The priority level of admins versus hospital staff

I have another sensitive topic to discuss today.  In fact, I discuss this with my wife often.  We've decided that the powers that be among the hospital community focus on the wrong areas so much that they lose sight at what they really should be focusing on. Moreover, they focus on things that will make sure they get full reimbursement for patients, when they should be focused on the patient.

I'm going to give you a for instance. For instance, yesterday I was called to the emergency room.  When I got down there there were eight orders, five EKGs and three breathing treatments.  The charge nurse said, "I want you to do the chest pain EKG first."

I said, "Well, there are three breathing treatments in here.  A therapeutic breathing treatment is more important than a diagnostic EKG."

So I set off to check on the three patients who were ordered on breathing treatments.  If treatments were ordered when they should be ordered, those three patients would be short of breath. However, after checking on them, it turned out that they were all breathing just fine.  So then, and only then, did I do the chest pain EKGs.

But, you see, there is a national policy, or a state policy maybe, that all chest pain EKGs be done within three minutes.  It has something to do with ACLS, but it also has also something to do with how the hospital gets reimbursed for that patient.  Of course I think it all comes down to money, so the powers that be focus on those chest pain EKGs as priority one.

Me, I'm fine with doing an EKG in an hurry, but not at the expense of therapeutics.  In RT school, I was always taught the therapeutics comes before diagnostics.  If you get an ABG, EKG and breathing treatment ordered, you to the treatment first.  The treatment, and not the ABG and EKG, can make a patient feel better right way.

I have a friend who works in OB, and she says it's no different there.  They focus on whether or not a patient gets a circumcision, or whether or not a mom who is in no way sick gets the flu or pneumonia vaccine, when what they should be focusing on is why breast feeding is important and how to do it, or how to correctly strap a child into a car seat.

So, you see, I think that sometimes the admins think on a completely different level as nurses and respiratory therapists.  Is this something that you should go and tell your boss today, no.  But there is an appropriate time and place to speak your opinion about things like this.

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Pneumonia readmissions on the decline

It appears Shoreline Medical is doing something right, at least when it comes to pneumonia readmission rates. As, compared to the national pneumonia readmission rate of 18%, our hospital had only a 2% readmission rate for the given time period of about a year.

Because of this, I was chosen to give a presentation to a group of respiratory therapy supervisors and managers. This was a unique and exciting opportunity for me, especially considering I was the lowest ranking RT at this meeting. Plus my boss chose me among all my peers to give the presentation.

I worked with the Quality Assurance Analyst for our hospital and created this really nice presentation. Then I spent quality time interviewing, going through charts, and researching all the things we do once a patient is diagnosed with pneumonia, and what we do to keep pneumonia rates down.

I actually learned quite a bit in this process about the administration side of things. What follows here is a summary of my presentation:

A goal at Shoreline Medical is that we all have our priorities in order.

Shoreline Medical is in a small town only a few miles off the shore of Lake Michigan. It's in a small town, a close nit community. And being a close nit community results in a close nit hospital. One of the reasons I chose to work here is because I felt Shoreline was kind of had a down home feel to it. Everyone got along, were good friends, had pot lucks, and stuff like that.

We started the process of getting our ducks in a row by focusing on the CMS Core Measures. To make sure all doctors, nurses and respiratory therapists are always thinking about the core measures, we are all in serviced on this every year by the Quality Assurance Department.

In the chart, before the doctor's orders section, is a bright orange laminated sheet that has all the core measures on it. This way, every time anyone looks at the orders he or she has to flip this page aside. And even if you don't read it, you know what's on it: the core measures. This is one simple reminder to everyone to focus on the core measures when writing and fulfilling orders.

The Core Measures for pneumonia are as follows:

1. Initial Antibiotic Timing (given within 6 hours)
2. Pneumococcal Vaccination if eligible
3. Influenza Vaccination if eligible (October to March)
4. Blood Culture drawn before initial antibiotics
5. Appropriate antibiotic selection
6. Smoking cessation advice and counseling given if indicated (if patient has smoked within the last 12 months)

The most important of the above are the pneumococcal Vaccination, Influenza vaccination and smoking cessation, as studies have linked all three with a reduction in secondary pneumonia. So our major emphasis was on these three.

