Published in the October 2012 issue of Today’s Hospitalist
ANY HONEST PHYSICIAN WILL ADMIT that during training, nurses prevented a lot of disasters. They reminded us to check wristbands when drawing blood for type and crossmatch and tactfully questioned our opiate dosages. ED nurses told us when a patient needed ICU care or could go to telemetry. Now that we’re experienced, though, we need less guidance … or do we?
Hospital nurses include not only those who keep our patients alive and make sure our orders are followed, but a wide range of nursing specialists. You probably know a cardiologist or surgeon whose notes are written by a registered nurse and then later cosigned with comments.
Nurse anesthetists intubate more patients than critical-care medicine specialists, as well as do most of the work preparing patients for surgery so they survive. And nurse midwives can handle most deliveries without raising a sweat.
In the last 20 years, changes in both laws and third-payer rules have made even more types of specialty nurses necessary. And despite some resistance from physicians, nurses can be critical to a hospitalist’s practice.
NPs and RRTs
While RNs increasingly earn bachelor’s degrees instead of the two-year certificate prevalent in the past, NPs need a master’s degree in nursing and at least a year of supervised practice to be certified.
They can take histories, do physical exams and work independently (depending on state regulations). And when hospitals are short on residents, NPs often staff rapid response teams (RRTs). An NP, accompanied by a respiratory therapist, can perform a physical exam and order tests without a doctor’s order. By the time you’re called (by either the RRT or the floor nurse), the NP may have diagnosed the problem and be able to give you initial results from the ECG, chest X-ray and lab work.
RRTs generally result in about a 75% drop in the number of code blues. And if the RRT suggests moving a patient to the ICU, you’d better have a very good reason to decline.
The nurse as case manager
If hospitalists have added one maxim to medical practice, it’s this: “Discharge planning begins on the day of admission.” Third-party payers increasingly refuse to pay for acute-care hospital days when a patient’s care can be given elsewhere, so you have to plan after-hospital care as early as possible.
Enter the case manager, who is usually an RN, occasionally assisted by a social worker. You may see notes on patients’ charts requesting “SNF screen” or physical therapy evaluations and offering to help arrange home visits. These hospital staffers have two main goals: reducing unpaid-for hospital days and preventing readmissions, both of which cost the hospital huge amounts of money.
It is short-sighted and unrealistic to think that case managers are mere bean-counters or tools of the administration. Unnecessary hospital days expose patients to nosocomial infections; mobilizing seniors protects them from disability and thromboembolism; and families who thought a patient could “just go home” adjust those expectations when they see their mom getting exhausted just standing by the bed with a husky therapist on either side.
So don’t just answer case managers’ questions. Listen to them. They can spare you much of the work of preparing patients and families for transfer to another facility, and they often have a better idea than you do of where to send a patient. (“Don’t let Riviera Pines tell you they do rehab; they don’t have enough therapists. Let’s try Senior Manor, they have speech therapists who can work with him on swallowing as well as walking.”)
You’ll understand better why it’s OK to move a patient directly from your ICU to a long-term acute care facility, or how to judge from physical therapy reports whether a SNF or an acute rehab hospital is a better first choice.
Few residency programs give much training in how to bill for hospital visits, or how to document so that third-party payers will reimburse you for your time. By now, though, your group or practice has probably given you some instruction on how much to write about patients’ history, physical exam, test results and diagnoses to get paid for a medium- or high-intensity visit.
But wait, there’s more! Those diagnoses are a big problem for the hospital, because both public and private insurers pay by the diagnosis and severity. They don’t pay by length of stay, which is another reason case managers keep an eagle eye on avoidable days.
Because of factors that are not always clear and may not make sense to doctors, similar diagnoses are reimbursed differently. Congestive heart failure is now subdivided into acute and chronic, left and right ventricular, systolic and diastolic. (Simple “pulmonary edema” doesn’t earn nearly as much.)
Even worse, things obvious to you must be stated explicitly to be paid; no matter how ventilator-dependent the patient may be, you have to use the words “respiratory failure” for the hospital to be reimbursed for the ICU care. And that ferritin level will not be paid for unless “anemia” or “possible iron overload” are among the diagnoses you report.
Because you don’t have time to consider every progress note in the light of reimbursement practices, coding specialists “mostly RNs “review charts and ask questions, usually left on the chart in brightly colored notes.
“Does this patient have hypokalemia?” sounds ridiculous when the level is 2.1, but those runs of IV KCl won’t get paid unless your note lists it as a diagnosis. The nebulizer treatments you added as an afterthought because you heard a few wheezes will be a freebie unless you include “reactive airway disease” somewhere in the chart.
Making an exhaustive problem list at some point in the hospitalization will not only help keep the hospital’s doors open but increase the odds that you too will be paid for the work you’ve done. Often, part of that list is prompted by calls or notes from a coding nurse, and that editing can make it clear what exactly you’re treating.
Taking an active role
If your hospitalist group hasn’t done so already, spend some time at your next meeting “and when orienting new members “to discuss how case managers and coding experts can help you, and vice versa. Meeting once a month to spot problems, such as delays in family consent for transfer or consultants who slow down discharge planning, can benefit both parties. Both of you will learn about your patients’ needs.
The next time somebody in the doctors’ lounge grumbles about having to “take orders” from hospital employees “like nurses “you might mention how much they save you in terms of dealing with the latest trends and regulations. And ask this: What’s so new, anyway?
After all, nurses have been telling doctors what to do for generations.
Stella Fitzgibbons, MD, has been a hospitalist since 2002 and has worked at numerous hospitals in the Houston area. She is profoundly grateful to all the nurses who have put up with her through the years.