Observation Medicine The Inpatient Fast Track

Transcription

1 Kirk Jensen, MD, MBA, FACEP Jody Crane, MD, MBA, FACEP Kevin Nolan, MStat, MA Stephen Bohan, MD, MS Observation Medicine The Inpatient Fast Track The presenters have nothing to disclose December 9, 2014 OBJECTIVES: Understand the difference between observation status and observation medicine Gain insight into the operational principles and goals of observation medicine Identify opportunities to improve patient flow in your hospital through the use of Observation Units and Clinical Decisions Units nsen, Crane, n, Bohan KN 1

2 Observation Status Outpatient designation in which patients are physically located in the hospital but are financially treated as if they are outpatients 3 Patients may be billed a higher level from the ED and/or billed hourly by the hospital Reimbursement for services varies widely based primarily on payer type Patients are charged a la carte for procedures and may be exposed to more out of pocket expenses Presents problems for patients as there is still a requirement for 3 inpatient days to qualify for CMS payment for SNF KJ 2-Midnight Rule 4 Designed to establish better definition around observation status as hospitals struggle to comply with recovery audits Is hotly debated as it does not solve many of the current issues related to the move towards observation medicine such as: Increased patient responsibility in the form of co-pays and other costs Eligibility requirements for long term care reimbursement (Medicare ACO Waiver) The future is uncertain KJ 2

3 Observation Medicine 5 Management of patients with relatively straightforward admission diagnoses Admissions mainly for diagnostic work-ups Disease course is relatively well-defined or knowable Primary goal-to reduce inpatient length of stay by: Streamlining care pathways Reducing variation Better aligning treatment capacity with patient demand KJ 6 Hospital Settings in Which Observation Services are Provided Setting Description Characteristics Type 1 Type 2 Type 3 Type4 Protocol driven, observation unit Discretionary care, observation unit Protocol driven, bed in any location Discretionary care, bed in any location Highest level of evidence for favorable outcomes; Care typically directed by ED Care directed by a variety of specialists; Unit typically based in ED Often called a virtual observation unit Most common practice; Unstructured care; Poor alignment of resources with patients needs Ross M. et. al. Protocol Driven Emergency Department Observation Units Offer Savings, Shorter Stay, and Reduced Admissions. Health Affairs. 32:12: , December KJ 3

4 Three Study Groups 7 Emory/Grady*, 2010 Georgia, 2010 US, ED Visits - Number 185,901 4,194, ,957,000 Observation Visits Number 7, ,593 1,392,000 Average (hrs) LOS Visits > 24 hrs 10.4% 44.4.% 29.0% Visits > 36 hrs Visits > 48Hrs Visits > 72hrs Rate of inpatient admission 13.1% 15.8% 23.2% Ross M. et. al. Protocol Driven Emergency Department Observation Units Offer Savings, Shorter Stay, and Reduced Admissions. Health Affairs. 32:12: , December 2013 *Emory/Grady - Type 1 Observation Units KJ 8 3 Considerations in Optimizing Your Observation Unit 1. A defined treatment location 2. Matching capacity and demand 3. Standard approach to care KJ 4

5 Observation Unit Location Type 1 Inpatient Observation Unit A discrete location with a defined number of rooms dedicated for observation patients. In or near the ED There is a blurred line between Observation Units and Clinical Decision Units. 9 Observation Better differentiated (would-be admissions), very clear, algorithmic workups and well-defined treatment endpoints. Examples: Chest Pain TIA COPD CHF CDU Shorter stay, managed by ED, undifferentiated and straightforward conditions that should go home soon. Examples: Abdominal pain Chest pain rule-out Matching Capacity and Demand 10 Involves understanding Inclusion/Exclusion patient populations, admission rates, and LOS This data will provide the foundation for occupancy analyses 5

6 Standard approaches to care 11 Dedicated physician group overseeingthe unit Well-defined patient population with inclusion/exclusion criteria Standardized diagnostic and treatment pathways fordifferent patient populations Standardized patient flow Standard approaches to care: Dedicated Physician Group 12 There should be a single physician group overseeing the unit and admitting to the unit, a closed unit. In many fee-for-service cultures, this is very difficult to accomplish This group should be responsible for: The admission and disposition of every patient Establishing protocols Performance improvement and accountability Consults should be minimized, if not eliminated 6

