observation, she says.

In the transmittal, CMS emphasizes that in no case may a nonphysician make a final determination that a patients stay is not medically necessary or appropriate, Hale says. The transmittal made it clear that case managers cannot change a physicians order for inpatient admission or take sole responsibility for determining the patients level of care. Only a physician can change a patient from inpatient status to observation services, she adds. This instruction, first published in 2004, references a change from inpatient status to outpatient. Observation may not be billed for the time a patient was thought to be an inpatient, as this service is billable only when a physician has ordered observation services, she says. Even though Transmittal 1760 makes reference to admission protocols: These reminders about physicians responsibility for the level-of-care order is evidence that CMS is not referring to a case management protocol in which the case manager is solely responsible for assigning a level of care, Hale adds. On April 22, 2009, National Government Services1 posted an opinion regarding the use of a case management protocol to determine level of care, Hale says. The following statement was included: Many facilities are attempting to implement a standing order practice that removes the physician from the decision-making process, and to date, CMS has given no indication that this practice is acceptable. If these protocols are used, then the inpatient admission is not recognized until the physician (nonphysician practitioner) responsible for the patients care concurs. However, CMS states that it expects hospitals to employ case management staff to facilitate the application of hospital admission protocols and criteria, and to facilitate communication between practitioners and the utilization review committee or Quality Improvement Organization. CMS allows the use of Condition Code 44 to address late-night or weekend admissions when no case manager is on duty to offer guidance but emphasizes that it is to be used sparingly. Use of Condition Code 44 is not intended to serve as a substitute for adequate staff or utilization management personnel or for continued education of physicians and hospital staff about each hospitals existing policies and admission protocols, the transmittal says. Hospital Conditions of Participation require all
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hospitals to have a utilization review committee with at least two physician members who review admissions for appropriateness of the level of care. Review of admissions may take place before, at, or after a hospital admission. In order for hospitals to file a Condition Code 44 claim, the medical record must have documentation of a physicians concurrence that an inpatient admission is not medically necessary and that the patient should have been registered as an outpatient. The reason for the change and those involved in the review should be documented as well. The practitioner responsible for the care of the patient must be consulted and allowed to present his or her views before the utilization review committee. To achieve success with level-of-care determinations, hospitals are going to need to change the practice of having case managers review a patients chart for medical necessity 24 hours or more after admission. The patients are going to have to be screened before or at the time of admission in order to facilitate appropriate level of care, even if that includes a referral to a physician advisor at the time the decision is made, Hale says. (Editors note: This article includes the most recent information from the Centers for Medicare & Medicaid Services as of July 31 and may be subject to change.)

Reference
1. National Government Services is one of the largest Medicare contractors in the country and has served as a Medicare contractor since 1966.

Complications in chest pain patients in crowded EDs

Symptoms of dysfunctional hospital

atients with heart attacks and other forms of chest pain are three to five times more likely to experience serious complications after hospital
HOSPITAL CASE MANAGEMENT / September 2009

admission when they are treated in a crowded ED, according to a new study published online in the journal Academic Emergency Medicine.1 The study followed 4,574 patients who were admitted to the Hospital of the University of Pennsylvania in Philadelphia for symptoms of chest pain over an eight-year period. Ultimately, 802 were diagnosed with an acute coronary syndrome; of those, 273 had a true heart attack. There were 251 complications that occurred in the hospital after initial ED treatment. Complications included serious events, such as heart failure, delayed heart attacks, dangerously low blood pressure, heart arrhythmias, and cardiac arrest. When the ED was at its highest occupancy and waiting room census, patients with acute coronary syndrome (ACS) were three times more likely to experience complications in the hospital. When the patient hours were highest, they were more than five times more likely to have a complication. Most of these complications occurred long after the patients left the ED, but while they were still in the hospital, notes Jesse M. Pines, MD, MBA, MSCE, assistant professor of emergency medicine and epidemiology at the hospital and lead author of the paper. The authors noted that these complications were not explained by what is or is not happening in the ED in terms of specific treatments and timing, such as giving patients aspirin or a timely EKG. Instead, they said, it pointed to a dysfunctional hospital. Jim Horn, MD, FACEP, medical director of the ED at Mercy Hospital Fairfield (OH), says, One thing I take away from this study is that expected basic quality care measures were received. I dont know if this is a marker of a dysfunctional hospital, but when patients are at their sickest, you potentially see a higher rate of complications, and when the ED is at its highest capacity, you often see patients with higher acuity. Nevertheless, the authors noted, the findings underscore the need for action on the part of hospital administrators, policy-makers, and emergency physicians. What can ED managers do to minimize these downstream complications? Patients have to be seen quickly and diagnosed appropriately, Pines says. There must be a good review of their old medical records; and the medications the patient is currently on have to be put into the system. Once the patient is to be admitted, the inpatient team has to come down, and there has to be a smooth transition of care from the ED team.
September 2009 / HOSPITAL CASE MANAGEMENT

