Observation medicine nursing considerations

Observation Medicine: Nursing Considerations

Mark Flitcraft RN MSNDirector Department of Nursing

Ronald Reagan UCLA Medical Center

Chicago September 2013

This speaker has no financial or other disclosure and is solely responsible for the content herein.

Welcome!!

UCLA Health SystemRonald Reagan UCLA MC

Of the more than 100 academic medical centers and their nearly 200 affiliated hospitals that are members of the nationwide University Health System Consortium, Ronald Reagan UCLA Medical Center is a leader in the U.S. for patient satisfaction among those institutions that reported their patient-satisfaction scores.

Ninety-six percent of our patients say they would recommend us to a friend or family member.

HCAPS Ronald Reagan UCLA

For the specified HCAHPS reporting period, 95% of patients rated the overall quality of Ronald Reagan UCLA Medical Center 7 to 10, where 10 represents the "best" hospital.

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Ronald Reagan UCLA MC

Tertiary/Quaternary Referral HospitalNumber of Beds – 520 WW

and 266 SMHAll Specialties-except burnAll Types of Transplants Operating Department

23 Operating Rooms & 16 SMHLevel I TraumaStroke CenterSTEMI

OBSERVATION OUTLINE• I. Observation Review

A. Settings B. Exclusions C. Examples• II. Business Case

A. Data based analytics 1. DRG review 2. Payer review

B. Stakeholder group assembly C. Cost Considerations

• III. Staffing MixA. Characteristics of ideal Charge NurseB. Nursing staff qualities

• VI. OBS Daily Operations • V. Quality Metrix

What is observation?

OBSERVATION STATUS

Observation

CMS Definition OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS)

PURPOSE OF OBSERVATION: “DETERMINE THE NEED FOR FURTHER TREATMENT OR INPATIENT ADMISSION.”

Specific, clinically appropriate services which include: * Ongoing short treatment

* Assessment * Reassessment

Observation by INTERQUAL

* Observation status* Observation units

* Rapid treatment units * Mckesson©

Observation should be considered if the patient does not meet acute care criteria and, • Diagnosis, treatment, stabilization and

discharge can be expected reasonably to occur in 24H

• Treatment and or procedures will require more than 6H observation

Observation further defined

…before a decision can be made regarding whether patients will require further treatment as hospital inpatients of if they are able to be discharged from the hospital.

Medicare Benefit Policy Manual

MEDICARE

• Part A – Inpatient Consumer burden: more limited, deductible based Government burden: All except deductible

• Part B – Outpatient Consumer burden: 20%Government burden: 80%

In FY2011 CMS recognized the newly created CPT subsequent observation care codes (99224-99226) .

• Under current Medicare rules, the program pays more for Part A inpatient stays than for Part B "observation" stays. Moreover, beneficiaries must be admitted for inpatient care for at least three days to qualify for follow-up care in a nursing home.

• When an auditor determines that a hospital inpatient stay should have been classified as an observation stay, the hospital generally loses the full Medicare payment for the stay. As such, many hospitals err on the side of caution to avoid losing full payments and classify patients as "observation."

OBSERVATION CAVEAT

Non-Covered Observation

Services which are not reasonable or necessary for the diagnosis or treatment of the Observation patient.

Services provided for the convenience of the patient, patient’s family, physician.

Examples of services which are part of another Part B service such as recovery room, pre-procedure prep, chemotherapy.


Observation

Who can admit a patient to Observation status?

“Observation services are covered only when provided by the order of a physician or another individual authorized by State licensure law and hospital staff bylaws to admit patients to the hospital or to order outpatient tests.”


OBSERVATION Status by Payer

COMMERCIALMEDICAREMEDICAID

Limited or none

Full / Defined Varies

Covered Observation Services

All hospital observation services that are medically reasonable and necessary are covered by Medicare


• Consider: Who will manage the medical care and oversight of Observation patients?

Usual OBS Settings • ED-based Observation 1• Dedicated Observation

unit2

• Virtual Observation 3• Integrated Observation

beds – Clinical Decision Unit

4

Staffing

• ED physician assigned to observation• Hospitalist assigned to observation• Combination

– Systems-based practice• When can stress tests get done?• PT evaluation/SNF placement

– Practice-based learning• The patient with exacerbation of chronic low back pain

RRUCLA Observation Unit Medical Coverage

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ATTENDING MD

HOSPITALIST

Nurse Practitioner

ATTENDING 8AM-6PMED-based Hospitalist –

6pm – 7am

NP #1 7am-6pmNP #2 3pm-11pm

• Management of the medical care and oversight of Observation patients is influenced heavily by geographic location and hospital flow and is a fundamental determination for an effective patient care area.

