Harbor:Observation placement - Revision history

Bchap23 at 00:26, 7 March 2024

2024-03-07T00:26:55Z

← Older revision		Revision as of 00:26, 7 March 2024
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	'''WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines.'''		'''WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines.'''
	<small>* Goal of our observation/Short Stay is admission avoidance		<small>
			* Goal of our observation/Short Stay is admission avoidance
	* Consider a brief additional stay in the ED if it will prevent an admission		* Consider a brief additional stay in the ED if it will prevent an admission
	* All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs		* All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs

Bchap23 at 00:26, 7 March 2024

2024-03-07T00:26:38Z

← Older revision		Revision as of 00:26, 7 March 2024
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	WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines.		'''WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines.'''
			<small>* Goal of our observation/Short Stay is admission avoidance
			* Consider a brief additional stay in the ED if it will prevent an admission
			* All Placement patients should go here unless explicitly instructed by the OBS attending to admit due to specific needs
			* (Previous: When boarding >5 obs patients in ED, admit DHS empaneled OBS-level patients)
			</small>

Andreawu: Replaced content with "WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines. ==See Also== *Harbor:Main ==Reference..."

2022-05-31T18:26:43Z

Replaced content with "WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines. ==See Also== *Harbor:Main ==Reference..."

← Older revision		Revision as of 18:26, 31 May 2022
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	~~==Background==~~		WE NO LONGER HAVE OBSERVATION STATUS/PLACEMENT. Patient needs to be admitted per Utilization Management/Interqual Guidelines.

	*Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable -
	*Only patients with internal medicine (or family medicine) covered illness can be placed on Obs/admitted to Short Stay Medicine. All other services require admission (or transfer)
	*Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition.
	~~===Observation/Short Stay Service Guidelines===~~
	*'''"Yes" to OBS/Short Stay'''
	** ''Placement: All patients requiring placement should go to OBS/Short Stay''
	** Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients if unable to arrange a safe outpatient plan.
	** TB rapid rule-out (GenExpert PCR) takes about 12 hours. Order:
	***AFB bundle
	***Saline chloride 10% for RT
	***2 specimen cups with 1ml and 5ml total expectorate

	*'''Do NOT Place on OBS/Short Stay (Admit instead)'''
	** COVID patients – take longer than two midnights, typically get admitted to medicine teams (Spiegel 11/2019)
	** Fever of unknown origin (FUO) – takes longer than two midnights to get cultures back (Spiegel 11/2019)
	** Coumadin bridging requiring heparin drip (Lewis - 7/2017)
	** Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)
	** Patients needing first ever dialysis (Spiegel/Daar 1/2019)
	** Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)
	** Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)
	** Pancreatitis may be better served with admission, but may fly in OBS (~40% admission rate)

	*Patients that are OOP
	** For patients who are (1) not safe for discharge home; (2) stable for transfer or can be stabilized for transfer; and (3) empaneled to an outside system
	*** '''Ask, via UR, that the patient be transferred for hospitalization within their empaneled system'''
	*** Clearly document why the patient’s medical condition makes it impossible to safely discharge them from the ED, and why they need acute medical care or additional evaluation.
	*** Ask, via UR, that the '''empaneled system grant approval for inpatient admission if they are unable to accept the patient''' in transfer.
	*** If the empaneled system both refuses to accept their patient in transfer (e.g., they have no capacity) and refuses to give approval for inpatient admission (e.g., the patient doesn’t meet their own internal criteria for requiring admission), then UR will determine whether the patient should be admitted or placed on OBS/CORE, based on our internal assessment of the likelihood that we will be able to successfully appeal the initial denial for authorization. '''If we believe that a successful appeal is likely, we will admit the patient to an inpatient service to continue to preserve OBS/CORE capacity for DHS patients.''' (Dr. Lewis 9/2019)

	==See Also==		==See Also==

Andreawu: /* Background */

2021-10-21T15:17:50Z

Background

← Older revision		Revision as of 15:17, 21 October 2021
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	==Background==		==Background==

	*Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable - ~~[Peterson 5/2016]~~		*Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable -
	*Only patients with internal medicine (or family medicine) covered illness can be placed on ~~obs~~. All other services require admission (or transfer) ~~[Lewis 5/2016]~~		*Only patients with internal medicine (or family medicine) covered illness can be placed on Obs/admitted to Short Stay Medicine. All other services require admission (or transfer)
	*Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition. ~~[Peterson 2/2019]~~		*Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition.
	===Observation Service Guidelines===		===Observation/Short Stay Service Guidelines===
	*'''"Yes" to OBS'''		*'''"Yes" to OBS/Short Stay'''
	** ''Placement: All patients requiring placement should go to OBS''		** ''Placement: All patients requiring placement should go to OBS/Short Stay''
	** Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients ~~(Lewis - 10/2017)~~		** Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients if unable to arrange a safe outpatient plan.
	** TB rapid rule-out (GenExpert PCR) takes about 12 hours. Order:		** TB rapid rule-out (GenExpert PCR) takes about 12 hours. Order:
	***AFB bundle		***AFB bundle
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	***2 specimen cups with 1ml and 5ml total expectorate		***2 specimen cups with 1ml and 5ml total expectorate

