I was hoping someone would address Interqual criteria for admission. I have a pretty good knowledge about this and apply it to justify “intensity of service.” It seems that most ED docs don’t understand these criteria and, as a result, we end up having “too many obs,” per our CEO. What do I do? How do I get everyone on board the “hospitalist agenda wagon”?
Dr. Hospitalist responds: Many hospitals now use either Interqual or Milliman to help them make determinations as to whether a patient should be inpatient or observation. Regardless of the resource used, there should be some basic understanding as to what determines the admission status—namely, the “intensity of service,” as you describe.
First things first: I would not let the ED doc determine the admission status. The ED physician should continue to occupy their binary decision algorithm of 1) home and 2) admission. Once they decide on admission, they should make no further decisions regarding the care of the patient. Why? Well, they don’t work upstairs (or down the hall), and they generally have a poorer understanding than you do about admission status and the most appropriate unit for your patient.
Nationally, ED physicians (through American College of Emergency Physicians policy statements) have adopted the approach of no longer writing “admission” orders, instead calling them “transition” orders. I would do nothing to discourage this approach, even though it does make more work for us as hospitalists. So, as a starting point, you and your team should determine the admission location and the status. It might require a change in workflow, but it will save you headaches in the long run. When it comes to admission status, things get a little trickier. Evaluation of the admission status includes “severity of illness” and “intensity of service.” Clearly, you have more to do with the determination of the latter than the former (at least we hope so), and that is where you will interact with the hospital’s utilization review service. Let’s focus on that for the time being.
Roughly, observation should be used for patients for whom stabilization and discharge are expected within 24 hours, the patient is hemodynamically stable, and the clinical diagnosis is unclear. It used to be that “obs”—or observation—was only used for 23 hours, but Medicare now allows up to 48 hours of observation. CMS has a list of initial diagnoses that they view as appropriate for obs, such as chest pain, CHF, and syncope.
On the inpatient side, here it is straight from CMS: “Inpatient care, rather than outpatient care, is required only if the beneficiary’s medical condition, safety, or health would be significantly and directly threatened if care was provided in a less intensive setting. Without accompanying medical conditions, factors that would only cause the beneficiary inconvenience in terms of time and money needed to care for the beneficiary at home or for travel to a physician’s office, or that may cause the beneficiary to worry, do not justify a continued hospital stay.” (You can read more by downloading this PDF: www.cms.gov/MLNMatters Articles/Downloads/SE1037.pdf.)
Beware, though: This is a bit like going down the rabbit hole—you can get lost in all the regulations and amendments. Which, to no one’s great surprise, explains why Milliman and Interqual operate such big businesses interpreting and applying these guidelines. We all know that you can’t control the phone calls coming from the ED. However, it is paramount that when you accept a patient, you document clearly and appropriately the admission status and the clinical criteria used to make your determination. Will everyone get it right every time? Probably not. Remember, though, that documentation will not only support the admission status, but also your professional fee billing.
Now what? Educate, educate, educate.
Ideally, you should meet with your case management/UR team and decide how to deliver the message to your group. Honestly, I think that a group responds better to explanations coming from one of their own rather than inviting the head of case management to come and speak for an hour. Rather than risk setting up an adversarial relationship with case management, consider filtering the message through your leadership. As a group leader, you need to be able to interpret hospital-driven directives and deliver the information to your group in a constructive manner. As working hospitalists, we need to understand the nonclinical factors that affect us—and our hospitals. It’s part of the job.