Plus and Minus OBS settingsED-based Dedicated unit Virtual Integrated

Billing Must differentiate from ED

Relative ease Challenging Challenging

Documentation Start and stop time sometimes not easy

Relative ease to focus on accurate documentation

Challenging Overcome able challenges

Staffing ED-based staffing ratio / models

Fixed and allows to flex off

Fixed Fixed

Provider oversight Challenging Allows for constant and consistency

Challenging May be confusing

Bed capacity to flex Limited Limited Most flex opportunity

Flex opportunity

Team partnerships (CM, Billing, Coding)

Challenging Best for team model

Challenging Doable

Observation status –time as the primary

equalizer and guide.

At least 8 hours Usually between 24-48

hours Rare > 48 hours

Business Case: Getting Started

1. Retrospective data review2. Time period to review3. Charges / Revenue4. Stakeholder identification 5. Deliverables before implementation

6. Staffing

Retrospective Data review key points

• Nothing unusual during this time period Consider:

*Nearby facility / hospital closure?*Newly reassigned volume by

major insurance provider

*Volume influx related to new program or provider

• Relatively constant volume

• Far enough away from actual hospitalization so that data is final in terms of profit and loss

Retrospective Data review key points

1. Admitted but billed as outpatients after coding review2. One day stays

* Opportunity window: 36-48H stays3. DRG groups 4. Procedure Group

Consider opportunity by volume for dedicated 5. Medical Record (encrypted) 6. Admit date 7. Admit Location / unit 8. Admitting Service 9. Admit status 10. Total billed charges11. Total billed charges less payer payment 12. Total billed charges less patient co-pay / share of cost 13. Total billed charges outstanding balance

Payer Review Key Points • Medicare - % of whole • Medicaid - % of whole • Contracted care – % of whole

Capitated care? Non capitated care?

• Private insurance - % of wholeHMO assigned?

• Military - % of whole• Self pay -% of whole

If not in contract language Observation status may need to be – consider advantage / disadvantage of contract language

inclusion.

EXAMPLE ADMITTED BUT BILLED AS OUTPATIENTS (6 mos)

Payor E Cases Avg Hrs In House

Total Charges

True Net Revenue

Act Var Cost

Act Total Cost

Var Contrib Margin

Profit (Loss)

MEDICARE 316 19.1 3,682,123

1,601,721

1,030,487

1,512,454

571,234 89,267

MEDI-CAL 186 8.9 1,293,732

252,406

257,145

365,867

(4,739) (113,461)

NON-SPON

19 14.8 65,279

34,794

10,387

16,507

24,407 18,287

PRIVATE 4 13.3 54,109

22,823

8,887

13,086

13,936 9,737

CONTR NCAP

433 10.7 3,569,361

912,471

660,301

965,652

252,170 (53,181)

CONTR CAP

10 19.8 133,262

880

27,463

41,875

(26,583) (40,995)

Grand Total

968 13.3 8,797,866

2,825,095

1,994,670

2,915,441

830,425 (90,346)

EXAMPLE ONE DAY STAYS (6 mos)

Payor Cases Avg Hrs In House

Total Charges

True Net Revenue

Act Var Cost

Act Total Cost

Var Contrib Margin

Profit (Loss)

MEDICARE 593 25.5 13,667,706

9,921,555

2,698,928

3,901,563

7,222,627 6,019,992

MEDI-CAL 258 25.6 4,320,195

472,776

904,542

1,310,076

(431,766) (837,300)

NON-SPON

165 21.7 2,142,737

355,546

372,181

584,895

(16,635) (229,349)

PRIVATE 40 25.2 667,863

285,683

134,704

198,374

150,979 87,309

CONTR NCAP

1,750 24.8 31,771,761

6,785,419

6,733,005

9,731,517

52,414 (2,946,098

)

CONTR CAP

40 22.9 813,206

143,252

149,290

224,127

(6,038) (80,875)

Grand Total

2,846 24.8 53,383,468

17,964,231

10,992,650

15,950,552

6,971,581 2,013,679

Example DRG group data review DRGOutpatients

DRGOne-day stay

PROCEDURE One-day stay

PROCEDURE

CHEST PAIN + none ABDOM AORT CHEST PAIN

SYNCOPE + none ACUTE APPE CHR ISCHEM

AICD / CARDIAC CATH

DEHYDRATE + none ALCOHOL WI

CONGESTVEHEART FAIL

SICKLE CELL + none ATRIAL FIB

VASCULAR PROC PNEUMONIA,

HEADACHE + none BENIGN NEO

ENDOCRIN PROC SYNCOPE

CHEST PAIN + PTCA CELLULITIS

80 / 20 Rule APPLIED DAILY OPERATIONS

Aim for the 80% of your DRG’s for staff competency!

