Discharge Planning Advisor

System achieves right patient, right level of care’

Training nurses to ask questions was key

An increasing number of one-day stays and patients who failed to meet admission criteria formed the impetus for a throughput initiative that is reducing inappropriate admissions at Sutter Health in Sacramento, CA, says Barbara Leach, RN, director of case management for Sacramento Yolo Sutter Health.

"My personal driver was getting patients into the right status of admission," she adds. "There is so much confusion, so much [area] that is gray, when an outpatient needs to remain for a longer period than normal because of unforeseen complications."

The Center for Medicare & Medicaid Services (CMS), Leach notes, sets a target percentage for one-day hospital stays by Medicare patients. The rationale, she explains, is that if a patient is only in the hospital for one day, the question arises as to whether the person might more appropriately have been given observation status, for example, or referred to a skilled nursing facility.

That issue, combined with the push to meet InterQual criteria — a group of measurable clinical indicators and diagnostic and therapeutic services that reflect a patient’s need for hospitalization — set the stage for the effort to place "the right patient in the right hospital at the right level of care, Leach says.

The first pilot project took place last June at Sutter General Hospital, she says, with a team composed of a case manager, a patient placement nurse already charged with assigning beds, and bed placement clerical staff who keep track of admission data and verify insurance eligibility.

"We live in an area where people change [insurance] carriers all the time, so one issue is determining whether a patient should even be admitted to this hospital," Leach notes. "We were often not finding out until a day or two later that someone was capitated to another hospital. The other hospital calls and says, Thanks for providing open-heart surgery to our patient.’ It doesn’t take too many of those cases to feel like you’re hitting bumps in the road."

Even if there still is the opportunity to transfer after a patient in another managed care plan is inappropriately admitted, she points out, "there is the disruption to the patient who has to move, and the expense to our hospital. We [incur the cost] of the most expensive day, and then we have to move the person to another facility."

To hospital administrators, Leach adds, she emphasized the initiative’s focus on controlling access so that only appropriate patients are admitted. To physicians, on the other hand, she stressed that it would facilitate the admission of their patients.

While some hospitals have a similar process in place for planned admissions, she notes, the Sutter project was designed around unscheduled admissions, which are "our Achilles heel."

"We had all these people managing information," Leach says. "They verified that [patients] had appropriate insurance and they validated with information from physicians that patients met InterQual criteria for level of care — whether telemetry, intensive care unit (ICU), observation or inpatient."

Once the level of care was established, the patient placement nurse was asked if a bed of that type was available, she says.

In the past, Leach adds, physicians would call and say they needed a bed at a certain level of care, and staff would respond that it was available or not. "We never knew [at that point] if the patient met criteria. Or, the [patient placement nurse] might say, I don’t have an ICU bed, but can you take a telemetry one?’ It might turn out that’s what the patient needed anyway."

The project also has "allowed us to dialogue" with physicians in the emergency department (ED) — where there is a case manager — when patients don’t meet InterQual criteria, she says.

"[The case manager] can say, The patient doesn’t meet inpatient criteria, but may need placement in an SNF [skilled nursing facility], and I can help you with that,’" Leach continues. "Or she can say, I need more information to qualify this patient for emergent admission. Please document the tests and procedures you are planning for this patient.’"

That means, she adds, that when physicians admit patients and say they’ll check on them later, the response now is, "That’s not enough — we need a plan of care in order to move [the patient] along in the process."

Recognizing the potential for conflict that questioning physicians about their orders can cause, she notes, staff choose their words carefully.

Instead of saying, "The patient doesn’t meet criteria," and having the physician respond, "I don’t care — admit him anyway," Leach says, "We might call and say, We need to better understand the treatment plan so we can put the patient in the right place.’"

In the past, she explains, physicians would simply write the orders and the patient would be taken to the nursing unit. "We would have that dialogue [with the physician] 24 hours after admission when the case manager was doing the utilization review and would say, Why is this person here?’"

Inappropriate admissions avoided

As a result of the Sutter General pilot, Leach says, staff were able to identify a number of ED patients that otherwise would have been inappropriately admitted to the hospital and refer them to outpatient treatment, place them in SNFs, or have them transferred to the facility designated in their managed care plan.

For all 51 patients admitted during the pilot — which was confined to the hours between 8 a.m. and 5 p.m. — staff were able to document that they met the criteria for admission," she says. "That’s not a huge number. We did this during a time when we were not getting slammed so we could work our process and have the necessary resources available."

By communicating with physicians, staff avoided admitting between seven and 12 people as inpatients, instead directing them to observation status or another type of care, Leach notes. "For example, physicians often will admit patients to the hospital for infusion, for hydration, but we have a clinic where that is done, so we can help set that up."

In the months since the pilot, the proactive communication with physicians has continued to work beautifully, she notes, adding that since the project began, with "every patient about whom [nurses] have dialogued with the physician regarding either level of care or criteria, the issue has been resolved prior to admit."

"The key has been to adequately train the patient placement nurses with questions to ask and alternatives to offer the physicians so they can be sure the patients are getting the treatment they need," Leach says. While Sutter Health has had the patient placement nurse function for some time, she says, formerly the job "was only to figure out what bed to put the patients in."

Apart from causing a financial loss to the hospital, Leach points out, she believes that inappropriate admissions are a quality of care issue. "The risks of being in the hospital — falls, medication errors, bed sores, infection — are all well documented. Those are all things that we are able to prevent if a person is not admitted unnecessarily to the hospital."

A pilot project done at the health system’s other hospital, Sutter Memorial, was a much bigger challenge, she says, because the majority of unscheduled admissions come through services other than the ED. That hospital, Leach explains, is located in a residential area and specializes in pediatrics, obstetrics, and cardiology. It also is a larger facility than Sutter General. Together, she notes, the two acute care facilities have well over 600 beds.

"Cardiology patients often come through emergent admits from other hospitals or scheduled admits from interventional procedures, such as heart catheterization or diagnostic imaging," she says. "We are dealing with specialists and with patients who are having procedures, not coming to the ED with a cold."

Because the patients being admitted may already be outpatients or may be coming from another facility, Leach adds, it is easier for them to "slip through the cracks." During the Memorial pilot, she says, only nine people were admitted through the ED.

Although data from that pilot haven’t been analyzed, Leach says, "we know anecdotally that we were very effective in the ED and that — even with the lesser number of admissions — probably impacted the same number of patients who were at the wrong hospital or needed to be hooked up with other services."

Hospital administrators initially were concerned that the steps involved in ensuring proper placement would delay patient throughput, she notes. "We provide tertiary care for multiple areas, so we have a specialty services network from all over California. We don’t want to lose that business by putting up barriers to admission."

Those fears proved to be unfounded, Leach says, noting that in both studies, the length of time between a patient presenting at the ED or outpatient department and being admitted to the hospital did not increase.

In fact, the time may have been shortened, she adds, "but we don’t have enough data to show that yet."

While the project’s patient placement nurse is currently working 10 hours a day, the goal is to have the kind of patient coordination done in the pilots in place around the clock, Leach says. "We’ll probably be making decisions on [hiring] that person or people based on some volume studies."

(Editor’s note: Barbara Leach can be reached at LeachB@sutterhealth.org.)