Observation Case Survey Results - Case #1, January 2021

This was a 68yo female with a h/o anxiety, depression, traumatic brain injury as a child with resultant seizure disorder who is admitted with inability to care for herself in setting of a new humerus fracture. I suspect she has a mild cognitive impairment and is on the border for her ability to care for herself but that the humerus fracture has limited her capacity. She also had a seizure and had not taken her medication in 3 days.

Committee Discussion: 

We received 40 responses with 31 (77.5%) opting for Observation status. Twenty-one respondents (52.5%) thought Neurology consultation was indicated, owing to the seizure. The local determination was for Observation services. The Utilization Management Physician should discuss the case with the attending physician to elucidate the facts of the case and suggest documentation improvements if indicated.

The crux of the two-midnight rule is an expectation (or fact) of a hospital stay spanning two midnights, for medically necessary acute hospital care. As documented, the patient presents with a definite inability to perform activities of daily living (ADLs). Medicare would not typically cover that care. Possible acute medical issues include her fracture, though that had already been deemed stable for outpatient management, and her seizure disorder. The available documentation does not establish a two-midnight expectation or acute medial necessity and emphasizes her need for custodial care but does document a planned evaluation of a possibly decompensated seizure disorder. Thus, a period of observation seems appropriate. If the patient is medically stable for discharge but cannot be discharged owing to a need for placement due to ADL needs, crossing a second midnight does not automatically merit an inpatient status. If documentation indicated a need for titration of pain meds, evidence of infection, further seizures, etc, then a medical necessity for the second midnight and inpatient status might be supportable. 

Selected responses:

“Although it could be argued that patient is not safe to go home, it could also be argued that patient could go to ED and be dispositioned from there, as patient more likely than not, will not receive any significant inpatient care. There really needs to be a space carved out in every hospital system for these types of custodial cases where they can sit and wait for safe disposition.”

’Document any deficits confirmed by PT/OT and impact on safety for discharge. While I would bring this patient into hospital as observation, would have low threshold for advancing to inpatient the following day if any skilled services required.’