The Medical Screening Exam and Acute Referral Decisions

1. The Medical Screening Exam and Acute Referral Decisions Jenny Soyke, M.D. Medical Director University Health Center University of Oregon ACHA 2012, Chicago May 31, 2012

2. Bio – Jenny Soyke, M.D. • B.A., University of Oregon • M.D., Oregon Health Sciences University • Family Medicine Residency, Madigan Army Medical Center (Tacoma, WA) • American Board of Family Medicine, 1992 – present • Board of Certification in Emergency Medicine, 1998-2008 • Emergency Physician in practice 1996-2009 • Medical Director at UO Health Center since 2009. • I have no conflicts of interest to disclose.*

3. Materials will be posted on ACHA website July 2 I will be posting both the full power point presentation and the handout on the ACHA website, where it will be available after July 2, 2012. The handout is simply a summary of the abstract, the topic relevance, the learning objectives, and the bibliography.

4. Who are we? • Physicians • Nurse Practitioners • Physician assistants • Registered nurses • Licensed or Credentialed Mental Health Professionals (Psychologists, LMFT, LCSW) • Other?

5. Medical Screening Exam • The Medical Screening Exam is a concept which came out of the implementation of EMTALA (COBRA) laws governing transfer of patients between hospital emergency departments, in order to protect the health and safety of transferred patients.

6. Acute referral decisions • When students present to the college health center with acute injuries or illnesses which can’t be handled within either the scope of practice or the available clinic hours of the health center, what are the best steps to follow to ensure the student’s health and safety as we transfer these patients to the appropriate level of care?

7. Is the MSE a knowledge gap in college health practice? College health centers outside of a medical school setting are typically ambulatory care centers with practical limitations in both scope of practice and clinic hours. What are the best methods to both ensure student safety and protect the reputation of your facility within your referral community as you make your referral decisions?

8. EMTALA The Emergency Medical Treatment and Labor Act The 2003 regulations define a "dedicated emergency department" as a state-licensed ER or a place where medical services are provided on an urgent basis, without the need for an appointment, including (significantly) hospital-based ambulatory care centers. At a DED, any request for medical treatment triggers EMTALA obligations.

9. This talk assumes context of non-EMTALA clinics. • Avoid use of the term “urgent care” or “walk in for urgent care” if you are not an EMTALA-compliant organization. • EMTALA is a law which advocates for patients. But you don’t want to be considered subject to the law if you are not required to be subject to the law, even though I’m going to urge you to honor the principles behind it.

10. Context of College Health • Though ambulatory care centers are not included in the EMTALA, the medical principles and medical ethics behind the medical screening exam are useful for application in college health. • By using the patient care principles behind EMTALA, we provide our patients the highest level of medical care in acute referral decisions. **KEY CONCEPT**

11. Exclusion Disclaimer If you share a campus with a medical school or other hospital, you almost certainly are subject to EMTALA. This talk is targeted to those health centers who are not subject to EMTALA.

12. Why discuss EMTALA when the law doesn’t apply to us? • “EMTALA compliance is, at base, a risk management endeavor.” (1) • In analyzing transfer situations, good patient care decisions lead to better patient outcomes, leading to decreased institutional risk. • Complicated discussions of actual situations and the competing interests at work are common to any acute referral situations, whether or not governed by EMTALA.

13. Provisions of EMTALA • “Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" must be provided with "an appropriate medical screening examination" to determine if he is suffering from an "emergency medical condition". If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospital in conformance with the statute's directives.” (1)

14. Any patient who "comes to the emergency department" requesting "examination or treatment for a medical condition" Any patient who comes to the student health centerrequesting "examination or treatment for a medical condition" EMTALA College Health

15. must be provided with "an appropriate medical screening examination" to determine if s/he is suffering from an "emergency medical condition". will benefit from "an appropriate medical screening examination" to determine if s/he is suffering from acondition which we can appropriately treat with the health centerresources at hand. EMTALA College Health

16. If he is, then the hospital is obligated to either provide him with treatment until he is stable or to transfer him to another hospitalin conformance with the statute's directives. If he is, we are obligated to either provide him with treatment until he is stable or to transfer him to an appropriate referral consultant or facilityas a matter of responsible medical practice. EMTALA College Health

17. If the patient does not have an "emergency medical condition", the statute imposes no further obligation on the hospital. If the patient does not have an "emergency medical condition", we still have anobligation to the student patient but have options to address her medical needs: Treating now Scheduling a subsequent appointment Referring elsewhere EMTALA College Health

18. The acute referral decision • When students present to the college health center with acute injuries or illnesses which can’t be handled within either the scope of practice or the available clinic hours of the health center, what are the best steps to follow to ensure the student’s health and safety as we transfer these patients to the appropriate level of care?

