sharon e. mace md, facep, faap director, observation unit director, pediatric education/quality...
TRANSCRIPT
Sharon E. Mace MD, FACEP, FAAPDirector, Observation Unit
Director, Pediatric Education/Quality Improvement
Research Director, Rapid Response Team Cleveland Clinic
Former Chair, ACEP Section of Observation Medicine
Faculty, EM Residency, MetroHealth Medical Center/Cleveland Clinic
Professor, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University
Observation Medicine Strategies:Observation Medicine Strategies:A Clinical ApproachA Clinical Approach
Tips for Success or FailureTips for Success or Failure
Observation Medicine Strategies:Observation Medicine Strategies:A Clinical ApproachA Clinical Approach
Tips for Success or FailureTips for Success or Failure
Number of Hospitals, Hospital Beds Number of Hospitals, Hospital Beds and EDs vs ED Visitsand EDs vs ED Visits
Number of Hospitals, Hospital Beds Number of Hospitals, Hospital Beds and EDs vs ED Visitsand EDs vs ED Visits
6
7
5
Hospitals(thousands)
HospitalBeds
(millions)
Number ofED Visits(millions)
1991 1993 1995 1997 1999 2001 2003 2005 2007 2009
90
120
80
130
110
100
0.9
1.2
1.3
1.1
1.0
12.6%
43.8%
21.5%
10.1%
Hospital Beds ED VisitsHospitals
4
6
5
EDs(thousands)
Allows physicians to evaluate and treat selected
patients over a finite time period which improves
ED flow and has many benefits
Purpose ofPurpose ofObservation MedicineObservation Medicine
Purpose ofPurpose ofObservation MedicineObservation Medicine
What Is Observation?What Is Observation? What Is Observation?What Is Observation?
While there are different interpretations, for Medicare from HIM-10 §455 (Pub. 100-2,Medicare Benefits Policy Manual, Chapter 6, §70.4):
Observation services are those services:
• (a) Furnished on a hospital’s premises
• (b) Includes use of a bed and periodic monitoring by nursing or other staff
• (c) Reasonable and necessary
• (d) To evaluate an outpatient’s condition
• (e) Determine the need for possible admission as an inpatient
• (f) Ordered by physician
• (g) Usually do not exceed one day
• (h) May go for up to 48 hours
• (i) Under unusual circumstances may exceed 48 hours
Why Observation MedicineWhy Observation MedicineWhy Observation MedicineWhy Observation Medicine
• Better patient care
• ↓ missed diagnoses
• Cost effective
• Rapid, efficient, evaluation / work-ups and treatment
• Risk management and malpractice, ↓ liability
• Psychosocial advantages
• Fiscal benefits
• Provided there are mechanisms for Observation Unit (OU) set up / maintenance
• OM is a process and a mindset, not a location
Organizational FrameworkOrganizational FrameworkOrganizational FrameworkOrganizational Framework• Patient criteria: inclusion, exclusion, OU
management, specific time frame
• Personnel: clinical and administrative
• Resources: location, equipment, supplies
• Specific policies and procedures
• Strong leadership empowered to clinically and administratively manage the OU
• Using policies, procedures, guidelines, clinical pathways, order sets, other tools
• Multidisciplinary teamwork approach / meetings
Admission Criteria for Admission Criteria for Observation Observation
Admission Criteria for Admission Criteria for Observation Observation
• Stable vital signs
• Non-critical, stable, “low maintenance”
• Do not need “intensive” nursing care
• Do not need “intensive” physician care
• Expected to have a disposition in a “reasonable” short time frame: observation, diagnosis,
treatment for < 24 hours
Acceptable Diagnoses for Acceptable Diagnoses for ObservationObservation
Acceptable Diagnoses for Acceptable Diagnoses for ObservationObservation
• Cardiac: chest pain*, CHF, syncope
• Respiratory illnesses: asthma, pneumonia-not acceptable: respiratory failure, epiglottitis, severe
hypoxemia, hypercapnia
• GI / dehydration: gastritis, vomiting, diarrhea-not acceptable: shock
• GU: kidney stone-not acceptable: obstruction with renal failure
* May want to start with chest pain: ensure success, then expand
Acceptable Diagnoses for Acceptable Diagnoses for ObservationObservation
Acceptable Diagnoses for Acceptable Diagnoses for ObservationObservation
• Infections: cellulitis, lymphangitis
• Neurology: seizures, viral meningitis, minor head injury
• Toxicology: ingestions, overdose
• Hematologic: sickle cell, hemophilia
• Chronic illnesses: DM glucose (not DKA)
• S/p procedures: oversedated, s/p LP etc.