DRG Top Case Count % of Total Cases

ESOPHAGITIS, GASTROENT MISC DIGEST DISORDR X MCC 17 10

RED BLOOD CELL DISORDERS W/O MCC 23 14% OBS SYNCOPE COLLAPSE 19 12%

CHEST PAIN 35 21%

KIDNEY URINARY TRACT INFECTIONS W/O MCC 16 10%

CELLULITIS W/O MCC 16 10%

RENAL FAILURE W CC 8 5%

OTHER KIDNEY URINARY TRACT DIAGNOSES W CC 8 5%

OBS Total 142 89%

OBS Inclusion / Exclusion sample criteria

OBS Exclusion Criteria•Hemodynamic instability requiring intensive care level of care or 1:2 nursing staffing•Psychiatric holds (5150) or violent patients• C Diff / H1N1 / TB patients in the negative airflow rooms and patient single bathroom • Adolescent / adult unit and does not accept patients younger than 13 years of age.• Preferred unit for ambulatory patients due to the two public bathrooms for patients. Unknown differentialUnable to mobilize (and was able to mobilize prior to current illness)Pt refusal of appropriate care

OBS Ward Room Exclusion CriteriaAny patient requiring any isolation precautions (contact, airborne, droplet) or who has GI illness (e.g., N, V, diarrhea) or copious drainage or secretions should NOT be placed in this holding area / Pediatric patient (< 13 years) / 5150 or Psychiatric Hold / Ventilators / Hemodynamic instability requiring intensive care level of care or 1:2 nursing staffing.

Stakeholder assembly

• Getting the right people on the team from the get-go!

OBS Team Members

• Aligning MD-Facility interests • Coding

• UR / Case Management • Admissions

• Billing / Revenue • Nursing

• Pharmacy • Compliance

• ED• PACU?

OBS Collaboration Partners

• ED based 24/7 RN / MD Case Management / Interqual review Prospective review• Unit-based RN Utilization Review Concurrent / Retrospective review• Unit-based nurse training • Dedicated MD / NP provider team training • Coding / Revenue Analysis • Compliance regular sessions

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Obtaining Buy-In:ED Physicians

• Improving “the numbers”– ED length of stay

• Time from triage to disposition for specific diagnoses

– Number of patients Leaving Without Being Seen– % of time ED closed due to “saturation”

• Utilization of Resources– Improved Hospital throughput

• Less ED MD and RN time and resources spent on “boarders”

Obtaining Buy-In:Internal Medicine Physicians

• Specially-trained support staff– Help with discharge– Billing

• Decreased paperwork burden• Geographical-based rounding

Academic Hospitalists:New Educational Opportunities

• Focus on “bread and butter medicine”• Focus on bedside physical diagnostics rather

than multiple imaging studies• Education on cost of care• Research opportunities on treatment

algorithms, patient safety, patient education

Best Practice Units

• Focus on guideline based provision of care, patient safety, and clinical outcomes

• Specially trained staff

• Focus on patient education

Collaboration with Stake Holders

• Consider: The relationship with Patient Business Services (PBS) at the outset.

• Connecting at the billing and charging level for Infusion/Hydration/IV Push as well as blood transfusions and vaccine administration injections for patients – can be a relationship

and communication strength.

• Reasons for this special connection are how the charges from an OBS area originate and are moved through the revenue cycle and billed to payors.

Connecting with Gonda Observation Unit

Charge posting

Documentation of services rendered

Place of Service ( ED) (GOU)?

Billing Review

DenialsUnderpayments/Overpayments

Audits

Consider: Observation status has multiple areas of Revenue Cycle connection points to Billing. Best Practice: Begin education and training on how to document and charge in these areas to reduce risk in over/under CPT coding and claims adjudication-denials or overpayments;

Develop a comprehensive program with Billing and Clinical staff starting with the Revenue Cycle to give a “big picture” on how charges generate onto a claim;

Nursing Staff drill down to documentation guidelines and CPT coding the services rendered;

Maintain a dialogue on a concurrent (pre-bill) review asking questions between Clinical staff and Billing staff to ensure that documentation and CPT coding coincide with the services performed.

