Get documents about "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
