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Mystery Solved: Which Patients Are Good Candidates For Acute Inpatient Rehabilitation?

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Occupational Therapy Environment, Saint Luke's Hospital, WA

For most physicians who practice inpatient medicine, acute inpatient rehabilitation facilities are mysterious places with inscrutable admissions criteria. This is partly because physical medicine and rehabilitation (PM&R) has done the poorest job of public relations of any single medical specialty (Does anyone know what we do?), and also because rehab units have been in the cross hairs of federal funding cuts for decades. The restrictive CMS criteria for inpatient rehabilitation have resulted in contortionist attempts to practice our craft in an environment where clinical judgment has been sidelined by meticulous ICD-9 coding.

But I will not bore you with the reasons behind our seemingly capricious admissions criteria. Instead I will simply tell you what they are in the simplest way possible. After much consideration, I thought it would be easiest to start with the contraindications to acute rehab – I call these “red lights.” If your patients have any of these, then they will not qualify for transfer to the acute inpatient rehab unit. I followed the absolute contraindications with relative contraindications (you guessed it, “yellow lights”) – these patients require some clinical and administrative judgment. And finally, I’ve listed the official green lights – the diagnosis codes and medical necessity rules for the ideal inpatient rehab candidate.

I hope that these rules demystify the process – and can help discharge planners, rehab admissions coordinators, and acute care attending physicians alike help to get the right patients to acute inpatient rehab.

RED LIGHT (Patient does not meet criteria, admission is not currently indicated):

  1. Inability to Participate: Patient cannot tolerate 3 hours of therapy per day.
  2. Unwillingness to participate: The patient does not wish to participate in PT/OT/speech therapies and/or shows no evidence of motivation in previous attempts to perform therapy
  3. Poor rehabilitation potential: The patient’s functional status is currently no different than their usual baseline. (Confirmed by previous history, medical records, or reliable source.)
  4. Dementia: The patient has a chronic brain deficiency that is not expected to improve and makes carryover of training unlikely or impossible.
  5. Doesn’t need help from at least 2 different rehab disciplines: The patient must demonstrate likely benefit from working with at least 2 of these: PT, OT, Speech.
  6. Acute illness or condition: The patient has an acute illness/condition requiring medical intervention prior to transfer to an acute rehab facility – these include:
    • septicemia (infection with fever and elevated white count)
    • delirium (medication effect, dehydration, infectious, toxic-metabolic)
    • unstable vital signs (severe hyper or hypotension, severe tachy or brady arrhythmia, hypoxia despite oxygen supplementation)
    • acute psychotic episode (including active hallucinations or delusions)
    • uncontrolled pain (the patient’s pain is not sufficiently controlled to allow participation in therapy)
    • severe anemia
    • extreme fatigue or lethargy due to medical condition
  7. Procedure or workup pending: The patient is in the middle of a work up for DVT, cardiac disorder, stroke, infection, anemia, chest pain, bleeding, etc. or is about to undergo a procedure (surgery, imaging study, interventional or lab test) that could alter the immediate course of his/her medical/surgical management.

YELLOW LIGHT (The patient may not be a good rehab candidate, clinical/administrative judgment required regarding admission):

  1. Possible poor rehabilitation potential: The patient’s prior level of function (PLOF) is likely low or similar to current level, however there is no clear documentation of the patient’s PLOF. It is unclear if aggressive rehabilitation will substantially improve the patient’s functional independence.
  2. Unclear benefit of ARU versus SNF: The patient is unlikely to avoid future placement at a skilled nursing facility. Would it be in the patient’s best interest to transfer there directly?
  3. Mild dementia or chronic cognitive impairment: The patient has carryover challenges but is able to participate and follow directions. There may be family members who could benefit from PT/OT/Speech training so they can take the patient home and be his/her caregiver(s).
  4. Unclear safe discharge plan:  The patient lives alone or has no family support or has no financial means to improve their living conditions or their home is unfit for living/safe discharge or patient refusing SNF but qualifies otherwise.
  5. Insurance denial: The patient’s insurer declines their inpatient rehab stay. Physiatrist may attempt to overturn decision or facility may wish to take patient on a pro bono status.  Uninsured patients may be candidates for emergency Medicaid. Facility must decide if they will lobby for it.
  6. Severe behavioral disorders (unrelated to acute TBI): Verbally abusive, violent, inappropriate or disruptive to other patients.
  7. The patient meets medical necessity criteria for acute inpatient rehab but their impairment is not represented by one of the 13 impairment categories approved by CMS. (E.g. medical debility, cardiac impairment, pulmonary disease, cancers, or orthopedic injury without required comorbidities). Admission may depend upon individual facility’s case mix and its current annual compliance rate with 60% rule.

