Interqual criteria - downgrades

  1. Hello, I am a Case Manager at an Acute Care hospital where I am also in charge of managing PCU downgrades. Our PCU is in between the ICU and a med/surg unit. So the goal is for the patient to be in the appropriate level of care based on Interqual guidelines.

    My question to other Case Managers is that I have been receiving feedback from the physicians saying - "The patient that you asked for a downgrade for is now upgraded to ICU." Or ... "The patient that you asked to have downgraded has expired."

    So ... it seems that my "criteria" on paper for asking for the downgrade may not necessarily match the patient condition. It's the old, "treat the patient, not the chart," idea. Right?

    I feel I have lost some credibility as a case manager when I am asking for downgrades based on Interqual guidelines ... but the patient is getting sicker.

    Has anyone else run in to this? I don't actually see each patient prior to asking for the downgrade, but I do get report from the Charge nurse. How can I be sure that the patient is appropriate for downgrade - going beyond just the Interqual guidelines?

    Thx, Anne Marie
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    About anne_marie_oregon, BSN, RN

    Joined: Nov '10; Posts: 123; Likes: 63
    RN; from US
    Specialty: 4 year(s) of experience in Emergency


  3. by   Neats
    I use interqual at work. Before I input my data findings I always try to speak with nurse who is providing the care or I find the 24 hour report. This report speaks volumes. Also IQ although is a great guide sometime does not reflect the current status of the patient. It is the gray area where you have to click on something but the documentation really does not fit it is then I look for additional information. I never try to make it fit in IQ the documentation ether fits or it does not. I would not worry about the "downgrade" you can only go by what is documented.
  4. by   SummerGarden
    OP: McKesson does not state that you are to use their guidelines to make clinical decisions because their guidelines are not a substitute for professional clinical decision making. That seems to be the case with what you are writing that you are doing and it is harming your reputation. I am not running into problems because I check patients. When I do not check patients directly, I do so indirectly (similar to what the above poster writes) and I review updated information before conducting a review. Also, in cases where patients are sicker and/or the patient does not meet continued stay guidelines, then I will advance/escalate my case according to my department's standards to perform a secondary review with a physician.
  5. by   anne_marie_oregon
    Hello MBARNBSN,

    Thank you for the input. I have been meaning to reply. Yes, I agree with you about, "When I do not check patients directly, I do so indirectly." I definitely feel that some of the downgrades we have been asking for on our floor have been too aggressive/harming our reputation. I work directly with the Charge RN/Clinical Supervisor to request the downgrades, and we have spoken about really making sure the downgrade requests are appropriate.

    As the Case Manager, I do not feel I have as good of a handle on the patient as the Clinical Supervisor, so I rely on the Clin Sup and the bedside RN to give me a good feel as to whether or not the patient is appropriate for downgrade.

    It's embarrassing to me when asking for a downgrade if the downgrade is inappropriate! And it makes me look bad/incompetent to the physicians!!! So we are all working together to remedy this.

    I think it boils down to really improving our process. And trying to manage all of the expectations we have upon us for discharge planning, interdisciplinary rounding, and downgrading. It is difficult to get it all done, to do a GOOD JOB and do it CORRECTLY when the volume of work is so high! :-)

    Thanks for the input.

    Anne Marie
  6. by   anne_marie_oregon
    Hello Neats, I agree with you on this, "Also IQ although is a great guide sometime does not reflect the current status of the patient."

    Anne Marie