walk out based on the wait. If something bad happens and it is disclosed that we gave an inappropriate wait time, it could be construed that we did, in fact, deter the patient.
Answer: This is indeed a tricky situation, and it is easy to violate EMTALA when you try to estimate waiting time for a patient. Nevertheless, it is possible to give an estimate of the waiting time without violating EMTALA as long as the message is delivered carefully and in a way that encourages the patient to stay for treatment, says Robert A. Bitterman, MD, JD, FACEP, director of risk management and managed care in the department of emergency medicine at Carolinas Medical Center in Charlotte, NC.
The ED staff often respond in a poor way when posed with this question, Bitterman says, so it is understandable that some ED managers would choose not to have staff answer it all. He can’t go along with that strategy, though.
"I think that if patients ask, you have a professional and ethical duty to tell them the truth," he says. "If the truth is such that it might be discouraging — we’re several hours behind — then our patients are big boys and girls and can handle the truth. If they decide to go see their doctor tomorrow, it’s up to them. The government can’t tell us not to answer a patient’s questions honestly."
That said, you just can’t blurt out an answer without carefully considering the concerns of the Centers for Medicare & Medicaid Services (CMS). CMS has made it clear that you can’t say anything that would economically coerce the patient into leaving, so the tricky part is all in how you provide that honest answer.
It has to be truthful in light of that particular patient’s category type, and the answer shouldn’t sound like a guarantee. Also, don’t throw out any flippant comments that might be seen as discouraging. Rather, you should you be sure to include an encouraging note.
That takes some finesse, so Bitterman advises training triage nurses in why this could be an EMTALA violation if they don’t answer carefully. And it would never be a good idea to simply post an amusement parklike sign that says, "The estimated wait to see a doctor now is 90 minutes." Neither should you offer an estimate of the wait time if the patient doesn’t ask first.
Here are some examples of what not to say in response to questions about waiting times:
• "You’re going to be here for hours," or "You’re going to be here forever."
• "We’re three hours behind. You might as well come back later."
• "You know, the wait is three hours. Are you sure you really want to wait?"
CMS could construe each of those to be EMTALA violations because you have, in effect, encouraged those people to leave your facility. Also, Bitterman issues this important reminder: Anyone affiliated with the facility can commit this violation, whether that person is a security guard, volunteer, or triage personnel. You should caution all personnel who might encounter patients in the ED about the importance of answering this question carefully.
In most cases, the best policy is to have everyone else direct the question to the triage nurse rather than trying to answer it at all, he says.
The attitude of the person answering the question can determine whether the answer violates EMTALA. The same facts provided in different ways either can encourage the patient to stay or sound like a suggestion to get out of your ED, Bitterman adds.
You run the biggest risk of this EMTALA violation when a patient catches hospital staff off-guard and they answer without thinking.
"Especially if they’re really busy, the staff members may say, Oh yeah, we’re really far behind. It’ll be a long time,’" he says. "That’s very common and may be said in a discouraging tone, especially if they think the patient’s complaint shouldn’t have brought them to the ED in the first place."
EMTALA doesn’t allow shooing patients away like that, of course, so ED managers must lead by example and not tolerate any such comments.
One good strategy is to train triage nurses and anyone else likely to encounter questions about waiting time to respond with a stock answer, adjusted to fit the facts. Bitterman suggests answering with something like this:
"Well, we’re about one to two hours behind for patients in your category. We’re working as fast as we can, but we’re not sure how long it will be. And we really don’t know all that much about your condition yet, so please stay."
And say it with a smile, even if the patient’s only complaint is a slight rash he’s had for three months.
Sources
For more information, contact:
• Robert A. Bitterman, MD, JD, FACEP, Director of Risk Management and Managed Care, Emergency Department, Carolinas Medical Center, 1000 Blythe Blvd., Charlotte, NC 28203. Telephone: (704) 355-5291. E-mail: [email protected].
Editors note: This column is part of an ongoing series that addresses reader questions about the Emergency Medical Treatment and Labor Act (EMTALA).You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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