19. Learning Objective #1 • Identify the medical decision making necessary to determine whether a patient presenting to a student health center for an acute concern has a condition which can be appropriately addressed at the student health center. • Content: Discussion of triage, resources for nurse triage, and the role of the physician or nurse practitioner in the medical screening exam.

20. Learning Objective #2 • Describe the essential components of the medical screening exam and how to apply the findings to decisions about evaluation, treatment and/or referral. • Content: List of chief complaint-driven components of the medical screening exam for the most commonly-presenting acute injuries or illnesses in the college health setting.

21. Learning Objective #3 • Identify the medical decision making necessary to determine whether a patient with acute concerns can be appropriately evaluated and treated with the available resources and within the available time frame of the student health center. • Content: List components of the above decision making related to the resources of the student health center, with recognition that SHS resources and hours vary widely.

22. Learning objective #4 • Discuss examples of acute medical problems likely to present to student health centers, and describe the components of the medical screening exam essential for evaluating disposition of each of these problems. • Case discussions with group participation.

23. Case discussions from the group • During the talk, if a case occurs to you, write down the following: • Major presenting symptom • Major components of initial exam • Complicating/competing social or other factors • Your question or your insight • Pass it to the aisle and I’ll do my best to choose some illustrative cases for discussion

25. What are our staff resources? • Physicians • Nurse Practitioners, Physician assistants • Registered nurses • Licensed or Credentialed Mental Health Professionals (Psychologists, LMFT, LCSW) • Ancillary services professionals: pharmacists, lab and X-ray technologists, etc.

26. Where do we work? • Med School health center with hospital (most likely subject to EMTALA) • Large health center with inpatient/infirmary capacity • Large health center with no inpatient capacity • Small health center with full time physician(s) • NP-staffed health centers • RN-staffed health centers

27. Learning Objective #1 • Identify the medical decision making necessary to determine whether a patient presenting to a student health center for an acute concern has a condition which can be appropriately addressed at the student health center. • Content: Discussion of triage, resources for nurse triage, and the role of the physician or nurse practitioner in the medical screening exam.

28. What are the components which influence decision-making in acute referral situations? • Available staff: consider their degrees, their background and their experience • Available resources: time, space and materials (equipment, tools, meds, supplies and ancillary services) • Condition of patient • Student financial constraints can be considered but must not lead you away from appropriate referral decisions. All of these add up to determine treatment capacity as applied to the individual patient.

29. What are your professional resources? • University of Oregon Health Center - Eugene • Primary Care – 12 FTE • 9 family physicians, 3 adult + 1 family nurse practitioners • Psychiatry – 3.4 FTE • 3 Psychiatrists (1.4 FTE) + 1 PMHNP + 1 QMHP • Women’s Health – 1.0 FTE • GYN 0.2 FTE + WHNP: 0.8 FTE • Two FP physicians have extensive ED backgrounds. • Two FP physicians are fellowship-trained sports medicine specialists. • Eight R.N.s working in advanced roles (nsg staff 30)

30. What are the components which influence decision-making in acute referral situations? • Available staff: consider their degrees, their background and their experience • Available resources: time, space and materials (equipment, tools, meds, supplies and ancillary services) • Condition of patient • Student financial constraints can be considered but must not lead you away from appropriate referral decisions. All of these add up to determine treatment capacity as applied to the individual patient.

31. What are your facility resources? U of Oregon Health Center – Eugene, OR • High complexity CLIA-certified laboratory • X-ray with computerized radiography • Pharmacy, full-service • Equipment for IV tx, splinting, casting, procedures • Dental Clinic with dentist and hygienists • Physical Therapy and Sports Medicine • Dietician and a certified diabetic educator

32. What are the components which influence decision-making in acute referral situations? • Available staff: consider their degrees, their background and their experience • Available resources: time, space and materials (equipment, tools, meds, supplies and ancillary services) • Condition of patient • Competing interests All of these add up to determine treatment capacity as applied to the individual patient.

33. What are the components which influence decision-making in acute referral situations? • Available staff: consider their degrees, their background and their experience • Available resources: time, space and materials (equipment, tools, meds, supplies and ancillary services) • Condition of patient • Competing interests All of these add up to determine treatment capacity as applied to the individual patient.

34. Competing interests • Student preference can go either way • Trust in health center and fear of the unknown • Trust in community resources over health center • Financial concerns (hospital, ambulance) • Student financial constraints can be considered but must not lead you away from appropriate referral decisions. • Available community resources

35. What is your location? Eugene, Oregon • Urban • Extensive community medical resources • Three emergency departments and hospitals; one is two blocks from campus • Urgent Care (non-hospital-affiliated), also two blocks from campus • Psychiatric ward in hospital close to campus

36. What are the components which influence decision-making in acute referral situations? • Available staff • Available resources • Condition of patient • Competing interests • Student financial constraints can be considered but must not lead you away from appropriate referral decisions. All of these add up to determine treatment capacity as applied to the individual patient.

