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
Bio – Jenny Soyke, M.D.
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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, 19982008
Emergency Physician in practice 1996-2009
Medical Director at UO Health Center since 2009.
I have no conflicts of interest to disclose.*
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.
Who are we?
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Physicians
Nurse Practitioners
Physician assistants
Registered nurses
Licensed or Credentialed Mental Health
Professionals (Psychologists, LMFT, LCSW)
Other?
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.
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?
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?
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.
This talk assumes context of
non-EMTALA clinics.
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Avoid use of the term “urgent care” or “walk
in for urgent care” if you are not an EMTALAcompliant 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.
Context of College Health
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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**
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.
Why discuss EMTALA when the law
doesn’t apply to us?
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“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.
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)
EMTALA
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Any patient who
"comes to the
emergency
department"
requesting
"examination or
treatment for a medical
condition"
College Health
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Any patient who comes
to the student health
center requesting
"examination or
treatment for a medical
condition"
EMTALA
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must be provided with
"an appropriate medical
screening examination"
to determine if s/he is
suffering from an
"emergency medical
condition".
College Health
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will benefit from "an
appropriate medical
screening examination"
to determine if s/he is
suffering from a
condition which we can
appropriately treat with
the health center
resources at hand.
EMTALA
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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.
College Health

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
facility as a matter of
responsible medical
practice.
EMTALA
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If the patient does not have
an "emergency medical
condition", the statute
imposes no further
obligation on the hospital.
College Health
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If the patient does not have
an "emergency medical
condition", we still have an
obligation to the student
patient but have options to
address her medical
needs:
Treating now
Scheduling a subsequent
appointment
Referring elsewhere
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?
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.
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Content: Discussion of triage, resources for nurse
triage, and the role of the physician or nurse
practitioner in the medical screening exam.
Learning Objective #2
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Describe the essential components of the
medical screening exam and how to apply
the findings to decisions about evaluation,
treatment and/or referral.
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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.
Learning Objective #3
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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.
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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.
Learning objective #4
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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.
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Case discussions with group participation.
Case discussions from the group
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During the talk, if a case occurs to you, write
down the following:
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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
What are our staff resources?
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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.
Where do we work?
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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
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.
What are the components which influence
decision-making in acute referral situations?
1.
2.
3.
4.
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.
What are your professional resources?
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University of Oregon Health Center - Eugene
Primary Care – 12 FTE
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Psychiatry – 3.4 FTE
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3 Psychiatrists (1.4 FTE) + 1 PMHNP + 1 QMHP
Women’s Health – 1.0 FTE
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9 family physicians, 3 adult + 1 family nurse practitioners
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)
What are the components which influence
decision-making in acute referral situations?
1.
2.
3.
4.
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.
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
What are the components which influence
decision-making in acute referral situations?
1.
2.
3.
4.
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.
What are the components which influence
decision-making in acute referral situations?
1.
2.
3.
4.
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.
Competing interests
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Student preference can go either way
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Financial concerns (hospital, ambulance)
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Trust in health center and fear of the unknown
Trust in community resources over health center
Student financial constraints can be
considered but must not lead you away from
appropriate referral decisions.
Available community resources
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
What are the components which influence
decision-making in acute referral situations?
1.
2.
3.
4.
5.
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.
Why do a medical screening exam?
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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.
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
Does the medical screening exam need
to be done by a physician?
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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.
Who is a
Qualified Medical Person?
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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.
Triage
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Resources for nurse triage
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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?
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Consult laterally with another colleague or up–
RN to NP, RN to physician, NP to physician,
physician to physician.
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.
The Medical Screening Exam
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Focused history (focused HPI plus pertinent PMHx
Vital signs
Mental status
Focused but thorough exam of affected body part
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Uncover
Undress
Remove bandages
A triage exam room is helpful
Quick labs can be helpful in some cases (UHCG,
UDIP)
Why do a medical screening exam?
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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.
The Ideal Medical Screening Exam
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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)
The Ideal Medical Screening Exam
 Clearly
identify and understand
your capacities in advance.
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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)
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)
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
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)
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)
The Ideal Medical Screening Exam