Consider: System generated and/or custom built pre-billing edits on claims for which we would expect the components of Infusion/Hydration/IV Push and blood transfusion charges to meet required billing criteria:

Example: There is a blood product charged but a missing transfusion chargeExample: There is a vaccine charge but there is a missing vaccine

administration chargeExample- There are two (2) “initial” charges same day for an

Infusion or Hydration (this is a good trigger that there was an IV started in the ER and both units are charging for the initial Infusion or Hydration)

CHARGES / REVENUE

• Keep it clean – have one rule for nursing / clinical OBS staff and use time as the equalizer.

• Risk: RAC/ OIG or charge inflation by payer!• Correct billing / documentation / patient care the first

time!

• Recommended Best Practice: One rule for all OBS patients and do not consider payer.

Avoid Payer Charge Distinctions!

Other Financial process considerations NURSING ADMIN CHARGEMASTER

NONCHEMO IV INFUSION 1ST HOUR 2010106 $280.000260 C8950 90780ZS C8950 C8950 4871 48718

NONCHEMO IV INFUSION EA ADD HR 3010106 $280.000260 C8951 90781ZS C8951 C8951 4871 48718

NONCHEMO IV PUSH EACH 2010106 $80.000940 C8952 90784ZS C8952 C8952 4871 48718

NONCHEMO INJECTION IM/SUBQ EA 2010106 $120.000940 90772 90782ZS 90772 90772 4871 48718

BLOOD TRANSFUSION 0-2 HR 3010104 $550.000391 36430

36430ZM 36430 36430 4871 48718

BLOOD TRANSFUSION 0-4 HR 6010104

$1,100.000391 36430

36430ZM 36430 36430 4871 48718


$1,650.000391 36430

36430ZM 36430 36430 4871 48718


$2,200.000391 36430

36430ZM 36430 36430 4871 48718


$2,750.000391 36430

36430ZM 36430 36430 4871 48718

CATHETERIZATION BLADDER STRAIT 0.5090205 $180.000761 51701

51701ZM 51701 51701 4871 48718

ARTERIAL PUNCTURE BLOOD DRAW 0090106 $20.000300 36600 36600TC 36600 36600 4871 48718

VENIPUNCTURE BLOOD DRAW 0090106 $40.000300 36415 Z5220 36415 36415 4871 48718

Other Financial process considerations OBSERVATION HOURLY CHARGEMASTER

OBSERVATION LVL1/HR DIRCTADMIT $100.0099218 9921827 G0379



OBSERVATION DISCHARGE EVAL $100.0099217 9921727

Observation Deliverables EXAMPLE

Nursing admission flowsheet

Pathway of care

Plan of care (NIC/NOC) Patient education brochure Chargemaster sheet Physician education

SOP Order sets

Audit form for tracking charge items Training / orientation packet for RN’s / UAP Scheduling guidelines

Observation Focus / Patient Expectations

The patient, patient’s family, and primary physician should be appraised at the time of admission to the GOU that this is a focused observation period to determine whether the presenting condition requires further inpatient care or can be managed as an outpatient.

Extensive diagnostic imaging is not appropriate for the Observation unit. Diagnostic imaging should be completed when possible prior to placement in the GOU.

OBS patients are given a unit brochure at admission explaining hourly Outpatient charges and share of cost.

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Staffing Considerations: Getting Started

The Right People, with the Right Mindset, Doing the Right Work,…Selection Points

Consider: Nursing Philosophy Model and Vision

Team Model compared to Maslow Hierarchy of Needs

Inattention to outcome – personal

success before team success

Avoidance of answerability

Lack of buy-in = ambiguity

Fear of conflict

Absence of trust

Self-Actualization

Esteem

Love / Belonging

Safety

Survival Same

STOPDomino

affect

Patrick Lencioni The Five Dysfunctions of a Team Maslow Hierarchy of Needs

Same

Individualistic focus

Team focus

US VERSUS ME

Consider the type OBS unit and select staff accordingly. ED-based is different than an integrated unitVirtual is different than a combined post-procedure unit

BEST OBS Registered Nurse characteristics: * Team oriented* Patient-centric* Able to think out of the box* Nursing experience important * Interested in patient teaching * Comfortable with degrees of autonomy * Not too detail focused, but also not too detail naïve * Strong interpersonal people skills* Solid clinical ability

An OBS unit is a rule-in, rule-out unit and as such – sometimes rules in!

