Sharon E. Mace MD, FACEP, FAAP Director, Observation Unit

1. Sharon E. Mace MD, FACEP, FAAP Director, Observation Unit Director, Pediatric Education/Quality Improvement Research Director, Rapid Response Team Cleveland Clinic Former Chair, ACEP Section of Observation Medicine Faculty, EM Residency, MetroHealth Medical Center/Cleveland Clinic Professor, Cleveland Clinic Lerner College of Medicine at Case Western Reserve University Observation Medicine Strategies:A Clinical ApproachTips for Success or Failure

3. Number of Hospitals, Hospital Beds and EDs vs ED Visits

6. Allows physicians to evaluate and treat selected patients over a finite time period which improves ED flow and has many benefits Purpose ofObservation Medicine

8. What Is Observation? While there are different interpretations, for Medicare from HIM-10 §455 (Pub. 100-2,Medicare Benefits Policy Manual, Chapter 6, §70.4): Observation services are those services: (a) Furnished on a hospital’s premises (b) Includes use of a bed and periodic monitoring by nursing or other staff (c) Reasonable and necessary (d) To evaluate an outpatient’s condition (e) Determine the need for possible admission as an inpatient (f) Ordered by physician (g) Usually do not exceed one day (h) May go for up to 48 hours (i) Under unusual circumstances may exceed 48 hours

10. Why Observation Medicine • Better patient care • ↓ missed diagnoses • Cost effective • Rapid, efficient, evaluation / work-ups and treatment • Risk management and malpractice, ↓ liability • Psychosocial advantages • Fiscal benefits • Provided there are mechanisms for Observation Unit (OU) set up / maintenance • OM is a process and a mindset, notalocation

12. Organizational Framework • Patient criteria: inclusion, exclusion, OU management, specific time frame • Personnel: clinical and administrative • Resources: location, equipment, supplies • Specific policies and procedures • Strong leadership empowered to clinically and administratively manage the OU • Using policies, procedures, guidelines, clinical pathways, order sets, other tools • Multidisciplinary teamwork approach / meetings

14. Admission Criteria for Observation Stable vital signs Non-critical, stable, “low maintenance” Do not need “intensive” nursing care Do not need “intensive” physician care Expected to have a disposition in a “reasonable” short time frame: observation, diagnosis, treatment for < 24 hours

16. Acceptable Diagnoses for Observation Cardiac: chest pain*, CHF, syncope Respiratory illnesses: asthma, pneumonia not acceptable: respiratory failure, epiglottitis, severe hypoxemia, hypercapnia GI / dehydration: gastritis, vomiting, diarrhea not acceptable: shock GU: kidney stone not acceptable: obstruction with renal failure * May want to start with chest pain: ensure success, then expand

18. Acceptable Diagnoses for Observation Infections: cellulitis, lymphangitis Neurology: seizures, viral meningitis, minor head injury Toxicology: ingestions, overdose Hematologic: sickle cell, hemophilia Chronic illnesses: DM  glucose (not DKA) S/p procedures: oversedated, s/p LP etc.

20. Patient Exclusion for Observation Critically ill Unstable vital signs Need “intensive” nursing care Need “intensive” physician care Anticipated length of stay > 24 hours

22. Unacceptable Diagnoses for Observation Shock Coma Respiratory failure Bacterial Meningitis Neutropenic fever Critically ill

25. Advantages of ObservationPrimary Care, Specialists • Expands patient base •  referrals,  office visits,  procedures,  admits • Easier to coordinate care • Better, faster evaluation • Improved MD profile • Clinical pathways • Quality, cost containment • ACOs • Disease management • Variation reduction • Other initiatives

27. Advantages of ObservationHospital • New product line • Expanded referral base • Better use of services at  cost •  lengthy inpatient admits •  trend outpatient services •  outliers: 1 day LOS • PEPPER report

29. Healthcare in Crisis • The 2.2 trillion healthcare sector is now mired in deep crisis related to safety, quality, cost and access that pose serious threats to the health and welfare of many Americans1 • An estimated 30 to 40 cents of every dollar spent on health care, or roughly three quarters of a trillion dollars per year is spent on costs associated with “overuse, underuse, misuse, duplication, system failures, unnecessary repetition, poor communication, and inefficiency”2 1 CMS 2 Lawrence National Academy Press

30. Per Capita Medicare Spending: Regional Variations Congressional Budget Office. Research on Comparative Effectiveness of Medical Treatments. 2008

31. CMS: Value BasedPurchasing Plan • Clinical quality • Adverse events • Patient safety • Patient centeredness • Avoid unnecessary costs • Investment in structural/system components: IT capability, care management processes/tools • Consumer driven: Performance results/Transparency

33. Success Depends Upon • Prompt physician decision making • Excellent documentation • “Empowered” observation nursing staff • Superb coding → ↑ reimbursement • Strong physician leadership • Administrative support • Buy in from other hospital departments, physicians, health care providers • Tools for success • Policies and procedures: includes inclusion/exclusion criteria, evaluation, treatment, disposition plan • Guidelines, clinical pathways

36. How to Succeed or Fail at Observation Medicine Observation Medicine Success Time (Length of Stay)

38. Observation = $$ Success • Major benefits • Easiest way to build beds • ↑ revenue per bed • ↓ labor costs/RN ratio • ↓ exposure to risk • ↑ quality • ↑ patient satisfaction • ↓ cost

42. Improved patient care:  missed diagnosis / severity Improved patient outcome  risk,  malpractice  ED patient throughput,  ED LOS  patient satisfaction Better public relations  ED volume Financial:  revenue,  denials,  penalties Observation Advantages

44. Recovery Audit Contractors (RAC) • Private corporations under contract via contingency to CMS • Review allclaims submitted by Medicare providers in order to prevent overpayments/underpayments • Akin to a whistle blower or bounty hunter • Focus: high-risk DRGs, 1 day stay, observation

46. United States Department of Justice Marcos Daniel Jimininez United States Attorney for the Southern District of Florida 99 N.E. Fourth Street, Miami, Fl. 33132 Press Release For Immediate Release – Feb.11, 2005 For information, contact public affairs Carlos B. Castillos Special counsel for public affairs (305) 961-9425 Cleveland Clinic pays U.S. 2.75 million

47. Questions