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
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)
Examples of most common conditions requiring
acute referral from student health centers
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Lacerations
Fracture/dislocations
Head injury
Abdominal pain
Dehydration
Severe infections
Pain
Psychiatric emergencies
Lacerations
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Caveats about lacs – don’t make a decision until you’re sure of
what you have
–
You don’t know what you have until you
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Remove the dressings entirely
Cleanse and explore the wound (sometimes it’s bigger than you
thought, sometimes it’s smaller than you thought). Assume likelihood
of foreign body within the wound (big risk mgmt issue).
If you decide to keep and treat the patient, be open to reversing
course if, after you anesthetize, cleanse and irrigate the wound, you
find that it’s deeper, dirtier or more complex than you feel comfortable
treating.
Each physician and NP knows her own limits on these. If you’re
not adept with facial lacerations, nail bed or other hand lacs or
complex layered repairs, it’s not in the best interests of either
the patient or the institution for you to do it.
Fracture/dislocation
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Adequate X-ray facility and professional clinician
capable of reading X ray?
Ability to properly splint with appropriate materials?
Ability to safely reduce a dislocation?
–
–
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Fingers, toes and patellae don’t typically require IV sedation
State of medical science for shoulders is to perform these
under IV sedation – decreases risk of nerve/tendon injury
Nerve injury is a big concern and time is of the essence for
hips, knees, ankles, elbows – call 911.
“I think I dislocated my shoulder.”
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Dislocated shoulder
AC joint separation
Humeral head fracture
Biceps tendon injury/rupture
Shoulder sprain
Clavicle fracture
The medical screening exam is essential to make
sure that you’re not sending a patient to the ED for a
condition you can actually treat yourself.
Traumatic Brain Injury –
It’s a Bear…..
Head injury
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Does the patient need a head CT?
–
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See ACEP recommendations
Do you have the capacity to order a head CT
nearby and maintain responsibility for the
patient?
Would the patient be dischargeable if the
head CT were negative?
–
See ACEP recommendations
Head injury – ACEP recommendations
“Which patients with mild TBI should have a
noncontrast head CT scan in the ED?
Level A recommendations (high degree of clinical
certainty).
A noncontrast head CT is indicated in head trauma patients
with loss of consciousness or posttraumatic amnesia
only if one or more of the following is present:
headache, vomiting, age greater than 60 years, drug or
alcohol intoxication, deficits in short-term memory,
physical evidence of trauma above the clavicle,
posttraumatic seizure, GCS score less than 15, focal
neurologic deficit, or coagulopathy.” (5)
Head injury – ACEP recommendations
Level B recommendations (moderate clinical certainty).
A noncontrast head CT should be considered in head
trauma patients with no loss of consciousness or
posttraumatic amnesia if there is a focal neurologic
deficit, vomiting, severe headache, age 65 years or
greater, physical signs of a basilar skull fracture, GCS
score less than 15, coagulopathy, or a dangerous
mechanism of injury.*
*Dangerous mechanism of injury includes ejection from a
motor vehicle, a pedestrian struck, and a fall from a
height of more than 3 feet or 5 stairs. (5)
Definition of mild TBI - ACRM
“The American Congress of Rehabilitation Medicine
delineated inclusion criteria for a diagnosis of mild TBI, of
which at least 1 of the following must be met:
1. Any period of loss of consciousness of less than 30 minutes
and GCS score of 13 to 15 after this period of loss of
consciousness;
2. Any loss of memory of the event immediately before or after
the accident, with posttraumatic amnesia of less than 24
hours; or
3. Any alteration in mental state at the time of the accident
(eg, feeling dazed, disoriented, or confused).” (5)
Definition of TBI - CDC
“The Centers for Disease Control and Prevention has developed a
similar conceptual definition for mild TBI (traumatic brain injury):
Occurrence of injury to the head, resulting from blunt trauma or
acceleration or deceleration forces, with one or more of the
following conditions attributable to the head injury during the
surveillance period:
● Any period of observed or self-reported transient confusion,
disorientation, or impaired consciousness
● Any period of observed or self-reported dysfunction of memory
(amnesia) around the time of injury
● Observed signs of other neurologic or neuropsychological
dysfunction
● Any period of observed or self-reported loss of consciousness
lasting 30 minutes or less.” (5)
Deciding if the head injury patient is
stable for outpatient evaluation - MSE
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HPI: was there LOC? Is there amnesia?
Mental status and Neuro Exam
Vital signs
Social situation
Extenuating circumstances (substances,
other trauma or injuries, vomiting, etc)
See ACEP recommendations for head CT
See ACEP recommendations for discharge
Head injury evaluation and acute
referral decisions
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Does the patient meet the definition of TBI?
Does the patient need a head CT based on ACEP criteria?
Would the patient be safe to be discharged after a negative
noncontrast CT? (see ACEP recommendation on this
question, next slide)
– If not, transfer rather than do outpatient CT.
Is the patient stable and safe to travel to an outpatient CT and
have you follow up the results?
Is there time left in the day for this to occur?
Would the patient be better served by getting the CT done in an
E.D. setting?
Does the patient need an ambulance? (significantly altered
mental status, unstable vital signs, unreliability of other
transport)
Can the patient be safely discharged if
CT is negative?
From ACEP recommendations
“Can a patient with an isolated mild TBI and a
normal neurologic evaluation result be safely
discharged from the ED if a noncontrast head CT
scan shows no evidence of intracranial injury?
Level A recommendations. None specified.
Level B recommendations. Patients with an isolated
mild TBI who have a negative head CT scan result
are at minimal risk for developing an intracranial
lesion and therefore may be safely discharged from
the ED.*
Therefore, these pts might be safe for an outpt CT
followed up by you.* (JMS)
* Next slide
Can the patient be safely
discharged if CT is negative?
There are inadequate data to include patients
with a bleeding disorder; who are receiving
anticoagulation therapy or antiplatelet
therapy; or who have had a previous
neurosurgical procedure in this population.”
(5)
(Therefore, these patients must go to the ED in
the first place. (JMS)
Abdominal Pain
What’s most common in college health?
 Appendicitis – see ACEP recommendations
(3)
 Urinary Tract Infection including
Pyelonephritis
 PID – pelvic inflammation secondary to STI
 ECTOPIC PREGNANCY always do a pregnancy test always
do a pregnancy test always do a pregnancy test pregnancy test!
Abdominal Pain
Risk Management in the Evaluation of Abdominal Pain
1.
Do not restrict the differential diagnosis solely by the location of
the pain.
2.
Do not use the presence or absence of a fever to distinguish
surgical from medical etiologies of abdominal pain.
3.
Do not assign a specific diagnosis which is unsupported by
history, physical, or laboratory findings.
4.
If you allow the patient to go home with close follow-up with
you, be sure to give written discharge instructions which
includes a specific follow up appointment and a list of reasons
for which the student should go to the emergency department in
the interim.
Options in evaluating abdominal pain
1. Use serial evaluations over several hours to improve
the diagnostic accuracy in patients with unclear causes of
abdominal pain.
2. Collect a complete data set before reaching a differential
diagnosis; consider a systemic data collection tool,
such as a formatted chart.
3. Perform a stool for occult blood test in patients with
abdominal pain.
4. Perform a pelvic examination in female patients with
abdominal pain.
5. Always do a pregnancy test in biologic females.
Signs and symptoms in abdominal
pain – when it’s obvious