Staff characteristics

Consider the OBS Charge Nurse

Characteristics of an Effective OBS Charge Nurse: *Ability to oversee and predict / forecast *Strong clinical ability *Detail focused *Leadership ability interpersonally *Proven problem-solving skills *Able to manage and multi-task at a high level *Handles stress effectively *Solution oriented *Patient-centric*Cost / financially aware

Manager Role

Hallmarks of Problems in OBS Nursing Staffing

• “This is how we always do it” • What is the staffing ratio law for OBS?• “I cannot take another admission – I just had one!”• Overwhelmed by important OBS details

such as documentation • Inability to follow through with a degree of

independence• Frequent complaining “This is unsafe”

FIT IS EVERYTHING!

Day to Day OBS Operations

Key operation Points

1. Documentation Provider and Nurse points

2. Charge Capture3. UR / Coding / Compliance/ SW / Patient Affairs partnerships4. Flow questions

This doesn’t look like an OBS patient does it?5. Quality Metric Indicators

OBS Documentation Basics

Provider key points: * Specific reason for observation * Consider order sets / protocols to streamline

and standardize care * No differential fishing / cherry picking!* Consider: Process for how to resolve questionable OBS cases* Template for charting – recommended!

Remember: Observation status for ____ (BE SPECIFIC!)

Consider RN charting to reflect ongoing need for Observation with Provider.

Consider Provider prompt for Observation status clarification at time points.

Nursing documentation key points:

• Start and stop time of IV push and IV infusion • Careful! No double-billing with ED• Reason for OBS admission documentation • Plans of Care – time specific orientation best!• Efficiency of flow

OBS admission assessment versus inpatient assessment• Patient education Observation status

PEARL: Teach versus Inform

Ancillary OBS staffing

Fixed or flexed?Role clarity important

Example: Cross-trained UAP clinical and secretarial Assignment guidelines –

Assigned to Registered Nurses not patients Customer service focus and service recovery trainingProductivity ideas:

Secretarial – scan and upload charts within 6H dischargeSecretarial – enter nursing charges

Sample daily charge capture flow chart

OBS Unit-based Hourly Charges

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Infusion Charging

• Unit-based RN training

• Shift-based completion and time of discharge review

• Unit clerk charge entry

• Cross-check confirmation process

• Scanning at time of discharge MD / NP provider orders

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Observation Quality Metrix

Quality Metrix Indicators

1. HCAPS Patient Satisfaction Data 2. Charge Capture3. Nursing administration charge submission time4. Patient Safety Indicators

Falls, PU, Med Error, Nosocomials, CLABSI 5. Readmission Rate 6. Core Measures: PNA Vaccination, Sepsis 8. Employee Satisfaction Scores9. Time to bed from ED bed assignment 10. Budget / Financials

Gonda Inpatient Unit - Performance Dashboard

RR UCLA Medical CenterPerformance Dashboard

Gonda

FY 2013

Target Threshold Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Mar-12 Apr-12 May-12 Jun-12 Jul-12 Aug-12

Blood

Specimen - Order Form Match - Wrong Patient (A1)9

00: green; 1: yellow

1+: red

0 0 0 0 0 0 0 0 0 0 0 0 0

Specimen / Order Form Mismatch (A3)90

0: green; 1: yellow1+: red

0 0 0 0 0 0 0 0 0 0 0 0 0

Falls

Falls per Month10 0 0: green; 1: yellow1+: red

0 1 0 1 0 0 0 0 1 1 0 0 1

Falls per 1,000 Patient Days100 0.00 4.98 0.00 5.24 0.00 0.00 0.00 0.00 4.78 4.88 0.00 0.00 4.42

CORE

Smoking Cessation Teaching (Audit)1190%

>90: green; 85-90%: yellow; <85%: red

58% 86% 94% 100% 83% 92% 82% 80% 94% 100% 56% 100% 94%

Patient Satisfaction*

HCAHPS - Would Recommend UCLA to Family6

82.6% (90th percentile) >90%tile: green; 89-50: yellow;

<49: red

81.4% 79.2% 86.4% 81.6%

HCAHPS - Rate Hospital677.3%

(90th percentile) >90%tile: green; 89-50: yellow; <49: red

74.7% 70.8% 85.9% 72.5%

HCAHPS - Treated with Courtesy & Respect by Nurses6


<49: red

80.5% 78.7% 75.9% 82.6%

HCAHPS - Got Help as Soon as Wanted6


<49: red

65.0% 62.7% 61.9% 68.4%

HCAHPS - Got Help Going to the Bathroom6


<49: red

69.7% 69.0% 67.7% 67.5%

HCAHPS - Confidence & Trust in ICU6


<49: red

no data no data no data

HCAHPS - Felt Emotionally Supported by ICU Staff6


<49: red

no data no data no data

HCAHPS - Education on Symptoms after Leave Hospital6


<49: red

74.3% 66.7% 77.5% 80.6%

% of Employees with CICARE Obs.18100% 90%: green; 89-50%: yellow;

