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observation-criteria

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									Observation vs. Inpatient Admitting Criteria


According to Interqual (Medical Necessity criteria utilized by CMS), Observation should be considered when
the patient is hemodynamically stable, does not meet acute care criteria and if any of the following apply:

                               o   Stabilization and discharge are expected within 24 hours.
                               o   More than six hours of treatment will be required
                               o   Clinical diagnosis is unclear and may be determined in less than 24 hours
                               o   Procedure requiring observation greater than 6 hours
                               o   Complications of ambulatory surgery / procedure
                               o   Symptoms unresponsive to at least 4 hours ED treatment
Commercial payers will only authorize observation up to 23 hours. Under Medicare observation is no longer
limited to 23 hours and can be used as an effective alternative until the need for admission is clearly
determined. Medicare will allow up to 48 hours of observation. However the physician is encouraged to
determine by 23 hours whether the patients need to be admitted or discharged to a lower level of care.

According to Medicare the following are indications for an extended Observation (up to 48 hours) and
generally lack medical necessity for inpatient admission unless specific complications or co-morbidities exist:

            o    Rule Out Myocardial Infarction / Chest Pain

            o    Asthma or COPD

            o    Simple Pneumonia

            o    Congestive Heart Failure

            o    Syncope or decreased responsiveness

            o    Atrial Arrhythmias

            o    Gastroenteritis/Esophagitis

            o    Renal Colic/UTI

            o    Dialysis
            o    Lower back pain

            o    Fracture, Sprain, stain of upper are or lower leg
Additional diagnosis appropriate for an observation stay according to commercial payers utilizing Milliman &
Robertson criteria include the following:

            o    Diabetes
            o    Rule Out CVA
            o    Hypertension
            o    Dehydration
The admission into observation or inpatient status is based on the patient’s severity of illness and the
intensity of service provided. Conversion of an observation case to inpatient is not based on time. A
patient in observation status should not be converted to an inpatient at the end of the 23-hour timeframe
unless the patient’s acuity and treatment meet inpatient.

Links:
Summary of Interqual Criteria – Observation Status

Milliman & Robertson – Chest Pain Criteria


                                             Observation Status




        Severity of Condition (SC)General              Exacerbation of neuro deficit >1

Compromised airway secondary to allergic                         Ataxia / incoordination
reaction
                                                                 Paresis / muscle weakness
Bleeding - BP>100 – no postural changes                Seizure / prolonged postictal state >10-15
and >one                                               min in pt with known history of seizures

        Bleeding disorder                                                      GI
        Epitasis with packing
                                                       Vomiting /Diarrhea/ Inadequate oral intake,
        Bleeding >24 hr.                              >1:
HCT <25% - without symptoms
                                                                 BUN>45, Creatinine > 3
Ingestion of toxic substance & stable                            HR > 100
Acute Ogliuria (<. 5ml/kg/h) without outlet                      NA > 150\
obstruction                                                      Urine Specific gravity > 1.030
Severe Pain >1:                                                  Postural Systolic BP drop >30
                                                                 Disorientation / Lethargy
        Sickle Cell Crisis
                                                                 Persistent vomiting & unresponsive to
        Unknown etiology, abdominal pain                         treatment in ER >3hr
        Potential renal calculi or                                             Metabolic
         pyelonephritis
                                                       BS < 50 requiring > 2 boluses of .50 glucose
        Intractable pain
Suicidal or Homicidal ideation, >1:                    BS > 400 >1:

        Intoxication                                                o   Disorientation / lethargy
        Dangerous behavior last 7 days                              o   New onset type I DM
        Organic Disease without a support                           o   Postural Systolic BP drop >30
         system.
                                                       K <3 or > 5.5
FUO – Temp >101 for >3wks
                                                       Na <120 or > 150
Toxic appearing with skin rash/infection >1:
                                                                                OB
        Temp > 100.4 or < 96
      WBC > 15,000                        Pregnancy, not in active labor, >1:
      HR 100-140
                                                 Abdominal pain / trauma
      Resp. 20-28
                                                  Fetal movement
                Cardiac/Respiratory
                                                 Gestational Rh incompatibility / Fetal
Asthma / Wheezing, Both                           genetic determination
                                                 Severe headache unresponsive to
      PEF 50-70% after >1                        IM/IV meds
       Bronchodilator > 3does (>2 if             Hyperemesis gravadarum &
       pregnant)                                  persistent vomiting unresponsive to
                                                  O/P hydration
       ER Treatment 1-3Hr
                                                 R/O labor or pre-term labor
       OP treatment >2d                          R/O HELLP / PHI /Pre-eclampsia
                                                 Rescue Cerclage
      Resp. rate<24/min
                                                 Ruptured / leaking membranes at
Carboxy-hgb 25-29% w/out mental status
                                                  term
change
                                                 Temp > 102
Chest Pain (cardiac) all:
                                                 Vaginal Bleeding < 1pad/H w/o fetal
                                                  compromise
      - CK-MB / Troponin I / Troponin T
                                                             Surgery/Trauma
      EKG unchanged / normal
      BP stable (systolic >100)           Foreign body unable to extract in ER
      Pain resolved in ER                 Post-op Ambulatory Surgery/ procedure, >1
DVT
                                                 Arrhythmia(s)
Dyspnea with P02 <60 or O2 Stat< 91%
                                                 Bleeding
Near Drowning without mental status              Recovery delay due to Anesthesia
change
                                                 Electrolyte imbalance
Spontaneous Pneumothorax, >15%                   Uncontrolled pain, headache or
                                                  Vomiting
Smoke inhalation
                                                 Psychotic Behavior
Syncope, unknown etiology                  Trauma with normal initial exam &
                                           suspected organ injury
Hypertensive emergency – Systolic> 250 /
Diastolic > 120 without organ compromise