	*'''Do NOT Place on OBS (Admit instead)'''		*'''Do NOT Place on OBS/Short Stay (Admit instead)'''
	** COVID patients – take longer than two midnights, typically get admitted to medicine teams (Spiegel 11/2019)		** COVID patients – take longer than two midnights, typically get admitted to medicine teams (Spiegel 11/2019)
	** Fever of unknown origin (FUO) – takes longer than two midnights to get cultures back (Spiegel 11/2019)		** Fever of unknown origin (FUO) – takes longer than two midnights to get cultures back (Spiegel 11/2019)
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	*** Ask, via UR, that the '''empaneled system grant approval for inpatient admission if they are unable to accept the patient''' in transfer.		*** Ask, via UR, that the '''empaneled system grant approval for inpatient admission if they are unable to accept the patient''' in transfer.
	*** If the empaneled system both refuses to accept their patient in transfer (e.g., they have no capacity) and refuses to give approval for inpatient admission (e.g., the patient doesn’t meet their own internal criteria for requiring admission), then UR will determine whether the patient should be admitted or placed on OBS/CORE, based on our internal assessment of the likelihood that we will be able to successfully appeal the initial denial for authorization. '''If we believe that a successful appeal is likely, we will admit the patient to an inpatient service to continue to preserve OBS/CORE capacity for DHS patients.''' (Dr. Lewis 9/2019)		*** If the empaneled system both refuses to accept their patient in transfer (e.g., they have no capacity) and refuses to give approval for inpatient admission (e.g., the patient doesn’t meet their own internal criteria for requiring admission), then UR will determine whether the patient should be admitted or placed on OBS/CORE, based on our internal assessment of the likelihood that we will be able to successfully appeal the initial denial for authorization. '''If we believe that a successful appeal is likely, we will admit the patient to an inpatient service to continue to preserve OBS/CORE capacity for DHS patients.''' (Dr. Lewis 9/2019)



	~~Chappell, 12/2020~~

	==See Also==		==See Also==

Bchap23: /* Observation Service Guidelines */

2021-02-09T21:14:53Z

Observation Service Guidelines

← Older revision		Revision as of 21:14, 9 February 2021
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	** Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)		** Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)
	** Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)		** Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)
	** Pancreatitis may be better served with admission, but may fly in OBS		** Pancreatitis may be better served with admission, but may fly in OBS (~40% admission rate)

	*Patients that are OOP		*Patients that are OOP

Bchap23: /* Observation Service Guidelines */

2020-12-08T21:09:13Z

Observation Service Guidelines

← Older revision		Revision as of 21:09, 8 December 2020
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	** Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)		** Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)
	** Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)		** Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)
			** Pancreatitis may be better served with admission, but may fly in OBS

	*Patients that are OOP		*Patients that are OOP

Bchap23: /* Observation Service Guidelines */

2020-12-02T20:56:46Z

Observation Service Guidelines

← Older revision		Revision as of 20:56, 2 December 2020
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	*Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition. [Peterson 2/2019]		*Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition. [Peterson 2/2019]
	===Observation Service Guidelines===		===Observation Service Guidelines===
	"Yes" to OBS		*'''"Yes" to OBS'''
	* '''Placement:~~'''~~ ~~'''~~All patients requiring placement should go to OBS'''		** ''Placement: All patients requiring placement should go to OBS''
	* Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients (Lewis - 10/2017)		** Patients should be placed on the most appropriate unit by the ED; if specialty services are not available in the desired timeframe (ie, GI, IR), the observation team may make the decision to admit such patients (Lewis - 10/2017)
	* TB rapid rule-out (GenExpert PCR) takes about 12 hours. Order:		** TB rapid rule-out (GenExpert PCR) takes about 12 hours. Order:
	**AFB bundle		***AFB bundle
	**Saline chloride 10% for RT		***Saline chloride 10% for RT
	**2 specimen cups with 1ml and 5ml total expectorate		***2 specimen cups with 1ml and 5ml total expectorate

			*'''Do NOT Place on OBS (Admit instead)'''
			** COVID patients – take longer than two midnights, typically get admitted to medicine teams (Spiegel 11/2019)
			** Fever of unknown origin (FUO) – takes longer than two midnights to get cultures back (Spiegel 11/2019)
			** Coumadin bridging requiring heparin drip (Lewis - 7/2017)
			** Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)
			** Patients needing first ever dialysis (Spiegel/Daar 1/2019)
			** Decompensated liver disease – if bleeding, SBP, or in need of diuresis, this will require at the very least two midnights (and typically at least 72 hours) for treatment (Spiegel 11/2019)
			** Surgical patients should go to their respective surgical service for admission; E.g., patients who are awaiting determination of if they will need surgical management (particularly those who come in overnight), with the statement in the chart “chief/specialty service to reassess in am”, etc. (Spiegel/Wu 11/2019)

