Administrative and Regulatory Issues Relating to Emergency Department Management of Musculoskeletal Emergencies

The local practice standards and guidelines that are in place to help deliver quality care represent a distillation of influences from many sources. These sources include federal and local legislative guidelines, third-party payers, state health departments, licensing agencies for hospitals, and board certification agencies. Local practice and referral patterns also have a significant influence on how quality medical care is delivered. Because every institution has varying degrees of influence from these sources, it is impossible to establish exact detailed rules for how any individual case at a specific institution should be handled. Regulatory compliance with hospital, local, state, and federal obligations is complex and often requires a dedicated hospital department. However, some general guidance about the way these forces influence bedside practice and areas of special interest to emergency orthopedic care are worth reviewing.


The scope of practice refers to the actions, procedures, and processes that are allowed to be performed by an individual given his or her education, training, experience, and licensing. Emergency physicians collaborate with a vast number of specialties, and their scope of care requires a broad range of treatments to stabilize patients and reduce morbidity and mortality.

Credentials or hospital privileges refer to the list of procedures and actions that an individual may perform while working at an institution.

Conscious sedation privileges require special consideration in emergency management of many musculoskeletal emergencies. Board-certified emergency physicians have special training, experience, and skill in managing the complexities of unscheduled patients with analgesia and sedation needs for brief painful procedures. With proper training and patient monitoring, emergency physicians safely deliver sedation using medications that are otherwise generally used in operative settings.


Consent is a process of communication between a capable patient and the physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. During the discussion, the patient should be made aware of the following:

  • Diagnosis

  • Nature and purpose of a proposed treatment or procedure

  • Expected benefits, most common risks, and alternatives

  • Risks of not having the treatment

Capacity is the ability to make decisions about care. It is a subjective evaluation and depends on the clinical situation, including the following:

  • Nature of medical condition

  • Understanding of treatment and its effect

  • Risks of undergoing or not undergoing the treatment

Written consent is a document containing the critical elements of the consent discussion and is generally signed by the patient. The written consent form documents the discussion and is frequently included in the permanent medical record. Certain emergency department procedures are better handled with a written consent to document the discussion and demonstrate the willingness of the patient to undergo the treatment. These procedures include the following:

  • Procedures requiring conscious sedation

  • Procedures with moderate or significant risk of short-term and long-term complications

  • Procedures with a reasonable alternative treatment, setting, or timing of care

Verbal consent is the same communication and exchange of information between the health care provider and patient as contained in the written consent form but without the formality of writing out and signing a consent form to document the discussion. Verbal consent should be documented in the medical record. Verbal consent is appropriate for most emergency department procedures. These include the following:

  • Procedures that are performed with the patient awake and interacting with the health care providers, for example, simple wound care and laceration repair, minor joint and fracture reduction done with local block and analgesia but no sedation

  • Procedures that the patient anticipates and requests, for example, when a patient presents requesting a dislocated shoulder be reduced and no sedation is needed.

Implied consent is not expressly granted but granted in an inferred manner based on actions and circumstances. Generally, only very basic and expected actions rely on implied consent in health care settings. These actions include removing a dressing for examination, obtaining necessary tests and x rays, and performing low-risk and generally comfortable procedures. Often a general and simple “consent for care” document is created during the emergency department registration process to cover these expected and incidental procedures during care.

Emergency consent relates to the fact that in certain emergency situations patient consent is presumed to exist for medical treatment that addresses the emergency. There are three general circumstances, as follows:

  • Unconscious patient consent for lifesaving and limb-saving treatment is implied.

  • A conscious patient who has impaired decision-making capacity generally requires the treating physician to obtain consent from next of kin. However, lifesaving and limb-saving treatment need not be delayed while attempting to obtain that consent.

  • Minor age patients generally require a parental consent. However, lifesaving and limb-saving treatment need not be delayed while attempting to obtain that consent.

A mature minor (usually a teenager <18 years old) may give informed consent if, given circumstances, the minor patient has the ability to understand the treatment goals and risks.

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Sep 30, 2019 | Posted by in ORTHOPEDIC | Comments Off on Administrative and Regulatory Issues Relating to Emergency Department Management of Musculoskeletal Emergencies
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