It has been a while since this question came up, but since I received it today, I want to share the answer that I gave to the facility.
I advise against blood pressure checks in the ED, but most people do them anyway.
CMS basically says that you can give blood pressure checks in the ED without triggering EMTALA. The catch is that the RESULTS and how you handle them MAY TRIGGER EMTALA, and so could any complaints or symptoms. BP screening at a health fair that is off-campus would not trigger EMTALA, because they did not “come to the hospital”. BP screenings at health fairs in the hospital would not trigger EMTALA, but the RESULTS might.
To be more specific, if the patient is on hospital property and says “Could you check my blood pressure, I have a pounding headache,” whether in a hospital clinic, ED, or health fair, that probably triggers EMTALA. If they add that it is the worst headache of their life or that they are having vision or coordination problems, that FOR SURE triggers EMTALA.
Let’s say that you offer BP screening in the ED during a specific time period every day or some other designated times. The patient just shows up for the free BP and has no complaints, no serious history, and asks for a check. You get the name, hopefully document it, and take the BP. In this case the results are within your limits of normal (which you document) and the patient is given the good news and sent on. You retain the records. You are not likely to have a problem with EMTALA.
On the other hand, several scenarios can give rise to CMS issues:
1. The patient comes to the ED, gets a BP check, and leaves, all without a record. You have no proof of anything, and the patient went home and stroked. CMS will cite you under EMTALA for no log, no triage, no proof the patient was stable for discharge, no proof of medical screening exam, improper transfer and whatever else they throw in the mix.
2. Patient comes in, is documented, given BP check which is mildly outside the normal values established in your hospital. The patient is sent home with instructions to follow up with their family physician at some indefinite time, etc. No MSE is offered, or if offered and refused, no refusal form is obtained. In this case, it is entirely up to CMS to decide whether they think a MSE was required. If the patient has an adverse event that gets reported, CMS will likely determine that you violated EMTALA for not providing an MSE or getting a refusal.
3. Patient comes in for BP check with history of BP issues and has a slew of health conditions and doctors, if you take a history. You probably didn’t. The patient has a significantly elevated or depressed BP that dramatically exceed your standards for normal. You document. You recommend that the patient promptly contact their physician and go to the office immediately. Or, you offer an MSE but it is refused. You do not get a written refusal. The patient leaves, and at some later time has an adverse event or goes to another hospital where they are admitted. CMS is extremely likely to cite you.
There are many other variations, and CMS addresses each case on an individual facts basis. You might survive an investigation without getting cited for the BP check, but get cited for another technicality on an entirely different issue. Regardless, the bad press on the investigation wipes out any patient relations value the BP checks may have provided.
I suggest you participate in a community based BP program of EMS, local organizations, local drug stores, local health fairs, scheduled programs in shopping centers, or whatever. Providing the service is great — doing it in the hospital, that could be a problem.
If you are going to do BP checks in the hospital for free, there are a lot of questions that need addressing that many folks don’t even consider, but should, including but not limited to:
- How are you going to log the patient and what are you going to log for proof of what you did if CMS or lawyers come inquiring?
- How much of a history are you going to get?
- Will you ask about any problems or symptoms that might take it out of a “simple” BP check presentation?
- What values will you put on “normal” “low” “elevated” and “significantly elevated” classifications for results?
- Is it ever safe to just refer an abnormal value to follow up with their doctor from an EMTALA perspective?
- When does the “simple BP check” trigger EMTALA and MSE? (and charging the patient)
- What do you do if you recommend “having the ED check you out” and patient refuses ED evaluation? (HINT – EMTALA written refusal)
- At what point does logging cease to be adequate and a medical record must be started?
As an addendum to this topic, I’d like to pose another scenario for your review. Hospital operates a community wellness center, within the hospital building, and as a department of the hospital. BP screenings are provided every M-W-F and performed by wellness center staff using an automated BP device much like a home device. No documentation that the BP equipment has been validated at any point against a more sophisticated piece of equipment. No competency testing for personnel is performed. BP values are maintained on index cards and kept in a box so there is an ongoing record of BP measurements for each individual patron seeking the service. If an “abnormal” result is obtained, the patron is told to check with their doctor.