Rebound tenderness – helpful when present, but
can’t be used to rule out a significant diagnosis
–

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
Do not depend on the presence of rebound tenderness to
make your referral decision.
Diaphoresis
Pallor
Significant hypotension
Significant hematemesis or melena
Rigidity
Signs and symptoms in abdominal
pain – when it’s NOT obvious

Patient is in a lot of emotional stress about
the pain but the belly is entirely soft and the
pain not well-localized.
–
–
–


Treat the pain
Gather information
Serial exams
Labs normal or equivocal – not helpful
There is no algorithm – just caveats
Abdominal Pain + Pregnancy



Abdominal pain + positive pregnancy test
requires you to evaluate the patient for
ectopic pregnancy.
Don’t think too hard about this – just do it.
Any reasons you can think of not to do these
tests are going to sound foolish when you
miss an ectopic pregnancy.
Pelvic ultrasound, quantitative HCG, CBC or
hemogram, +/- Rh factor
Acute referral decisions in abd pain

Vital sign stability?
–

Physical exam
–

Fever, tachycardia, hypotension?
Rebound, rigidity
Stoicism?
Increase your index of suspicion/concern
in favor of referral
 Cultural or language barriers – be careful
–
Practical and social
considerations - abdominal pain
 Can
serial exams be done within the
health center over a period of multiple
hours?
 Will the patient have easy access to follow
up in the ER during the evening or
weekend if he/she fails to improve?
 Can you get CBC and UA back in a timely
manner at your H.C.?
 Does the patient require pain medication
which you can’t provide?
Medical Screening Exam
in abdominal pain


