Interqual?

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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.

Thanks,

Ginger

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Specializes in Home health.

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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AnnemRN,

Thank-you for replying. I appreciate it.

Ginger

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Specializes in Home health.

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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Specializes in pre hospital, ED, Cath Lab, Case Manager.

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.

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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.

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I work on a floor called the "Gumbo" floor, patients look sick, are sick but may not have WBC 42. So we are totally out of luck on how to make them meet criteria. Its exhausting. Outpatient in some situation last

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!

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missieRN said:
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.

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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.

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I've never been concerned about having to answer to lawyers, as my answer will always go something like:

#1 I do not admit or discharge patients. Their care is directed by the attending physician, as is medically and ethically appropriate.

#2 My employer uses the InterQual criteria as a guideline for non-medical staff to assess our utilization of resources, not to "force" an early discharge.

#3 If at anytime a concurrent stay does not meet the InterQual criteria as I understand it, it is the policy of my employer for the case to be presented to the Physician Advisor (MD) for review. All decision making in this process is directed by the MEDICAL STAFF. Period.

Interqual is intended to be a guideline, not a absolute end authority. I have discussed numerous cases with the McKesson folks, who are most helpful and reasonable. In my experience, if their guidelines are followed about 90% or more of all cases that I see in acute care can be directed to the an appropriate level of care be it acute, SNF, LTAC, HH, etc.

I grant you, it can be difficult at times to meet InterQual but constantly reminding myself that the final determination is Medical not Nursing has helped me.

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Specializes in Psychiatry, Case Management, also OR/OB.

I really liked lawrence1rice's succint reply to the question posed. :idea: It's so good I'm gonna steal it. (thanks in advance). Interqual is an evidence-based methodology of determination of medical necessity. McKesson uses these tools to determine severity of illness(how sick are they???) and intensity of service (what are we doing for them here that can't be done at another level of care???). The problem in getting folks to meet, is that they may have only one of 2 required issues met. The key thing to remember is that medical care is a physician-driven issue. I have many times told reviewers that we disagree with their determination, and they are free to send it on up for medical review. I work trauma case management, so my people usually meet it coming in the door, but it can be a struggle for the "on the fence" type of case, or with docs who admit without medical necessity. I take Remicaid for my RA, and developed a severe Pyelo. I had >18,000 wbc, fever >105 (Mckesson rounds up 1 degree for core body temp), hematuria and pyuria, and I'm immunocompromised, and I still didn't get admitted, cuz I could still take po (barely), wasn't vomiting, and succeeded at OP tx! I missed 10 days of work, but by God I didn't need to be in the hospital!!!:angryfire

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