These core measures are what works according to the most recent best practice evidence to improve patient outcomes and decrease costs for pneumonia patients. The question we had to ask ourselves is: how do we use these core values to get our ducks in a row

Data from our core values back in 2007 showed that Shoreline Medical was about 80% in all of these core measures except for antibiotic timing within 6 hours. In this, we had no data whatsoever, which means we probably didn't even do it.

Yet if you look at data from the first and second quarters of 2010 you can see that we are at or near 100% on nearly every core measure. When it comes to smoking cessation we were at 92%, yet that was basically due to a miscommunication between a doctor and a nurse. So even while we've improved, we still use this data to improve even further, as there is always room for improvement.

So basically back in 2007 we did not have all our priorities in order, and in 2010 we did. So how do we get our priorities in order?

Actually, if you look at pneumonia readmission data other than the above mentioned three month period our hospital at at 16.5%, which is no different than the U.S. National Rate. .

Yet from January to March 2010. During that span we had 52 pneumonia patients, and only one readmission rate.

These improved statistics based on the core measures show we are doing something right. They prove that we have our ducks in a row. The question you are asking is: how did we get our ducks in a row?

The first thing we did was back in 2007 we joined the Keystone Collaborative. We have a champion Internist, a physician from ER, and one from surgery and general practice as our champions. Then we have one nurse from critical care, the general floors, and one from the emergency room.

We also have a representative from lab, x-ray, pharmacy, quality assurance, computer analysis, respiratory therapy (that's me) etc., and we meet every month to analyze data from core measures to create and improve clinical pathways and order sets to improve patient outcomes and reduce costs for our hospital.

The key here is that we review modern wisdom and come up with better practices for our hospital. Anyone can do research, or come up with new ideas, and can share them with any member of the keystone

committee, and then this new wisdom is brought to and reviewed by the committee and changes are made as appropriate.

Basically the point of the Keystone Committee is to do what works and skip doing what's not working.

The following is our pneumonia order set:

Our order set includes the following as options for the doctor to check:

• Code status
• Vitals routine or ___________
• Record input and output, daily weight, pulse oximetry every shift
• EKG on admission
• Chest x-ray on admission and on day 3
• Lab work (if not already done): CBC, CMP, UA, Sputum for gram stain, culture and sensitivity, blood culture prior to administration of antibiotic (this has to be done within three hours of admission)
• AM labs_______________
• Oxygen at _______ lpm or per protocol or _________
• Respiratory treatments: Albuterol 2.5mg with 3cc normal saline Q6 hours, up to ____ hours prn
• Respiratory treatment: Atrovent 0.5 mg in 2.5 ml normal saline QID
• Antibiotic therapy (1st dose to be given in ER) or immediately after blood culture drawn)
• Community Acquired Pneumonia (non CCU): Levaquinn 500 mg IVPB Q24 hours times 3 days, then Levaquin 500 mg PO daily
• Community Acquired Pneumonia (CCU or stepdown patients): Rocephin 1 gm IVPB Q24 hours and Zithromax 500 mg IVPB Q24 hours and Levaquin 750 mg IVPB Q24 hours and Azactam 2 GM IVPB Q12 hours
• Nosocomial Pneumonis (check all that are indicated from list of meds and doses)
• IV Fluid ____________
• Tylenol 650 MG PO Q4 hours prn for pain
• Xanax 0.25 mg PO Q6 prn for anxiety
• Restoril 15 MG PO QHS prn for insomnia
• MOM 30 ML PO BID prn for constipation
• Robitussin 10 ml PO Q4 hours prn for cough

(I left a few things off, but that's basically the gist of it).

This is our pneumonia hymn book. It's all the things that the best practice evidence shows works to help pneumonia patients get well. It's one sheet of paper, which makes it very simple.

As you'll note, some of the things on here are automatically ordered -- the doctor has no choice. For instance, x-ray on admission and in the am times three days, and certain labs on admission and in the am.