The previous discussion assumes you have time for a complete
evaluation. What if the patient walks in 20 minutes before
closing time?
Minimum needed for MSE:
– Focused history of present illness
– Pertinent PMHx: Hx surgery, pregnancy, DM,
IBS?
– Focused exam (appropriately
uncovered/undressed)
– Referral decision vs. return appointment for next
AM
Script for late in day referral



It doesn’t serve the patient well to do a too-rapid,
incomplete abdominal pain evaluation.
Don’t be rushed to make a decision if you truly feel
you need more time with the patient for a safe
decision.
“We need a few hours to do serial exams and get the
complete work-up that you need, and it’s not
possible at this time of day. For your health and
safety, my opinion is that you need to go to …..”
Dehydration – referral decisions




Available staff, resources, time and space need to
be weighed as a whole.
Even without capacity for IVF, a young healthy
patient can be supported with antiemetics and
watched through oral rehydration for a whole day if
you have the time and space.
How long since last urination (was it yesterday?)
Symptomatic hypotension, symptomatic tachycardia,
and altered mental status – if you don’t have
capacity for fast high-volume IVF, expedite referral.
Infection – considerations in referral
decisions

Peritonsillar cellulitis or abscess
–
–
Is nonsurgical treatment with IV antibiotics and oral
steroids community standard in your community? That
depends on your ENT consultant. CALL ENT for their
opinion.
Is the airway threatened?

Cellulitis of face or extremity

True meningeal signs – time is of the essence - 911
Pneumonia – in the absence of asthma or other complications, can frequently be treated as
outpatient if the patient is not hypoxic.
Kidney infection – with outpatient IV antibiotics and IVF, in the absence of pregnancy,
hospitalization not always required.


Infection – considerations in
referral decisions





Peritonsillar cellulitis or abscess
–
Is nonsurgical treatment with IV antibiotics and oral steroids community standard in
your community? That depends on your ENT consultant. CALL ENT for their opinion.
–
Is the airway threatened?
Cellulitis of face or extremity
True meningeal signs – time is of the essence - 911
Pneumonia – in the absence of asthma or other
complications, can frequently be treated as
outpatient if the patient is not hypoxic.
Kidney infection – with outpatient IV antibiotics and
IVF, in the absence of pregnancy, hospitalization not
always required.
Pain - Uncontrolled pain
is a medical emergency


However, knowing the source of the pain is
equally as important as the existence of pain
in your decision-making about acute referral.
Is the source of the pain a potentially
unstable condition?
–
–
–
Abdominal pain
Severe headache
Trauma
Pain – is it acute or chronic?


Uncontrolled pain is a medical emergency,
however if the patient has chronic back pain
or chronic headaches, less likely to need
acute referral.
For acute pain associated with a condition
you are able to treat (infection, muscle pain,
minor injury, UTI, etc) be sure to treat the
pain along with the condition.
Treating pain in the health center





Many students haven’t started with the most basic
self-treatment of acetaminophen or NSAID prior to
presenting for care, so that can be a good place to
start.
IM or IV ketorolac (don’t give for potential surgical cases)
IM or p.o. opiates
Treating the underlying condition (injury or infection,
for example) which is causing the pain
Non-pharmaceutical alternatives are more difficult to
schedule on an acute basis (massage and other
alternative modalities)
Psychiatric Emergencies

Is patient a danger to self or others?
–




Our definition of safety for our students is probably more conservative than
the definition of safety for an independent adult psych patient seen in the
E.D.)
Is there an acute underlying medical condition or
substance intoxication?
What are your resources to assist you in evaluating the
patient?
What social resources can be identified for the support of
the student (family, dorm mates, R.A., etc).
What psychological or psychiatric follow-up can be
arranged in addition to primary care follow-up?
Is lab testing necessary in the MSE of
acute psychiatric patients? (ACEP)
“What testing is necessary in order to determine
medical stability in alert, cooperative patients with
normal vital signs, a noncontributory history and
physical examination, and psychiatric symptoms?
Level B recommendations.
 In adult ED patients with primary psychiatric
complaints, diagnostic evaluation should be directed
by the history and physical examination. Routine
laboratory testing of all patients is of very low yield
and need not be performed as part of the ED
assessment.” (4)

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.

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.
What component of the MSE would
result in an immediate acute referral?






Focus on those components which would
result in an immediate decision. Examples:
Head injury – altered mental status
Significant hypoxia with fever
Hypoxia with chest pain and SOB
Unstable vital signs
Orthostatic hypotension if no capacity for IV
You can apologize for your limits, but
don’t be embarrassed by them.