7 Standard approaches to care A Well-Defined Patient Population 13 A Well-Defined Patient Population Clinical Decision Unit Condition Guidelines Emory Midtown Hospital Emory University Hospital Grady Memorial Hospital (Grady conditions are bulleted) Index of CDU protocols (GMH italicized) 14 ABDOMINAL INJURY 3 ABDOMINAL PAIN. 4 ACUTE HEART FAILURE. 5 ALLERGIC REACTION..6 ASTHMA.7 ATRIAL FIBRILLATION ACUTE ONSET..8 BACK PAIN.9 CELLULITIS..10 CHEST INJURY...11 CHEST PAIN POSSIBLE ACS..12 COPD EXACERBATION.13 DEEP VEIN THROMBOSIS..14 DEHYDRATION OR VOMITING. 15 DILANTIN TOXICITY..16 ELECTROLYTE ABNORMALITY...17 GASTROINTESTINAL BLEED. 18 HEADACHE..19 HEAD INJURY. 20 HYPEREMESIS GRAVIDARUM. 21 HYPERTENSIVE URGENCY..22 HYPOGLYCEMIA..23 HYPERGLYCEMIA...24 PNEUMONIA.. 25 PYELONEPHRITIS.27 RENAL COLIC..28 SEIZURES SOCIAL ADMISSIONS...30 SUPRAVENTRICULAR TACHYCARDIA SYNCOPE. 32 TRANSFUSION OFBLOOD AND BLOOD PRODUCTS..33 TRANSIENT ISCHEMIC ATTACK...34 VAGINAL BLEEDING..35 VERTIGO

8 15 A Well-Defined Patient Population: Inclusion/Exclusion Examples ABDOMINAL INJURY (NON-PENETRATING) INCLUSION CRITERIA Cooperative patient with stable vital signs (RR>8 or <24, SBP>100, P>60 or <110) No Peritoneal Signs Negative initial imaging studies (i.e. CT) Pertinent lab results acceptable (e.g., Hbg) Surgery consult documented CDU INTERVENTIONS NPO initially, advance per physician Repeat Hct q 4-6 hours (if pertinent to patient s management) Serial abdominal examinations (e.g. q 4 hours) If indicated by physician, serial ultrasounds Immediate reevaluation of ED physician or surgeon if patient develops: - Significant vomiting - Increasing abdominal pain - Increased tenderness -Worsening vital signs: Decreased BP, increased HR, fever EXCLUSION CRITERIA Uncooperative patient, patients requiring restraints Impending alcohol withdrawal syndrome ETOH estimated >200mg/dl at transfer Pregnancy >20 weeks Abnormal vital signs (above) CT scan not done or significant acute abnormality DISCHARGE CRITERIA Patient is ambulatory Serial abdominal exams essentially negative Repeat labs reviewed and stable (Specifically any Hb drop?) Vital signs reviewed and stable Patient able to tolerate PO Appropriate follow-up established Surgery agrees with disposition A Well-Defined Patient Population: Diagnostic Exclusion Criteria 16 General Total Care patients Symptomatic anemia Any patient who requires 1:1 monitoring and/or restraints (dementia/suicidal) Patients with possible airway compromise Patients requiring ICU or clear multi-day stay >20 week pregnancy with abdominal/pelvic complaints Overdoses requiring cardiac monitoring Uncorrected hyperkalemia (K>6) or hypokalemia (K<2.5) Patients needing trauma evaluation or observation secondary to trauma Shock from any source (septic, anaphylactic, cardiogenic, neurogenic) Cardiac STEMI/NSTEMI Rising Indeterminate or positive troponins Recent episode of V tach of V fib Persistent chest pressure in high risk CAD patient Symptomatic 2 nd / 3 rd degree heart block Neuro Persistent stroke symptoms or onset within 6 hours Uncontrollable Seizures Pulmonary Patient in moderate to severe respiratory distress PNA with PORT score above 90 PE that is associated with either hypoxemia and is either saddle or bilateral burden Either spontaneous or traumatic pneumothorax ID Impending sepsis (specifically elderly with urosepsis) Concern for or diagnosis of bacterial meningitis 8

