Neshoba County General Hospital Emergency Department
Medical Screening Project
Project Purpose & Overview
On Monday, August 1, 2011, Neshoba County General Hospital will begin a new medical screening process in the Emergency Department (ED). The process is designed to decrease the number of non-urgent patients seeking treatment through the ED. Decreasing the volume of non-urgent patients has several benefits. There is a finite amount of resources available at any given time in the Emergency Department. If these resources are tied up with patients who would be better suited in a clinic environment, it would stand to reason that the patients who do need emergency treatment could be underserved. Another problem common to emergency departments across the country is the abuse of the ED by those who take advantage of the EMTALA regulations, by those who seek treatment for minor complaints, and by those who have no intention of paying for the treatment. This abuse causes an enormous financial strain on the hospital.
As of August 1, 2011, patients who are triaged as a class 4 or 5, the lowest acuity levels, will receive a medical screening exam in an ED room by a nurse practitioner or physician. If the screening exam confirms that the patient is non-urgent, they will be given the option of seeking treatment at a clinic or making arrangements with the admission clerk to be seen in the ED. Patients will be given information on our Urgent Care Clinic which can assist them if they choose to seek treatment elsewhere. Patients also have the option of going to their primary care physician for treatment including Choctaw Health Center for Native American patients.
One of the reasons patients are not commonly screened out of ED's is the fear of liability and violating the EMTALA regulations. EMTALA is the Emergency Medical Treatment and Labor Act. This is a law requiring hospital ED's to provide a medical screening exam to any patient presenting regardless of their ability to pay. The law requires that any patient with an emergent condition be at least stabilized and transferred to an appropriate level of medical care. EMTALA does not state that hospitals must provide free treatment if a medical screening exam reveals a non urgent condition.
Prior to this, Neshoba County General Hospital ED has provided each patient with full treatment regardless of whether the patient's condition was urgent or non-urgent. However, it is Neshoba County General Hospital ED's intent to provide a medical screening exam prior to treating a patient as required by EMTALA, in order to alleviate overcrowding and overburdening of Neshoba County General Hospital's ED.
Details of Medical Screening
There is a difference between triage and a medical screening exam. In Mississippi, the State Board of Nursing does not consider the medical screening exam to be within the scope of practice of an RN. It is within the scope of practice for advanced practice nurses, such as nurse practitioners, to do the medical screening exam. Triage will continue to be performed by an RN in the emergency department and consists of a problem focused nursing assessment and vital signs. The medical screening exam will then be conducted by a nurse practitioner or physician on patients identified as level 4 or 5 by the triage RN. Patients with higher acuity, such as levels 1 - 3, will be taken into the emergency department and seen as usual. Once service has been rendered, these patients will be asked for any co-pays or deductibles upon discharge from the emergency department.
The triage system Neshoba County General Hospital ED will be using is called the Emergency Severity Index System, Version 4, which is a nationally recognized standard triage system. The system has 5 levels with level 1 being an immediate emergency such as cardiac arrest, and level 5 being a very low acuity patient that requires no resources for treatment. Patients are assigned levels by the RN based on their chief complaint, age, vital signs, history, and objective and subjective data gathered during triage.
The medical screening exam will be conducted by the licensed independent practitioner, following protocols established by the ED medical staff. If a patient is triaged a level 4 or 5, but during the screening exam the practitioner determines there may be underlying medical issues that require further assessment, the patient will be treated appropriately.
Admission clerks will be in the ED to assist patients. For patients who are deemed to be urgent, co-payments, deductibles and fees will be requested upon discharge. Patients deemed non-urgent from the medical screening will receive information from an admission clerk about all options available to them. A financial assistance form will be offered and the admissions clerk will explain that the patient or their representative must complete and return the application, along with any supporting documentation, to the financial services office. The admissions clerk will also explain to the patient that if the application is approved, it will result in a discount on the patient's bill for future visits and they will be notified as to the amount they will be responsible to pay at future visits. If the patient still wants to be treated in the emergency department, they will be required to pay $125 prior to treatment. Patients with insurance deemed non-urgent will be asked to pay their co-pay and deductible prior to treatment if they want to continue with treatment in the ED.