	~~Do '''NOT''' Place on OBS (Admit instead)~~
	* Coumadin bridging requiring heparin drip (Lewis - 7/2017)
	* Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)
	*Patients needing first ever dialysis (Spiegel/Daar 1/2019)
	*Patients that are OOP		*Patients that are OOP
	** For patients who are (1) not safe for discharge home; (2) stable for transfer or can be stabilized for transfer; and (3) empaneled to an outside system		** For patients who are (1) not safe for discharge home; (2) stable for transfer or can be stabilized for transfer; and (3) empaneled to an outside system
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	Chappell, 8/~~2017, Peterson 1/2019~~		Chappell, 12/2020

	==See Also==		==See Also==

Bchap23: /* Observation Service Guidelines */

2019-09-19T20:40:11Z

Observation Service Guidelines

← Older revision		Revision as of 20:40, 19 September 2019
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	* Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)		* Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)
	*Patients needing first ever dialysis (Spiegel/Daar 1/2019)		*Patients needing first ever dialysis (Spiegel/Daar 1/2019)
	*Patients that are OOP(Lewis 9/2019)		*Patients that are OOP
			** For patients who are (1) not safe for discharge home; (2) stable for transfer or can be stabilized for transfer; and (3) empaneled to an outside system
			*** '''Ask, via UR, that the patient be transferred for hospitalization within their empaneled system'''
			*** Clearly document why the patient’s medical condition makes it impossible to safely discharge them from the ED, and why they need acute medical care or additional evaluation.
			*** Ask, via UR, that the '''empaneled system grant approval for inpatient admission if they are unable to accept the patient''' in transfer.
			*** If the empaneled system both refuses to accept their patient in transfer (e.g., they have no capacity) and refuses to give approval for inpatient admission (e.g., the patient doesn’t meet their own internal criteria for requiring admission), then UR will determine whether the patient should be admitted or placed on OBS/CORE, based on our internal assessment of the likelihood that we will be able to successfully appeal the initial denial for authorization. '''If we believe that a successful appeal is likely, we will admit the patient to an inpatient service to continue to preserve OBS/CORE capacity for DHS patients.''' (Dr. Lewis 9/2019)

PetersonMike123: /* Observation Service Guidelines */ add OOP to OBS exclusions

2019-09-03T20:30:15Z

Observation Service Guidelines: add OOP to OBS exclusions

← Older revision		Revision as of 20:30, 3 September 2019
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	* Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)		* Multi-drug resistant history requiring antibiotics while awaiting culture results (Lewis - 7/2017)
	*Patients needing first ever dialysis (Spiegel/Daar 1/2019)		*Patients needing first ever dialysis (Spiegel/Daar 1/2019)
			*Patients that are OOP(Lewis 9/2019)

PetersonMike123: /* Background */ Remove CAP section, add transfer section

2019-04-30T21:35:54Z

Background: Remove CAP section, add transfer section

← Older revision		Revision as of 21:35, 30 April 2019
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	==Background==		==Background==

	*Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable - Peterson 5/2016		*Any OOP patients needing observation or CORE services should be transferred to an in-network hospital if they are stable - [Peterson 5/2016]
	*Only patients with internal medicine (or family medicine) covered illness can be placed on obs. All other services require admission (or transfer) - Lewis 5/2016		*Only patients with internal medicine (or family medicine) covered illness can be placed on obs. All other services require admission (or transfer) [Lewis 5/2016]
	*~~If the hospitalist is capped (cap is 20 if single overnight hospitalist coverage, which includes Obs and CORE leftover from dayshift, new Obs or CORE, and new admissions), and you~~ have a ~~patient you’d like to place in Observation, CORE, or an admission:~~		*Patients who would have been admitted but are pending a transfer that is delayed should NOT be placed on OBS just for that reason. These transfers often do not occur quickly. Only place such patients on OBS if they would have been OBS appropriate by their medical condition. [Peterson 2/2019]
	**Do not place the order for ~~obs placement, CORE, or the ‘request for admit’ order~~. ~~This becomes confusing for nursing who is actually managing the patient~~. Only place ~~this order when you~~ have ~~discussed the patient and the care officially transfers to the inpatient/obs/CORE physician~~.
	**Continue to manage the patient until the next hospitalist shift starts (typically 7:30am) or the next medicine slot is available.
	**Do put in an Attending Admit Note at the time of the actual admit decision but document in your notes that patient is being held in the ED due to lack of hospitalist/~~Medicine capacity.~~

	===Observation Service Guidelines===		===Observation Service Guidelines===
	"Yes" to OBS		"Yes" to OBS