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The conclusion of the emergency department (ED) visit involves several important aspects of medical care.

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A medical provider must decide whether to admit or discharge the patient from the ED. If a patient is deemed suitable for discharge, discharge and follow-up instructions may represent the final opportunity that the medical provider has to bridge the transition between ED care and a resolution of the patient's condition. This chapter will explore issues to be considered when determining disposition from the ED and issues related to patient discharge and follow-up care.

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A 37-year-old man presents to the ED with substernal chest pain of 3 hours' duration. He is a former smoker and his mother died from a heart attack at age 60. Physical examination, laboratory testing, and EKG are all within normal limits. It is a Friday evening and no provocative testing will be available until Monday morning. Should this patient be admitted or discharged?

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When deciding whether or not to discharge a patient from the ED, many factors come into play. Perhaps the most important determining factor about whether a patient should be admitted or discharged from the ED is the clinical condition of the patient.

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Unstable Patients

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Unstable patients must either be admitted to the hospital or transferred to a facility that has the capability to care for the patient. This rule is not just medically appropriate, it is also a requirement imposed on hospitals by federal EMTALA laws.1 Patients falling under the Emergency Medical Treatment and Active Labor Act (EMTALA) rubric not only require a medical screening examination, but also require stabilizing treatment of any emergency medical condition that is discovered during that medical screening examination. The definition of “emergency medical condition” as used in EMTALA is

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A disease or process with acute symptoms of sufficient severity such that the absence of immediate medical attention could reasonably be expected to seriously jeopardize the health of the patient or unborn child, to cause serious impairment to bodily functions, or cause serious dysfunction to any bodily organ or part.2

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Acute strokes, acute myocardial infarctions, and acute respiratory failure are all examples of unstable emergency medical conditions, which would warrant admission to the hospital.

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Patients Requiring Transfer

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In some instances, an emergency medical condition may be diagnosed, but unable to be stabilized at the presenting facility. For example, a patient suffering an acute myocardial infarction who has failed thrombolytic therapy may require urgent cardiac catheterization. However, if the hospital does not have the capacity to perform primary coronary intervention, transfer to another facility with the capability to primary coronary intervention may be indicated.

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Federal EMTALA laws also impose requirements upon transfer of patients between facilities. If a patient with an emergency medical condition is to be transferred to another ...

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