9 A Well-Defined Patient Population: General Exclusions from the CDU 17 PATIENTS WITH INCOMPLETE CHART HIGH SEVERITY OF ILLNESS HIGH INTENSITY OF SERVICE PATIENTS FOR WHOM INPATIENT ADMISSION IS CLEARLY NEEDED AGE LESS THAN 15 YEARS OLD OBSTETRIC PATIENTS OVER 20 WEEKS PREGNANT PATIENTS AT RISK OF SELF HARM ANTICIPATED CDU LENGTH OF STAY LESS THAN 4 HOURS OR OVER 24 HOURS PATIENTS WITH (1) AN ACUTE GAIT DISTURBANCE, (2) RULE OUT HIP FRACTURE, OR (3) OVER AGE 65 WITH BACK PAIN Standard Approaches to Care Standardized Diagnostic and Treatment Pathways 18 Diagnostic, Treatment, and Medication components Customized for each different condition Coordinated with physicians, nurses and pharmacy Minimize or eliminate consults in favor of diagnostic and treatment pathways defined by specialty leadership 9

10 Observation Protocols by Condition Insulin Drip 2. GI Bleed 3. Renal Colic 4. Abdominal Pain 5. Vertigo 6. Allergic Reaction 7. Headache 8. Back Pain 9. TIA 10. Cellulitis 11. A fib 12. Pneumonia 13. DVT/PE 14. Heart Failure 15. Pyelonephritis 16. Chest Pain 17. Hypertensive Urgency 18. Hypertensive Urgency 19. Asthma 20. Metabolic Dehydration 21. Routine Medications 22. Pain Management 23. Warfarin 24. Potassium Replacement 25. Magnesium Replacement 26. Basal Bolus Insulin 27. Syncope Anatomy of the Observation Protocols 20 Non-Medication Orders Medications Prompt for medication reconciliation Vital Signs Activity Type of test/ plain films Intake/Output Labs Diet Consults Radiology Indication, as needed Alert physician if: SBP < 110 HR > 100 Dizziness Chest Pain Contrast vs. no contrast Medication name Dose Strength Route (IV, PO, SC, etc.) Frequency Prompts for standard orders: Potassium replacement Magnesium replacement Routine medications 10

11 21 Observation Protocol for Chest Pain- Non-Medication Orders Non-Medication Orders 1. Perform medication reconciliation 2. Cardiac monitoring IV Fluid Rate ml/hrx liters then ml/hr 3. Vital Signs Vital signs every 4 hours 4. 2 L/NC Monitor pulse ox: every 4 hours Titrate to keep POX > 93% 5. Activity Ad Lib Bedrest OOB w/assist May participate in PT/OT as tolerated 6. Intake and output, every 4 hours 7. EKG EKG STAT EKG with serial cardiac enzymes and as needed for chest pain 8. Insert saline lock 9. Labs at CBC D-dimer Chem 7 Lipid panel PT/INR BNP 6 hours Hepatic Panel 12 hours Lipase 10. Diet: Regular 1800 ADA Clear Liquid 2 gram sodium NPO Low calorie Puree Other 11. Consults Case Management Cardiology 12. Document symptom reassessment every 4 hours 13. Contact physician immediately for any of the following (unless otherwise notified by physician): SBP < 100 HR > 110 Complaints of dizziness Complaints of chest pain 22 Observation Protocol for Chest Pain -Radiology Radiology 14. CXR Indication: PA/Lat Portable 15. 2D Echocardiogram, indication: 16. Stress test type: 17. CT chest angio (r/o PE) 18. Venous Doppler: 11

12 Observation Protocol for Chest Pain-Medications 23 Medication Dose Strength Route Frequency 19. Aspirin: contraindication (Y/N) 81 mg 325 mg 20. Simvastatin OR 40 mg Atirvastatin 80 mg. PO PO Daily Daily 21. Metoprolol 12.5 mg 25 mg 50 mg Other PO BID: (Hold if HR < 60 and/or SBP < 90) 22. Clopidogrel 300 mg 600 mg 23. Clopidogrel 75 mg PO Daily 24. Enoxaparin (Lovenox) 1 mg/kg: mg PO Now SC One time Every 12 hours 25. Nitroglycerin (Nitrostat) 0.4 mg SL For chest pain every five minutes 26. Nitropaste ½ inch Apply to chest wall For chest pain change every 8 hours (Hold for SBP < 120) 27. Morphine 2 mg IV Prn every 30 minutes x 2 for unrelieved chest pain 28. Norvasc (for patients with bradycardia: betablocker 5 mg PO Daily contraindicated) 29. Diltiazem (for cases of afib) 60 mg PO Every 12 hours x 2 doses 30. Carvedilol (Coreg) mg PO Daily 31. Lisinopril 10 mg PO Daily 32. Furosemide 20 mg PO Every 12 hours x 2 doses 33. Losartan 25 mg PO Daily 34. Digoxin 0.25 mg PO Daily Protocols (Complete Standard Orders): 35. Potassium replacement 36. Magnesium replacement 37. DVT Prophylaxis 38. Complete routine medication 24 Key Contacts Here Key Contacts Here 12

