Sharon E. Mace MD, FACEP, FAAP

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Observation Medicine StrategiesA Clinical
ApproachTips for Success or Failure

• Sharon E. Mace MD, FACEP, FAAP
• Director, Observation Unit
• Director, Pediatric Education/Quality Improvement
• Research Director, Rapid Response Team Cleveland
  Clinic
• Former Chair, ACEP Section of Observation
  Medicine
• Faculty, EM Residency, MetroHealth Medical
  Center/Cleveland Clinic
• Professor, Cleveland Clinic Lerner College of
  Medicine at Case Western
  Reserve University

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Number of Hospitals, Hospital Beds and EDs vs ED
Visits
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Purpose ofObservation Medicine

• Allows physicians to evaluate and treat selected
  patients over a finite time period which
  improves ED flow and has many benefits

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What Is Observation?

• While there are different interpretations, for
  Medicare from HIM-10 455 (Pub. 100-2,Medicare
  Benefits Policy Manual, Chapter 6, 70.4)
• Observation services are those services
• (a) Furnished on a hospitals premises
• (b) Includes use of a bed and periodic monitoring
  by nursing or other staff
• (c) Reasonable and necessary
• (d) To evaluate an outpatients condition
• (e) Determine the need for possible admission as
  an inpatient
• (f) Ordered by physician
• (g) Usually do not exceed one day
• (h) May go for up to 48 hours
• (i) Under unusual circumstances may exceed 48
  hours

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Why Observation Medicine

• Better patient care
• ? missed diagnoses
• Cost effective
• Rapid, efficient, evaluation / work-ups and
  treatment
• Risk management and malpractice, ? liability
• Psychosocial advantages
• Fiscal benefits
• Provided there are mechanisms for Observation
  Unit (OU) set up / maintenance
• OM is a process and a mindset, not a location

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Organizational Framework

• Patient criteria inclusion, exclusion, OU
  management, specific time frame
• Personnel clinical and administrative
• Resources location, equipment, supplies
• Specific policies and procedures
• Strong leadership empowered to clinically and
  administratively manage the OU
• Using policies, procedures, guidelines, clinical
  pathways, order sets, other tools
• Multidisciplinary teamwork approach / meetings

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Admission Criteria for Observation

• Stable vital signs
• Non-critical, stable, low maintenance
• Do not need intensive nursing care
• Do not need intensive physician care
• Expected to have a disposition in a reasonable
  short time frame observation, diagnosis,
  treatment for lt 24 hours

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Acceptable Diagnoses for Observation

• Cardiac chest pain, CHF, syncope
• Respiratory illnesses asthma, pneumonia
• not acceptable respiratory failure,
  epiglottitis, severe hypoxemia, hypercapnia
• GI / dehydration gastritis, vomiting, diarrhea
• not acceptable shock
• GU kidney stone
• not acceptable obstruction with renal failure

May want to start with chest pain
ensure success, then expand
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Acceptable Diagnoses for Observation

• Infections cellulitis, lymphangitis
• Neurology seizures, viral meningitis, minor
  head injury
• Toxicology ingestions, overdose
• Hematologic sickle cell, hemophilia
• Chronic illnesses DM ? glucose (not DKA)
• S/p procedures oversedated, s/p LP etc.

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Patient Exclusion for Observation

• Critically ill
• Unstable vital signs
• Need intensive nursing care
• Need intensive physician care
• Anticipated length of stay gt 24 hours

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Unacceptable Diagnoses for Observation

• Shock
• Coma
• Respiratory failure
• Bacterial Meningitis
• Neutropenic fever
• Critically ill

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Advantages of ObservationPrimary Care,
Specialists

• Expands patient base
• ? referrals, ? office visits, ? procedures, ?
  admits
• Easier to coordinate care
• Better, faster evaluation
• Improved MD profile
• Clinical pathways
• Quality, cost containment
• ACOs
• Disease management
• Variation reduction
• Other initiatives

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Advantages of ObservationHospital

• New product line
• Expanded referral base
• Better use of services at ? cost
• ? lengthy inpatient admits
• ? trend outpatient services
• ? outliers 1 day LOS
• PEPPER report

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Healthcare in Crisis

• The 2.2 trillion healthcare sector is now mired
  in deep crisis related to safety, quality, cost
  and access that pose serious threats to the
  health and welfare of many Americans1
• An estimated 30 to 40 cents of every dollar spent
  on health care, or roughly three quarters of a
  trillion dollars per year is spent on costs
  associated with overuse, underuse, misuse,
  duplication, system failures, unnecessary
  repetition, poor communication, and
  inefficiency 2
• 1 CMS
• 2 Lawrence National Academy Press

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Per Capita Medicare Spending Regional Variations
Congressional Budget Office. Research on
Comparative Effectiveness of Medical Treatments.
2008
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CMS Value BasedPurchasing Plan

• Clinical quality
• Adverse events
• Patient safety
• Patient centeredness
• Avoid unnecessary costs
• Investment in structural/system components
  IT capability, care management
  processes/tools
• Consumer driven Performance results/Transparency

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Success Depends Upon

• Prompt physician decision making
• Excellent documentation
• Empowered observation nursing staff
• Superb coding ? ? reimbursement
• Strong physician leadership
• Administrative support
• Buy in from other hospital departments,
  physicians, health care providers
• Tools for success
• Policies and procedures includes
  inclusion/exclusion criteria, evaluation,
  treatment, disposition plan
• Guidelines, clinical pathways

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How to Succeed or Fail at Observation Medicine
Observation Medicine
Success
Time (Length of Stay)
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Observation Success

• Major benefits
• Easiest way to build beds
• ? revenue per bed
• ? labor costs/RN ratio
• ? exposure to risk
• ? quality
• ? patient satisfaction
• ? cost

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Observation Advantages

• Improved patient care ? missed diagnosis /
  severity
• Improved patient outcome
• ? risk, ? malpractice
• ? ED patient throughput, ? ED LOS
• ? patient satisfaction
• Better public relations
• ? ED volume
• Financial ? revenue, ? denials, ? penalties

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Recovery Audit Contractors (RAC)

• Private corporations under contract via
  contingency to CMS
• Review all claims submitted by Medicare providers
  in order to prevent overpayments/underpayments
• Akin to a whistle blower or bounty hunter
• Focus high-risk DRGs, 1 day stay, observation

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United States Department of Justice

• Marcos Daniel Jimininez
• United States Attorney for the Southern District
  of Florida
• 99 N.E. Fourth Street, Miami, Fl. 33132
• Press Release
• For Immediate Release Feb.11, 2005
• For information, contact public affairs
• Carlos B. Castillos
• Special counsel for public affairs
• [phone]
• Cleveland Clinic pays U.S. 2.75 million

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Questions