37. Why do a medical screening exam? • Avoid inappropriate referrals. • Avoid having a patient deteriorate during a transfer because of a factor not identified prior to the transfer. • Gain information in order to knowledgeably stabilize the patient • Gain information for a knowledgeable discussion with the referral consultant • Information to decide the appropriate referral direction.

38. Why Do a Medical Screening Exam? • Better and safer patient care • Your health service will be treated with more respect from your referral resources which may result in better care for your students in the future

39. Does the medical screening exam need to be done by a physician? • EMTALA language specifies “qualified medical person” (1) as determined by the institution. • However, EMTALA also says “any assessment which is done by any person other than a physician has a much higher risk of being found insufficient under EMTALA.” (1) This is risk management. • Special qualifications matter: a WHNP or PMHNP may be more qualified than a specific physician for some particular acute referral situations, for example.

40. Who is a Qualified Medical Person? • RN-staffed health centers • NP-staffed health centers • Have a plan • Know your resources • Attempt to have the medical screening exams done by the clinicians with the most advanced knowledge or degree applicable to the situation.

41. Triage • Resources for nurse triage • Protocol books and courses • Physicians and nurse practitioners on staff • EXPERIENCE COUNTS • When in doubt, consult. Who is the best person to make the needed decisions? • Consult laterally with another colleague or up– RN to NP, RN to physician, NP to physician, physician to physician.

43. Learning Objective #2 • Describe the essential components of the medical screening exam and how to apply the findings to decisions about evaluation, treatment and/or referral. • Content: List of chief complaint-driven components of the medical screening exam for the most commonly-presenting acute injuries or illnesses in the college health setting.

44. The Medical Screening Exam • Focused history (focused HPI plus pertinent PMHx • Vital signs • Mental status • Focused but thorough exam of affected body part • Uncover • Undress • Remove bandages • A triage exam room is helpful • Quick labs can be helpful in some cases (UHCG, UDIP)

45. Why do a medical screening exam? • Avoid inappropriate referrals. • Avoid having a patient deteriorate during a transfer because of a factor not identified prior to the transfer. • Gain information in order to knowledgeably stabilize the patient • Gain information for a knowledgeable discussion with the referral consultant • Information to decide the appropriate referral direction.

46. The Ideal Medical Screening Exam • Clearly identify and understand your capacities in advance. • Recognize quickly if a student may need an acute referral – the longer it takes to recognize this, the more likely the patient will be dissatisfied by the process. • Perform the medical screening exam and understand clearly why you need to transfer/refer. • Be able to communicate your medical decision making to the patient and to your referral consultant. • Stabilize the patient even if you can’t treat the patient definitively. (Dressing, splint, pain meds, etc)

47. The Ideal Medical Screening Exam • Clearly identify and understand your capacities in advance. • Recognize quickly if a student may need an acute referral – the longer it takes to recognize this, the more likely the patient will be dissatisfied by the process. • Perform the medical screening exam and understand clearly why you need to transfer/refer. • Be able to communicate your medical decision making to the patient and to your referral consultant. • Stabilize the patient even if you can’t treat the patient definitively. (Dressing, splint, pain meds, etc)

48. The Ideal Medical Screening Exam • Clearly identify and understand your capacities in advance. • Recognize quickly if a student may need an acute referral – the longer it takes to recognize this, the more likely the patient will be dissatisfied by the process. • Perform the medical screening exam and understand clearly why you need to transfer/refer. • Be able to communicate your medical decision making to the patient and to your referral consultant. • Stabilize the patient even if you can’t treat the patient definitively. (Dressing, splint, pain meds, etc)

49. The Ideal Medical Screening Exam • Clearly identify and understand your capacities in advance. • Recognize quickly if a student may need an acute referral – the longer it takes to recognize this, the more likely the patient will be dissatisfied by the process. • Perform the medical screening exam and understand clearly why you need to transfer/refer. • Be able to communicate your medical decision making to the patient and to your referral consultant. • Stabilize the patient even if you can’t treat the patient definitively. (Dressing, splint, pain meds, etc)

50. The Ideal Medical Screening Exam • Clearly identify and understand your capacities in advance. • Recognize quickly if a student may need an acute referral – the longer it takes to recognize this, the more likely the patient will be dissatisfied by the process. • Perform the medical screening exam and understand clearly why you need to transfer/refer. • Be able to communicate your medical decision making to the patient and to your referral consultant. • Stabilize the patient even if you can’t treat the patient definitively. (Dressing, splint, pain meds, etc)