<50%: red

21.0% 24.0% 33.0% 26.0%

# of Call Lights12 1707 1594 1635 1586 2306 1687 1835 2463 1483 1942 1960 1735 1460

Operations

Average Length of Stay14 2.2 <3: green; 3-4: yellow; >4: red 2.2 1.9 1.7 1.5 2.1 1.7 2.3 2.2 2.1 1.9 1.9 2.1 1.8

Financial

Average Daily Census167.7 7 7 5 6 8 6 8 9 7 7 8 10 7

FTE Total1738 41 43 41 41 44 43 41 42 43 44 41 42

Actual Inpatient Hours versus OBS Hours

FY11 FY12

AVERAGEINPAT LOS 61.98734H 58.76H

AVERAGE OUTPAT LOS 32.1885H 29.3H

OBS versus Inpatient Dollars

• Average Inpatient Telemetry Charge $7500.00

• Average Observation Charge $5,214

• 8/2009 – 6/28/2010

OBS Controlled Substance Discharge RX

• Consider: Controlled substance prescriptions are issued for a limited period only (Recc: 3-7 days only.

• Patient notice of this OBS unit rule is given through the Patient Education Brochure.

• Adherence to pain EBP medication regimens is required.

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Obs “Hall of Fame”Was this pt REALLY admitted to the Observation Unit?

• 19yo with nausea and vomiting for several weeks

• 30lb wt loss• Admitted to obs…? For PO intolerance.• Diagnosis: widely metastatic testicular cancer

Obs “Hall of Fame”

• 100yo man• Hgb 7.0• INR 4.5• New massive flank hematoma• Admit to GOU for “transfusion support”

Obs “Hall of Fame”

• 24yo woman• h/o L hip dysplasia and chronic pain (on

chronic oral opioids)• Has severe worsening of L leg and foot pain• New bluish discoloration of L foot• “admit to obs for pain control”

Final Thoughts

• “If you could get all the people in an organization rowing in the same direction, you could dominate any industry, in any market, against any competition, at any time.”

Author Unknown

On Flexibility and Fluidity…

Contact Information

Contact informationMark Flitcraft RN MSN

[email protected]# 310 267 9529

mailto:[email protected]

• Lencioni, P. (2002). The five dysfunctions of a team: a leadership fable, San Francisco, CA: Jossey-Bass.

Resources• http://www.cms.gov/Regulations-and-Guidance/Guidance/

Transmittals/downloads/R2282CP.pdf

• http://www.advisory.com/Daily-Briefing/2012/08/13/Would-relaxing-payment-rules-improve-patient-care

• http://www.aha.org/advocacy-issues/rac/contractors.shtml

• http://www.medicare.gov/cost/

• http://www.scha.org/files/documents/medicare_inpatient_only_procedures_2012.pdf

Part A ServicesBlood In most cases, you won't have to pay for blood or replace it. Home Health: $0 for home health care service; 20% durable medical equipmentHospice Care: $0 for hospice; $5 per prescription for outpatient prescriptions

5% of the Medicare-approved amount for inpatient respite care Hospital Inpatient Stay: $1,156 deductible per benefit period

$0 for the first 60 days of each benefit period$289 per day for days 61-90 of each benefit period$578 per "lifetime reserve day" after day 90 of each benefit period Skilled

Nursing Facility Stay: $0 for the first 20 days each benefit period$144.50 per day for days 21-100 each benefit periodAll costs for each day after day 100 in a benefit period

Part B ServicesPart B Deductible $140 per year.Blood In most cases you won't have to pay for blood or replace itHowever, you will pay a copayment for the blood processing and handling services for every unit of blood.Clinical Laboratory Services: $0 for Medicare-approved services.Home Health Services: $0 for Medicare-approved services. You pay 20% for DME. Medical and Other Services: 20% of the Medicare-approved amount for most doctor services Mental Health Services: 40% of the Medicare-approved amount for most outpatient mental health care.* In 2012, there may be limits on physical therapy, occupational therapy, and speech language pathology services. If so, there may be exceptions to these limits.Note: All Medicare Advantage Plans must cover these services. Costs vary by plan and may be either higher or lower than those noted above. Review the Evidence of Coverage from your plan.