GREEN LIGHT (The patient is a good candidate for acute inpatient rehab if they have no red or yellow lights, meet criteria for medical necessity AND meet the impairment categories listed below):

MEDICAL NECESSITY DEFINITION:

Acute inpatient rehabilitation services are medically necessary when all of the following are present:

  • Individual has a new (acute) medical condition or an acute exacerbation of a chronic condition that has resulted in a significant decrease in functional ability such that they cannot adequately recover in a less intensive setting; AND
  • Individual’s overall medical condition and medical needs either identify a risk for medical instability or a requirement for physician and other personnel involvement generally not available outside the hospital inpatient setting; AND
  • Individual requires an intensive inter-disciplinary, coordinated rehabilitation program (as defined in the description of service) with a minimum of three (3) hours active participation daily; AND
  • Individual is medically stable enough to no longer require the services of a medical/surgical inpatient setting; AND
  • The individual is capable of actively participating in a rehabilitation program, as evidenced by a mental status demonstrating responsiveness to verbal, visual, and/or tactile stimuli and ability to follow simple commands.  For additional information regarding cognitive status, please refer to the Rancho Los Amigos Cognitive Scale (Appendix B); AND
  • Individual’s mental and physical condition prior to the illness or injury indicates there is significant potential for improvement; (See Note below) AND
  • Individual is expected to show measurable functional improvement within a maximum of seven (7) to fourteen (14) days (depending on the underlying diagnosis/medical condition) of admission to the inpatient rehabilitation program; AND
  • The necessary rehabilitation services will be prescribed by a physician, and require close medical supervision and skilled nursing care with the 24-hour availability of a nurse and physician who are skilled in the area of rehabilitation medicine; AND
  • Therapy includes discharge plan.

13 Diagnosis Codes Approved by CMS for Acute Inpatient Rehab

1. Stroke

2. Spinal cord injury

3. Congenital deformity

4. Amputation

5. Major multiple trauma

6. Fracture of femur (hip fracture)

7. Brain injury

8. Neurological disorders, including:

• Multiple sclerosis

• Motor neuron diseases (Guillain Barre, ALS)

• Polyneuropathy

• Muscular dystrophy

• Parkinson’s disease

9. Burns

10. Arthritis: Active polyarticular rheumatoid arthritis, psoriatic arthritis, and seronegative arthropathies

resulting in significant functional impairment of ambulation and other activities of daily living;

11. Vasculitis: Systemic vasculidities with joint inflammation resulting in significant functional impairment of ambulation and other activities of daily living

12. Severe or advanced osteoarthritis (osteoarthrosis or degenerative joint disease) involving two or more weight bearing joints (elbow, shoulders, hips, or knees but not counting a joint with a prosthesis) with joint deformity and substantial loss of range of motion, atrophy of muscles surrounding the joint, and significant functional impairment of ambulation and other activities of daily living

13. Knee or hip joint replacement, or both, during an acute care hospitalization immediately preceding the inpatient rehabilitation stay and also meets one or more of the following specific criteria:

  • The patient underwent bilateral knee or bilateral hip joint replacement surgery during the acute care hospital admission immediately preceding the IRF admission
  • The patient is extremely obese with a Body Mass Index of at least 50 at the time of admission to the IRF or
  • The patient is age 85 or older at the time of admission to the IRF.

References:

http://www.anthem.com/medicalpolicies/guidelines/gl_pw_a051177.htm

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/downloads/InpatRehabPaymtfctsht09-508.pdf

http://www.gpo.gov/fdsys/pkg/FR-2013-08-06/pdf/2013-18770.pdf

Do Elite Academic Centers Provide Better Hospital Care?