                     CNS

Suspected CNS Infection

Grade III concussion

Disorientation/ Increased lethargy
                                    Observation Status
                                     Level of Service
                                    Discharge Criteria




Level of Service >1 (Excludes PO meds         D/C Guidelines (Meet both clinical & Level of
unless noted)                                 care)

Assessment q4h >1:                            General >1:

      Bleeding                                         Allergic reaction resolved
      Monitoring, > 1                                  Bleeding controlled last 6h
                                                        Hct > 25%
      Arrhythmia(s)
                                                        No s/s withdrawal
      Lab
                                                        Not unsafe to self or others
      Neurologic signs
                                                        Pain controlled
      Oximetry/ABG
                                                         toxic levels
      PEF
                                                        Urine output >.5 ml/kg/h
      Urine output
                                                        Vital signs stable last 8h
      Uterine/Fetal
                                              Cardiac/ Respiratory, >1:
      Vital Signs
                                                        Absent Carboxy-Hgb
      Psychotic Behavior
                                                        Chest pain resolve, MI R/O and no
      Vomiting / Diarrhea                               evidence of ischemia
Blood Products / Volume Expander                        DVT R/O or anticoagulants started
Insulin adjustment > 3/24H / Pump                       No syncopal episodes
regulation                                              O2 Sats > 91% /PO2 > 60 / return to
                                                         baseline
IVF 100ml/h
                                                        Wheezing resolved / PEF >70% /
LMWH (Initial dose)                                      returned to baseline
                                              CNS, >1:
Medication(s) >2 does, >1:

                                                        Neurologically stable
      Analgesics
                                                        Repeat LP negative
      Anticoagulants
                                              GI / metabolic: >1:
      Antiemetics
      Anti-infectives                                  BUN < 45
      Antipsychotics                                   HR 50-100
      Bronchodilators                                  NA 125-150
      Corticosteroids
      Diuretics                                               PO fluids tolerated
      Glucose 50%, multiple boluses                           Vomiting & diarrhea controlled
      Kayexalate PO / enemas &                                BS 70-250
       Hyperkalemia
                                                               K 3-5.5
      Muscle Relaxants
                                                        OB, >1:
      Narcotic Antagonists
      Sedatives / anti-anxiety agents                         Contractions controlled / cervix
                                                                unchanged
      Tocolytics
                                                               Fetal compromise resolved
Medication(s) >1 does, >1:
                                                               Fever resolving
      Anticonvulsants                                         Maternal/Fetal stability post PUBS
      Antihypertensives                                       No Bleeding
      Glycosides                                              No evidence of injury, all:
      Vasodialtors                                             Fetal HR stable
Repeat LP w/in 12 h
                                                                No bleeding on ambulation
Psychiatric crisis intervention / stabilization
                                                                No contractions
with observation q15 min

PUBS > 1x/24 h                                                 Pain resolved
                                                               Vomiting controlled & able to
O2> 28% & oximetry / ABG                                        maintain hydration
Therapeutic Throacentesis                               Surgery/Trauma, >1

                                                               Bleeding controlled 8h

                   Chest Pain (Milliman & Robertson)
                   Goal LOS = Ambulatory to 1 Day

                   Admission is indicated for any one of the following:


                          High Suspicion of MI after screening evaluation (Refer to
                           table below)

                          Suspected cardiac ischemia with factors precluding rapid
                           evaluation protocol including any one of the following"

                               o    Prior known MI or unstable angina
                               o    Complication of MI or ischemia (eg, ventricular
                                    arrhythmia, syncope)
                               o    New ECG findings consistent with MI or ischemia
                               o    Instability (eg, hypotension, hypertension, heart
                                    failure, arrhythmia)
                               o    Inability to complete exercise test
                                    (eg, <1 block exercise tolerance, hemiparesis)
       MI (Refer to MI, acute guideline)
       High-risk unstable angina (Refer to Angina guideline)
       Other acute causes requiring hospitalization
        (pulmonary embolus, new stroke, aortic dissection,
        mediastinitis)
MI risk Indicator List

High risk is determined by any one of the following indications:


 Indication 1                      MI on ECG:
                                   ST segment elevation or Q wave
                                   in 3 or more leads not known to
                                   be old



 Indication 2                      Ischemia or strain on ECG:
                                   ST segment depression or T
                                   wave inversion in 2 or more
                                   leads not known to be old



 Indication 3                              Chest pain < 48 hours
                                            old
 Must have presence of all                 History of angina or MI

                                           Pain > 1 hour duration

                                           Pain worst than usual or
                                            similar or earlier MI


 Indication 4                              Chest pain < 48 hours
                                            old
 Must have presence of all                 Pain radiating to left
                                            arm, shoulder or neck

                                           Age >40

                                           Pain is not radiating to
                                            back, not stabbing in
                                            nature, not reproduced
                                            by palpation


 Indication 5                              Systolic BP <110mm hg

                                           Rales above bases on
 Chest pain with any one of the             exam
 following risk factors:
                                           Known unstable
                                            ischemic heart disease

								
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