The ER nurses are involved right away, because if that patient is in the ER at the five hour mark, they have to make sure a sputum is obtained, and that the patient has been given that initial antibiotic within 6 hours. They have a system to assure this is done, and checks and balances.

As soon as the patient is admitted, the orders are entered into the computer system, and reminders are automatically sent to all the respective departments as to what they have to do and when. In RT department sheets are printed off so we know what our role is for that patient.

For lab and x-ray, what they have to do is printed up on their respective printers, and plus the procedures they have to do are put on the tracker when they are due so they are reminded in that way too.

It's simple. This order sheet is our hymn book: it makes sure we are all singing from the same hymn book.

Then we have our extubation protocol (to see our extubation protocol click here). This order set is part of the ventilator bundle. It works similar to the pneumonia bundle, in that when it comes to intubated patients, it makes sure we are all singing from the same hymn book.

The neat things about our extubation protocol is that when we were in school in 1995 we learned that the cuff pressure should never exceed 20 cwp. Now we are taught to always exceed 20 cwp. The reason is to prevent aspiration , and to prevent ventilator acquired pneumonia.

Another thing to prevent pneumonia is that the circuit not be broken. To do this we use MDIs instead of nebulizers. Also, we do not disconnect the circuit to suction, and use in line suction catheters instead.

Another key is the daily sedation protocol. Every night around 2 a.m. we automatically take all our patients off sedation so that by 6 a.m. we can analyze the patient for readiness to wean.

Here comes another laminated sheet. As part of our ventilator protocol we have a sheet that acts as an algorithm to speed time from intubation to extubation. Actually, the key to a good extubation protocol is that as soon as the patient is intubated we start thinking about extubation.

If the patient can be extubated in 2 hours, now that's possible. Years ago if the attending went on vacation the other doctors didn't extubate because they didn't want to offend the attending. Sometimes we RTs would wonder why the patient was still intubated. Now, that never happens, or rarely happens.

Our Algorithm goes something like this:

Weaning Screen:

1. FiO2 less than or equal to 40%
2. PEEP less than or equal to 5
3. HR greater than 50 or less than 120
4. Temp. less than 100.5
5. SpO2 greater than 90 unless otherwise directed by physician
6. Systolic BP greater than 90
7. Minimal or no sedation
8. No Vasopressors
9. No signs of respiratory distress
10. Able to follow commands
11. Adequate cough
12. Secretion thin and minimal
13. Plateau pressure less than 30 cwp

If the answer is no, then you stop and reanalyze the next day. If the answer is yes, then you move on to the next step, which is to do a 5 minute spontaneous breathing trial (SBT). (ETT 8.0 or greater use a CPAP of 5 and PSV of 0, ETT 7.5 or smaller use CPAP of 5 and PSV of 5)

Now you do a second weaning screen based on the same criteria as above.

If the patient fails the screen, the SBT is stopped and patient returned to previous settings.
If the patient passes, the following is completed and analyzed:

1. NIF greater than 20
2. VC greater than 10 ml/kg
3. VT greater than 5
4. RR less than 30
5. VE greater than 5 and less than 15
6. RSBI (f/vt) less than 100

If the patient passes this criteria, continue SBT for 30-120 minutes. Then do another weening screen as mentioned above. If patient passes do an ABG and call physician for order to extubate.

So basically we no longer simply do weaning parameters every day, we are actually completely assessing the patient using the common sense, best practice evidence approach. Patients are getting extubated quicker, and VAP is now pretty much nonexistent at our hospital.

Another key is education. As soon as the pnuem order set is initiated the emergency nurse educates the patient about pneumonia. Then the nurse on the floor educates the patient, and then the RT is in the room every six hours, and he or she educates the patient some more.

We make sure not only do our patients learn about pneumonia, they also know about their disease. For example, if they have COPD we make sure they know the early warning signs of an exacerbation so they can nip it in the bud next time and don't have to be readmitted.

We make sure they know if they start to get more short of breath than usual, or have increased cough or sputum production, or change in color of sputum, that they call their doctor or come into the emergency room.