Don’t feel pressured to treat a patient or perform a
procedure which is clearly outside your scope of
practice.
Everybody has something that they don’t know.
Know yourself, know your limits, and keep educating
yourself to appropriately expand them
It is not in the best interests of the patient, the
institution or the clinician to risk a poor outcome
when you feel you’re out of your depth.
Know your capacities and resources.




Have a plan for decision-making.
These decisions are sometimes easy, but frequently
are complex with competing interests to consider.
Don’t skimp on the medical screening exam – make
sure you have the information you need.
Communicate clearly with the student and with your
referral consultants about your assessment.
The role of time and timing –
particularly end of the day decisions




It’s not only about your convenience – it’s also about
safety.
Can you safely and completely evaluate the patient
in the time available? Don’t be tempted to cut
corners because an abdominal pain pt walked in at
4:30 PM.
Consider convenience to other patients. What
happens to the other patients needing care if it will
take you an hour to repair complicated lacerations?
What is the budget impact from overtime costs for
nursing, x-ray, lab, pharmacy, etc?
The role of timing



A head injury or an abdominal pain patient is
not the same at 9 AM and at 4 PM.
Serial exams – important in many
conditions– require a stretch of time.
With the medical screening exam, decide
what they need, then decide if you can
provide it safely and completely in the time
available. If not, arrange transfer.
Scripts

“I’m going to consult _____ because I’m
concerned you may need to be transferred to
the emergency department.”
–

It is wise not to present the transfer as a “done
deal” because sometimes your consultant will
recommend a perfectly acceptable treatment you
can provide, then it’s difficult for the patient to
change gears.
“I want you to have the appropriate treatment
for your condition.”
Scripts

“I am terribly sorry; we want to take care of
you here, but my medical judgment is that
you need treatment that we can’t provide
here.”
–
Be specific about what the other facility can do for
them that you can’t do.

“This is what I would recommend if you were
my own daughter/son.”

“I am aware you’re concerned about money, but I’m
very concerned about keeping you safe.”
Components of a responsible transfer
1.
2.
3.
4.
5.
6.
7.
Do the medical screening exam, and
document it.
Make a decision as quickly as possible
Determine a safe transport method
Get the patient’s permission
Stabilize for transport
Call consultant
Send medical records
Components of a responsible transfer
5. Stabilize for transport – depends on distance



Control bleeding
Splint/immobilize
Relieve pain – use short-acting when possible for
abdominal pain.
6. Call consultant

Include discussion about stabilization treatment.
7. Send medical records


Stat transcription or handwritten record of your
evaluation and treatment. Include X rays and labs.
Don’t delay transport but this is essential – fax if
necessary.
How to Make the Transfer Smooth




Tell the patient you are going to consult to
help make the decision.
Be careful about telling the patient what will
happen prior to speaking with the consultant
– sometimes the consultant will have a
different approach.
Tips for consulting (next slide)
Make a decision about appropriate transport.
EMTALA rules re: transfers (FYI)








Medical screening exam is required.
Patient has been stabilized within the facility’s capacity.
Patient has been counseled about the risks and benefits of
transfer and advised that you believe the risks are outweighed
by the benefit.
Patient signs consent.
Both the receiving consultant and the receiving facility have
been contacted and have accepted the patient.
Medical records are sent with the patient.
All of the above is documented on a form that goes with the
patient.
Transport capacity is adequate for the patient’s condition.
How to present the patient to a
consultant for an acute referral.




Be succinct – what were the key points in your
decision-making? What is your diagnosis or Diff Dx?
This is not a grand rounds presentation.
Cut to the chase, then be ready with details when
asked.
Tell the consultant what you want to do, and
what you need from them. Is it an opinion, an
acceptance of transfer, and/or advice about
stabilization treatment prior to transfer? Be clear.
Consulting for transfer
– early pregnancy and pain

“I have a 22 year old woman with a positive
pregnancy test and acute significant LLQ
pain. I’m concerned about ectopic pregnancy
and I’m arranging transport to the E.D.”
–
Be prepared to answer questions about
abdominal exam, orthostatic stability, bleeding,
last meal, Gravida Para and Rh status.
Consulting for transfer
– shoulder dislocation

“I have a 30 year old male with a right
dislocated shoulder by exam, and I’m
sending him over to you immediately by
private car. We are not going to manipulate it
here without adequate anesthesia.”
–
Be prepared to answer questions about time of
injury and neurovascular exam.
Consulting for transfer – possible DVT