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A well-to-do patient recently boasted to me about an expensive insurance plan that he had purchased to “guarantee” that he had access to the best healthcare in the United States. Coverage included access to elite academic centers (all the usual suspects) and a private jet service for emergencies. He was utterly confident that his investment was worth the price, but I withheld my own misgivings.

Hospital quality data suggest that “fancy, brand name hospitals” provide better patient care. But unfortunately there is no guarantee of good outcomes for anyone who sets foot in a hospital. My experience doesn’t exactly square with quality data, and although I realize that there are teams of public and private sector analysts out there furiously rating and ranking hospitals with all manner of outcomes data, I don’t think it means a whole lot for the individual “worried well” patient. Here’s why:

1. Higher overall patient complexity may mean less attention for you. Academic medical centers specialize in caring for those who are often too sick or too complicated to be cared for elsewhere. This means that each patient requires more staff time to address their long list of diseases and conditions. Everything from medication reconciliation to medical testing, to bedside care, requires more time from each provider taking care of them. If you happen to be on a medical floor with complicated neighbors, expect to see less of your doctors and nurses. It’s not fair, but this happens regularly at elite centers, and it’s not in your best interest.

2. Less-experienced physicians may be providing the bulk of your care. Academic teaching hospitals are actively involved in training young doctors, and the least experienced among them will likely be providing the majority of your care (and reporting up to the overseeing physicians). Because of the exhausting complexity of very sick patients, if you are not among the very sickest (or provide a steady stream of diagnostic conundrums requiring the input and expertise from the top experts), your care will be left in the hands of the residents. This doesn’t mean you won’t get good care, but it introduces some degree of risk.

3. You may be exposed to really bad germs. Drug-resistant bacteria are born in places that use big-gun antibiotics. Again, with more challenging cases and infectious diseases in the patient mix, more antibiotics are used and more drug-resistant bacteria develop. Although academic centers make great efforts not to spread infections, it can happen. And if you do get a hospital-acquired infection, it’s probably going to be a bad one.

4. More providers means more opportunity to make EMR-based medical errors. As I’ve argued in recent blog posts, electronic medical records are error prone for a number of reasons. The more people entering data into your record, the more opportunity for mix ups and confusions. Academic medical centers may boast more specialists and a higher staff to patient ratio, but this is not always a good thing. The fewer the number of providers caring for you (especially nurses), the better you are known to them, and therefore the lower the risk of certain mistakes.

5. More tests and procedures aren’t always a good thing. Academic centers have access to a larger breadth of technology, which means that they are more likely to order more tests and procedures. Imaging studies, biopsies, lab tests, and advanced surgical procedures can provide additional information that can change the course of therapy. But they also have the ability to initiate wild goose chases, further testing, unnecessary anxiety, and additional risk (and expense) to the patient. Judicious use of technology is important, but with less experienced physicians on the team, they are more likely to reflexively order a test than to rely on their clinical experience regarding diagnosis and treatment.

6. Many “moving parts” increase your risk for errors, mix ups, and longer wait times. The larger the hospital, the more chances there are for accidental substitutions, name confusion, and test scheduling conflicts. It may seem improbable that these events still occur (Don’t we have bar codes on wrist bands that have solved this problem? You ask.), but if you’re a physician clicking between electronic medical records of patients with the same last name, no bar code will save you. I myself was a patient in the ER of a large elite academic center once, when the security guards confused me with a volatile psychotic patient previously located in the bay that my stretcher was moved into. They almost got the four-point restraints on before I convinced them to re-check my identity with the nurses. Awkward. Also, if you need an MRI or CT scan at a level 1 trauma center, you could be waiting a long time for it as sicker patients bump you from the schedule.