Plus, as soon as pneumonia order set is entered in the computer, an order for RT to do smoking cessation is printed off in the RT department. Several studies show that if when a patient is vulnerable, when he's sick in the hospital, that if someone nudges them to quit they are more likely to quit.

And then when the patient is discharged another paper is printed off that is a pneuminia fact sheet for the patient to take home with them. It is basically a reinforcement of everything they've learned about pneumonia, and is reviewed by the discharge planner.

It's also a reminder to the RN to make sure the patient has had his vaccines while admitted, and to reinforce to the patient that they get their annual pneumonia and flu vaccines.

So basically the pneumonia order set is our hymn book: it gets everyone on the same page from the RT to lab to nurse and x-ray and lab and doctor. We all know exactly what our role is for that patient

Another thing we have an emphasis no is good hand washing. We have signs over every sink that remind of the importance of hand washing. Another sign over every sink describes proper hand washing technique.

We also have hand sanitizer in every room and in various locations, and we encourage or professionals to use this between every patient, and after touching anything in the room, and before touching anything even on their own possession. We also encourage use of hand sanitizers before leaving the room, even if they ultimately wash their hands.

We have some of our nurses are anonymous spies who make note of who they see not washing their hands, or not doing so correctly. We have other pamphlets around the hospital that remind nurses, RTs, and even patients to keep your eyes open, and "It's okay to ask."

So good hand washing is key to preventing the spread of infection.

Another bonus at Shoreline is we are a close nit hospital. This results in really good communication. For example, if I'm in the room and I see something wrong with the patient, I talk to the nurse or sometimes I go right to the doctor.

Instead of the nurses calling the doctor and assuming they know what's wrong with the patient, they often call RT instead so we can use our experience and education to work with the nurse in deciding what needs to be done.

Likewise, many times the doctor calls me up and asks me what I'm thinking is wrong with the patient and what we should do. This is great for morale.


We also have a Rapid Response Team. And another thing is we have good support and encouragement. For example, if an RN calls me to assess a patient, and the patient is fine when I get their, is on the crapper or something, I don't say, "You stupid dummy. Why did you waste my time?"

Instead I say, "Hey, that's fine. You were being proactive. That's good. It's better to be safe than sorry. You did great."

Besides, it's better to be proactive than reactive. If you're proactive you are nipping it in the bud. If you're proactive you may stop the problem from occuring, and then you get no credit. But it's better to be proactive and get no credit becasue the problem never occured, than to be reactive. If you're reactive, that means the problem already occured.

It means the patient is already septic, or in failure, or whatever. If you're being reactive, it means the patient is already in need of critical care services, and may need to be in the hospital longer, and cost the hospital more. If your'e proactive, that means improved outcomes and reduced costs.

So it's better to be proactive than reactive.

So starting with the core measures, the keystone collaborative and weekly keystone meetings, to the pneumonia bundle, and then with the small town close nit touch, we have been able to get all of our priorities in order here at Shoreline Medical. That's how we did it.

Thank you. Any questions.

For more information, check out the following resources:

• AHRQ (Agency for Healthcare Research and Quality) http://www.ahrq.gov/
• MHA Keystone Center http://www.mhakeystonecenter.org/
• MPRO http://www.mpro.gov/
• Quality Net http://www.qualitynet.org/
• Blue Cross/Blue Shield www.bcbs.com/innovations

Hospital Quality Assurance Analyzer

One of the newer jobs in the hospital setting is the hospital is quality assurance analysis, and the position of quality assurance analyzer or manager. Basically speaking, this is a person who is responsible for making sure the hospital is doing what is needed to improve outcomes of patients and to reduce costs.

The best definition I found on the Internet was at Hospital Quality Assurance Services, which describes a historical view of the hospital as whatever the doctor wanted to do he or she did, and whatever he ordered was completed by the medical staff, be it the nurse, respiratory therapist, x-ray tech, or lab tech. The doctors pretty much had the run of the mill per se.

Yet then came the day of the HMO and the Medicare, where third party insurance companies and the government were paying the majority of the bills.

