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    Just wondering what exactly this is. I think is has to do with determining acuity of care but would like to see what case managers in the industry define it as.


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  2. 26 Comments...

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    Interqual is a set of criteria used to determine if a patients hospital length of stay is appropriate. The criteria is based on the diagnoses and any treatments involved in the patients care. It is a guideline used by IPA's that are supposed to save money by preventing unnecessary bed days.
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    Thank-you for replying. I appreciate it.

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    I hope my answer was helpful.
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    InterQual is a product of the InterQual division of McKesson, but you can find lots of samples of their decision or criteria flow sheets on line. They have > 3500 customers (hospitals, managed care orgs, etc) so they must be doing something right. These also cover all kinds of case management, such as outpatience cases, when to refer to a specialist, etc. Think of them as consensus statements, which they are in part based on as well as McKesson's medical experts. Just some of what I am uncovering from considering interviewing with them, so I am biased.
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    The criteria is broken up several ways. Pre admission, Admission, Continued Stay and Discharge screes/criteria. For admissions and pre admissions SI or Severity of Illness criteria must be met, then IS Intensity of Service criteria must be met. For continued reviews only the IS criteria is used. There are Criteria for adults, peds, SNFs, rehab, DME to name a few. It make the decision making process pretty cut and dried. It Can be frustrating to use sometimes when you know the admission is valid but the criteria aren't being met.
    Last edit by NRSKarenRN on Aug 13, '12
    JerseyLilly likes this.
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    I am pretty sure that whoever came up with "Interqual" has never tried it! You almost have to be dead to meet the criteria.
    edgwow likes this.
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    I work on a floor called the "Gumbo" floor, patients look sick, are sick but may not have WBC < 1,500 or a PO2 > 42. So we are totally out of luck on how to make them meet criteria. Its exhausting. Outpatient in some situation last <23 hrs and that is not long enough to get lab and other diagnositc done. The patient would probably die if we let them go home, so the hospital eats the cost in the gap.

    When are the new InterQaul Adult Criteria books coming out? Each year they max the criteria so I'm looking forward to the new revisions.

    Maybe the new books will tell us to line line the patients up in a holding pattern in the parking lot until they are sick enough to come indoors. Ha!
    edgwow likes this.
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    Quote from missieRN
    I am pretty sure that whoever came up with "Interqual" has never tried it! You almost have to be dead to meet the criteria.
    The Medicare guidelines are similar. You have to be dead to get admitted, and then you wouldn't need Medicare; you would need an undertaker.
    JerseyLilly likes this.
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    Most hospitals and some insurance companies use Interqual guidelines to admit patients to the hospital. It is expensive to maintain the books but if you as a case manager ever have to answer to a lawyer as to what criteria you discharged a patient ( if you have the pressure like we do to meed Medicare LOS) you can refer to your Interqual book.
    JerseyLilly likes this.

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