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The Healthcare Financial Management Associ ation (HFMA) in Chicago has updated a training kit designed to help hospitals comply with Medicare’s three-day payment window rule.
The rule is a Medicare regulation requiring bundling of all diagnostic and certain nondiagnostic services performed within three days of an inpatient admission on the same inpatient bill to Medicare. It applies only to acute care hospitals.
"DRG Watch: Complying with the 3-Day Win dow Rule" is an updated version of "DRG Watch: A Multi-Phase Instructional Program for DOJ Compliance," which HFMA launched in 1996.
The revised program features information based on the Health Care Financing Administra tion’s final three-day window rule, published in Febru ary 1998. It includes a training video, a desk reference guide/workbook, audio teleconferences, and custom advice through HFMA’s Knowledge Network.
By Patty Calver, RN, BSN
Margaret Rider, RN
Deanne Hetrick, RN, BSN
Jean McGraw, RN
Harborview Medical Center
Harborview Medical Center (HMC) in Seattle began looking at alternate methods of chest pain evaluation in 1996. This was in response to the need to standardize the rule-out protocol and to provide more efficient care to those patients entering the hospital with atypical chest pain and non-diagnostic ECG changes.
HMC is a teaching hospital staffed with cardiology attendings, cardiology fellows, and residents. Based on each practitioner's previous experience, a series of several different laboratory tests and follow-up studies were ordered. This resulted in laboratory testing requiring anywhere from six hours to 24 hours to rule a patient out for a myocardial infarction (MI).
The admitting resident team admitted medical intensive care unit patients in addition to the cardiology patients. Critically ill patients received early rounds and the less acute rule-out (R/O) MI patients received late afternoon rounds. The late afternoon rounds prevented timely follow-up testing and discharges of the R/O MI patient population.
A group of caregivers led by one of the attending cardiologists developed the idea of an acute cardiac evaluation unit (ACE-U) devoted to the efficient and quality care of the R/O MI patient. Involved in the planning of this new unit were the medical director for the acute cardiac evaluation unit, the associate director of critical care, and nurse managers and staff nurses from the coronary intensive care unit (CICU), emergency department, and medicine/telemetry floor. Also involved were the nuclear medicine medical director and technologists, the project manager for clinical pathways, the medicine clinical nurse specialist, and representatives from nutrition, laboratory medicine, social work, and physical therapy. This group reviewed the current R/O MI/uncomplicated MI pathway and divided this pathway into two separate pathways: R/O MI and uncomplicated MI. The group then revised the R/O MI pathway to more efficiently reflect the needed care for this patient population. (See pages from R/O MI pathway, pp. 156-158.)
Revisions made based on trial
While construction of the ACE-U was in progress, the pathway was trialed in the CICU and Medicine/Telemetry floor with patients meeting pathway criteria. Based on the trial, further revisions were made.
The ACE-U opened as a four-bed open-bay unit with an attached room holding a single-head Spect Scan Nuclear Medicine Camera. Central to the unit is a nurses station with central telemetry monitoring for the ACE-U and other telemetry areas within the hospital. One CICU critical care nurse per shift staffs this unit. On the day and evening shift, a medical assistant assists with the care. The average daily census is slightly greater than two. Most admits occur between 1300 and 1700, and most discharges occur between 1100 and 1700.
Once the ACE-U opened, several issues arose. Discussions at staff meetings and informal problem-solving sessions occurred regularly. Problems included different interpretations of admission criteria among physicians, nursing staff, and nursing supervisors; delays in admission to the ACE-U from the ED; and delays in nuclear medicine scanning. Delays occurred with discharges and scheduling follow-up testing. Also, work-flow issues for the staff were significant.
A small core of CICU staff members volunteered to focus their attention and time in the ACE-U. Their goal was to problem-solve and focus on quality improvement both for the patients in the ACE-U and the ACE-U itself. This group proved to be the key to the success of the ACE-U (and remains so today). The group's consistent focus and ability to problem-solve has streamlined the care of the patients and has resulted in consistent quality care for the patients.
Education of emergency department (ED) staff, nursing supervisors, attendings, and residents decreased admission and initial nuclear medicine scan time. Review of inappropriate admissions paired with education of medical staff, nursing supervisors, and ACE-U staff on admission criteria decreased inappropriate admission. Arrange ments with the cardiology attendings resulted in the resident team rounding in the ACE-U prior to the intensive care units. This allowed for earlier decisions for follow-up testing and discharge. Networking with the Cardiology Department for stress testing and clinic appointments provided timely follow-up testing for patients. Additionally, evaluation of work-flow issues resulted in providing more convenient supplies, more computer work stations, and additional evening shift medical assistant support.
The ACE-U has resulted in the rapid flow of patients from the ED to the ACE-U, rapid identification and treatment of patients with acute MIs, decreased lengths of stay for patients with R/O MI, and consistent patient education and follow-up. Staff continue to identify barriers to quality care and address them individually. This staff dedication is key to caring successfully for the atypical chest pain patient.