Basically, it goes something like this:

" Traditionally, doctors have always enjoyed a great deal of freedom in their practices. Till some time back, the techniques for monitoring and assessing the quality of care they provided in the hospital were based on internal peer reviews. But with the growth of consumer awareness movements, public concern of health care priorities, governmental concerns about rocketing healthcare costs, new hospital accreditation guidelines and financial constraints of health institutions, hospital quality assurance has become compulsory for hospitals to project the quality of care, they provide."

So it's the role of the quality assurance analyzer to make sure of the following (the following information obtained from http://www.careerplanner.com/ and virginia.gov/careerguides/hospitalQAanalyzer):

1. Monitor data obtained from CMS Core Measures and record the data for review by both the CMS and the hospital's monthly Keystone Committee.


2. To come up with ideas for improving performance on core values to improve patient outcomes and reduce costs.


3. To consider relative costs and benefits of potential actions to choose the most appropriate one.


4. Understanding written sentences and paragraphs in work related documents.


5. Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.


6. Talking to others to convey information effectively.


7. Communicating effectively in writing as appropriate for the needs of the audience.


8. Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions or approaches to problems.


9. Using mathematics to solve problems.


10. Identifying measures or indicators of system performance and the actions needed to improve or correct performance, relative to the goals of the system.


11. Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.


12. Using scientific rules and methods to solve problems.


13. Interprets and implements quality assurance standards in hospital to ensure quality care to patients


14. Reviews quality assurance standards


15. Studies existing hospital policies and procedures


16. Interviews hospital personnel and patients to evaluate effectiveness of quality assurance program.


17. Writes quality assurance policies and procedures.


18. Reviews and evaluates patients' medical records, applying quality assurance criteria.


19. Selects specific topics for review, such as problem procedures, drugs, high volume cases, high risk cases, or other factors.


20. Compiles statistical data and writes narrative reports summarizing quality assurance findings.


21. May review patient records, applying utilization review criteria, to determine need for admission and continued stay in hospital.


22. May oversee personnel engaged in quality assurance review of medical records.

They work with doctors, administrators, and other staffers at the hospital by organizing data, such as core measures, and to use that data in such a way as to improve performance at the hospital, and to reduce costs.

When by reviewing data they observe a problem, they notify the appropriate officials or department heads, who get to the bottom of the problem and then try to rectify it.

For example, it's the job of the Utilization Review Manager to double check charting to make sure charting is complete, protocols and order sets are complete, and that everything is complete in order to meet Intensity of Service (the patient was sick enough to be admitted) and Core Measures (every thing that needed to be ordered based on the most up-to-date wisdom was ordered for that patient).

If a problem is encountered that, it must be determined if this was an isolated problem, or if it is a problem that goes deeper.

For instance, when the core values were first monitored in 2007 at Shoreline Medical, smoking cessation orders were missed 70% of the time. This data was reported by the Quality Assurance Analyzer, and later brought up at a monthly Keystone meeting, where a plan was set in place to improve in this area.

Now smoking cessations are completed and charted accurately nearly 100% of the time.

Another problem back in 2007 was it was discovered via studies that pneumonia patients who received a flu vaccine and pneumococcal vaccine were less likely to get secondary pneumonia and return to the hospital. This this was made into a core measure.

Back in 2007 only 70% of patients received these vaccines. In 2010 nearly 100% of pneumonia patients receive these vaccines.

So you can see, it's the job of the quality assurance analyzer to analyze this data and to come up with idea, and to work with others in the hospital, to solve problems. The entire purpose of this position is to benefit the patient. If the patient is being treated properly, then the cost to the hospital, the government, and private insurance companies would be less.

Now, instead of doctors running the show, protocols, order sets, and improved clinical pathways make sure that certain procedures are automatically performed once a patient is diagnosed with a particular diagnosis (DRG), especially when studies show these procedures are known to improve patient outcomes.

For example, when a patient comes to the ER with chest pain, he automatically has to have an EKG completed within 10 minutes. If the patient is admitted and diagnosed with chest pain observation, the patient automatically has an EKG ordered ever two hours times six hours, then every morning for the next two days.

He will also automatically be ordered on oxygen, and have a stress test ordered for the next day. These are all automatic because they are proven to improve patient outcomes.

