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Status determined before bed assignment
UR nurses, physicians work together to get it correct
Before a patient at Christus St. Vincent Regional Medical Center is registered or assigned to a room, a utilization review nurse in the hospital's Patient Intake Center reviews the patient's clinical information and collaborate with the admitting physician to determine that patient's status.
Getting the patient status correct on the front end ensures compliance with the Centers for Medicare & Medicaid Services (CMS) regulations, assures that the hospital is paid appropriately for the services it provides, and will help the hospital avoid problems when the Recovery Audit Contractors (RAC) and other CMS auditors review hospital records, says G. Paul Stec, MD, physician director of utilization and care management at the Santa Fe, NM, community hospital.
"We establish the patient's status prior to registration and prior to the room being assigned. This way, we aren't changing a physician's order. We are just making sure that the order that is being issued is correct. Once you get the status registered wrong, you can't fully correct the mistake," Stec says.
The goal of the Patient Intake Center is to make certain that the admissions status is correct and that the documentation is complete so that when an audit does occur, the documentation is so solid that there is no question about it, he adds.
"It is a red flag to CMS if there is not a clear patient admission order. If the order says only 'admit,' the RAC is going to dig deeper into the chart. We want a clean order that avoids audits," Stec says.
Every admission goes through center
Every admission to the acute care hospital, regardless of payer, goes through the hospital's Patient Intake Center, with the exception of patients on the labor and delivery floor.
The Patient Intake Center nurse screens the admissions whether they are direct admissions from physician offices, transfers from other hospitals, admissions from the recovery room after surgery, or admissions from the emergency department.
Physicians either call the Patient Intake Center and give the nurse a verbal order or use a pre-printed faxable form. The nurse reviews the patient's clinical information and the admission orders and makes sure that they correlate.
"Part of our process is the exchange of clinical information. The nurse is making certain that the status fits the patient and that it is properly documented in the admission orders. When the physician faxes or verbally issues the admission order, the clinical diagnosis should coordinate with the order. If the orders and clinical information do not correlate, it is the nurse's obligation to call the doctor and get the information needed," Stec says.
If the patient status clearly should be observation, the nurse contacts the physician and discusses it.
"Since she is a RN, if they agree that the order should be different, she can take the verbal order and make the status more correct, as per the physician's order," Stec says.
When a patient is being transferred from another hospital, the patient intake nurse makes sure that the patient has an accepting physician who will care for the patient at St. Vincent. "This ensures that the physician who is caring for the patient in the hospital is fully informed about the patient's clinical condition," he explains.
At St. Vincent, the emergency department physicians do not handle admissions. They call the admitting physician who may be either a physician in the community or a hospitalist.
The hospital's hospitalist program provides care for about 70% of the patients.
The Patient Intake Center nurse fills out an admissions work sheet and sends copies to bed control and the admitting and registration department.
The worksheet includes patient demographics, diagnoses, comorbidities, primary admitting diagnosis, and primary comorbidity. It includes information that the admitting nurse can use for room selection, such as fall risk, mental status, and need for isolation, along with information about the level of care.
Another section includes the time the nurse got the order, the time the work sheets are faxed, and the time she contacted the physician for additional information if appropriate.
There is a section the nurse can use if she needs to ask the physician for additional clinical information.
If the patient is being transferred from another hospital, there is a section with the name and phone number of the transferring physician and the name of the accepting physician.
The bed control department uses the information to select the level of care and identify the proper bed for the patient.
The registration and admitting department verifies the insurance, notifies the insurer, and admits the patient.
"What the registration staff must complete for an observation patient is different from what they must do for someone admitted in inpatient status. Our process ensures that they have the information they need to complete the registration," he says.
At St. Vincent, the Patient Intake Center is staffed by nurse case managers 16 hours a day. During the night shift, the patient intake process is completed by the nursing supervisor who also is in charge of bed control. Her work is reviewed by the Patient Intake Center nurse the following morning.
The hospital has an observation management case manager who is assigned to review all patients in observation status within an eight- to 12-hour window after admission.
"If she finds anything that might have impacted the patient status, she discusses it with the PIC nurse," Stec says.
"We have an active auditing program and a continuing education process to ensure that we are getting the status correct. The staff get together once a week and review the cases about which there are questions," he adds.
The hospital set up its Patient Intake Center in December 2008. The need became apparent when the hospital became affiliated with Christus Health, a nonprofit, faith-based system of more than 40 hospitals and long-term care centers with headquarters in Dallas, Stec says.
"The case management director and I visited Christus Santa Rosa Hospital in San Antonio, TX, which the Christus system had designated as a Best Practice Patient Intake Center. We worked with Santa Rosa's case management director Roxanne Jenkins to adapt the model to meet the needs of St. Vincent," he says.