7. Traveling to a center of excellence means post-acute care services will be harder to arrange. If you are recovering from a serious illness or surgery far away from home, case managers will probably have a harder time connecting with services to help you upon discharge. If you need visiting nurses, home-based therapists, durable medical equipment, or follow up care (either with specialists or primary care physicians) all of that will be more challenging to arrange because the case managers don’t have them in their virtual Rolodex. Because of the complexity of the healthcare system, it takes years of effort for good case managers and discharge planners to streamline the process of getting through to the “right person” at each service provider and providing them with the “correct” insurance information and completed forms and paperwork. If they’re lobbying for you out of state or in a far away county, they will probably end up spending a lot of time on hold, or talking to the wrong person. And when you finally arrive home and the visiting nurse doesn’t show up, or you don’t have your walker after all… you will not be happy.

8. You may be stuck with an enormous, post-hospital price tag. Most people nowadays have insurance that covers care at certain “preferred” facilities at a much lower cost to the patient. If you go “outside of network” you may be responsible for a much higher percentage of your care cost than you bargained for. Before you decide to opt for the big brand name academic medical center for your care or procedure, double check with your insurance provider regarding what your part of the cost will be.

If you (or your loved one) are in the unfortunate position of having a rare, life-threatening, or extremely complicated host of diseases and conditions, then you may have no choice but to go to an academic medical center for care. If you’re like my wealthy patient, though, and can afford what you think are insurance upgrades to provide you with access to the “best care available,” you may discover that better care is actually found closer to home.

In an upcoming post, I’ll describe my experience with hospital characteristics that tend to predict a higher quality of care. You may be surprised to find that there isn’t a whole lot of overlap between my personal measures and what we are led to believe are the important ones. :-)

Hospital Nursing Care: Some Observations And Suggestions

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As I travel the country providing coverage for inpatient rehab units, I have been struck by the generally high quality of nursing care. Excellent nurses are the glue that holds a hospital unit together. They sound the first alarm when a patient’s health is at risk, they double-check orders and keep an eye out for medical errors. Nurses spend more time with patients than any other hospital staff, and they are therefore in the best position to comment on patient progress and any changes in their condition. An observant nurse nips problems in the bud – and this saves lives.

Not only are nurses under-appreciated and under-paid, they are suffering as much as physicians are with new digital documentation requirements. Just as patients are receiving less face time with their physicians, they are also suffering from a reduction in bedside attention from nurses. The need to record data has supplanted our ability to listen to the patient, causing anguish for patients, physicians, and nurses alike.

This being our lot (and with continued “quality improvement” policies that will simply add to the documentation burden) we must find ways to optimize patient care despite inane bureaucratic intrusions. I believe that there are some steps that nurses and doctors can take to improve patient care right now:

1. Minimize “floating.” (Floating is when a nurse is pulled from one part of the hospital to fill in for a gap in coverage in a different unit). It is extremely difficult for nurses to take care of a floor full of patients they’ve never met before. Every time that care of a patient is handed off to someone else (be they MD or RN), there is a risk of forgetting to follow through with a test, procedure, or work up. Simply knowing what “normal” looks like for a given patient can be incredibly important.

For example, left sided weakness is not concerning in a patient with a long-time history of stroke, but what if that is a new finding? If you’ve never met the patient before, you might not realize that the weakness is new and constitutes an emergency. How does a nurse know if a patient’s skin ulcer/rash/pain etc. is better or worse than yesterday? Verbal reports don’t always clarify sufficiently. There are endless advantages to minimizing staff turnover during a patient’s hospital stay. Reducing the total number of nurses who care for individual patients should be a number one priority in hospitals.

2. If you see something, say something. There are a host of reasons why nurses may be hesitant to report patient symptoms. Either they don’t know the patient well and think that the new issue could be “normal” for that patient, or perhaps the physician managing the patient has been unreceptive to previous notifications. However, I am always grateful when a nurse goes out of her way to tell me her concerns, because I generally find that she’s on to something important. My general rule is to over-communicate. If you see something, say something – because that episode of patient anxiety in the middle of the night could be a heart attack. And if I don’t know it’s happening, I can’t fix it.

