Observation status: RN's job to change to Inpatient?

[Zippy Head]

Ever since I was a little RN, admitting would call and tell me that my patient had been Observation status for too long and today, right now, it had to be changed to Inpatient status, meaning I had to call the MD and get that changed. The first few years, I was working nights, and I would get this hassle heaped upon me near to midnight. I recall the charge nurse enforcing that view, making me call an MD at midnight to change to Inpatient. He was not pleased.

Now I'm a bigger RN and nothing has changed. My hospital recently changed from non-profit to for-profit, and they are noticeably more disagreeable regarding the Observation topic. Case managers chase after the RN and stress her out about this "changing to Inpatient status," and if that doesn't work, they bully the charge nurse.

My question to you: whose job is this? The MD admits to Observation, yet Admitting won't call them. Case management won't call them. Everyone dumps on the RN, like it's her job to do everything (another topic). This thing must go on in your hospitals, how do you handle it?

[eriksoln, BSN, RN]

Ever since I was a little RN, admitting would call and tell me that my patient had been Observation status for too long and today, right now, it had to be changed to Inpatient status, meaning I had to call the MD and get that changed. The first few years, I was working nights, and I would get this hassle heaped upon me near to midnight. I recall the charge nurse enforcing that view, making me call an MD at midnight to change to Inpatient. He was not pleased.

Now I'm a bigger RN and nothing has changed. My hospital recently changed from non-profit to for-profit, and they are noticeably more disagreeable regarding the Observation topic. Case managers chase after the RN and stress her out about this "changing to Inpatient status," and if that doesn't work, they bully the charge nurse.

My question to you: whose job is this? The MD admits to Observation, yet Admitting won't call them. Case management won't call them. Everyone dumps on the RN, like it's her job to do everything (another topic). This thing must go on in your hospitals, how do you handle it?

The answer to that lies within your organization. My hospital may say it is the nurse's to track, others will tell Case Management to have it properly handled. It all depends on the views of the administration/management.

My first job ever was at a hospital with very aggressive case managers. They'd do exactly as you described wanting this and that phone call made. Sometimes I'd help out, sometimes not. Depended on what kind of acuity I was facing with regards to my pt. load. In the end though, if it did not get done, admin. was not calling for my head, they were writing up the case manager. That, more than anything else, is what decides who's "job" it is. Case management knew, if I was busy and ignoring their requests, they'd have to do it for themselves or perhaps face a write up.

On the other hand, when I was a travel nurse, I worked at a few facilities where it was different. There were less case managers and the impetus of this task seemed to fall more on the shoulders of the nurses. It was a different atmosphere though. Case management was too busy to spend half an hour convincing nurses to make a phone call for them that would take less than five minutes to do for themselves. At these hospitals, nurses were more aware of a pt's admit status, it was considered a part of report. Our rounding sheets had that info. directly beneath the name.

I do consider this issue a part of nursing. There are insurance repercussions for the hospital, and more importantly, the pt. if someone spends time in the hospital under the wrong admit status. Insurances will jump on this mishap and not pay for whatever time the pt. was there under "observation" status. They pay many people much money to find things of this nature. When this happens, the hospital will hand the bill to the pt. We as nurses are not doing our pt's any favors if we fix their hyperglycemia, but send them home unable to afford insulin because they instead have to pay a hospital bill that could have been avoided for them with a proper admitting order.

The case managers at your facility sound like the one's from my first job. Don't let them bully you into neglecting your patients while you make phone calls they can/should be making. You are an RN, not the Social Services Dept. secretary. If you are busy and don't see yourself having a window of opportunity to make the call for them.......say so and leave it at that, walk away, don't even bother listening to their pleas. They may counter with the age old "It only takes two minutes", to which I always replied "And you've wasted ten minutes trying to get me to do if for you..........you could have corrected five improper admits while you were standing here bothering me." They got the point eventually. Remember, most case managers are slow learners.......nurses who realized they could not tow the line as a nurse so they jumped ship over to case management. They are a dime a dozen, don't let'em bother you.

