Email Discussion Group: Post Procedure Admitting

(Thank you to acjmom52@hotmail.com for our latest discussion group question, below).
(Thank you to acjmom52@hotmail.com for our latest discussion group question, below).
Post-procedure order sheets Our department has created new post-procedure order sheets which require a designation for type of admission. Patients are to be admitted to observation status unless there is no chance they will be discharged in 24 hours from the time the admission orders were written. I have found that most physicians have an understanding of these regulations but don’t think about it at the time of admission. The requirements from CMS change so frequently this is understandable. We have the opposite problem in that our docs frequently admit them as inpatients despite the plan to discharge them in 24 hours. You can change your OBS patient to inpatient status within that first 24-hr period but the opposite is not true. So you are in a decent position, IF you have someone following the admission closely and get the status changed to IP. Case management is responsible for that in this institution but, as CNS, I attempt to educate the staff nurses also. Monica C. Simpson, RN, MSN, CCRN, Cardiovascular Clinical Nurse Specialist, The Heart Center of Excellence, Broward General Medical Center, Fort Lauderdale, FL, mcsimpson@nbhd.org Discharge from Recovery? We presently admit our patients post procedure, but our doctors also want to keep our patients in our Cath Lab Recovery for 23-hour observation. In fact, our doctors would like to discharge IP’s and move them to our Recovery room post procedure and be discharged from there. Is anyone doing something similar? BCole@ftsm.mercy.net All patient I/Ps Since we are a facility doing intervention without surgery on-site, we need to have all of our patients become I/P (CMS reimbursement issue). Drug-eluting stent placement was not reimbursed on an OBS/OP basis the APC for this went into effect July 1st . Natalie D. Beiler, Assistant Director of Cardiology, Rockingham Memorial Hospital NBEILER@RHCC.com A 23-hour observation All of our PCIs are admitted to the CSSU for an overnight criteria. We call this a 23-hr observation. The following morning if all the lab work is okay then they’ll be dismissed. If their lab work, CPK, and troponin level all bump up, then they’ll become a full admit. Whether they stay in the short stay or go to the floor depends on bed availability in the hospital. Kevin, ldrich3@comcast.net Seek a win/win result Why do they have a choice? I guess that because we are putting 2-30 cases through a 15-bed recovery room has something to do with it. We are almost always at operating capacity through our the hospital. There are bed meeting held daily to strategize where to put patients. All early cases are assigned beds on the floor as soon as they are available. Late cases are assigned beds on the floor if they become available if they don’t, then the patients stay the night in recovery and are discharged from there the next day. It is to the physicians’ benefit that the patients move to the floor. Many overnight patients can create gridlock in recovery as early as 9 or 10 in the morning. Reimbursement I thought it was better for IP than 23 hour. I guess if their decision impacts their practice, then it will make a difference to them. I also think that you need to ask why they want them to be in observation rather than IP. Are you staffed to manage that? Is the care different? Is reimbursement different? Is it more convenient? Is there a difference in post-procedure complications? Time to get every one to the table, discuss issues, make a plan and write a policy that everyone can agree on. Remember, if there are underlying issues (like patient care) you might also be agreeing to re-educate staff on another unit how to care for your specific patient population. You might need to get input from finance. (both on the reimbursement issue and on the nursing hours wasted when there are available staffed beds elsewhere in the hospital. Try to turn this into a win/win. Anna, annasmith@chi-east.org Patients tend to follow standard routes Our patients go back to the outpatient floor if they do not have any interventions done and just have a diagnostic cath. They usually get discharged the same day. If patients have a interventional procedure, they are admitted to the tele floor and usually are discharged the next morning. Annie Ruppert RN Annie.Ruppert@sharp.com Patients go to Telemetry Our hospital (located in San Diego) admits all patients to one of our Telemetry units post procedure. Our cardiologists are more comfortable doing this, and we have no recovery or observation area. It is my understanding that a 23-hour observation patient is an outpatient in the eyes of payers. Keeping a patient for 23 hours will not affect your reimbursement. All of our DES patients are inpatients, as are all of our bare mental stent patients. Mike, Mike.Martin@sharp.com Patients admitted for 24 hrs post We are a demonstration project for doing PCI without on-site surgical backup. Therefore, all of our patients are admitted for 24 hrs post procedure. We also had to get a carve out from the private insurers. carletta@weirtonmedical.com Currently all of our PCI patients are admitted overnight. We are starting a series of construction projects which will add an additional cath lab, cardiac ORs and double the size of our holding area. We will very likely begin 23-hr observation in the holding area at that time but volume will be a driving factor on that use. We also always have inpatient bed availability problems (one of the main reasons for having a holding area!) and deal with that daily. With the addition of the above services and DES, managing the expected volume increases will be interesting! One thing that we were able to do with the current bed status problem, based on the fact that the holding area is only staffed 7a-7p, is that the post cath patients are placed as second in priority only to an acute MI. All other admission types then are assigned available beds after that. The alternative we offered was that nursing supply the holding area staff, if needed, after 7pm, but with their shortage that was not feasible either. The decision was made between nursing, admin and cardiologists. Bed management comes to the lab every am to check our schedule, and even those scheduled as OP are placed on the bed list for assignment (you can always release a bed!). This has helped immensely in our patient flow, though there is always still the occasional wait for that ER patient who comes through the lab. The fact that DES does currently pay better as inpatient also influenced our decision to hold off on starting observation in the holding area. You have to consider the cost of staffing 24 hrs vs. your potential volume and actual profit. It did not work for us at this time, so we will re-examine that service once our construction is completed. pam_ragland@bshsi.com Have a suggestion for a future question? Would you like to join the Cath Lab Digest Email Discussion Group? Email us at: cathlabdigest@hotmail.com