The Emergency Medical Treatment and Active Labor Act (EMTALA) is a federal law established in 1986 that requires hospitals or other acute care facilities who offer emergency services to provide a medical screening examination to each person presenting to the emergency department. A medical screening exam is done to determine whether or not an emergency medical, not nursing, condition exists. EMTALA requires the assessment of a patient for the existence of an emergency medical condition before the patient can be transferred or released from the emergency department. An emergency medical condition is defined under federal law, 42CFR §489.24, and may be readily viewed in its entirety at a http://www.emtala.com or the Code of Federal Regulations web page at http://www.gpoaccess.gov/cfr/retrieve.html. An understanding of what EMTALA is and what is meant by performing a medical screening exam is essential to the RN performing this task.
Question 1: Can a RN Perform A Medical Screening Exam?
The EMTALA guidelines and frequently asked questions (FAQs) indicate that a facility may credential specific registered nurses and develop bylaws specifying which RN nursing staff is considered to be "qualified medical personnel" and under what circumstances a physician must be consulted and/or must physically come to the unit/facility. In addition to being permitted by an employing facility, however, the RN must also be competent to carry out the assigned task in a manner that complies with the NPA and board Rules.
A RN may be able to perform a medical screening exam if he/she possesses adequate knowledge and skills and there are adequate support systems and standing orders in place; however, the RN should always have telephonic access to a physician who is also capable of physically responding to do a hands-on evaluation if needed or requested by the RN. RNs who do not hold advanced practice authorization cannot independently engage in medical diagnosis or prescription of therapeutic or corrective measures, as this is beyond the scope of practice for a RN.
Question 2: Can a LVN perform a medical screening exam?
The board believes that the performance of a medical screening exam is not within the scope of practice for a LVN, regardless of years of experience or post-licensure continuing education at the LVN level. As defined in §217.11(2)(A) the scope of practice for a LVN is limited to performance of a focused assessment of an individual client, thus a comprehensive RN nursing assessment is the minimum level of assessment acceptable to conduct a medical screening exam. Even if a physician wishes to delegate assessment of medical conditions and/or treatments to a LVN, the LVN is accountable for only accepting those assignments within his/her scope of practice as outlined in the NPA and in Rule 217.11, Standards of Nursing Practice. Position Statement 15.11 Delegated Medical Acts contains additional information on physician delegation to nurses.
Question 3: Is a medical screening exam the same as triage?
No, a-medical screening exam is not the same as triage. The differentiation is discussed in depth under the Interpretive Guidelines for Enforcement for 42CFR §489.24 on the EMTALA web page. This guideline to surveyors states in part that "[i] Individuals coming to the emergency department must be provided a medical screening examination beyond initial triaging. Triage is not equivalent to a medical screening examination. Triage merely determines the order in which patients will be seen, not the presence or absence of an emergency medical condition
Question 4 How do the NPA and Rules apply to RNs performing medical screening exams under EMTALA?
The definition of "professional nursing" in Texas Occupation Code §301.002(2) of the Nursing Practice Act (NPA) states that the practice of professional nursing "does not include acts of medical diagnosis or prescription of therapeutic or corrective measures." This means an act must not require the RN to exercise independent medical judgment or medical diagnosis, as this is the practice of medicine, not nursing.
Rule 217.11, Standards of Nursing Practice, contains the minimum standards of acceptable nursing practice. Some of the standards in Rule 217.11 that would apply to EMTALA medical screening exams performed by a RN include, but are not limited to, the requirements that a RN must:
- (1)(A) know and conform to the NPA, rules, as well as federal, state, or local laws affecting the nurse’s current area of practice;
- (1)(B) maintain a safe environment for clients and others;
- (1)(D) accurately and completely report and document: (i)-(vi);
- (1)(M) institute appropriate nursing interventions that might be required to stabilize a client’s condition and/or prevent complications;
- (1)(P) collaborate with the client, members of the health care team and, when appropriate, the client's significant other(s) in the interest of the client's health care;
- (1)(T) accept only those nursing assignments that take into consideration patient safety and that are commensurate with one's own educational preparation, experience, knowledge and physical and emotional ability.
- (3)(A)(i) performing comprehensive nursing assessments regarding the health status of the client.
Regardless of practice setting, the nurse's duty to keep patients safe cannot be superseded by physician orders, facility policies, or administrative directives see Position Statement 15.14 Duty of a Nurse in Any Practice Setting, http://www.bon.state.tx.us/practice/position.html# 15.14. To assist in determining if a task is within an individual nurse's scope of practice, nurses may utilize the board's "Six-Step Decision-Making Model for Determining Nursing Scope of Practice." This document is under "Scope of Practice" in the "Nursing Practice" section of the BON's web page at http://www.bon.state.tx.us/practice/pdfs/dectree.pdf
Question 5: Can an Advanced Practice Nurse Perform A Medical Screening Exam?
Advanced practice nurses (APNs) are RNs who have completed a formalized education program, e.g., Master's or Post-Master's APN curriculumthat enables them to engage in certain aspects of medical diagnosis and medical management within their advanced practice role and specialty. Advanced practice recognition is not sufficient on its own to qualify an APN to perform all types of medical screening exam. The APN would have to be authorized in an appropriate role and specialty, e.g.,Acute Care Nurse Practitioner, Adult Nurse Practitioner or Family Nurse Practitioner for evaluation of general medical conditions of adults. A Family Nurse Practitionercould also evaluate pediatric patients.A Certified Nurse Midwife, Women's Healthcare Nurse Practitioner, or Clinical Nurse Specialist in Women's Health would have appropriate educational preparation to perform medical screening exams on obstetrical patients. Conversely, a Neonatal Nurse Practitioner would not be able to determine the presence or absence of general medical conditions of adults or obstetrical conditions of women as this is not part of the Neonatal Nurse Practitioner'sadvanced educational preparation.
Other sources of information on EMTALA include:
- Texas Medicaid Office through the Health and Human Services Commission of Texas at mailto:contact@hhsc.state.tx.us or locate the office nearest to you by calling 2-1-1 or using the HHSC web page to find your Area Information Center (AIC) at http://www.hhs.state.tx.us/tirn/aicsearch.asp
- EMTALA web page at www.emtala.com EMTALA FAQs http://www.emtala.com/faq.htm Interpretive Guidelines for Medicare Participating Hospitals in Emergency Cases http://www.emtala.com/ig.pdf
- Centers for Medicare and Medicaid Services at http://www4.cms.hhs.gov/EMTALA/ or national toll free number 1-822-267-2323.
- Emergency Nurses Association http://www.ena.org/government/emtala/article2.asp
- Code of Federal Regulations Home Page http://www.gpoaccess.gov/cfr/index.html
- American Academy of Emergency Medicine http://www.aaem.org/emtala/