ACPA Observation Cases January 2023

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* 1. Seventy-five-year-old female with a history of atrial fibrillation on blood thinner was brought to the emergency room by ambulance after falling at home. She also had a recent fall about a week ago. She said she hit her head but did not lose consciousness. She was placed in hospital bed to be closely observed, especially with blood thinner usage.

Physical therapy evaluation recommended a short-term skilled nursing facility to improve her mobility. The patient also tested positive for COVID with no active symptoms.

Based on freedom of choice, the patient selected two skilled nursing facilities close to her family and was willing to go to either. The social worker contacted both facilities and noted that the first facility required a negative COVID test before admission, and the second facility could not accommodate the patient for another three days due to staffing shortage. Noted, the hospital also has one floor closed due to staffing shortage as well; at the same time, the hospital has outside transfers lining up to be admitted urgently.

1-Since this patient highly likely will not be discharged for several days, what is her most appropriate status, outpatient/observation or inpatient?

Inpatient

Outpatient/Observation

comments

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* 2. With the need for hospital beds to accept urgent transfers, what is the best way to handle this discharge dilemma considering the patient's medical condition is stable to be discharged and can be managed in a skilled level of care?

Await until patients facility of choice can accept patient

Expand referrals to additional facilities in the region or state

Issue an advanced beneficiary notice as patient is custodial care at this point with no further acute medical needs

Comments?

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* 3. There are many challenges imposed on healthcare due to the pandemic; what are your thoughts regarding how healthcare system should act differently, especially when facing staffing shortages?

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* 4. 80-year-old male with past medical history of CVA, HTN, Atrial fibrillation on Xarelto who presents with brief episode of tingling in left arm. Initial CT head is negative for any acute process. By the time hospitalist comes down for evaluation, patient’s symptoms have resolved. Patient is placed in Observation status for TIA with expected LOS of 1 Midnight. Hospitalist orders the stroke order set which includes neurology consultation, neurological assessments, ECHO and MRI/MRA to rule out acute CVA. After 1 Midnight, the physician advisor reviews the case and notes patient has no recurrence of symptoms. Patient’s MRI/MRA is negative for acute process. However, given atrial fibrillation on anticoagulation, the attending does not want to discharge prior to ECHO being completed. Unfortunately, the ECHO team is backed up and may not be able to perform the ECHO until the next day.

Since the patient is expected to spend a 2nd midnight pending ECHO, what status do you recommend?

Continue as Observation

Continue in Observation and document avoidable delay on ECHO department

admit as inpatient

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* 5. After 2nd Midnight, ECHO is performed but it is 5pm and there is still no final read on the ECHO.

Continue Observation

Continue Observation and document another avoidable delay on ECHO dept

I chose inpatient above so continue inpatient

I would now admit as inpatient

comments?

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* 6. Would your status recommendation change if this patient was Medicare fee for service or Medicare Advantage? Please add further details in comments

yes

no

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