Updates & Reminders
PCR Test Shortage
As of today, 01/08/2022, lab informed me that NW only has 40 COVID PCR tests left. Additionally, they only have a single respiratory panel machine in operation and are currently 5 days back-logged for these.
Consequently, we need to cease ordering any COVID/Flu/RSV/Respiratory Panel PCRs. We only need to order COVID antigens at this time for patient that will be discharged. I will update this again once more things change.
For admissions, the process is the same as before - if covid antigen is negative, but have a high-risk, high-suspicion patient, then can order the PCR. Otherwise, the rapid antigen is sufficient for admissions.
AMA
Managing AMAs
by
Dr. Fred Poage, FSED Medical Director, Amarillo, TX
Dr. Brad Blaker, Regional Medical Director, Michigan
AMA: Against Medical Advice
The term 'Against Medical Advice' or 'AMA' is commonly understood to indicate when a patient chooses to leave before the treating physician believes it is medically safe to discharge. Please note it is important to distinguish AMA from ELOPED, whereby the patient leaves the treating facility prior to discussing this with the physician.
Background
AMA discharges account for approximately 2% of all discharges.
AMA discharges are at significantly higher risk of readmission, with an overall readmission rate of 20% compared to general rate of 3%.
AMA readmissions cost up to 56% higher than expected from initial hospitalization.
Analysis
Decreasing AMA discharges should be a top priority for all physicians, including Emergency Medicine, Hospital Medicine, and Critical Care.
When busy, it is challenging to commit the time to discussing with a patient his/her desire to leave AMA.
Inpatient AMA discharges have been correlated with a misunderstanding of the expected length of stay.
Physicians can help mitigate this by not underestimating the length of stay when asked.
Considerations
Know that the treating physician is still responsible to provide as safe and as appropriate care as possible, including prescriptions, referrals, and follow-up.
Most Important: ensure the patient understands that we want him or her to return so we can continue providing care; we do not believe leaving at this time is in their best interest.
Ensure the nurse informs the physician any time a patient wants to leave AMA.
Avoid the myth that insurance/Medicaid/Medicare will not pay if the patient leaves AMA.
Know that frequent physician reassessments and clear communication with the patient can decrease AMA rates.
Establish a dedicated AMA-liaison.
Documentation
Documentation of AMAs is critical. Example:
The patient has decided to leave AMA because___.
He / she has normal mental status and adequate capacity to make decisions.
The patient refuses hospital admission and wants to be discharged.
The risks have been explained to the patient, including ___, worsening illness, chronic pain, permanent disability and death.
The benefits of admission have also been explained.
The patient had an opportunity to ask questions about his / her medical condition.
The patient was treated to the extent he / she would allow and knows that they may return for care.
Follow-up has been discussed and arranged with Dr. ___.
Summary
Patients who leave AMA should be taken seriously. Your goal is to encourage the patient to stay and complete the recommended treatment. If he / she still chooses to leave, proper chart documentation outlined above along with a signed AMA form can help to mitigate risk.
__________________________________________________________________________
References
Syzek, Tom, MD, The Sullivan Group, Do's & Don'ts of AMA: Patients Who Leave Against Medical Advice (thesullivangroup.com).
MagMutual, When Good Patients Make Bad Decisions an AMA Form Protects Me, Right?,www.magmutual.com, Nov, 9, 2016
Mayz, Kurtis, A. JD,MD, MBA, FACEP, Top 5 Legal Risks in Five Minutes or Less, ACEP21, Boston Convention Center, Boston, MA Oct, 26, 2021.
FED Registration Flow
Watch the video below regarding the new FED Registration Flow we will be implementing on January 3, 2022. We have trialed this and it works very well and tremendously helps the flow and communication between registration clerks with nurses and physicians. Below is the process:
There will now be clipboards on the wall, under the light switch, in every room. These clipboards hold the form that registration needs to get the patient registered. When a patient is brought to the room, the tech/nurse/physician will hand the clipboard to the patient, instructing them to fill it out while they are waiting. This will cut out extra trips by the registration clerk just to hand the patient the form.
When the physician has seen the patient, they will click the drop-down under “BA (Bed Assignment)” column on the tracking board and select “MD Evaluating”.
This signals the registration clerk that they can now go see the patient to discuss billing and payment collection.
When the registration clerk has completed everything they need with the patient, they will click the drop-down under “BA (Bed Assignment)” column on the tracking board and select “None” - which makes that entry blank again.
This signals the nurse that registration is done with the patient.
When a patient is discharged and the house is on the board, nursing must wait until “MD Eval” has been removed by the registration clerk before the nurse can send the patient out.
It will take some getting used to for this process, but we have trialed it with different physicians, nurses, and registration clerks, and it has been universally praised for cutting down on extra trips by registration, cutting out the nurses having to ask registration if they are done, and improving our collections as well.