3. Please don’t diagnose patients without input. I’ve found that nurses generally have excellent instincts about patients, and many times they correctly pinpoint their diagnosis. But other times they can be misled, which can impair their care priorities. For example, I had a patient who was having some difficulty breathing. The nurse told me about it immediately (which was great) but then she proceeded to assume that it was caused by a pulmonary embolism. I explained why I didn’t think this was the case, but she was quite insistent. So much so that when another patient began to have unstable vital signs (and I requested her help with preparing for a rapid response) she stayed with the former patient, believing that his problem was more acute. This doesn’t happen that frequently, but I think it serves as a reminder that physicians and nurses work best as a team when diagnostic conundrums exist.

4. Help me help you. Please do not hesitate to come to me when we need to clean up the EMR orders. If the patient has had blood glucose finger stick checks of about 100 at each of 4 checks every day for 2 weeks, then by golly let’s reduce the checking frequency! If the EMR lists Q4 hour weight checks (because the drop down box landed on “hour” instead of “day” when it was being ordered) I’d be happy to fix it. If a digital order appears out of the ordinary, ask the doctor about it. Maybe it was a mistake? Or maybe there’s a reason for Q4 hour neuro checks that you need to be aware of?

5. Let’s round together. Nurses and physicians should really spend more time talking about patients together. I know that some physicians may be resistant to attending nursing rounds due to time constraints, but I’ve found that there’s no better way to keep a unit humming than to comb through the patient cases carefully one time each day.

This may sound burdensome, but it ends up saving time, heads off problems, and gives nurses a clearer idea of what to look out for. Leaving nurses in the dark about your plan for the patient that day is not helpful – they end up searching through progress notes (for example) to try to guess if the patient is going to radiology or not, and how to schedule their meds around that excursion. Alternately, when it comes time to update your progress note, isn’t it nice to have the latest details on the patient’s condition? Nurses and doctors can save each other a lot of time with a quick, daily debrief.

6. Show me the wounds. Many patients have skin breakdown, rashes, or sores. These are critically important to treat and require careful observation to prevent progression. Doctors want to see wounds at regular intervals, but don’t always take the time to unwrap or turn the patient in order to get a clear view. Alternatively, some MDs simply unwrap/undress wounds at will, leaving the patient’s room without even telling the nurse that they need to be re-wrapped. In some cases, it takes a lot of time to re-dress the complex wound, adding a lot of work to the nurse’s already busy schedule (and offering little benefit, and some degree of discomfort, to the patient).

Nurses, on the other hand, have the opportunity to see wounds more frequently as they provide dressing changes or peri-care at regular intervals. Most nurses and doctors don’t seem to have a good process in place for wound checks. I usually make a deal with nurses that I won’t randomly destroy their dressing changes if they promise to call me to the patient’s bedside when they are in the middle of a scheduled change. This works fairly well, so long as I’m willing/able to drop everything I’m doing for a quick peek.

These are my top suggestions from my most recent travels. I’d be interested in hearing what nurses think about these suggestions, and if they have others for physicians. I’m always eager to improve my patient care, and optimizing my nursing partnerships is a large part of that. :lol:

Why Don’t Patients Fill Their Primary Care Physician’s New Prescriptions?

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A Canadian study published today in the Annals of Internal Medicine suggests that about one third of new prescriptions (written by primary care physicians) are never filled. Over 15,000 patients were followed from 2006 to 2009. Prescription and patient characteristics were analyzed, though patients were not directly interviewed about their rationale for not filling their prescriptions.

In short, patients were less likely to fill a prescription if the treatment was expensive, but certain types of drug indications had consistently higher non-fill rates:

  • Headache (51% not filled)
  • Ischemic heart disease (51.3% not filled)
  • Thyroid agents (49.4% not filled)
  • Depression (36.8% not filled)

Overall, hormonal (especially Synthroid), ENT (especially Flonase), skin, and cardiovascular drugs (especially statins) had the highest non-fill rates.

As far as those prescriptions more likely to be filled, antibiotics (especially for urinary tract infections) ranked number one.

Trends towards prescription compliance were seen among older, healthier patients, and those who were switching medications within a class rather than starting an entirely new drug. Patients who received prescriptions from a doctor that they visited regularly (rather than a new provider) were also more likely to fill their prescriptions.

