Hospital Operations/ Continuum of care

What is EMTALA?

The Emergency Medical Treatment and Labor Act (EMTALA) was enacted by Congress in 1986. The Act’s original intent was to prevent hospitals from refusing to see patients based on inability to pay and to assure patients were transferred only when appropriate and in a safe manner.

EMTALA compliance is important and necessary for emergency departments to provide safe, quality care. When a patient presents to a dedicated emergency department or is on hospital property and requests care EMTALA is immediately in effect. Medical screening examinations or treatment cannot be delayed to inquire information about an individual’s insurance status or payment method.

Providers are obligated to provide a medical screening examination, determine if an emergency medical condition exists and stabilize or if the patient cannot be properly stabilized, provide the appropriate transfer. EMTALA obligations end when a patient is seen, screened and admitted for hospital services, when a patiently is appropriately transferred, when no emergency medical condition exists or when a patient has been offered a screening exam and informed of the risks but refuses treatment.

How is emergency medicine staffed?

Historically, the first person in the emergency department a patient would meet is not a clinical provider but an administrative registration clerk. These staff members take a patient’s name, date of birth and other personal details and collect insurance provider information. Once checked-in, a patient might see a triage nurse next.

However, with improved ED systems as well as governmental law (EMTALA), the first person a patient will meet is a clinical provider whose job it is to medically screen a patient and triage that patient to an appropriate level of care. The registration person may see the patient next, or at some point later in the patient’s ED visit.

Care in the ER is not first-come, first-served. If a patient arrives at the ER in an ambulance, unconscious or unresponsive, or with symptoms that might indicate a heart attack or stroke, the triage process puts that patient at the top of the list, ensuring care before a patient with a less-serious illness or injury.

Once moved to the treatment area, a patient will be cared for by the primary emergency department nurse. Often a registered nurse, this person has a degree in nursing and the training and experience to manage and assist with a variety of emergency situations, from complaints about broken bones and sprained ankles to cardiac arrest. An emergency department nurse may clean wounds and burns, suction an airway, administer intravenous fluids, aid in neurological evaluations, field family members’ concerns and arrange for transportation to another floor of the hospital.

Some emergency departments also have a charge nurse, an experienced nurse responsible for overseeing the flow and dynamics of the entire nursing department and managing complex patient cases. The first half hour you’re treated in the ER, the charge nurse may be one of several nurses assisting your primary emergency department nurse in providing preliminary care and interventions.

Also, in the treatment lineup: your physician or advanced practice clinician (APC, either a physician assistant or nurse practitioner). The physician or APC may be the first provider to see a patient or possibly the last. This depends on a variety of factors including the acuity of the patient and how busy the department is at a given time. Attending physicians have completed medical school and residency, and are either medical doctors (MDs) or Doctor of Osteopathic Medicine (DOs). PAs have specialized training after college directed at assisting physicians in a number of fields, including emergency medicine. NPs have nursing degrees and further specialized medical training.

Value Stream Mapping (VSM)

Value stream mapping (VSM) is a lean manufacturing or lean enterprise technique used to document, analyze and improve the flow of information or materials required to produce a product or service for a customer.

In the emergency department, VSM guides teams through a process which helps determine the best course of action for any given issue. For example, VSM is known to help key stakeholders understand the value of utilizing rapid treatment areas (RTAs) in the ED – working in conjunction, VSM and RTAs help decrease wait times, decompress waiting rooms, enable a more efficient assessment of patients and improve the overall patient experience.

Health Insurance Portability and Accountability Act (HIPAA)

Health Insurance Portability and Accountability Act (HIPAA) is the United States legislation that provides data privacy and security to safeguard medical information. HIPAA was created as a means of modernizing the flow of healthcare information, stipulate how personally identifiable information maintained by the healthcare and healthcare insurance industries should be protected from fraud and theft, and address limitations on healthcare insurance coverage.

The act consists of five titles:

  • Title I of HIPAA protects health insurance coverage for workers and their families when they change or lose their jobs.
  • Title II of HIPAA, known as the Administrative Simplification (AS) provisions, requires the establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans and employers.
  • Title III sets guidelines for pre-tax medical spending accounts.
  • Title IV sets guidelines for group health plans.
  • Title V governs company-owned life insurance policies.

Rapid Treatment Area (RTA)

A rapid treatment area (RTA) is an identified space, typically close to triage in the emergency department, which is used to help manage patient flow and throughput. A successful RTA allows for continual forward progression for patients which decreases wait times, decompresses waiting rooms and increases patient satisfaction. When an RTA is utilized, patients are efficiently assessed, a medical screening exam (MSE) is performed and necessary diagnostic testing is initiated shortly after a patient arrives.

Left Without Treatment (LWOT)

Left without treatment (LWOT) refers to a patient encounter that ended before the individual received treatment from a provider. This can include those who see a provider and leave before treatment or those who leave without being seen by a provider during their stay.

Left Without Being Seen (LWBS)

Left Without Being Seen (LWBS) refers to a patient encounter that ended with the patient leaving the healthcare facility, typically an emergency department, before being seen by a provider.

Medical Screening Exam

A medical screening exam (MSE) is the initial exam performed when a patient presents to a dedicated emergency department and requests care. MSEs are to be performed by a qualified medical person, which should be determined in the hospital or health system’s bylaws. The goal of a medical screening exam is to determine if there is an emergent medical condition occurring.

Discharge Planning

Discharge planning refers to the process of determining what care is needed after a patient leaves the hospital. The process should result in specific recommendations including what events or symptoms would require the patient to seek follow-up care or visit the emergency department (ED).

The goal of discharge planning is to optimize a patient’s recovery from the hospital, coordinate future care and follow up appointments, decrease possible adverse events and reduce readmissions. A proper discharge plan is communicated both written and verbally. This helps patients understand the principle diagnosis and treatment received during hospitalization, his or her responsibilities after discharge, defines a follow-up plan and what symptoms or occurrences should prompt the individual to return to the hospital.

At minimum, elements in a patient discharge summary should include:

  • Reason for hospitalization with specific principle diagnosis
  • Discussion of hospitalization
  • Patient’s condition at discharge
  • Comprehensive and reconciled medication list or documentation noting the patient was provided a full reconciled medication list


Incoming hospital patients are most commonly evaluated based on the five-level Emergency Severity Index (ESI) to determine the order in which they should be treated:

  • Level One: Patients with life-threatening/critical condition(s) and/or patients who are unresponsive. This level is immediately bedded.
  • Level Two: High-risk patients with unstable vital signs. These patients are experiencing severe pain or sickness.
  • Level Three: Stable vital signs but significant discomfort and/or sickness is present. Often more than two resources are needed to make patient disposition.
  • Level Four: Low risk patient with stable vital signs. One resource is needed to make patient disposition. Often treated through fast-track, if available at the facility.
  • Level Five: Low-risk patient with stable vital signs. No resources are needed. For example, a patient needing a prescription or a patient needing a cut stitched. Patients at this level are often seen through a fast-track, if available.