Admissions denials in the ER

[ERNURSE4MS]

Today I had something wierd happen. We had and elderly female come in by ambulance. CC diarrhea x 3 days, weakness, generalized malaise. This pt had HX of DM2, HTN, Arthritis, and recent-aputation of l great toe 3 days ago. VS wnl. labs drawn- alittle dehydrated but nothing severe. K+ 3.3, pt had poor support system. Unable to get up to bsc, 3 watery stools while in the ER. ERMD spoke w pts Primary doc. orders for admit. Case management contacted to review chart prior to adm. CM stated pt didnot meet criteria for adm or obs. ERMD contacted Primary doc- She didn't care admit anyway. CM stated "OK, we will need a letter of denial, but OK" that was all she said. We sent pt upstairs to med surg. Next thing I know the DON was in ER raising ****.She stared shouting-" Are you going to take up a collection because the hosp is not going to pay for this"WTF? She said that we were supposed to hold pt in ER till HEN(??) or letter of denial was signed. I have never heard of this noone else had either. I politely told her that I didnot know that we were supposed to do this because noone had told us and the was no policy regarding this. I would remember and never do this again. She seemed to think that the CM was supposed to have told us. NOONE told us ANYTHING about that. She the turned around and left. We all agreed that she handled that poorly but what I want to know is this common knowledge. DON made out like this was a Medicare guideline and aHEN(???) letter had to be signed. I know very little about CM. Also would like to note the CM only review charts 8-4 M-F. and only ER adm not direct adm from MD office.Not at night on on weekend and noone I spoke with knew anything of this. I am sure I will hear from my NM tomorrow but would like your opinion on the matter.

[mommatrauma, RN]

We haven't had anything happen with such a severe an outcome, but we now have case management stationed in our ER for the better part of the day, 7 days a week, with a handy dandy admission criteria book...if they don't fit, you can't admit...the days of social admissions are done...Sad to say, but it does makes sense, there are plenty of BS admissions all the time that used to get admitted because they are poor follow-up, or the docs feel bad, or the family "couldn't take care of them" or they don't know what else to do with them...in the meantime, there are a few like grandma, who get caught in the loophole...the criteria are strict and unwavering...although, if the docs are concerned enough about keeping the patient, they work very closely to make something fit, and so does case management...When case management isn't there, our Docs are still bound by the book, does more slip through the cracks, sure it does, but you better believe that when case management gets a hold of it...there's hell to pay...I don't think that our DON becomes unprofessional and has a yelling match about it, but there is definitely something said...Sounds like grandma could have been tanked up with some fluids, some immodium and given a po potassium supp and d/c to home w/follow up w/PCP...if she didn't get any better, then she'd probably have met criteria to be admitted...The case managers, also in situations like that, at least in my hospital, where there rarely is a great support system and good follow up, will set up a few home health visits until the patient is back on their feet...As much as I would like to think healthcare isn't a business...it is...hospitals like everyone else must pay the bills...and insurance companies just are paying out like they used too...and these older patients can barely pay for their medicine let alone a couple thousand dollars in hospital bills....its sad, but its all the more reason as ER's and nurses, we must be on our toes to be the patient advocate, because in an ever changing economic climate, we are the few things they have left...They need that good care more than ever now while they are with us since the chances of them staying with us are less likely...one of the other unfortunate things is as well, that it tends to jam us up in the ER a little bit more because those patients the ER Docs are on the fence about that just don't quite fit the book...end up spending more time with us for a pseudo-obs period until they are sure they are comfortable letting them go...That all being said, as a whole, I haven't seen TOO much of a difference in who and how we admit...I think this has been coming for a long time its just more obvious now...because case management has always been there, but they are no longer just behind the scenes or moving the already admitted patients out quicker...now they come to the root of the "problem" and nip it in the bud...

[Katnip, RN]

Now if they could only use similar criteria in the triage area. We wouldn't have to do free pregnancy tests or fix hangnails.

[mommatrauma, RN]

Now if they could only use similar criteria in the triage area. We wouldn't have to do free pregnancy tests or fix hangnails.

AMEN to THAT!!!

[traumaRUs, MSN, APRN]

I'm an ER case manager in a large level one and the HEN (?) letter you are talking about is what we call a Denial of Benefits letter. However, we don't issue them in the ER. My role in the ER (we have coverage 18 hours a day M-F and 8 hours each on Sat/Sun) is to divert admissions. I can do this with direct nursing home admissions (which is what I would have tried in this case), home health, family assistance, other community services. I also use Interqual criteria for admission (the book) but my major role is assisting with discharge planning. There are still some that fall through the cracks but I work very hard to ensure that everyone gets the care they deserve.

[ERNURSE4MS]

:) Thanks for the replies. My thing is that the CM and DON acted like everyone was supposed to know all the medicare guidelines. What I know about CM would fit in a thimble with room left over. Also the DON told us that the HEN was supposed to be done in the ER or the pt got to stay 2 days free?(or maybe the hosp couldn't get reinbursement. I had just never encountered this situation before. I kinda got a little irritated that the DON came into the ER and threw such a fit. If had just been the DON and me behind closed doors I may have not gotten so tiffed. She did this in the middle of the Nurses station and everyone present got yelled at including EMS. It wasn't even my pt. The nurse who had the pt was not an ER nurse and usually worked nights so I kinda deflected the ire from her because she REALLY didn't know better. Anyway I'm sure ALOT of memos and inservices and meetings will come from this incident... Sigh...