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CMS extends "two-midnight" review period

March 2014

Published in the March 2014 issue of Today’s Hospitalist

CMS extends two-midnight “educational” period

WHILE MEDICARE’S TWO-MIDNIGHT RULE for admissions remains in effect, the Centers for Medicare and Medicaid Services (CMS) has announced a further extension of what the agency calls the “probe and educate” review period related to the new rule.

Slated to end March 31, the review period will now last through Sept. 30, 2014. During this period, Medicare administrative contractors (MACs) will continue to select claims from individual hospitals to review facilities’ compliance with the new rule, then educate hospitals that need further clarification. According to the CMS, MACs should be selecting 10 claims to review for most hospitals, but 25 for larger ones. MACs will also review claims from long-term acute care hospitals and inpatient psychiatric facilities.

Also in this extended review period, RACs will not generally be conducting post-payment audits of claims for admissions taking place between Oct. 1, 2013 and Oct. 1, 2014.

The controversial new rule, which was issued last August, says that inpatient admissions are generally appropriate when a physician expects a Medicare beneficiary to need to spend at least two midnights in the hospital and admits the patient based on that expectation.

Rehab patients and readmissions

MORE THAN ONE IN 10 PATIENTS discharged from inpatient rehab facilities are readmitted to acute care hospitals within 30 days after discharge from rehab.

Authors of a study published in the Feb. 12 issue of the Journal of the American Medical Association looked at 2006-11 Medicare data for more than 700,000 patients discharged from hospitals to rehab facilities. The patients included in the study had one of six conditions: lower extremity fracture, lower extremity joint replacement, stroke, brain dysfunction, neurological disorders and debility.

While the overall 30-day readmission rate to hospitals for patients discharged from rehab was 11.8%, only 5.8% of patients with lower extremity joint replacement were readmitted, compared to 18.8% of those with debility.

The authors also found that the top readmission DRGs included conditions that could be targeted for interventions, such as kidney and urinary tract infections, pneumonia, and nutritional disorders. Nearly half of all the readmissions within 30 days took place in the first 11 days after patients were discharged from rehab.

Success with before-noon discharges

INTERVENTIONS PUT IN PLACE on two units at a New York academic center boosted the percentage of patients being discharged before noon from 11% to 38%.

Innovations adopted at Langone Medical Center’s Tisch Hospital included adding 3 p.m. multidisciplinary rounds to identify patients who can be discharged before noon the next day; creating a Web site to share that discharge information and generating a 4:30 p.m. e-mail to all staff, including hospitalists and bed management; reviewing records first thing in the morning for patients flagged for a before-noon discharge; and providing daily feedback on the initiative via unit boards as well as using posters to track the initiative’s success.

Staff also contact family members the day before for patients scheduled to be discharged before noon the next day. While the average time of discharge was moved up in the day by 1.5 hours, 30-day readmission rates among discharged patients dropped from 14.3% to 13.1%. The study was posted online in January by the Journal of Hospital Medicine.

Watches are out, close-toed shoes are in

WHILE IT IS STILL UNCLEAR how doctor attire may contribute to in-hospital infections, a group of experts has released recommendations for what physicians should “and shouldn’t “wear in acute-care hospitals outside of ORs.

Writing in the February 2014 issue of Infection Control & Hospital Epidemiology, members of the Society for Healthcare Epidemiology in America recommend that doctors in the hospital be “bare below the elbows” and avoid long-sleeved clothes, wristwatches and jewelry. The experts also recommend not wearing open-toed shoes or high heels.

For hospitals that mandate the use of long-sleeved white coats, those hospitals should issue two or more coats to each physician to encourage more frequent laundering. Ideally, white coats should be laundered daily and no less than once a week, and hospitals should consider providing onsite laundry service.

Also according to the recommendations: Hospitals that mandate white-coat use should install hooks to allow doctors to remove their coats before coming into contact with patients.

Hospital codes: plain language, not colors

WHILE THE TIRED-AND-TRUE “code blue” for medical emergencies will remain in use, most hospitals in Missouri have moved to adopt plain language, not color codes, for emergency alerts.

According to a January article in the St. Louis Post-Dispatch, the Missouri Hospital Association came up with the recommendation to use plain language instead of color codes after a tornado severely damaged a hospital in Joplin, Mo., in 2011.

Instead of announcing color codes that only medical personnel understand, paged alerts will instead name the actual emergency such as a tornado or hurricane warning, a child abduction, a bomb threat, or an armed intruder. A source quoted in the article noted that while color codes were adopted to try to keep patients and visitors calm during an emergency, hospitals now worry that using such codes may lead to a dangerous delay in response.

Already, the article noted, nearly 90% of the hospitals in the state are using the plain-language emergency codes, with the rest planning to follow suit.

Business boot camp for doctors only

HAVE A MEDICAL DEVICE you’d like to patent or a startup idea to get off the ground? An MD husband-and-wife team has set up a business service to help physicians turn those ideas into business plans.

Based in Austin, Texas, the Walters Physician Incubator holds monthly meetings where physicians are coached by business school professors, lawyers, marketing executives and venture capitalists. Residents and medical students are also welcome to attend.

The goal of the sessions, according to CNN Money coverage, is to help doctors learn how to package their ideas into a business plan, pitch that plan to potential investors and raise funds. The company was founded in 2013.

For now, the service is free, but the company may start charging membership fees to doctors who participate. The founders of the incubator “an orthopedic surgeon and a family physician “themselves launched DocbookMD in 2009, a communication application that allows physicians to share secure patient information.