This study was not designed to elucidate the exact rationale behind prescription non-adherence, but I am willing to speculate about it. In my experience, patients are less likely to fill a prescription if a reasonable over-the-counter alternative is available (think headache or allergy relief). I also suspect that they are less likely to fill a prescription if they believe it won’t help them (skin cream) or isn’t treating a palpable symptom (statin therapy for dyslipidemia). Finally, patients are probably nervous about starting a medicine that could effect their metabolism or cognition (thyroid medication or anti-depressant) without a full explanation of the possible benefits and side effects.

I was surprised to see how compliant patients seem to be with antibiotic agents (at least, filling the initial prescriptions). Given the increasing rates of antibiotic resistance, this reinforces the need to limit prescriptions to those agents truly indicated, and to analyze bacterial sensitivities during the treatment process to optimize medical management.

My take home message from this study is that providers need to do a better job of explaining the reasoning behind new prescriptions (their necessity, consequences of non-compliance, and risk/benefit profiles) and reviewing the overall cost to the patient. If a cheaper, effective alternative is available (whether OTC or generic), we should consider prescribing it. Providers can likely improve medication compliance rates with a little patient education and price consciousness. Extra time should be spent with patients at higher risk for non-compliance due to their personal situation (age, degree of illness, income level) or if a specific drug with lower compliance rates is being introduced (Synthroid, statins, etc.) Regular follow up (especially with the same prescriber) to ensure that prescriptions are filled and taken as directed is also important.

Failure To Communicate: The Dangers Of Inadequate Hospital Handoffs And What To Do About It

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One of my biggest pet peeves is taking over the care of a floor-full of complicated patients without any explanation of their current conditions or plan of care from the physician who most recently treated them. Absent or inadequate verbal and written “handoffs” of patient care are alarmingly common in my experience. I work primarily as a locum tenens physician, traveling across the country to “cover” for my peers on vacation or when hospitals are having a hard time recruiting a full-time MD. This type of work is particularly vulnerable to gaps in continuity of care, and has heightened my awareness of the prevalence of poor sign-outs.

Recent research suggests that communications lapses are the number one cause of medical errors and adverse events in the healthcare system. An analysis published in the Archives of Internal Medicine suggests various kinds of consequences stemming from inadequate transfer of information, including missed diagnoses, incomplete work ups, ICU admissions, and near-miss errors. I have personally witnessed all manner of problems, including medication errors (the patient’s full list of medical conditions was not known by the new physician), lack of follow up for incidental (though life-threatening) findings discovered during a hospital stay, progression of infection due to treatment delay, inappropriate antibiotic therapy (follow up review of bacterial drug resistance results did not occur), accidental repeat fluid boluses in patients who no longer required rehydration (and had kidney or heart failure), etc.

It has long been suspected, though not unequivocally proven, that sleep deprivation (due to extended work hours and long shifts) is a common cause of medical errors. New regulations limiting resident physician work hours to 80 hours a week have substantially improved the quality of life for MDs in training, but have not made a remarkable difference in medical error rates. In my opinion, this is because sleep deprivation is a smaller contributor to the error problem than incomplete information transfer. If we want to keep our patients safe, we need to do a better job of transferring clinical information to peers assuming responsibility for patient care. This requires more than checklists (made popular by Atul Gawande et al.), it’s about creating a culture of carefulness.

Over the past few decades, continuity of care has been undermined by a new “shift worker” or “team”  approach. Very few primary care physicians admit patients to local hospitals and continue to manage their care as inpatients. Instead, hospitalists are responsible for the medical management of the patient – often sharing responsibility as a group. This results in reduced personal knowledge of the patient, leading to accidental oversights and errors.  The modern shift-worker model is unlikely to change, and with the rise of locum tenens physicians added to the mix – it’s as if hospitalized patients are chronically cared for by “float staff,” seeing the patient for the very first time each day.