• Appendix RRUCLA examples

Current RRUCLA Protocols 2013 Chest pain Syncope Uncomplicated alcohol withdrawal Gastroenteritis/ dehydration Electrolyte abnormalities Asthma Cellulitis PO intolerance with a readily remediable cause Symptomatic anemia/ thrombocytopenia with a known cause- admit

for transfusion Sickle cell disease with an uncomplicated acute pain episode Low-risk upper gastrointestinal hemorrhage Community-acquired pneumonia with a Risk Class below IV (see

algorithm)

83

Acute Gastroenteritis/PO Intolerance/DehydrationObservation Unit Inclusion Criteria• Dehydration with orthostatic hypotension or tachycardia• Cause thought to be reversible within 24hrs ie viral or bacterial gastroenteritis• Inability to tolerate crucial PO medsExclusion Criteria• Bloody emesis• Hematochezia with falling hematocrit• Sodium <125• Severe acute renal failure not likely to resolve with hydration (FeNa suggestive ofintrinsic renal damage etc)• Bicarbonate <12 on chem. Panel• Anion gap>15• Impending shock***See Forms Portal for Standardized Acute Gastroenteritis Order Set***

Observation Unit Stay for Transfusion ServicesInclusion Criteria1. Known cause for anemia and/ or thrombocytopenia (e.g., MDS with transfusiondependence)2. Anemia should be symptomatic or patient should be at risk of complications (e.g.,pts with known coronary artery disease) without urgent transfusion. If theseconditions not met, outpatient transfusion services should be arranged.3. Thrombocytopenia with minor bleeding (epistaxis, gingival bleeding)4. Thrombocytopenia and clinical assessment reveals increased risk of bleedingwithout urgent transfusion5. Patient’s hematologist or oncologist (or primary medical doctor if patient does notsee a hematologist or oncologist) should be contacted and verify that a medicalshort stay is acceptable and that further extensive workup is not currentlyindicated for a given patient.

Observation Unit Stay for Transfusion ServicesExclusion Criteria1. Hemodynamic instability2. Major bleeding3. Unknown cause of anemia or thrombocytopenia4. Further extensive inpatient workup expected (e.g., bone marrow biopsy withdischarge decision expected to depend on results)5. Febrile neutropenia6. Other active comorbid conditions (pneumonia, CHF, etc.) that would justifyinpatient admission7. Hematologist/ oncologist requests full inpatient admission

Nonvariceal UGIB: Inclusion/Exclusion Criteria for Gonda ObservationInclusion Criteria1. Likely diagnosis of nonvariceal upper GI bleed2. Hemodynamically stable3. Rockall Risk Score ≤ 2 in those who have had endoscopy performed prior totriage (If Rockall Risk Score calculated at >2 after endoscopy performed in ObsUnit, consider transfer to inpatient service).

Exclusion Criteria1. Known Esophageal/Gastric Varices2. History of known portal hypertensive gastropathy3. History of Liver Disease/Failure4. Evidence of stigmata of chronic liver disease on physical exam (spider angiomata,caput medusa) and laboratory data (elevated INR, low albumin, high bilirubin)5. History of Recent Abdominal Surgery (risk of aortoenteric fistula) includingrecent hepatobiliary tree instrumentation (risk of hemobilia)6. History of Disseminated Malignancy (pancreatic ca)7. History of chronic pancreatitis8. Orthostatic Hypotension9. Renal Failure10. Overtly Bloody Nasogastric Tube Aspirate11. Other Active Medical Conditions (CHF, New Angina, etc.) that warrant aninpatient admission

Complete Rockall Risk Score

Variable Points

0 1 2 3

Age <60 60-79 80

Shock Pulse rate >100 SBP < 100

Comorbidity Any other major comorbidity

Renal failure, Liver failure, disseminated

malignancy

Diagnosis Mallory Weiss lesions, no lesion observed and no stigmata of recent

hemorrhage

Peptic ulcer, varices, erosive disease,

esophagitis,

Malignancy of upper GI tract

Stigmata of recent hemorrhage

No stigmata or dark spot in ulcer base

Blood in upper GI tract, adherent clot, visible or

spurting vessel

PEF 33-75% of best or predicted after initial ED treatments PEF > 75% best or predicted but: Respiratory Rate >25, or Pulse >110, or Cannot complete a sentence in one breath, or Pt does not have acceptable air movement or has severe

wheezing on clinical exam, or Pt’s symptom resolution and PEF improvement lasts for only a

short period of time after each treatment, or SaO2 <95% or pt’s known baseline

Asthma

Inclusion Criteria for Observation Unit

• PEF <33% of best or predicted after initial ED management/treatments• Pt with asthma and signs/symptoms of concomitant active medical

illness (infiltrate on CXR suggestive of PNA, suspicion of CHF based on history, clinical exam, or BNP >100, etc.)

