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The Top Five
 
 
 
 
 
 
 
 
 
 
 
 
 
February 28, 2014
TWO-MIDNIGHT RULE
1. CMS: further clarification on inpatient admissions
The CMS has issued new clarifications related to its two-midnight rule in terms of admission certification and transfers. Because residents and NPs in most states do not have admitting privileges, they may act as a proxy for admission orders, but those orders must be countersigned and certified by an attending before discharge. (Verbal orders must also be signed and certified.) In states where NPs have admitting privileges, according to the CMS, NPs can sign their own admission order—but that order still needs to be certified before discharge by an MD or DO. As for transfers, receiving hospitals can take into account the time and care patients received at their initial hospital when deciding whether the two-midnight benchmark for admission will be met. Excessive wait times at the initial hospital, ambulance time during transfer or time spent in a hospital for non-medically necessary care should be excluded from that determination. Read more on the CMS Web site.
 
MEDICAL HOMES
2. Medical homes don't cut costs, utilization
New research delivers disappointing results for a three-year medical home pilot project: In the study, primary care medical homes did not reduce costs or the number of patient hospitalizations or ED visits, compared to control practices. Writing in JAMA, researchers found that the medical homes performed significantly better than controls on only one of 11 quality measures, which was screening for diabetic nephropathy. The cost of care in medical homes was the same as in controls, although each physician in the medical homes earned an average bonus of $92,000 over three years. According to an editorial, the study debunks the notion that medical homes can serve as "a generic, low-level, unselective approach to health care delivery for all." Instead, the editorialist wrote, the next phase of medical-home development should identify which high-utilization patients need high-intensity services. Read more in JAMA.
 
ACADEMIC MEDICINE
3. Patient safety and work-hour reform
How has the 2011 work-hour reform affected patient outcomes? Not too much, according to a one-site observational study posted online by the Journal of Hospital Medicine. Researchers looked at both the pre- and post-reform data at one academic center for both the resident and hospitalist (nonresident) services in terms of length of stay, 30-day readmission rates, ICU admissions and mortality. They found that patients on the residents' service post-reform were more likely to be admitted to the ICU (5.7% vs. 4.5%) but less likely to be readmitted after 30 days (17.2% vs. 20.1%). A comparison of pre- and post-reform data for both the resident and hospitalist services, however, found no significant differences in patient outcomes. Read more in the Journal of Hospital Medicine.
 
EMERGENCY MEDICINE
4. ED wait times
How does your hospital stack up to its competitors in terms of ED wait times? The "ER Wait Watcher" Web feature created by ProPublica notes that the national average time for waiting in the ED to see a physician is 28 minutes, with wait times in different states ranging from a high of 46 minutes in the District of Columbia to a low of 17 minutes in Utah and 18 minutes in Colorado. (Nationally, the average time spent in the ED before being sent home was 138 minutes.) The site also allows you to enter your zip code and see what the wait times are for surrounding hospitals, the travel time to each of those facilities and how many patients would "definitely recommend" using a particular hospital. Read more in ProPubilca.
 
OBSERVATION
5. Arguing your way out of observation?
Hospitals and physicians have taken note of a NBC Nightly News report this week that revealed many of the problems related to observation status: Patients often aren't aware that they're in observation, and patients in observation don't qualify for Medicare SNF coverage if they need rehab. But what's the report's solution for patients who find themselves in observation? "Argue," according to the reporter, "and be persistent." The report described one stroke patient whose wife asked so many questions about his being in observation that an administrator "relented" and changed his status to inpatient. "Fight for a status change in the hospital," the report concluded, "because Medicare appeals later on can take years." Read more on the NBC News Web site.
 
FEATURED JOBS
Northeast: 14 patient census one hour from Boston
Northeast: Medical Director for 12-person group
 
 
 
 
 
 
 
 
 
 
 

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