UM Guidelines

	Added Clinical Indications for 23 Hour Observation and Glossary:
	Question # Description Yes No 1 Is the patient having continued vomiting OR orthostatic changes (dizziness or BP changes) after 3 - 4 hours of ER rehydration and IM/IV anti-emetics? Approve Go to # 2 2 Electrolyte Imbalance? Na > 156, K< 2.5, pH < 7.30, Bicarb < 18)? Approve Go to # 3 3 Significant comorbidity, CHF or Pregnancy, or Age > 65 or Age < 12, or IDDM with Gastroparesis, Ketoacidosis or BS > 300? Approve Go to # 4 4 Hematemesis? Approve Refer to MD 23 Hour Observation Glossary Medical (non-surgical) Admission Hospitalization to rule out a serious condition is appropriately an extended observation if the condition can usually be ruled out in less than 24 hours. Observation rather than admission is appropriate for an established medical condition that has a high chance of responding to a brief period (less than 24 hours) of intensive treatment and thereby obviating the need for inpatient care. If, at the time of admission, the patient demonstrates signs and/or symptoms severe enough to warrant the need for services of such intensity that they can be furnished safely and effectively only on an inpatient basis, then an inpatient admission is appropriate. Medical (non-procedure) Observation Medical observations will be evaluated in a fashion similar to the process used for procedures. Outpatient observation is for the purpose of determining whether a patient requires admission as an inpatient or other treatment. Observing a patient for up to 24-hour should be adequate in most cases. Some patients might require services into the second 24-hour period. In all cases the underlying consideration will be whether there is a question that must be answered before the decision can be made to admit or discharge. Outpatient Observation services are defined as the use of a bed and periodic monitoring by hospitals nursing or other ancillary staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for possible inpatient admission. They are not to be used as a substitute for medically necessary inpatient admissions. They are not to be used for the convenience of a hospital, its physicians, patients, or patients’ families, or while awaiting placement to another health care facility. Observation services can be divided into three categories: Observation associated with an outpatient procedure, observation associated with a medical condition, and treatment room use associated with a non-surgical procedure. Procedure Based Observation In the appropriate conversion of an outpatient procedure to an observation status, there should be an event which heralds a time period during which is unclear whether the patient will be able to go home or will need to be fully admitted. That event should trigger an order, which (in the absence of a physical transfer) will mark the beginning of the observation period. Note that this event does not have to come at the end of the recovery; you may have an abbreviated recovery period, which then converts to observation. This is appropriate. Sources BlueCross BlueShield of Tennessee network physicians. April - June 2008.