Imagine the following interaction between an emergency nurse and a patient:

Nurse: "Hi, what can I do for you today?"

Patient: "I cut my finger."

Nurse: "Okay, let's get your blood pressure while I ask you a few questions. When was your last tetanus shot? Are you allergic to anything? Tell me all of the medications you take including herbal preparations and non-prescription medications. Have you had a recent cough, fever, or unexpected weight loss? Have you fallen in the past year? Have you received influenza vaccine since October? Do you feel safe at home and in your relationships? How is your appetite? Have you ever tried to hurt yourself? Have you ever felt like you should cut down on your drinking? Have you ever received pneumococcal vaccine? Have you been hit, kicked, or otherwise injured by anyone in the past year? Do you smoke? Are you dizzy or having trouble with your balance? Can you read? Let me just swab your nose so we can check for methicillin-resistant Staphylococcus aureus (MRSA). Do you have any problems chewing or swallowing? Do you have any thoughts about harming yourself or someone else? Do you have any problems walking or taking care of yourself at home? Now, I'm going to swab your cheek so we can test you for human immunodeficiency virus (HIV)."

Ridiculous? Yes. Believable? Maybe. Outside the realm of possibility? No.

You probably recognize most of these as components of screening processes that you are already doing or have been asked to perform in the emergency department (ED). You may think that the HIV screening example is an exaggeration, but in February of this year a large academic medical center announced plans to routinely perform rapid HIV testing of all adults seen in the ED (Snyder, 2008). In addition, if a patient requires admission to the hospital as an inpatient, you may be asked to perform a total body assessment of skin integrity and a urinalysis to document conditions for which hospitals will not be reimbursed unless they are present on arrival. And that's just this year; stay tuned for new requirements in the upcoming years.

At least the HIV screening program mentioned above is a research project attempting to determine whether diagnosing HIV infection during an ED visit leads to earlier intervention and better patient outcomes. Unfortunately, not all screening activities are based on sound evidence. A recent study published in the Journal of the American Medical Association (Harbarth et al., 2008) concluded, "Overall, our real-life trial did not show an added benefit for widespread rapid screening on admission compared with standard MRSA control alone in preventing nosocomial MRSA infections in a large surgical department" (p. 1156).

Screening also presents ethical concerns. Edmond, Lyckholm, and Diekema (2008) argue that the unintended adverse effects of widespread screening for MRSA may include "decreased contact with healthcare workers, increased depression and anxiety, and increased rates of noninfectious adverse events among patients placed in contact precautions." Thus, an ethical conflict arises between the welfare of an individual patient versus the population of patients not colonized with MRSA. In addition, placing large numbers of patients on contact precautions could create patient placement nightmares for hospitals and lead to increased ED overcrowding and ambulance diversion (Harbarth et al., 2008). Screening also poses a dilemma with regard to societal resource allocation, is it the best way to spend scarce healthcare dollars? The answer is not "yes" for every condition.

If we had unlimited resources, including time and nurses, screening for all of these conditions during an ED visit might be feasible. After all, an ED visit is the only healthcare contact for many people, especially the uninsured or underinsured. But therein lies the problem; many people do not have access to comprehensive primary and preventative care. However, the mission of EDs is the polar opposite: to provide rapid assessment and intervention for acute, unanticipated conditions-hence the word emergency in the name. Many of these screening activities are irrelevant to an ED patient's presenting complaint. One could make a convincing argument for screening ED patients in specific circumstances for almost anything, just not for every condition with every patient at every ED visit. So why are regulatory agencies, payers, and our own institutions insisting that we perform an ever-increasing number of primary healthcare functions while facing growing numbers of nonurgent patients, unprecedented overcrowding with boarding of inpatients, and a nursing shortage? We believe the answer lies in emergency care providers' ability to be flexible and do what needs to be done.

We care for patients of all ages, all acuities, and with problems of all body systems (i.e., all comers)-even when our stretchers are full and our nurses are overwhelmed. Over the past 40 years, EDs have become America's healthcare safety net. We are victims of our own success, and it is threatening to drag us, and our patients, under. Society needs to focus on creating an infrastructure that provides patients consistent and ready access to preventive and primary care and let us focus on emergencies. The time is now to demand a rationale approach screening by engaging in dialogue with payers, regulatory agencies, and institutions about what is pertinent to the patient's ED visit and what is reasonable in terms of screening for unrelated conditions. If we continue to perform more and more tasks that are not congruent with our primary mission, we risk crippling an emergency care system that is already faltering. Then, everyone in the United States will be "working without a net."

Jean A. Proehl, RN, MN, CEN, CCRN, FAEN

Emergency Clinical Nurse Specialist, Dartmouth-Hitchcock Medical Center, Lebanon, NH

K. Sue Hoyt, RN, PhD, FNP-BC, CEN, FAEN, FAANP

Emergency Nurse Practitioner, St. Mary Medical Center, Long Beach, CA

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