[wooh, BSN, RN]

Our case managers just put the order on the chart to change it. When we had paper charting, they'd put the paper on the chart for the MD to sign whenever they next picked up the chart. With computer charting, it's just put in as a verbal and the doc cosigns it when they get a chance.

It has to be changed, it's not like the doc is going to say, "NO! They've been here 3 days, but I still want them as a 24 hour observation!"

[wooh, BSN, RN]

I will add, it's really ridiculous the way nobody except the nurse can call a doc. Pharmacists calling you to call them (when they could just as quickly call the doc instead and be done with it.) Radiology the same. Respiratory and physical therapy. WHY oh WHY do in 3 phone calls what could be done in 1 and instead of involving 3 people, only involve 2?

[netglow, ASN, RN]

Your new world will totally revolve around LOS/GMLOS.

[JulieCVICURN, BSN, RN]

In our facility, it is the RN's job to notify the MD that the patient needs to stay longer and be changed from observation to inpatient. BTW, you absolutely must (or at least, someone must) do this because for Medicare/Medicaid (I don't know which or if it's both) there is a certain $$ amount for observation. If you do not get the status changed, the facility gets screwed out of astronomical amounts of reimbursement. This is why people are chasing you down, desperate to get it done properly. It's expensive to make the mistake of not changing it.

Also, it was explained to us that the reason the RN does it is because it is us who really gathers the information so that the doctor can make that call. We are to make sure the patient is stable, not bleeding, etc., before we can tell the doctor it's ok to let them go home or if they need to stay. How's a social or case worker going to know that?

ETA: I do think it sucks that we have to do EVERYTHING. Wipe my ass, call my doctor, walk my dog. Kiss my butt.

[Flying ICU RN]

This brings two questions to my mind,...

Is this a clinical issue, or an administrative one?

Has any Nurse ever lost a license due to administrative neglect?

I would wait until morning.

[eriksoln, BSN, RN]

In our facility, it is the RN's job to notify the MD that the patient needs to stay longer and be changed from observation to inpatient. BTW, you absolutely must (or at least, someone must) do this because for Medicare/Medicaid (I don't know which or if it's both) there is a certain $$ amount for observation. If you do not get the status changed, the facility gets screwed out of astronomical amounts of reimbursement. This is why people are chasing you down, desperate to get it done properly. It's expensive to make the mistake of not changing it.

Also, it was explained to us that the reason the RN does it is because it is us who really gathers the information so that the doctor can make that call. We are to make sure the patient is stable, not bleeding, etc., before we can tell the doctor it's ok to let them go home or if they need to stay. How's a social or case worker going to know that?

ETA: I do think it sucks that we have to do EVERYTHING. Wipe my ass, call my doctor, walk my dog. Kiss my butt.

Any chance you can vacuum my living room somewhere in there.

Oh, and call my mom and tell her I am coming around 5 for dinner.

[JulieCVICURN, BSN, RN]

I don't even vacuum my own living room. You could die holding your breath waiting for me to do yours!

[abundantjoy07, RN]

I don't think I should have to be bothered with administrative stuff like that. It's just not a concern of mine. Mine main focus is caring for the patient and not tackling these issues. I mean our jobs already emcompass so much. We are seen as the jacks of all trades but do we really need more stuff to bother with?

[CrunchRN, ADN, RN]

"ETA: I do think it sucks that we have to do EVERYTHING. Wipe my ass, call my doctor, walk my dog. Kiss my butt."

:yeah::yeah::yeah::yeah::yeah::yeah::yeah::yeah::yeah::yeah:

[Flo., BSN, RN]

our case mangers get on our case all the time to call the doc to have this or that done. If I have time I ask them to change it, if not I don't worry about it. I am more concerned with the immediate needs of my pts than a billing issue. We have one case manager that interrupts RNs all the time to ask questions that are easily found in the chart like what pain meds is the pt on and how have the sugars been running. It drives me nuts!