InterQual 2013 Release Deep Dive Overview of Acute Adult Criteria Changes

Transcription

1 InterQual 2013 Release Deep Dive Overview of Acute Adult Criteria Changes Laura McIntire, RN, MA, CPHM Product Manager, InterQual Chrissy Finn, RN, BSN, MSN, CPHM Clinical Lead Elisia Willette, RN, BSN, MSN, CPHM Clinical Content Specialist April 30, 2013

2 Agenda Clinical Revisions Review Process Books Enhancements / Content Updates Resources Questions and Answers 2

3 Clinical Revisions MHS Customer Hub: Top Documents section Potential care management impact 3

4 Review Process Available: o Review Manager Help files o First section in the book Page RP-4, Surgical Subsets: o Criteria for patients who have an ambulatory procedure complication requiring Observation can be found in a condition specific subset for the new condition or on Post-Op day 1 under the Observation level of care within the General Surgical subset. For complications requiring treatment at a higher level of care, it may be appropriate to apply criteria using the Intermediate or Critical level of care. 4

5 Review Process, Continued. Page RP-5, Extended Stay: o NOTE: When the endpoint includes the language since initiation, the criterion can only be applied for the total number of days specified and includes the time treatment was delivered in another subset. o Redirection to the Extended Stay subset is a standard option for patients meeting Non-Responder criteria. The Extended Stay subset is comprised of conditions, diagnoses, and symptoms, meaning the actual condition or diagnosis may not be stated or specified in the criteria. For conditions, diagnoses, or symptoms not addressed in the extended stay subset, secondary review is appropriate. 5

6 Review Process, Continued Page RP-5, Episode Days: o An episode day is a calendar day, which begins at 12:00 a.m. regardless of the time of admission. However, the exception to this would be admissions in the evening (e.g., after 6 p.m.); in which case, episode day one may be used for admission day and the next hospital day Page RP-6, Responder Status: o Responder criteria are introduced on the first episode day that a patient may be clinically stable for discharge. Once responder criteria are introduced, from that episode day on, there will always be responder criteria and either partial responder or non-responder NOTE: The exception to this rule occurs in the Extended Stay, General Medical, and Nursery subsets. These subsets will have all three responder types on some episode days. 6

7 Review Process, Continued Page RP-7, Conducting a Review: o If conducting a concurrent review at the time of admission, reviewers can only use data that are available at the time the decision was made to admit. o If conducting a retrospective review, use data from the episode for the day that the review is being conducted. This includes information that may have been pending or incomplete at the time the decision to admit was made. Page RP-12, Level of Care Tips (enhanced this section) Page RP-12, Level vs. Place (enhanced this section) 7

8 Review Process, Continued 8

9 New Book Binder 9

10 Book Binder Side by Side 10

11 Book Binder Use Your Sheet Lifter! 11

12 New Subsets Acetaminophen Overdose Acute Cholecystitis Carbon Monoxide Overdose Cystic Fibrosis Diabetes Mellitus Diabetic Ketoacidosis Hyperglycemic Hyperosmolar Syndrome Hypoglycemia Pancreatitis Sickle Cell Crisis 12

13 Observation Enhancement Removed location of OP treatment (e.g., after 1h of ED tx) Expectation: treatment above/beyond usual regimen 13

14 Additional Enhancements Extended Stay o Aligned with General Medical o Gap enhancements Responder criteria - enhanced beyond simple vital signs Intermediate and Critical additional IS for stepping up or down Note Icons moved to Episode Day 1 in Review Manager 14

15 Discharge Screen Enhancement Viewable in left navigation pane of Review Manager 15

16 General Subset Enhancements General Medical o Added consistent headers (all levels of care) o Consolidated Episode Days Day 1 Day 2 Day 3-x o Imbedded time-limiting endpoints to Day 3-x o Broke out additional conditions into separate subsets * See Review Process Enhancements (see page RP-4 General Subsets ) 16

17 Demonstration 17

18 FAQ Baseline How to apply a criteria point that includes and < baseline when you don t know what the patients baseline status is? The term baseline refers to the patient s usual status prior to admission. In order to apply the criteria point and < baseline the reviewer should have documentation of the patient s baseline. When there is no documentation of a patient s baseline status, it may be presumed to be normal. 18

19 FAQ Baseline, Continued Examples: O 2 sat 92% (0.92) or baseline can be interpreted as: o O 2 sat greater than or equal to 92% OR o O 2 sat greater than or equal to the patient s baseline (usual status) O 2 sat 91% (0.91) and < baseline requiring supplemental oxygen can be interpreted as: o O 2 sat less than or equal to 91% and it is less than the patient s documented baseline OR o O 2 sat less than or equal to 91% and the patient s baseline is unknown 19

20 FAQ Dual Diagnosis How to apply criteria for a patient with multiple conditions? Example: A patient presents with HF and a wound infection Both conditions are documented in the medical record at the time of admission and both are severe enough to require admission o The reviewer conducts an Episode Day 1 review using the Infection: Skin subset. o On Episode Day 3, the wound infection is improving 20

21 FAQ Dual Diagnosis, Continued Responder criteria met for wound infection but the patient still has a low O 2 sat (persistent HF) o The reviewer should move to the HF subset and look at criteria for Episode Day 1 and Day 2 to confirm: Admission on Episode Day 1 for HF would have been appropriate Criteria on Episode Day 2 would have been met o Apply Episode day 3 criteria in the HF subset to perform the next review 21

22 Resources Simulation Webinars Customer Hub Customer Support Acute Level of Care Show me demo (available now!) Ask-The-Expert (May/June/July/August) Clinical Revisions Documents Frequently Asked Questions (FAQs) Webinar Recordings/Simulation Announcements Submit and Review Support Cases Searchable Knowledge base Create a new case through the Customer Hub cesupport@mckesson.com Support: 1(800)

23 MHS Customer Hub Go to the login page: Click Need a User ID and Password? Enter your address 23

24 Questions and Answers 24