Develop observation stay protocols now
Avoid the trap of last-minute decisions
Now is the time to draft a protocol for observational services. With impending changes by the Baltimore-based Health Care Financing Administration (HCFA) to the Medicare Hospital and Intermediary manuals, your observation practices are going to come under greater scrutiny, says Jeffrey Royer, JD.
Rather than scrambling to get a treatment decision made in the 20th hour of an observational stay, a clearly worded protocol will benefit caregivers and patients alike by ensuring decisions are made at the right time, says Royer, the managing shareholder in the Boca Raton, FL, office of the law firm Buckingham, Doolittle & Burroughs. Royer, who practices health care law and is a frequent speaker on HCFA issues, recommends including the following elements in your observation protocol:
1. Create expectations.
A policy outlining observational services should set expectations and define the purpose of observation. "The expectation should be that observational patients be evaluated and decisions made quickly," Royer says. "Information should be gathered and given to the physicians in a timely manner. Physicians must know that there is a time limit for them to make admitting decisions."
When observation patients are scattered throughout the hospital and housed in the same room with inpatients, caregivers do not make significant distinctions between the two different types of patients. "[Observational patients] tend to be treated as inpatients," Royer says. "Doctors only see them when they make rounds." This tends to lengthen stays in observation.
The policy should spell out that observation patients, by definition, are awaiting a decision on their admission, Royer says. Such a policy would be especially helpful to hospitals without designated observation units.
2. Expedite assessment.
Nurses should assess on each shift whether observation patients meet certain criteria for admission or discharge. This assessment should be done quickly and regularly during each shift. If the patient meets criteria, the physician should be notified.
3. Educate physicians.
Some physicians fail to distinguish between recovery time and observation time, especially after a surgical procedure. Some physicians order a post-procedure observation period, while others have standing orders for observation after certain procedures.
That issue is expressly addressed in the proposed HCFA regulations:
The following types of services are not covered as outpatient observation room services:
* Services for postoperative monitoring during a standard recovery period (e.g., 4-6 hours).
* Standing orders for observation following outpatient surgery.
* A patient may not be discharged to outpatient observation status after an inpatient hospital admission.
HCFA's proposed explanation of coverage for observation services may provide an ideal opportunity for an inservice presentation that reviews definitions of recovery and observation time. "Observation decisions have to be based upon the clinical facts of this patient at this time," Royer says. "The more we make a generic decision about a class of patients -- such as all cardiac cath patients go into observation following their procedure -- the more problems that creates."
3. Notify physicians of patient status in a timely manner.
Notify physicians of their patients' status at a specific time, such as hour 20 of an observation stay. This way a decision can be made within the appropriate time frame.
4. Establish a supervisory role.
"From a utilization review perspective, either a UR person or a nursing supervisor on the floor must prod the nurses on the floor to expedite the more frequent evaluation of [observation] patients," Royer says. Even if a policy covering observation patients is established, that does not ensure compliance. In facilities that have observation patients mixed in with the inpatient population, it is too easy to treat all patients the same.
Royer suggests setting up a process that has the admissions department notify the utilization management department the same day a patient is designated for observation. Typically, the utilization management department does not find out who is in the hospital for observation until the morning after such a designation is made. *