“I have a 40 year old male/female with a swollen
right leg, shortness of breath and hypoxia with an O2
sat of 88%. I’m concerned about pulmonary
embolism from DVT, and I’m sending him/her
without labs, coming to you by ambulance.
–
–
Be prepared to answer questions about risk factors, onset of
symptoms, and medical history.
Why are the labs or X ray not part of this patient’s medical
screening exam?
Consulting for hypoxia

“I have a 28 year old woman with lupus who
presented today with shortness of breath and an O2
sat of 85%. She comes up to 92% on O2. She is not
anticoagulated.”
–
–
Be prepared with medical history and exam findings.
This is a case of sending a patient with a differential
diagnosis instead of a diagnosis, as there are multiple
possible diagnoses here, but the patient’s condition
warrants immediate transfer because of the seriousness of
the differential diagnoses.
The Medical Screening Exam is
essential


You do not have the information you need to
appropriately transfer the patient unless you
examine them.
In order to make an acute referral, you need either a
diagnosis or a differential diagnosis based on a
competent medical screening exam.
–
–
–
–
Focused, pertinent HPI and pertinent PMHx
Vital signs, mental status
Focused exam – uncover, undress, remove bandages
Quick labs such as UHCG or UDIP can be helpful
Social and Practical Considerations

We want to take care of our students ourselves, but
sometimes that’s not the best medical care for them.

Reputation: we want to handle these cases in ways
that give the students confidence in our work and in
a way that makes our professional colleagues
respect our work.

We cannot allow concerns about financial stresses
to the uninsured or underinsured student unduly
influence our medical decision-making. Making the
wrong decision for these reasons won’t help the
patient and won’t stand up in court.
Should you charge for the medical
screening exam?




It depends on your system.
There is a charge for the medical screening exam in
the E.D.
Was treatment initiated – did the student receive
services?
The medical screening exam is a service in itself,
however students can feel very frustrated if they are
charged for being told they need to go elsewhere for
care. But you have provided a service.
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.
Summary


The medical screening exam is a concept which is
part of EMTALA, to ensure that patient transfer
decisions are made with adequate information and
communication to ensure patient safety.
Though student health centers aren’t typically
subject to EMTALA, the concepts behind the law can
serve as an example to guide us in evaluating
patients and making safe transfer decisions and
arrangements.
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.
The Medical Screening Exam is
essential


You do not have the information you need to
appropriately transfer the patient unless you
examine them.
In order to make an acute referral, you need either a
diagnosis or a differential diagnosis based on a
competent medical screening exam.
–
–
–
–
Focused, pertinent HPI and pertinent PMHx
Vital signs, mental status
Focused exam – uncover, undress, remove bandages
Quick labs such as UHCG or UDIP can be helpful
Sample Cases


Audience participation
Sample cases
Medical Screening Exam and Acute Referral Decisions
in the Context of College Health Centers - Bibliography
1.
Emtala.com. Frequently Asked Questions about the Emergency Medical
Treatment and Active Labor Act (EMTALA). http://www.emtala.com/index.html
2.
American College of Emergency Physicians Clinical Policies
http://www.acep.org/clinicalpolicies/
3.
American College of Emergency Physicians, Clinical Policy: Critical Issues in
the Evaluation and Management of Emergency Department Patients with
Suspected Appendicitis. Annals of Emergency Medicine.2010; 55:71-116
4.
American College of Emergency Physicians, Clinical Policy: Critical Issues in
the Diagnosis and Management of the Adult Psychiatric Patient in the
Emergency Department. Annals of Emergency Medicine.2006; 47(1):79-99.
5.
American College of Emergency Physicians Clinical Policy: Neuroimaging and
Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting.
Annals of Emergency Medicine.2008; 52(6):714-748.
Additional Resources

Shaider, Jeffrey J., et al (Editors), Rosen and
Barkin's 5-Minute Emergency Medicine Consult, Fifth
Edition, 2010.

Tintinalli, Judith, et al; Tintinalli's Emergency
Medicine: A Comprehensive Study Guide, Seventh
Edition, 2010

Briggs, Julie K. Telephone Triage Protocols for
Nurses, Third Edition, 2007
Contact information
Jenny Soyke, M.D., University Health Center
1232 University of Oregon, Eugene, Oregon 97403-1232
jsoyke@uoregon.edu