Total Quality Assurance Services notes that, "The success of all hospital quality programs depend on the interest and commitment of the administrators, physicians, nurses and paramedical staff. A lack of interest is far more damaging than any technical error in the evaluative process. Thus coordinators of hospital quality assurance courses must select strategies that evoke interest and commitment and does not burden the staff with activities they do not believe in."

So quality assurance monitoring is essential to reviewing data, improving quality of services provided, and communicating new ideas for continued improvement.

Likewise, "Hospital quality assurance activities extend beyond the usual sources of information like medical charts or service records. With additional sources – like resource allocation, rates of utilization and results of consumer surveys that provide insight into the broader dimensions of medical care, it is possible to enhance the value of these quality programs."

Making sure core measures and Intensity of service is met may often result in order sets and protocols that generally seem to throw everything we have at the patient in order to make sure we cover our bases, all with the idea that we want to make sure we are reimbursed.

It's complicated, maybe even frustrating, yet necessary. Yet with continued involvement and input from RTs and RNs, the end result of improved clinical pathways should result in protocols that allow the RTs and RNs to do what works as opposed to what does not work.

Yet while the transition is made, there may be some unnecessary throw ins, such as breathing treatments on every patient admitted for pneumonia, IVs on every patient admitted to the emergency room while this wouldn't be needed if you went to the doctor's office, and lab draws on every patient.

The role of the QA analyzer is not to make life more miserable and to cause us RTs to become burned out. However it may seem that way at times. Some of us RTs and RNs may think these analyzers are more concerned with paying the bills than taking care of patients.

Yet the ultimate goal is to improve outcomes and lower costs. So by working with your quality assurance analyzer or manager, you may be able to determine the statistics to justify the changes you have for improving your departmental services.

For more information about quality assurance check out this link.

What it utilization review?

Every hospital has a former nurse who has the position of utilization review. This is the person who's job it is to walk around the hospital, check all the charts, and make sure the patient is sick enough, requires certain services, and is in the hospital the recommended number of days.

According to Kevin Reese, Utilization Review is defined this way:

"Hospital utilization review plans are the documentation that determine how long a patient stays in a hospital for treatment or even if the patient is admitted to a hospital for treatment. It a process aimed at providing quality patient care in a cost-effective manner, reducing hospital admissions and lengths of stay in medical facilities. It compares proposed treatment options to national averages and standards, and is used to determine whether private insurance companies or government-backed Medicaid covers hospital lengths of stay."

Also consider the following:

"Getting patients out of hospitals and into their homes or alternative treatments as quickly as possible is a cost-saving measure aimed at keeping medical costs to a minimum. As soon as a person enters the hospital, a discharge plan is put into effect in hopes of getting the person out of the facility as quickly as possible due to the normally higher medical care costs associated with hospitals. Case managers, hired by insurance companies, are often used to work out discharge plans with hospitals and physicians. Should questions arise about care after a person is discharged, a board of specialists normally will address the case and make a decision on whether care steps taken were appropriate or if the length of stay was appropriate. That decision determines insurance coverage for those procedures."

For further reading click here.

The review process is generally based on Core Measures and Intensity of Service. Core measures is defined this way:

Core measures are the things the medical staff must do when a patient is admitted under a specific core measure set: acute mycardial infarction, heart failure, pneumonia, and surgical care. Within these four sets there are 27 core measures that are based on scientifically-researched standards of care that have been shown to result in improved clinical outcomes for patients.

They have also provided a focus for the development of Clinical Pathways and Standard Orders, both of which assist in the consistent provision of optimal care to patients.

Each individual hospital uses analysis of their own core measures as a means of evaluating performance at their own institution, and as a method of improving this performance.

Intensity of Service basically means that a patient is sick enough to be admitted to the hospital. According to Medicare, Medicaid and HMOs (at least in Michigan), for a patient to meet Intensity of service certain procedures need to be ordered to prove the patient was sick enough to be admitted.

For example, for a patient admitted for pneumonia or bronchitis must have bronchodilators ordered no less than every six hours for at least 24 hours, or any of the following: an IV at greater or equal to 75cc/hour, oxygen equal to greater than 28%, IV/IM intibiotics, or three bronchodilator treatments within the first 24 hours.

