Do patients leave with life-threatening conditions?
When a patient in your ED left without being seen (LWBS), you have two major worries: That the patient left with a life-threatening condition, and your increased liability risks.
"LWBS patients are one of the hot points for EMTALA [Emergency Medical Treatment and Labor Act] investigations, and carry a medical malpractice threat as well," warns Stephen A. Frew, JD, vice president and risk consultant with Johnson Insurance Services, a Madison, WI-based company specializing in risk management for health care professionals.
To reduce risks of LWBS patients, do the following:
- Track all patients.
Be sure that you have someone available close to your ED entrance to log all potential patients, says Marc Augsburger, RN, BSN, manager of the emergency care center at Covenant HealthCare in Saginaw, MI. "You need to know who left without being seen, in case the Centers for Medicare & Medicaid Services (CMS) asks to see your log, he says. "It also gives you a time frame as to how long the patient waited."
The ED has a greeter who logs in the patient’s name and chief complaint before triage. "If a patient complains that he came to the ED and didn’t get seen or got ignored, he should still appear on that log," Augsburger says. "The greeter is the first set of eyes and can keep nursing staff from missing anyone coming in the door who may walk out undetected."
- Document carefully.
Document the history given by the patient and any reassessments that occur while the patient is waiting, says Pamela S. Rowse, RN, quality/risk consultant for the ED at St. Rose Dominican Hospital in Henderson, NV. "Six hours sitting in a waiting area without a reassessment of vital signs is going to open up major legal inquiries," she warns.
If you can’t get a patient seen quickly enough, document your communications with physicians and charge nurses, says Rowse. "The bottom line is, if you can’t get a bed for a patient, go directly to the ED physician," she advises. "They are concerned about their liability as well and will generally make certain that adequate intervention and placement occur. If this doesn’t work, then move up your chain of command."
- Avoid violations of EMTALA.
If a LWBS patient refuses care, this is not in itself a violation of EMTALA, says Frew. "These events, however, cause investigators to focus on the incident, the circumstances, the allegations, the policies and procedures, and any documentation," he says. "As a result of this close scrutiny, hospitals are frequently cited for violations directly related or associated with the LWBS event."
If the patient left because they felt that they were being discriminated against, it becomes an EMTALA issue, says Rowse. Body language such as shrugging of shoulders, the rolling of eyes, or a curt response can make patients feel unwelcome, she warns. "Unintended negative comments can result in patients leaving and ultimate negative outcomes," she says. Avoid statements such as the following, advises Rowse:
- "Well, as you can see, we are extremely busy. You are going to have a very long wait."
- "You will have to understand that there will be a minimum of a four-hour wait to get into the back."
- "There are a lot of people that are more critical than you, and you will just have to wait your turn."
These incidents are sometimes investigated as a direct complaint from a patient, which typically occurs when patients think that their care was denied or delayed because of their financial status, says Frew.
Reviewers will look for documentation that details your interactions with the patient up to the time of leaving, he says. "CMS expects literal compliance with hospital policies and procedures and affords very little margin for nursing personnel to deviate from the written process," he notes. "In the absence of documentation, CMS is prone to accept the patient’s interpretation of events, which typically results in the hospital being cited for a violation."
- Have patients sign a refusal of care form.
The form must state the hospital’s obligations, the risks of leaving without assessment, and the benefits of staying for completion of medical screening and stabilization, says Frew. "Forms must be individualized as much as possible, and checkbox forms are often faulted as inadequate," he notes.
At Covenant’s ED, an "against medical advice" form advises patients that if they choose to leave, their condition could worsen. "Only a small portion of patients do sign the form, but we try to capture as many as possible," says Augsburger.
If the patient fails or refuses to sign the refusal of care form, document all efforts to obtain the signature and why they were unsuccessful, advises Frew. "It is also helpful to document the exact language that the patient used to refuse the signature," he says.
If the patient leaves without your knowledge, that also needs to be documented. "Some hospital policies and procedures require that a patient’s name be called at least three times over 15 minutes to confirm that they have left," says Frew. "Document by noting the fact that the name was called and at what times."
Sources
For more information on patients who leave without being seen, contact:
- Marc Augsburger, RN, BSN, Manager, Emergency Care Center, Covenant HealthCare, 900 Cooper Ave., Saginaw, MI 48602. Telephone: (989) 583-6259. Fax: (989) 583-7181. E-mail: [email protected].
- Stephen A. Frew, JD, Vice President-Risk Consultant, Johnson Insurance Services, 525 Junction Road, Suite 2000, Madison, WI 53717. Telephone: (608) 245-6560. Fax: (608) 245-6585. E-mail: [email protected].
- Pamela S. Rowse, RN, Quality/Risk Consultant, Emergency Department, St. Rose Dominican Hospital — Rose de Lima Campus, 102 E. Lake Mead Drive, Henderson, NV 89015. Telephone: (702) 616-5548. Fax: (702) 898-6381. E-mail: [email protected].
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content