Status matters: Observation order pilot for patients admitted through BSSF ED

Dear teammates,

Starting Aug. 1, Bon Secours St. Francis Hospital ED physicians and PAs will enter only observation orders on patients being admitted through the ED.  This is a pilot study that will be expanded quickly to our other facilities if successful.

Payors and CMS believe that level of care (observation vs. inpatient) is a decision of the attending physician who sets the treatment plan and expectation of length of stay.

In April, we began registering patients admitted from any of our EDs to another hospital as observation. Review of 100 percent of the May admissions from either RSF Berkeley Hospital or Bon Secours St. Francis Hospital to another hospital (154 patients) confirmed that the admitting physician’s order always determined level of care.  Patient status at discharge was not affected by interhospital registration.

It is a quirk of our Cerner build that it does not recognize a planned status order but does require a status order to bed the patient.  As a physician or APP admits a patient from the ED, the orders are always planned to allow them to be initiated by the floor nurse and to prevent their being activated in the ED.  Therefore, the attending’s planned status order is not yet activated and cannot be used to bed the patient.

When initiating admission PowerPlans, please double check that they include a status order.  Please remember to ask for a status order when taking telephone admission orders.

Conflict between ED order and admitting order regarding level of care leads to problems several times every day. This has regulatory and financial repercussions.  It impacts patient satisfaction due to multiple sets of paperwork presented and leads to confusion. It unnecessarily increases the work done by utilization review and case management. Having the ED place observation orders to allow patient to be bedded and planned orders initiated by his/her nurse will allow the admitting physician to determine level of care and will prevent conflict.

Please let me know of any questions or concerns.

Lou Applebaum, MD, FCCP
Chief Physician Advisor
Roper St. Francis Healthcare

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