So, to make sure Intensity of Service is met, or to make sure the patient meets criteria, and to make sure the hospital is meeting the core values, clinical pathways for each particular diagnoses have been created and are reviewed monthly at our regular Keystone Meetings.

Clinical pathways generally consist of one or a combination of two methods:

1. Order sets (often called protocols)
   
2. Protocols

(Note: I have a post coming soon that describes the different pathways in more detail)

According to this article by Dr. David Schechter at Family Practice Management, while this whole procedure is a hassle, the goal is noble:

• To make sure the patient really needs to be admitted (see intensity of service)
• To make sure the patient really needs acute care
• To make sure the patient "really" needs continued acute care
• To make sure the patient really needs critical care
• To make sure the patient the patient is discharged in a timely manner
• If the patient needs a diagnostic test, can it be done as an outpatient
• Could the patient's needs be better met another way.
• Did the patient really need the level of care he received?
• Could the patient have received a lower level of care?

According to Family Practice Management, "The review process may seem like nothing but a hassle to you, but it’s a necessary evil. Studies have repeatedly shown great variations in care across the country for patients who have a given diagnosis or problem. Furthermore, practicing physicians often simply aren’t aware of the options for lower-level care in their areas."

A good example here is the patient who came to the ER complaining of chest pain and who's cardiac enzymes and EKG came back normal. The patient was admitted with the diagnosis of rule out chest pain and scheduled for a stress test in the morning. Upon review, it was determined the patient could have been discharged and come in for a stress test as an outpatient.

Yet, according to Dr. Schechter, "If the patient had continued to have chest pain or unstable angina, were receiving a nitroglycerin drip or had gotten a positive enzyme test result, then the review decision would have been quite different."

For the doctor, making the right choice may be based on the following:

• Are the patient’s vital signs stable?
  
• Has a diagnosis been made?
  
• Has a treatment plan been initiated and modified, if necessary?
  
• What acute nursing needs (and other needs) are present? Can these needs be met at a lower level of care?
  
• Have you considered alternatives to hospitalization? Why are they not feasible, in your opinion
  

Options for lower level of care may be:

• A skilled nursing facility
  
• The hospital’s transitional care unit
• A hospice, for terminal patients
• A rehabilitation center, for patients needing physical, occupational or speech therapy
• A convalescent/custodial care center (nursing home)
• Home nursing visits for help with wound care, IV medications or total parenteral nutrition
• Outpatient diagnostic testing facilities
• Outpatient physical, occupational or speech therapy.

Of course, determining this may be the job of the "hospital’s discharge planner."

The Utilization Review Manager will also want to make sure the doctor documents well. For instance, Dr. Schechter notes the following:

• If patient needs to be in the hospital, the "why" should be in the chart

• If patient’s status is “observation” or “24-hour stay” rather than “admission,” this should be made clear. It will matter to some insurers.
• If the patient is unstable, it should be specified how
• Document the patient’s acute needs (e.g., “unable to stand or walk to the bathroom,” “still febrile,” “vomiting every four hours despite IV Compazine”) rather than simply stating that the patient has acute needs.
• It should be emphasized in the progress note any abnormal physical exam findings, vital signs or lab values. And make your progress notes legible."

The physician may disagree with the utilization review people from the insurance company, and if this is the case, an appeals process may take place.

Now, CMS expects a doctor will only admit a patient who needs to be admitted, and therefore expects a diagnosis and to be honest. Therefore, they do not allow for a person to review charts and tell a doctor what he should diagnose or order in order to get reimbursement.

For this reason different medical institutions will have unique names for the department and managers in charge of utilization review. For simplicity sakes, we will go by the name Quality Assurance Manager, and refer to this department as Quality Assurance (QA).

Next Wednesday I will expound the the specific jobs of the Quality Assurance Manager, and the ethics involved regarding this position.

No consistency

Do you ever wonder about consistency at your hospital when it comes to physicians? Sometimes the "inconsistency" can give us RTs a headache.

