The right patient status is not always obvious, says Wanda Pell, MHA, BSN, a director with Novia Strategies, a national healthcare consulting firm.
There are patients whose condition and circumstances put them in the shadowy area between meeting criteria for an inpatient stay and being an outpatient with observation services, she adds.
“Patient status is so confusing because there are so many shades of gray,” Pell says.
Whether a patient stays two midnights often hinges on the time of day he or she comes in, Pell points out. Patients who come in at 10 p.m. are much more likely to stay over two midnights than those who come in at 3 a.m., she points out.
“If you take the stand that if a patient is in the hospital for two midnights, it has to be an inpatient stay, you would include patients who were waiting for a test or procedure or who were waiting for the physician to read the results,” she says.
Pell points out that many times when patients need to be placed in a bed, there isn’t enough information from test results to admit them as inpatients. If a consulting physician is called in, it also extends the length of time the patient is in the hospital. First, the consultant has to come to the hospital. Then, he or she orders tests, waits for the results, and interprets them. All of this lengthens the stay, Pell adds.
She points out that many hospitals don’t operate on a 24/7 basis and don’t provide cardiac stress tests, cardiac catheterizations, ultrasounds, and other tests and procedures on weekends, extending the ED stay of patients who present on weekends.
For instance, if a patient arrives at the ED with chest pain on Saturday morning and has to wait until Monday morning for a stress test, her or she will be in the hospital over two midnights but still won’t meet inpatient criteria.
“You end up with a lot of down time between those two midnights. This adds time and cost to the episode of care without adding value,” she says.
The practical solution would be to check the cardiac enzymes and if they aren’t elevated, send the patient home and schedule the test as an outpatient when the lab is open. “Physicians are reluctant to send patients home in these situations for fear that something might go wrong — and then the hospital has a liability problem and patient relations issue,” Pell says.
In the long run, the solution would be for the hospital to expand the hours of its ancillary departments, Pell says. “Some hospitals are looking at their volume on weekends, the cost of keeping patients over the weekend, and determining if expansion would be a cost-effective investment,” she says.
Meanwhile, case managers should review the charts of patients receiving observation services every four to six hours to determine if they meet admission criteria.
Another situation is patients who don’t meet inpatient criteria, but can’t be discharged safely because they live alone and need assistance. If they stay in the hospital as an outpatient, they won’t meet the three-day stay needed for Medicare to cover a skilled nursing facility admission, if that becomes appropriate. On the other hand, if they are admitted, the stay is likely to be denied because they don’t meet inpatient criteria.
Many hospitals don’t have a psychiatric unit, or if they have one, it’s usually filled, Pell says. There may be patients with mental health issues who can’t be discharged from the ED safely, but they don’t qualify for an inpatient stay. “The only option is to put them in a bed as an outpatient and know that they will have a long stay,” she says.
It’s important for case managers to track patients who have long stays and determine why the long stay occurred, Pell says. Many times, they are waiting for testing or consultations.
“Case managers need to develop categories and assign avoidable days to those patients just as they would for an inpatient stay,” she says.
Pell suggests that case managers report the results to the leadership and the utilization management committee.
“Case managers should keep in mind that InterQual or Milliman Care Guidelines are merely guidelines, and that there will be patients who are exceptions,” adds Mark Clemens, RN, senior managing consultant with Berkeley Research Group.
Clemens gives the example of a patient who comes in with sharp chest pains and is found to have hyperglycemia. Both chest pain and hyperglycemia typically qualify for an observation stay, not an admission. But if the physician indicates, with supporting documentation, that it will require two midnights to diagnose and treat the patient, the patient would qualify for an inpatient admission under the Two-Midnight Rule, Clemens says.
The case manager or physician advisor should make sure the physician provides detailed documentation of the reasoning behind the admission, Clemens says.
Or there may be a patient with pulmonary edema and comorbid cardiac issues who has to be intubated, but recovers quickly and can be extubated. “The patient has a short inpatient stay. It should not be denied if the documentation is explicit and clear,” Clemens says.
When patients have long outpatient stays, the case manager should consult the physician advisor for guidance in determining appropriate status, Clemens suggests. He recommends that hospitals have processes for reviewing all short stays for proper documentation.
There are patients whose condition and circumstances put them in the shadowy area between meeting criteria for an inpatient stay and being an outpatient with observation services.
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