Patient Exclusion for Patient Exclusion for ObservationObservation
Patient Exclusion for Patient Exclusion for ObservationObservation
• Critically ill
• Unstable vital signs
• Need “intensive” nursing care
• Need “intensive” physician care
• Anticipated length of stay > 24 hours
Unacceptable Diagnoses for Unacceptable Diagnoses for ObservationObservation
Unacceptable Diagnoses for Unacceptable Diagnoses for ObservationObservation
• Shock
• Coma
• Respiratory failure
• Bacterial Meningitis
• Neutropenic fever
• Critically ill
Advantages of ObservationAdvantages of ObservationPrimary Care, SpecialistsPrimary Care, Specialists
Advantages of ObservationAdvantages of ObservationPrimary Care, SpecialistsPrimary Care, Specialists
• Expands patient base referrals, office visits, procedures, admits
• Easier to coordinate care
• Better, faster evaluation
• Improved MD profile
• Clinical pathways
• Quality, cost containment– ACOs
– Disease management
– Variation reduction
– Other initiatives
Advantages of ObservationAdvantages of ObservationHospitalHospital
Advantages of ObservationAdvantages of ObservationHospitalHospital
• New product line• Expanded referral base• Better use of services at cost lengthy inpatient admits trend outpatient services outliers: 1 day LOS• PEPPER report
Healthcare in CrisisHealthcare in CrisisHealthcare in CrisisHealthcare in Crisis
• The 2.2 trillion healthcare sector is now mired in deep crisis related to safety, quality, cost and access that pose serious threats to the health and welfare of many Americans1
• An estimated 30 to 40 cents of every dollar spent on health care, or roughly three quarters of a trillion dollars per year is spent on costs
associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency” 2
1 CMS2 Lawrence National Academy Press
Per Capita Medicare Spending: Per Capita Medicare Spending: Regional VariationsRegional Variations
Per Capita Medicare Spending: Per Capita Medicare Spending: Regional VariationsRegional Variations
Congressional Budget Office. Research on Comparative Effectiveness of Medical Treatments. 2008
CMS: Value BasedCMS: Value BasedPurchasing PlanPurchasing Plan
CMS: Value BasedCMS: Value BasedPurchasing PlanPurchasing Plan
• Clinical quality
• Adverse events
• Patient safety
• Patient centeredness
• Avoid unnecessary costs
• Investment in structural/system components: IT capability, care management processes/tools
• Consumer driven: Performance results/Transparency
Success Depends UponSuccess Depends UponSuccess Depends UponSuccess Depends Upon
• Prompt physician decision making• Excellent documentation• “Empowered” observation nursing staff• Superb coding → ↑ reimbursement • Strong physician leadership
- Administrative support• Buy in from other hospital departments, physicians,
health care providers• Tools for success
- Policies and procedures: includes inclusion/exclusion criteria, evaluation, treatment, disposition plan
- Guidelines, clinical pathways
Success
Time (Length of Stay)
Observation Medicine
How to Succeed or Fail at How to Succeed or Fail at Observation MedicineObservation Medicine
How to Succeed or Fail at How to Succeed or Fail at Observation MedicineObservation Medicine
Observation = $$ SuccessObservation = $$ SuccessObservation = $$ SuccessObservation = $$ Success
• Major benefits
• Easiest way to build beds
• ↑ revenue per bed
• ↓ labor costs/RN ratio
• ↓ exposure to risk
• ↑ quality
• ↑ patient satisfaction
• ↓ cost
Observation AdvantagesObservation AdvantagesObservation AdvantagesObservation Advantages
• Improved patient care: missed diagnosis / severity
• Improved patient outcome risk, malpractice ED patient throughput, ED LOS patient satisfaction
• Better public relations ED volume
• Financial: revenue, denials, penalties
Recovery Audit Contractors (RAC)Recovery Audit Contractors (RAC)Recovery Audit Contractors (RAC)Recovery Audit Contractors (RAC)
• Private corporations under contract via contingency to CMS
• Review all claims submitted by Medicare providers in order to prevent
overpayments/underpayments• Akin to a whistle blower or bounty hunter• Focus: high-risk DRGs, 1 day stay, observation
United States Department of JusticeUnited States Department of JusticeUnited States Department of JusticeUnited States Department of Justice
Marcos Daniel Jimininez United States Attorney for the Southern District of Florida99 N.E. Fourth Street, Miami, Fl. 33132
Press ReleaseFor Immediate Release – Feb.11, 2005For information, contact public affairs
Carlos B. CastillosSpecial counsel for public affairs(305) 961-9425
Cleveland Clinic pays U.S. 2.75 million
QuestionsQuestions