Inpatient admission vs observation status

[BJJVP]

How does your hospital/emergency dept handle this issue? Do the doctors decide the status? Do they specify explicit criteria? Do they have a nurse who helps "guide" under which status the patient is placed?

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[Apollyon]

Here, it's up to the admitting doc. We have to specifically ask them. Our bitch utilization reviewer person, ex post facto, dings everyone if someone doesn't make the cut.

 

[engineeredout]

We have a nurse "care manager" who decides it based on criteria out of a large book

 

[deleted859535]

Our bitch utilization reviewer person, ex post facto, dings everyone if someone doesn't make the cut.

I lol'd.

 

[RustedFox]

"Care Manager".

This is THE reason why US healthcare is so expensive. We have people whose job is so "manage your care".

Isn't that what WE physicians do; Manage to care for the patient... ?!

Nahhh, we need to pay several other people to undermine our authority. Makes it more worthwhile. So much value added there.

 

[gamerEMdoc]

We initially dealt with it by letting the admitting doc decide. But there were too many that didn't know what they were doing. They were choosing "admission" because "we get paid more for an admission"... totally overlooking the fact that they get paid nothing if it doesn't meet admission criteria. It got so botched by the inpatient side, that it was left up to the discretion of the ED provider, since we were more independent of the financial side of the equation, and generally had a better gut of whether a patient was a more than or less than 2 midnights kind of case. We still discuss it with the admitting doc, but ultimately, the decision is ours. As a general rule, it's much easier to go from an Obs and make it an admission. It's very difficult to go the other way. So if someone is borderline, its easier to just Obs them and let case management figure out if it meets criteria once they are hospitalized.

 

[Apollyon]

We initially dealt with it by letting the admitting doc decide. But there were too many that didn't know what they were doing. They were choosing "admission" because "we get paid more for an admission"... totally overlooking the fact that they get paid nothing if it doesn't meet admission criteria. It got so botched by the inpatient side, that it was left up to the discretion of the ED provider, since we were more independent of the financial side of the equation, and generally had a better gut of whether a patient was a more than or less than 2 midnights kind of case. We still discuss it with the admitting doc, but ultimately, the decision is ours. As a general rule, it's much easier to go from an Obs and make it an admission. It's very difficult to go the other way. So if someone is borderline, its easier to just Obs them and let case management figure out if it meets criteria once they are hospitalized.

I've always been told (in SC, HI, and PA) that obs can go inpatient, but you cannot - full stop - go inpatient to obs. It just cannot be done.

 

[gamerEMdoc]

I've always been told (in SC, HI, and PA) that obs can go inpatient, but you cannot - full stop - go inpatient to obs. It just cannot be done.

That is my understanding as well. So if you guess inpatient, and it doesn't meet the criteria for inpatient, then the insurance can just choose not to pay for the visit. So for borderline cases, its always safer to go with Observation. If it meets inpatient criteria, it can get upgraded to an admission during the light of day when all the bean counters and case management can figure it all out.

 

[Apollyon]

Exactly.

 

[GeneralVeers]

I've never understood why this is up to us. The simplest answer is to make everyone obs so that I don't get a "ding". The admitting doc can always change them later. Oh wait they didn't see the patient within 12 hours in enough time to change over to inpatient status? Not my fault....

Obviously any ICU patient, or patient undergoing a surgical procedure I make inpatient status.

 

[BJJVP]

I've never understood why this is up to us. The simplest answer is to make everyone obs so that I don't get a "ding". The admitting doc can always change them later. Oh wait they didn't see the patient within 12 hours in enough time to change over to inpatient status? Not my fault....

Obviously any ICU patient, or patient undergoing a surgical procedure I make inpatient status.

We make overdoses that go to the ICU observation status. Appendicitis and I believe cholecystitis also start out as observation at our hospital. Certain fractures going to the OR also are observation status. It really doesn't make a whole lot of medical sense. I agree that we should have no input into this. I just want the patient to leave the ED once their emergent work-up/treatment is complete.

 

[RustedFox]

I make 100% of my patients "observation".

I have a lot of conversations with senior citizens about why they're in "observation" status and not "inpatient", and what they can do to persuade me to make them "inpatient".

My response is always the same:

"I don't get to make that decision. Someone else who is not a physician does. Don't like it? Me neither. Shame, what the federal government has done over all these years."

 

[RustedFox]

We make overdoses that go to the ICU observation status. Appendicitis and I believe cholecystitis also start out as observation at our hospital. Certain fractures going to the OR also are observation status. It really doesn't make a whole lot of medical sense. I agree that we should have no input into this. I just want the patient to leave the ED once their emergent work-up/treatment is complete.

Appys, Choles, and single ortho fractures are also "obs" at my place.

I just do what I'm told to do.

Care "managers".

Manage. Manage. Manage.

Manage to drive up the cost.

Just shut the phuck up and pay the bill, insurers.

 

[Tiger26]

We make the decision here as well, which I've never really understood because I haven't done a day of inpatient medicine since my first rotation of the fourth year of med school. I have no idea how long they're going to stay in the hospital.

My response is the same as Rusted Fox, which is especially interesting when I can tell they voted for that hope and change

 

[Apollyon]

The OR pts, for us for dispo, are "OR/SPU" (Short Procedure Unit). I THINK, but am not sure, that, if the SPU folks need more time, they go inpatient.

Likewise, ipso facto, if a pt goes to ICU, they're inpatient. I suggested the angioedema pts as ICU-obs, and was roundly shot down. Finally, I was told that pts that need to be admitted for blood transfusion are inpatient.

I don't make the rules.

 

[GeneralVeers]

The OR pts, for us for dispo, are "OR/SPU" (Short Procedure Unit). I THINK, but am not sure, that, if the SPU folks need more time, they go inpatient.

Likewise, ipso facto, if a pt goes to ICU, they're inpatient. I suggested the angioedema pts as ICU-obs, and was roundly shot down. Finally, I was told that pts that need to be admitted for blood transfusion are inpatient.

I don't make the rules.

I'm told the same thing on ICU patients. The variability is maddening. If an ED doc is putting in the admission order, then it should always be fore Obs, and should be responsibility of inpatient attending or case manager to change the status.

 

[engineeredout]

The entire concept of observation status benefits exactly nobody except insurance companies.

 

[Angry Birds]

I flip a coin, disregard it, and then take a guess.