The physicians are the PRIMARY driver for this process to work - it is just 2 clicks for us to do but will make a huge impact on the flow and efficiency of the FEDs.
GST Expansion & NP’s to the Rescue!
We are expanding our beds at GST. This already started and should be completed by Friday. We are converting rooms 1, 4, 6 to twin-bed rooms with a curtain divider. Additionally, we are putting in 2 hall-beds as well. This will expand our ability to see patients and also allow for a 2nd midlevel to see patients as well. (I am still working on what this flow will look like).
I got approval (and guarantee) to extend daily (10a-10p) mid-level support at TSQ through March 31!
I got approval to create a “Scheduled Midlevel On-Call Schedule” in addition to the regular schedule, and this will be implemented by the end of the week. In addition to the currently scheduled providers, we are creating a set “Mid-level On-Call Schedule” where a specific mid-level will be on-call from 10a-10p each day, so if you need help at TSQ or GST, then you have a specific provider whom you can call to come in an help (instead of the mass-text I’ve been doing). This schedule will be posted here on the FED Newsletter Website. This will go a long way to helping out and have guaranteed support when we need it.
AMA Discharges
An appropriate AMA discharge requires that the physician/np/pa has a discussion with the patient/family regarding the risks of leaving AMA and appropriate documentation of this conversation and that the patient/family expressed understanding and acceptance of the risks of leaving AMA. Additionally, we need to assure the patient that we still want to take care of them to best of our ability - providing prescriptions when appropriate, referrals, follow-up - as well as encouraging them to return if they worsen and we will be happy to take care of them. Lastly, we should not get into the billing factor or make statements such as “If you leave AMA, you’re insurance will not pay.” This is a myth that has been perpetuated, unfortunately, for years. I have found no evidence to support this myth.
Lab Call-backs, GST Break-Room, Splints, Dilaudid Shortage, FED Holds
GST Staff Break-room: Please be conscientious of using the recliner in the staff break-room. That is a community break-room, and it is NOT intended to be used as a ‘sleep-room’. Feel free to go relax and decompress for a bit, but please do not ‘set up shop’ with blankets and pillows and shut the door with the lights off. That is the only area of the building that anyone can get a chance to decompress and it is not fair to restrict the nurses from using it. If time permits and you want to get some shut-eye, then use a clean patient room.
Lab Call-Backs: I know some have had some consternation over the “outpatient labs results” basket by the physician work-station. Anytime we are on shift, we need to go through these regularly.
Positive - we need to call and document this call in the chart. If no answer, then write the ‘date/time/no answer/signature’ on the physical paper, so we can try again later.
Negative - can give to the nurses go call the patient.
Splinting Inservice: I am excited to have Mariela Rico with AdaptHealth DME Orthotics provide individual in-services on all of the splints we stock at the FEDs. Please welcome her when she arrives! I have arranged for her to visit each of us in December at 08:00am when we are on shift at TSQ. I have asked her to stock some new splints for boxer-fractures, distal radial fractures, locking knee splits, LSO and TSO, among others. If there is a specific splint you think would be useful, let me know so we can get it stocked.
Dilaudid Shortage: There is a national shortage of IV hydromorphone, and we are reaching critically low levels at the hospital. We will not be able to replenish the supply at the FEDs at this time. GST has only one vial left, and TSQ has 12 left. The estimated resupply dates range from beginning-to-mid December, so hopefully this will be a short-lived shortage. IV morphine and fentanyl are still readily available at this time.
Tuesday, December 07, 2021 @ 06:30pm
Please RSVP for this program by using the following link:
http://www.medforcereg.net/SALG132590
FED Admission Holds
This is becoming an issue again; I wanted to review our transfer process. Please review the flow policy which actually has the patient transfers to be out of units in 30 minutes; however, this was pre-covid with issues that we have never faced before. FED patients will be given room assignment priority.
<CLICK HERE TO READ THE FLOW POLICY>
The physician will put a decision to admit in Cerner
Either the physician will call the transfer center or they may ask the nurse to call and ask if a MS/ICU bed will be available in the next 4 hours.
IF YES – physician will admit per usual process by securing an admitting physician and place the AOT order in Cerner and the RN will be in contact with the inpatient RN and call the ambulance for transfer as soon as the room is available.
IF NO – physician can pursue transfer to other facility: ED to ED or Direct Admit beginning with BSA
If no other admission avenue is available and the patient is appropriate for NW Services, the physician will admit to NW and the FED CN will work with the ED CN to initiate an ER to ER transfer. It is an expectation that both CNs will act with courtesy and respect in working out a transfer plan.
If the ER to ER transfer is not going smoothly, the RN will call the house supervisor for assistance. The house supervisor will assist in a transfer plan and/or escalate the issue to the AOC as needed.
EKO Stethoscope Discount
http://ekohealth.com/
I recently purchased an EKO 3M Littmann Core Digital Stethescope, and it is amazing! It blue-tooth connects to your phone and shows rhythm strips, HR, and can help with murmurs. You can also do a recording and send it to your favorite cardiologist. Feel free to take advantage or add it to your Christmas Wish List.