AsthmaExclusion Criteria for Observation Unit

• Any features of life-threatening asthma including:– SpO2<90% on room air– Silent chest– Cyanosis– Signs of fatigue/ poor respiratory effort– Bradycardia– Arrhythmia– Relative hypotension– Exhaustion, confusion, or coma– PaCO2 >42mm Hg (note: ABG not required before admission in clinically

stable pts)

AsthmaExclusion Criteria for Observation Unit

Risk Stratification(See Guidelines)

History Physical Exam EKG

High Risk (any one)Bradycardia < 40Pauses > 3 sec.Trifascicular blockAfib/FlutterNSVTEKG ST abnl, QT hDysfunctional pacer/defibSx/Signs of CHFIschemic chest painSevere valvular diseaseEvidence of GI blood loss

Moderate Risk (any one)Age > 60Hx CAD, CHFOld LBBB, stable Q wavesFam Hx premature (< 60 y/o)Sudden deathPacer/defib functioningSymptoms not consistent with vaso-vagal eventPostural BP > 15 mmHg Persistent BP <100 syst.

Low RiskAge < 50 No cardiac Hx, findingsSx’s consistent w/ vaso-vagal eventNo orthostatic BP drop

Admit CCU Service Observation Unit Discharge to Outpatient follow-up

Syncope AlgorithmSyncope – abrupt and transient loss of consciousness with spontaneous recovery without intervention.

Severe or repeated pre-syncope is an alternative diagnosis.

Alcohol Withdrawal Inclusion Criteria

• Clear diagnosis of alcohol withdrawal or acute alcohol intoxication after a complete history and physical examination

• Has an objective medical reason for observation (abnormal vital signs, altered level of consciousness needing repeat neuro checks, hypoglycemia, marked electrolyte abnormalities, etc.)

• High probability of response to treatment and discharge from hospital within 48hours

Alcohol Withdrawal Exclusion Criteria

• Delirium (during current presentation)• Seizure (during current presentation)• Alcoholic hepatitis• Pancreatitis• Active GI bleeding• Wernicke’s encephalopathy• Severe alcoholic ketoacidosis• Aspiration pneumonitis/ pneumonia

Alcohol Withdrawal Exclusion Criteria (Continued)

• Hemodynamic instability (hypertensive emergency or hypotension)

• Rhabdomyolysis• Other uncontrolled comorbidities (chf, diabetes, etc.)

expected to prolong hospitalization• Profound intoxication with inability to protect airway• Anticipated need for nursing facility placement at conclusion

of current hospitalization• Anticipated need for Neuropsychiatric Hospital bed at end of

hospitalization (unless NPH bed is currently being held for this patient)

Cellulitis Obs Inclusion Criteria

• Clear or probable diagnosis of cellulitis after complete history and physical examination

• High probability of response to treatment and discharge from hospital within 48hours

Obs Unit Exclusion Criteria for Cellulitis

• Tissue necrosis or crepitus on examination• Severe pain (may indicate a deep infection)• Signs of systemic toxicity/ possible early sepsis• Neutropenia• Diabetic foot with surgical intervention likely

prior to discharge

Risk Factors for Slow Response of Cellulitis to Treatment

• Cellulitis located on hand, periorbital region, scrotum, neck, or over joints • Diabetic patient without imminent surgical intervention• Peripheral vascular disease• Patient with chronic lymphedema or severe chronic venous stasis• Collagen-vascular disease on immunosuppressant medications• Other conditions associated with immunosuppression (active malignancy,

HIV, CKD, cirrhosis, s/p splenectomy)• Organ transplant recipients• Cellulitis with suspected subjacent osteomyelitis• Bite wounds• History of IV drug use/ skin popping• History of colonization or infection with resistant organisms

Common “Off Protocol” Admissions

Acute pain UTI/pyelonephritis Psychiatry patients needing short term medical

monitoring prior to admission Acute intoxications Headache Low-risk arrhythmia

Observation medicine nursing considerations

Health & Medicine

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