How to Handle Complaints
Given the current utilization of the Emergency Department, it is inevitable that there will be some complaints or questions raised about this process. It is important that complaints be handled consistently. Neshoba County General Hospital Emergency Department has developed some basic scripting for administrative personnel who may field these complaints. Please utilize the scripting as much as possible so we are all consistent in our message. The personnel directly involved in the planning and implementation of this project are Dr. Jon Boyles, ED Medical Director, Beth Burns, ADON / Risk Management, Brenda Jayroe, ED Nurse Manager, Mary Jenkins, Director of Financial Services, and Sheila Boswell, Patient Access Supervisor. Please do not hesitate to contact these individuals if questions arise that are not covered in the scripting provided.
Neshoba County General Hospital ED Sample Responses to Complaints
Complaints related to being screened as a non-emergency medical condition
EMTALA (Emergency Medical Treatment and Active Labor Act) regulations require emergency departments to provide all patients, who request treatment for a medical condition, with a medical screening exam to determine whether they have an emergency medical condition. Neshoba County General Hospital provided you with that screening as required.
A licensed medical professional makes the determination as to whether someone's clinical condition is an emergency medical condition and would require treatment in an emergency department setting. You were seen by a licensed practitioner and it was his or her clinical determination that you did not have an emergency medical condition.
Complaints regarding non-emergency medical condition patients being asked to pay to stay in the ED for treatment
You were seen by a licensed practitioner and it was his or her clinical determination that you did not have an emergency medical condition. Neshoba County General Hospital provides information on Urgent Care Clinic for those that have been determined to have a medically non-urgent condition. However, as a community based hospital, Neshoba County General Hospital wants to ensure that anyone who desires treatment has an option to receive that treatment. For those that want to continue with Emergency Department treatment, it is necessary to require up-front payments to help offset the cost of resources needed to treat a non-emergency medical condition in the ED setting.
Responses to Questions about Medical Screening
Neshoba County General Hospital has initiated the medical screening process due to overcrowding in the Emergency Department and the strain on resources this causes. There are a limited number of ED physicians and personnel available at any given time. If these resources are tied up with patients who would be better served in a clinic setting, there is the potential that patients with emergency medical conditions could be underserved.
Neshoba County General Hospital is committed to its service to the community. By screening patients to the most appropriate care setting, we will improve service to those who are presenting with true emergency medical conditions.
More than 23,000 patient visits are made to Neshoba County General Hospital Emergency Department each year. Medical Screening for non-emergent conditions will reduce overcrowding in the ED and increase availability of staff and resources for the treatment of true emergency medical conditions.
In an effort to improve Emergency Department services, Neshoba County General Hospital will make some changes effective August 1, 2011 that will improve service to emergent patients and reduce the overcrowding in the Emergency Department.
EMERGENCY DEPARTMENT TO MAKE CHANGES BEGINNING AUGUST 1, 2011 TO IMPROVE SERVICE AND REDUCE OVERCROWDING
Beginning August 1, 2011, all individuals who come to Neshoba County General Hospital Emergency Department seeking treatment will be triaged to determine how serious their medical condition is. For patients presenting with a true medical emergency or high risk factors, there will be no change in the initial process. However, once service has been rendered, those patients will be asked to pay their co-pay/deductible upon discharge or set up payment arrangements at that time. Patients who do not have a serious condition will receive a medical screening exam by a nurse practitioner or physician to confirm that their condition is non-emergent.
If the nurse practitioner or physician confirms that the patient does not have an emergency medical condition
and has no significant high-risk factors, then the patient will be offered:
Information about alternative options for appropriate care (Urgent Care Clinic, primary care physician)
If the patient chooses to be seen in the ED even after being determined to have a non-urgent problem, they will be asked to pay their co-pay/deductible on their insurance.
For patients with no insurance, there will be a charge of $125 required prior to continuing treatment or the amount set forth according to their financial assistance status.
When an unforeseen and sudden medical need that does not qualify as a medical emergency does arise, consider a visit to the Neshoba Urgent Care Clinic
Emergency Department Director
Brenda Jayroe, RN
Emergency Department Nurse Manager