Consider the following:

1. Dr. C lectured me that it's not the role of RTs interpret EKGs


2. Dr. X lectured me that it is the role of RTs to interpret EKGs, and lectured me when I didn't call him with the interpretation (we don't have an in house doctor at night here)

Consider the following:

1. Dr. A orders Xopenex on all his patients (He said, "Xopenex is the almighty med")


2. Dr. B orders Albuterol on all his patients (she agrees Xopenex should be called Hoaxenex)


3. Dr. C. orders Duoneb on all his patients


4. Dr. D. orders Xopenex with Atrovent on all his patients


5. Dr. E orders any combo of the above, and sometimes just Atrovent alone


6. Dr. F lets me order what I want and at any frequency, "Just let me know what you do."


7. Dr. G lets me order what I want and at any frequency, "Just let me know what you do."

Consider the following:

1. Dr. A is an ER doctor who wants me to hunt him down and show him all EKGs


2. Dr. C is an ER doctor who wants me to hunt her down and show her all EKGs, and lectures me when I don't.


3. Dr. B is an ER doctor who does not want me to hunt her down with every EKG, that I'm fully qualified to know what one's to take to her right away


4. Dr. F and Dr. G are both ER doctors and they trust me to use my common sense

I can tell you when Dr. F and G are working my morale is highest, and when I have an opinion I am quick share it with them. If I think someone needs a treatment I will give it, and when I give an assessment with share the results.

The other ER doctors act as though my opinion, my expertise, and my education are no different than that of a hospital volunteer, and treat me as such. When these doctors are working my morale is lowest.

It would seem to me a protocol would not only benefit these doctors but the morale of us RTs too. However, both doctor F and G have made it quite clear they would overrule a protocol even if there was one. But that's fine by me as they have that right.

Still, is my hospital the only one with this much inconsistency?

No smoking, and no smelling like smoke!!!

I thought it was interesting a few months back when the administrators at Shoreline decided this hospital was going to go smoke free. Not only are employees no longer allowed to smoke on campus, they cannot leave and come back smelling of smoke.

My dad told me when grandpa was on his death bed in a hospital just after I was born in 1970 grandpa wanted a cigarette real bad and no one would give him one. So dad gave him one of his cigarettes. Grandpa would take a puff every few hours, and one smoke would last a long time.

In the 1980s hospitals started to crack down on smoking. And, about the same time nurses were allowed to wear more creative clothing than those prototypical white nursing uniforms and caps, smoking disappeared from hospitals.

When I was hired here in 1997 there was still yellowed tile in the nurses report rooms from when they used to smoke there. The elder nurses here have told me of how they used to sit and smoke at the nurses station while they charted. Patients used to smoke in their rooms.

They have finally disappeared, but we used to have little red magnets that said, "No Smoking" plastered on the file cabinets in the RT Cave. I never once used one, but these were supposed to be stuck onto the doors of rooms where oxygen was in use.

The policy eventually was changes so that if you wanted to smoke you had to go out to your car. However, I remember several nights the nurses would poke their heads out the door and puff. This habit was ended, however, when one summer many patent's had their windows open, and the smoke wafted in. Many patent's complained, and the practice was put to a sudden end.

So up until a few months ago my co-workers who smoked were allowed to do so with restrictions. However, that has come to an end. No person who works here is allowed to smoke on campus. Not only that, no person who works here can smell of smoke. Not following this policy is grounds to be sent home. And, if it is evident someone is not willing to comply, this is grounds for dismissal.

At first I thought this was quite harsh, but after further thinking about it I think this is pretty good, especially since this is a hospital, and many of our patients are Asthma and COPD patients who can have an attack just smelling smoke on someone.

I know this is true because just tonight I had to give a breathing treatment to an asthmatic kid, and both his parents reeked of smoke and filth. When I walked out of that room I had to use my inhaler, and I have controlled and mild asthma.

If it were a factory making a policy like this, I think I'd feel this policy is going too far. I think it's fine for a business to tell someone they can't smoke on campus, but to say they can't come in smelling of smoke is a bit overboard. Yet this is perhaps for the best for a hospital.