13 Examples of Observation Protocols 3. How do we select a stress test with imaging?: Based on the above, here is the breakdown of what is available and where Emory University Hospital CDU 7/2011 Emory University Hospital CDU Weekdays, 7AM-5PM o Male any age, or Female >55; norenal failure: BMI <30, no known CAD = Lexiscan technecium SPECT Dobutamine stress echo Exercise stress echo if able to exercise Coronary CTA (EUH only) BMI > 30, known CAD, or no available SPECT isotopes = Lexiscan Rubidium PET on hold Lexiscan technecium SPECT o Female <55: Dobutamine echo Exercise Stress echo Adenosine MRI o Severe Asthma / COPD; renal failure: Dobutamine echo Dobutamine SPECT (rest / stress sestimibi) Lexiscan Rubidium PET on hold

14 Evidence Based Pathways Standard Approaches to Care Standard CDU Patient Flow Emory University School of Medicine Clinical Decision Unit Manual,

15 Case Study: ED Observation Unit 29 BRIGHAM AND WOMEN S 20 YEAR EXPERIENCE Stephen Bohan, MD, MS SB BWH EDOU/CHARACTERISTICS EFFICIENCY Beds LOS- 13 hours Throughput-1.8 patients/bed/day 12% of ED visits/7200 patients per year 120,000 patients SB 15

16 BWH EDOU/CHARACTERISTICS SAFETY 31 One (1) unexpected death (1996) Dreaded words= OBS to ICU Once every two years Reasons Structured Care Protocols = built in communication Same team Structured Documentation SB BWH EDOU/CHARACTERISTICS PATIENT SATISFACTION 32 Patient Complaint Rate = 3/21,000 Reasons: Minimal repetition of story Rapid simple transfer Hospital bed Expectation (and reality) of Home in AM Design promotes continuous engagement with patient Note: Above is despite 7/10 bays being curtained, with only one bathroom for all 10 pts. SB 16

17 BWH EDOU/Characteristics 33 SB BWH EDOU/Characteristics 34 SB 17

18 BWH EDOU/Characteristics Finances 35 OBS care is outpatient 1. APC bundles ED and OBS=$1250 Does not bundle IV or IV med or procedures Virtually no denials Avoided admission creates capacity upstairs with insignificant capital investment e.g. no CON, no building Ann Arbor lesson 2. Physician payments complex can discuss SB Upstairs Downstairs v2.0 Syncope 36 Metric EDOBS Inpatient Length of Stay 29 hrs 47 hrs Admission Rate 15% 92% Cost $ Outcomes Same Same Safety Same Same Pt satisfaction Same Same Savings due to shorter LOS/multi site study-bwh one site SB 18

19 Beyond BWH/ Emory 37 Metric CDU In Patient Length of Stay 25.6 hrs 61.2 hrs Cost $890 $1547 Full testing 97% 91% Subsequent stroke 3 2 Ross, MA An Emergency Department Diagnostic Protocol for Patients With Transient Ischemic Attack: A Randomized Controlled Trial Annals of Emergency Medicine Vol. 50, Issue 2, Pages , SB OBS Co Payments/ Urban Myth 38 Elderly patients paying outrageous amounts for being in hospital for Observation (CNN, MSNBC, NYT, WSJ, Evening News x 3) FACT On average, Medicare paid three times more for a short inpatient stay than an observation stay, and beneficiaries paid almost two times more Beneficiary=$401 for OBS vs $725 for INPATIENT 94% of OBS patients paid less than inpatient deductible. File under: Never clutter your argument with facts Office of the Inspector General CMS (7/2013) SB 19

20 Summary: Optimizing Your Observation Unit A defined treatment location 2. Matching capacity and demand 3. Standard approaches to care, including A dedicated physician group overseeing the unit Well defined patient population with inclusion/exclusion criteria Standardized diagnostic and treatment pathways for different patient populations Standardizedpatient flow KJ 20