Horn says, I agree these are all things that we strive for. Still, says Pines, a different approach must be taken in light of the studys findings. ED managers need to realize that these particular patients are at higher risk, he says. They must communicate with their physicians that during crowded

CNE questions
9. According to CMS, what percentage of heart failure patients are likely to be readmitted within 30 days of discharge? A. 18.2% B. 19.9% C. 24.5% D. 27.3% 10. According to a study in the New England Journal of Medicine, what percentage of patients rehospitalized within 30 days of discharge had not seen a physician for follow-up. A. 50.2% B. 64% C. 19.9% D. 32.5% 11. In addition to reviewing the readmissions within 30 days, look further and analyze those who are readmitted within seven days or the same day, says Toni Cesta, PhD, RN, FAAN. A. True B. False 12. The Baylor Health Care heart failure team started with a 12-item action plan to reduce heart failure readmissions and honed it down to how many items? A. Eight B. Five C. Four D. Three
Answer key: 9. C; 10. A; 11. A; 12. C.

CNE instructions

urses participate in this continuing education program by reading the issue, using the provided references for further research, and studying the questions at the end of the issue. Participants should select what they believe to be the correct answers, then refer to the list of correct answers to test their knowledge. To clarify confusion surrounding any questions answered incorrectly, please consult the source material. After completing this semester's activity with the December issue, you must complete the evaluation form provided in that issue and return it in the reply envelope provided to receive a credit letter.

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times, even though it is very easy to focus on only the most critically ill patients, those with chest pain are at higher risk for having complications when the ED is crowded regardless of whether or not they have ACS [acute coronary syndrome]. Thus, Pines says, at these times there must be an even greater focus on the different processes of emergency care. Horn says, Were always concerned when volume is high, but our goal is still to see every patient quickly and diagnose them appropriately but quickly. In my place, the [chest pain] patient gets an EKG as soon as he hits the door.

Reference
1. Pines JM, Pollack CV Jr., Diercks DB, et al. The association between emergency department crowding and adverse cardiovascular outcomes in patients with chest pain. Acad Emerg Med 2009; June 22. Epub ahead of print. Doi: 10.1111/ j.1553-2712.2009.00456.x.

Education reduces peds asthma readmits

Experts say programs can be provided by ED

he medical literature shows that educating children and their parents about asthma can reduce return visits to the ED as well as hospital admissions, and experts say the ED may well be the best place to provide that education. The Cochrane Library, a London-based publication of The Cochrane Collaboration, an international organization that evaluates health care research, recently reviewed 38 randomized controlled trials involving 7,843 children.1 The authors concluded that educational interventions were effective in reducing the risk of subsequent ED visits by just more than 25% and that educational intervention also resulted in fewer unscheduled doctor visits. I think its great that there is evidence to support this, says Joseph Zorc, MD, an associate professor of pediatrics and emergency medicine and attending physician at The Childrens Hospital of Philadelphia. So many patients come to the ED with their asthma not well managed. Vincent Wang, MD, associate director of the division of emergency and transport medicine at Childrens Hospital of Los Angeles, agrees. Wang adds that the need is even greater today because
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primary care physicians simply dont have as much time as they did formerly for educating their patient. Wang and Zorc agree that a one-size-fits-all approach to education will not work. Wang says, It needs to be customized. There can be some generalization, but every patient has different needs. So, for example, common issues such as causes of asthma and asthma triggers could be made into a single education module, but medications, individual exacerbations, and the method used to teach the patient and the family must be customized. Basically, when patients come to the ED, they are in different stages of their disease, as is true with any chronic disease, adds Zorc. They also have different levels of understanding. Many times younger children are just learning, or their parents may just be coming to grips with the fact that their child needs regular preventive medicine. Not everyone is comfortable with that. The best way to determine those specific needs is to assess the family, he says. How do you make that assessment? You do it the same way a lot of great clinicians have always done, Zorc says. You talk to the family and ask a few questions about what theyre doing and what they think their childs needs are. Zorc and Wang provided asthma education in their EDs; in fact, Zorcs department has an entire section devoted to asthma treatment. There are six rooms reserved for asthma patients, and they are staffed by respiratory therapists (RTs) and nurse practitioners (NPs). The department also has an observation unit where kids can go for 1224 hours. This is a team approach, Zorc explains. The RTs spend time with the family, especially focusing on devices and inhalers. The NPs handle the assessments and education. Wangs facility has an asthma action plan a packet of general information about asthma and specific care the patient has received. Every packet has several common components, and the rest is filled out by the provider based on what the patient requires for immediate care and in the future.

Reference
1. Haby MM, Waters E, Robertson CF, et al. Interventions for educating children who are at risk for asthma-related emergency department attendance. Cochrane Database Syst Rev 2009; Issue 1. Art. No.: CD001290. Doi: 10.1002/14651858. CD001290.

HOSPITAL CASE MANAGEMENT / September 2009