ED nurses do MSEs to cut triage delays
[Editor's note: This is the first of a two-part series on medical screening examinations (MSEs) performed by emergency nurses. This month, we report on two EDs that have implemented this practice. Next month, we'll cover the potential liability risks of nurse-performed MSEs and how to them.]
Have you ever wondered why ED nurses aren't the ones to perform medical screening examinations (MSEs) required by the Emergency Medical Treatment and Labor Act (EMTALA)? Although this is legally permitted, it's rarely done.
Some EDs, however, have had excellent results with this practice, including MetroHealth Medical Center in Cleveland, which went live with nurse-performed MSEs in March 2008.
"The MSE process is completely separate from triage," reports Karen Smith, RN, MSN, director of nursing for the ED. For patients between the ages of 18 and 65 with any of 16 chief complaints based on physician-approved protocols, a specially trained triage nurse performs the MSE, which includes asking a list of questions. (See list of the 16 complaints, left.) "Any time the nurse has a gut feeling, even if the patient says 'no' to all the questions, she can override the protocol," notes Smith.
If the nurse determines that there is no medical emergency, the patient is given two choices: They can wait to be seen in the ED with a copay, or $75 upfront deposit for self-pay patients, or follow-up care is arranged in one of the hospital's clinics or satellite offices. "We have 16 sites to choose from, including right across the street, and we often get them seen by a physician the same day. We are not saying, 'There's the door.' We are offering them resources," says Smith. "Usually these patients would wait hours, because their acuity is not one that warrants immediate attention. As the only Level 1 Trauma Center in this region, we can get hit with multiple traumas."
Because there are fewer people in the waiting room, sicker patients are now seen faster. "A lot of times, a sick patient will come in, see a full waiting room, and leave," notes Smith.
About half of the ED's 50 triage nurses have gone through the MSE training, which includes updates on EMTALA, triage guidelines, and role playing. Nurses also demonstrate competency with observation by a clinical nurse specialist, who researches, prepares, and presents the training.
At University of California Irvine (UCI) Medical Center in Orange, more than 80 of the ED's 100 nurses now perform MSEs, after taking a preceptorship with an experienced ED nurse who is credentialed to conduct the MSE.
Many EDs don't have nurses do MSEs because physicians are concerned about liability risks, says Darlene Bradley, RN, PhDc, CNS, CCRN, CEN, MICN, FAEN, UCI's director of emergency/trauma services. "In our program, once the nurse has completed the training and passed the exam, they have to do a number of adult and peds MSEs. The attending physician then validates that the nursing assessment was correct," she says. "In this manner, they feel a part of the process and approve that the nurse is credentialed to provide this level of service."
To perform MSEs, nurses have must have five adult and five pediatric MSEs completed, reviewed and validated by an attending board-certified ED physician, says Sylvia Chavarria, RN, a clinical nurse III at UCI, one of the ED nurses who provides the preceptorship.
The benefit of MSE triaging is that patients are properly triaged based on their acuity," says Chavarria. "Patients that are ill and have a true emergency are then able to get back to the ED within an appropriate time frame. The patients are taken directly to the treatment area where emergency interventions and ongoing care can occur. This expedites the care of the patient."
ED nurses use this triage acuity system
Below is the acuity system used by triage nurses in the ED at University of California Irvine Medical Center in Orange:
- Level 1: Life-threatening, such as respiratory distress, full arrest, and unconscious patients. These patients are taken straight back to a bed, and the medical screening examination (MSE) is completed at the bedside.
- Level 2: An emergency medical condition exists, such as chest pain, severe abdominal pain, dislocated joints, or psychiatric patients that are homicidal or suicidal. These patients are triaged with appropriate interventions initiated within 15 minutes, as bed placement becomes available.
- Level 3: An emergency medical condition cannot be excluded, such as minor abdominal pain, minor extremity injuries, lacerations, pain scales less than 7, back pains, and vaginal bleeding. If an open bed is available, the patient is placed in the appropriate care area. If not, the patient is placed in the sub-waiting area to be registered and placed in a bed within two hours.
- Level 4: No emergency medical condition exists, such as medication refills, school or work releases, and referrals for orthopedics and nonemergent eye conditions.
If the patient is found to be a Level 4, he or she is sent to registration. The ED registration clerk calls the ED attending physician to see the patient in the registration cubicle. "At that time, the attending determines if a medical emergency exists or not," says Sarah Landrum, RN, clinical nurse II in the ED. "If one does exist, the patient is registered and placed in the appropriate care area when a bed is available. If one does not exist, the patient is then triaged out to a community clinic."
[Editor's note: This is the first of a two-part series on medical screening examinations (MSEs) performed by emergency nurses. This month, we report on two EDs that have implemented this practice. Next month, we'll cover the potential liability risks of nurse-performed MSEs and how to them.]You have reached your article limit for the month. Subscribe now to access this article plus other member-only content. TESTING
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