Saving Lives by Discharging Patients

We often talk about length of stay, and you all should know by now that I absolutely hate when the Medicare geometric mean length of stay (GMLOS) is used as a goal for every patient in each Diagnosis-Related Group (DRG).

I’ll repeat my mantra: the goal length of stay for every patient is when every single day of their hospital stay is spent providing medically necessary hospital care. If they don’t require hospital care, they shouldn’t be in the hospital.

Well, last week saw the publication of another article that demonstrates the importance of reducing avoidable days. This study looked at patients 75 years of age and older who were admitted to the hospital but were required to be kept in the ED overnight due to the lack of an inpatient bed. Compared to patients who did not have to board in the ED, the boarded patients had a 41-percent higher risk of dying in the hospital, more adverse events (including falls and nosocomial infections), and longer overall lengths of stay.

Now, this data is probably not a surprise to anyone, but sometimes you do need data to motivate change. Maybe it’s worth risking a bad patient satisfaction score from the patient upstairs who wants to stay another day but has no medical necessity, in order to save another patient from harm or even death.

Moving on, Kepro, the Quality Improvement Organization (QIO), released their November newsletter, which included what they called an immediate advocacy success story. In this case, it was an inpatient who was not happy with the attending physician and their impending discharge, so their representative filed a discharge appeal. Kepro ruled in favor of the patient. As Kepro describes it, “However, in the appeal determination provided to the facility, the Kepro peer reviewer had requested a neurological consult, but the attending physician at the hospital refused to do the consult and wrote another discharge order.”

Kepro states that they then contacted the hospital director of quality and patient safety, who then contacted the patient’s case manager to discuss the request for the consult by the Kepro reviewer with the attending.

Wait a minute. First, this started as a discharge appeal. In a discharge appeal, the QIO is supposed to determine if ongoing hospital care is warranted, not whether additional consultations by specialists are required. Their reviewer determined that ongoing hospital care was necessary, and the hospital and attending complied. They likely did not issue the Hospital-Issued Notices of Noncoverage (HINN) 12 and would not have charged the patient for the inpatient days, awaiting the appeal determination. But when the determination was issued and the attending informed, the attending apparently did not feel that a neurology consultation was necessary, so they did not order one – and in addition, they felt that at the point the appeal determination was received, the patient was stable for discharge (so the attending again ordered discharge).

As Kepro describes it, this evolved into an immediate advocacy issue concerning the quality of care provided by the physician, since that consultation was not ordered. In that case, section 5035.3 of the QIO Manual requires the QIO to contact the practitioner and give the practitioner an opportunity to participate.

Kepro did no such thing. I would bet that, as at many hospitals, the attending has no idea who the director of quality is, and yet Kepro considered that person to be representing the physician’s views. We have all played the telephone game as children; the likelihood that the information received and conveyed by the attending physician matched what the QIO medical director said and heard is small.

Now, don’t get me wrong: patients have a right to appeal their discharge and request help through the immediate advocacy process provided by the QIOs, but the QIOs really need to follow the rules, just as we do. In this case, it seems that the QIO medical director should have called the attending physician to discuss not only the rationale for the neurology consultation but also the patient’s concern about their care.