ORIGINAL CONTRIBUTION emergency department, refusal of treatment
Refusing Care to Patients Who Present to an Emergency D e p a r t m e n t In July 1988, our emergency department adopted a policy of refusing to treat patients in the ED if they failed to have what was considered an emergency condition. Screening examinations were performed by triage nurses to determine whether patients were eligible to be seen in the ED. Patients whose vital signs fell within specific categories and who had one of 50 minor chief complaints were refused care in the ED and referred to off-site clinics. The referral of these patients out of the ED after a screening examination falls within the scope of legislation governing ED care and transfer (federal COBRA, Cal SB-12, and Title 22) as determined by the University of California legal counsel. In the first six months of this n e w triage system, 4,186 patients were referred from the ED; this represented 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 84% were referred to off-site nonuniversity clinics, and I5% were referred to a university-affiliated faculty-staffed clinic. Follow-up letters and telephone calls to their clinics identified no patients who needed retriage to an ED, and only 54 patients (1.3%) complained about their referral out of the ED. Only 42 patients returned to the ED within 48 hours of initial triage, and none had a deterioration of their condition. In conclusion, a selective triage system m a y be used to effectively decompress an El), although further study is needed to identify potential rare adverse outcomes. [Derlet RW, Nishio DA: Refusing care to patients who present to an emergency department. Ann Emerg Med March 1990;19:262-267.]
Robert W Derlet, MD Denyse A Nishio, MD Sacramento, California From the Divisen of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, California. Received for publication May 25, 1989. Revision received October 2, 1989. Accepted for publication November 13, 1989. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989. Address for reprints: Robert W Derlet, MD, Division of Emergency Medicine, Tr 1219, University of California, Davis, Medical Center, 2315 Stockton Boulevard, Sacramento, California 95817.
INTRODUCTION Hospital emergency departments provide care to patients whose needs for "immediate" care vary widely.< 2 Many definitions of "emergency" have been adopted by various organizations and agencies that share important concepts. 3-6 For example, the California legislature (SB-12, 1986) defines emergency medical condition as "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient's health in serious jeopardy; (2) Serious impairment of bodily functions; or (3) Serious dysfunction of any bodily organ or part." The American College of Emergency Physicians' description of an emergency is more specific and detailed, and it expands the concept beyond the "life and limb" definition. Although debate has ensued on defining which conditions constitute an emergency compared with a nonemergency, most EDs provide care to all persons who present.< 8 Federal legislation and certain state regulations require that at least a screening examination be done on patients who present to EDs. 9 Neither federal nor California state law requires treatment unless the patient has an emergency condition. In some EDs in the United States, a moderate number of patients present to EDs with minor complaints.
Refusing Care to Patients Who Present to an Emergency D e p a r t m e n t In July 1988, our emergency department adopted a policy of refusing to treat patients in the ED if they failed to have what was considered an emergency condition. Screening examinations were performed by triage nurses to determine whether patients were eligible to be seen in the ED. Patients whose vital signs fell within specific categories and who had one of 50 minor chief complaints were refused care in the ED and referred to off-site clinics. The referral of these patients out of the ED after a screening examination falls within the scope of legislation governing ED care and transfer (federal COBRA, Cal SB-12, and Title 22) as determined by the University of California legal counsel. In the first six months of this n e w triage system, 4,186 patients were referred from the ED; this represented 19% of total ambulatory patients who presented to the triage area. Of the 4,186 patients refused care, 84% were referred to off-site nonuniversity clinics, and I5% were referred to a university-affiliated faculty-staffed clinic. Follow-up letters and telephone calls to their clinics identified no patients who needed retriage to an ED, and only 54 patients (1.3%) complained about their referral out of the ED. Only 42 patients returned to the ED within 48 hours of initial triage, and none had a deterioration of their condition. In conclusion, a selective triage system m a y be used to effectively decompress an El), although further study is needed to identify potential rare adverse outcomes. [Derlet RW, Nishio DA: Refusing care to patients who present to an emergency department. Ann Emerg Med March 1990;19:262-267.]
Robert W Derlet, MD Denyse A Nishio, MD Sacramento, California From the Divisen of Emergency Medicine, University of California, Davis, Medical Center, Sacramento, California. Received for publication May 25, 1989. Revision received October 2, 1989. Accepted for publication November 13, 1989. Presented at the Society for Academic Emergency Medicine Annual Meeting in San Diego, May 1989. Address for reprints: Robert W Derlet, MD, Division of Emergency Medicine, Tr 1219, University of California, Davis, Medical Center, 2315 Stockton Boulevard, Sacramento, California 95817.
INTRODUCTION Hospital emergency departments provide care to patients whose needs for "immediate" care vary widely.< 2 Many definitions of "emergency" have been adopted by various organizations and agencies that share important concepts. 3-6 For example, the California legislature (SB-12, 1986) defines emergency medical condition as "a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in any of the following: (1) Placing the patient's health in serious jeopardy; (2) Serious impairment of bodily functions; or (3) Serious dysfunction of any bodily organ or part." The American College of Emergency Physicians' description of an emergency is more specific and detailed, and it expands the concept beyond the "life and limb" definition. Although debate has ensued on defining which conditions constitute an emergency compared with a nonemergency, most EDs provide care to all persons who present.< 8 Federal legislation and certain state regulations require that at least a screening examination be done on patients who present to EDs. 9 Neither federal nor California state law requires treatment unless the patient has an emergency condition. In some EDs in the United States, a moderate number of patients present to EDs with minor complaints.
