Patients properly placed as throughput streamlined
Unscheduled admissions targeted
An access initiative at Sutter Health in Sacramento, CA, is helping streamline throughput while placing "the right patient in the right hospital at the right level of care," says Barbara Leach, RN, director of case management for Sacramento Yolo Sutter Health.
Part of the impetus for the project was an increasing number of one-day stays, which the health system's administration was "not thrilled with," adds Leach. The Centers for Medicare & Medicaid Services (CMS), she notes, sets a target percentage for one-day hospital stays by Medicare patients. The rationale, Leach explains, is that if a patient is only in the hospital for one day, the question whether the person might more appropriately have been given observation status, for example, or referred to a skilled nursing facility arises.
Another problem, she says, was that an increasing number of patients at Sutter's two acute care hospitals, which together have well over 600 beds, were not meeting InterQual criteria — a set of measurable clinical indicators, as well as diagnostic and therapeutic services, that reflect a patient's need for hospitalization.
"My personal driver was getting patients into the right status of admission," Leach says. "There is so much confusion, so much [area] that is gray, when an outpatient needs to remain for a longer period than normal because of unforeseen complications."
The first pilot project took place during the last week of June at Sutter General Hospital, she says, with a team composed of a case manager, a patient placement nurse already charged with assigning beds, and bed placement clerical staff who keep track of admission data and verify insurance eligibility.
"We live in an area where people change [insurance] carriers all the time, so one issue is determining whether a patient should even be admitted to this hospital," Leach notes. "We were often not finding out until a day or two later that someone was [taken] to another hospital. The other hospital calls and says, ‘Thanks for providing open-heart surgery to our patient.' It doesn't take too many of those cases to feel like you're hitting bumps in the road."
Even if there is still the opportunity to transfer after a patient in another managed care plan is inappropriately admitted, she points out, "there is the disruption to the patient who has to move, and the expense to our hospital. We [incur the cost] of the most expensive day, and then we have to move the person to another facility."
Initiative focuses on controlling access
To hospital administrators, Leach adds, she emphasized the initiative's focus on controlling access so that only appropriate patients are admitted. To physicians, on the other hand, she stressed that it would facilitate the admission of their patients.
While some hospitals have a similar process in place for planned admissions, she notes, the Sutter project was designed around unscheduled admissions, which are "our Achilles heel."
"For a week, we had all these people managing information," Leach says. "They verified that [patients] had appropriate insurance and they validated with information from physicians that patients met InterQual criteria for level of care — whether telemetry, intensive care unit [ICU], observation or inpatient."
Once the level of care was established, the patient placement nurse was asked if a bed of that type was available, she says.
In the past, Leach adds, physicians would call and say they needed a bed at a certain level of care, and staff would respond that it was available or not.
"We never knew [at that point] if the patient met criteria. Or, the [patient placement nurse] might say, ‘I don't have an ICU bed, but can you take a telemetry one?' It might turn out that's what the patient needed anyway."
The project also has allowed dialogue with physicians in the emergency department (ED) — where there is a case manager — when patients don't meet InterQual criteria, she says.
"[The case manager] can say, ‘The patient doesn't meet inpatient criteria, but maybe needs placement in an SNF, and I can help you with that,'" Leach continues. "Or she can say, ‘The patient doesn't meet criteria, and in order to [admit at that level], we would need to do the following tests so we can escalate care.'"
That means, she adds, that when physicians admit patients and say they'll check on them later, the response now is, "That's not enough — we need a plan of care in order to move [the patient] along in the process."
Recognizing the conflict that could ensue from questioning physicians about their orders, she notes, staff choose their words carefully.
Instead of saying, "The patient doesn't meet criteria," and having the physician respond, "I don't care. Admit him anyway," Leach says, "We might call and say, ‘We need to better understand the treatment plan so we can put the patient in the right place.'"
In the past, she adds, physicians simply would write the orders and the patient would be taken to the nursing unit. "We would have that dialogue [with the physician] 24 hours after admission when the case manager was doing the utilization review and would say, ‘Why is this person here?'"
Inappropriate admissions avoided
As a result of the Sutter General pilot, Leach says, staff were able to identify a number of ED patients that otherwise would have been inappropriately admitted to the hospital and referred to outpatient treatment, place them in SNFs, or have them transferred to the facility designated in their managed care plan.
For all 51 patients admitted during the pilot — which was confined to between 8 a.m. and 5 p.m. — staff were able to document that they met the criteria for admission, she says. "That's not a huge number. We did this during a time when we were not getting slammed so we could work our process and have the necessary resources available."
By communicating with physicians, staff avoided admitting between seven and 12 people as inpatients, instead directing them to observation status or another type of care, she notes. "For example, physicians often will admit patients to the hospital for infusion, for hydration, but we have a clinic where that is done, so we can help set that up."
Apart from causing a financial loss to the hospital, Leach points out, she believes that inappropriate admissions are a quality-of-care issue. "The risks of being in the hospital — falls, medication errors, bed sores, infection — are all well documented. Those are all things that we are able to prevent if a person is not admitted unnecessarily to the hospital."
A pilot project at the health system's other hospital, Sutter Memorial, was a much bigger challenge, she says, because the majority of unscheduled admissions come through services other than the ED. That hospital, Leach explains, is located in a residential area and specializes in pediatrics, obstetrics, and cardiology. It is also a smaller facility than Sutter General.
"Cardiology patients often come through emergent admits from other hospitals or scheduled admits from interventional procedures such as heart catheterization or diagnostic imaging," she says. "We are dealing with specialists and with patients who are having procedures, not coming to the ED with a cold."
Because the patients being admitted may already be outpatients or may be coming from another facility, Leach adds, it is easier to let them "slip through the cracks." During the Memorial pilot, she says, only nine people were admitted through the ED.
Although data from that pilot haven't been analyzed, Leach says, "we know anecdotally that we were very effective in the ED and that — even with the lesser number of admissions — probably impacted the same number of patients who were at the wrong hospital or needed to be hooked up with other services."
Hospital administrators initially were concerned that the steps involved in ensuring proper placement would delay patient throughput, she notes. "We provide tertiary care for multiple areas, so we have a specialty services network from all over California. We don't want to lose that business by putting up barriers to admission."
Those fears proved to be unfounded, Leach says, noting that in both studies, the length of time between a patient presenting at the ED or outpatient department and being admitted to the hospital did not increase.
In fact, the time may have been shortened, she adds, "but we don't have enough data to show that yet."
The goal is to have the kind of patient coordination done in the pilots in place around the clock, Leach says. "We'll probably be making decisions on [hiring] that person or people based on some volume studies. We use Navicare, which allows us to track all bed requests so we know the time from request to placement and all steps in between.
"We'll be tracking the periods when we need someone and when the nursing supervisor can manage it with enough InterQual training," she adds.
Sutter is in the process of training its current patient placement nurses on InterQual so they can ask those questions and be aware of the patients who stand out, Leach says. "My fantasy is to develop a transfer center where all of the steps of this process happen: Someone is dialoguing with the physician and potentially taking admission orders."
(Editor's note: Barbara Leach can be reached at [email protected]. Information about Navicare can be accessed by e-mailing [email protected]. Look for information on a throughput study focusing on cardiac patients and Sutter's 24/7 patient access coordinator in future issues of Hospital Access Management.)
An access initiative at Sutter Health in Sacramento, CA, is helping streamline throughput while placing "the right patient in the right hospital at the right level of care," says Barbara Leach, RN, director of case management for Sacramento Yolo Sutter Health.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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