Covid-19 Vaccine Mandate
Team,
In compliance with CMS requirements, NWTHS has stated that all healthcare providers or employees that work within the hospital walls in any capacity must either be fully vaccinated by January 4th, 2022, or have filed a religious or medical exemption. In order to meet the January deadline, Northwest Texas is requiring that all relevant personnel either have received the first, or only in the case of J & J, vaccine shot by December 6th or have submitted their exemption request. Any individual who does not meet this requirement will be unable to work at the hospital as of December 7th.
Please send the required documentation A.S.A.P. to Willa White, Credentialing Specialist with APP at wwhite@appartners.com, and cc me as well. Do not send it to NW. APP is coordinating everything. Let me know if you have questions.
Work/School Notes
Please ensure ALL work notes get entered in Cerner under Patient Education. It would be even better for you to document in your note if you provided a work/school note, with what restrictions, and for how long. We have run into a few situations where a patient claims they “lost” their work note and “the doctor said I could be off for a week”. Additionally, we have had a couple of situations where the employer needed documentation as well. If you are having the nurse enter the work/school note, then make sure to let them know they need to enter it in the patient’s chart under Patient Education. Anyone can find and use the work/school notes I made by searching for "Poage” in Patient Education.
Dr. Glock Post-Op Patients
Dr. Glock has requested that he be called on any of his post-op patients that present to the FEDs for companies related to their surgery with him. Please do not prescribe any narcotics until you discuss the case with him. Additionally, he politely requests that we do not provide any work notes until discussed with him. He recently had an issue with the worker’s comp and HR department for a patient’s job which contradicted what he had laid out initially. Dr. Glock has been tremendously helpful for us at the FEDs and is always happy to help out - let’s ensure we keep good relations with him as a group. Thank you!
Down Codes & ARC Select
Down Codes: Team, we need to really work on our charting to ensure we are being compensated appropriately for the level of work we do. We had 33 charts down coded in September based simply because we did not document the EKG. We had a couple of other down codes for missing HPI, ROS, and PFSH. However, the biggest area is not documenting the EKG. We MUST document this in the “Medical Decision Making” section. If you don’t see an EKG section, you can add it by right-clicking on Medical Decision Making and then Insert Sentence, where you can select EKG.
ARC Select: go-live this Thursday, Nov 11, 2021. ACR Select is a national standard imaging decision support system based on the American College of Radiology (ACR) Appropriateness Criteria® (AC). ACR Select is integrated with your Cerner computerized provider order entry (CPOE) workflow and guides ordering providers to the most appropriate medical imaging exam. This ensures that the right patient gets the right scan for the right indication. You can view the documentation HERE and HERE.
MIPS TIPS: Provider Education Tools
Don’t forget to review the MIPS TIPS! You can find them HERE.
Covid19 Antibody Infusions & Testing
Regional Infusion Center: the FEDs are no longer stocking antibody infusions, and all patients meeting criteria for antibody infusion should be referred to the Amarillo Regional Infusion Center. You can view & print HERE the form under the “Referral Forms” section of the Newsletter. The physician needs to fill out the top and middle sections, and the patient can fill out the bottom. Don’t forget to sign the form! The nurse can make a copy for the patient, fax the original, and then file it to be scanned into the patients chart.
Covid/Flu/RSV Testing: Andrea and I are working on improving this process so we do not have to call the patient back the next day. Further updates as they develop.
Midlevel Coverage
The volume at Town Square has dramatically dropped off over the past 4 weeks, and does not support full midlevel coverage. For November, we need to forgo scheduled midlevel coverage. I have discussed with Cesar and the plan at this time for November is to have an ad-hoc call system for midlevels at Town Square. If you reach a point where you are inundated, call me. I will send a mass-text to all the midlevels to see if anyone is available to help out (they are guaranteed 6 hours of work if they can come in). It has been a real challenge trying to staff the FEDs, and I appreciate your understanding and support during this time.
Georgia FED will continue having full midlevel coverage noon-10pm every day.
Sars-Cov-2/Flu/RSV PCR
We can now order ‘Covid+Flu+RSV’ PCR swabs instead of the whole respiratory panel. We still have to send to the main, and so will need to let the patient know they will receive a call within the next 24-36 hours with the result.
Midlevels
All midlevels will be operating up at the front desk at both FEDs. The expected process is that they will see all 4 & 5’s and any patients requiring more than a simple swab, urine, or X-ray - basically anyone needing “line & labs” needs to be transferred to the ‘back’ and the physician on-shift needs to assume full care for that patient. The goal for mid-levels is to help keep the front-end process flowing efficiently - and not having them running from back-and-forth between the front and the back. If a patient requires “line & labs” or is sent to the back, then the physician needs to take over the care for that patient.