As a physician frustrated with the dangers of chronically poor sign-outs, these are the steps that I take to reduce the risk of harm to my patients:

1. Attend nursing change of shift as much as possible. Some of the most accurate and best clinical information about patients may be obtained from those closest to them. Nurses spend more face-to-face time with patients than any other staff members and their reports to one another can help to nip problems in the bud. I often hear things like, “I noticed that Mr. Smith’s urine was cloudy and smelled bad this morning.” Or “Mrs. Jones complained of some chest pain overnight but it seems to be better now after the Percocet.” These bits of information might not be relayed to the physician until they escalate into fevers, myocardial infarctions, or worse. In an effort to not “bother the physician with too much detail” nurses often unwittingly neglect to share subtle findings that can prevent disease progression. If you are new to a unit or don’t already know the nursing staff well, join their morning or evening sign out meeting(s). They (and you) will be glad you did.

2. Pretend that every new patient needs an H&P (complete history and physical exam). When I pick up a new patient, I comb through their medical chart very thoroughly and carefully. I only need to do this once, and although it takes time, it saves a lot of hassle in the long run. I make note of every problem they’ve had (over the years and currently) and list them in a systems-based review that I refer to in every note I write thereafter.

3. Apply the “trust but verify” principle. I read other physicians’ notes with a careful eye. Electronic medical records systems are notorious for “copy and paste” errors and accidentally carrying over “old news” as if it were an active problem. If a physician notes that the patient has a test or study pending, I’ll search for its result. If they are being treated empirically for some kind of infection, I will look for microbiologic evidence that the bug is sensitive to the antibiotics they are receiving. I’ll ask the patient if they’ve had their radiology study yet, and then search for the result. I’ll review the active medication list and see if one of my peers discontinued or started a new medicine without letting me know. I never assume that anything in the medical record is correct. I try my best to double check the notes and data.

4. Create a systems-based plan of care, reconcile it each day with the active medication list. I like to organize patient diseases and conditions by body systems (e.g. cardiovascular, endocrine, gastrointestinal, neurologic, dermatologic, etc.) and list all the diseases/conditions and medications currently being offered to treat them. This only has to be done thoroughly one time, and then updated and edited with additional progress notes. This helps all consultants and specialists focus in on their particular area of interest and know immediately what is currently being done for the patient (both in their system of interest and as a whole) with a glance at your note. Since medications often have multiple purposes, it is also very helpful to see the condition being treated by each medication. For example, if the patient is on coumadin, is it because they have a history of atrial fibrillation, a prosthetic heart valve, a recent orthopedic procedure, or something else? That can easily be gleaned from a note with a systems-based plan of care.

5. Confirm your assessment and plan with your patient. I often review my patients’ medication and problem list with them (at least once) to ensure that they are aware of all of their diagnoses, and to make sure I haven’t missed anything. Sometimes a patient will have a condition (otherwise unmentioned in their record) that they treat with certain medications at home that they are not getting in the hospital. Errors of omission are not uncommon.

6. Sign out face-to-face or via phone whenever possible. These days people seem to be less and less eager to engage with each other face-to-face. Texting, emailing, and written sign-outs often substitute for face-to-face encounters. I try to remain “old school” about sign-outs because inevitably, something important comes up during the conversation that isn’t noted in the paper record. Things like, “Oh, and Mr. Smith tried to hit the nursing staff last night but he seems calmer now.” That’s something I want to know about so I can preempt new episodes, right nursing staff?

7. Create a culture of carefulness. As uncomfortable as it is to confront peers who may not be as enthusiastic about detailed sign-outs as I am, I still take the initiative to get information from them when I come on service and make sure that I call them to provide them with a verbal sign-out when I’m leaving my patients in their hands. By modeling good sign offs, and demonstrating their utility by heading off problems at the pass, I find that other doctors generally appreciate the head’s up, and slowly adopt some of my strategies (at least when working with me). I have found that nurses are particularly good at learning to tell me everything (no matter how small it may seem at the time) and have heard time and again that things “just run so much more smoothly” when we communicate and even “over-communicate” when in doubt.

“The Devil is in the details.” This is more true at your local hospital than almost anywhere else. Reducing hospital error rates is possible with some good, old-fashioned verbal handoffs and a small dose of charting OCD. Let’s create a culture of carefulness, physicians, so we don’t get crushed with more top-down bureaucratic rules to solve this problem. We can fix this ourselves, I promise.

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

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