80 year female with past medical history of type II DM, HTN, Hyperlipidemia, Atrial fibrillation not on anticoagulation, with traditional Medicare, who presented to the ED complaining of left upper extremity numbness. Patients symptoms had resolved by the time patient was evaluated in the ED and posted under observation status for TIA. Patient’s blood pressure medications were held to allow for permissive hypertension. After 1 midnight, patient underwent MRI brain which was found to be positive for small acute ischemic infarct. Case was sent for second level review and felt to be appropriate for OBS since patient’s symptoms had resolved with plan for discharge later that day. However, in the evening patient’s SBP elevated to 190s, home BP medications resumed but attending cancelled patient’s discharge due to elevated systolic blood pressure as a risk factor for recurrent stroke. Attending reaches out to you to re-consider status determination with plan to keep patient in house for a second midnight for hypertension management. Observation or Inpatient? 

Committee Discussion

Out of 28 total responses, 24 (85%) of Physician Advisors recommended admit to inpatient status. 

Most common rationale to support inpatient status included medical necessity to manage elevated BP closely in setting of an acute stroke. Uncontrolled hypertension as a risk factor for CVA can pre-dispose patient to recurrent CVA thus warranting hospital level care for a second midnight to monitor for hypertension. One of the comments impressed on the importance of having clear documentation of risk of adverse event in a patient with acute CVA with uncontrolled hypertension. As Physician Advisors, in addition to status determination, we also play a key role in guiding our clinicians towards appropriate documentation as well to highlight the medically necessary care being provided. 

15% of the Physician Advisors who favored observation felt the patient was asymptomatic and clinical status did not meet inpatient criteria especially if patient was just being monitored without any active titration in medications. Another concern was elevated BP is a sequalae of permissive hypertension and if patient continues to be asymptomatic there is no clear medically necessity for a second midnight.