Observation Case Survey Results - Case #2, December 2020

A 72-year old male with a history of treated and well-controlled hypertension and traditional Medicare presented to the ED at 7 P.M. with a chief complaint of 3 episodes of right-sided upper extremity weakness and possibly slurred speech lasting 15-20 minutes and occurring over the prior 5 days. At the time he presented, he was recovering from an episode that had started 1 hour before. He complained of mild right upper extremity weakness and some clumsiness. 

Past history was positive for 20 years of hypertension, treated with hydrochlorothiazide and lisinopril. There was no history of diabetes, coronary artery disease, or stroke. The patient was a prior smoker of 2 packs per day but had quit 5 years previously.

On initial exam, the patient was afebrile. His blood pressure was 184/92 supine and 176/84 standing. Heart rate was 96. Cardiopulmonary exam was unremarkable. Bilateral carotid bruits were heard. On neurological exam, the patient had normal speech. There was a slight right upper extremity drift, but no other deficits. ECG showed normal sinus rhythm with many atrial premature contractions. Complete blood count and chemistries were unremarkable. CAT scan of the brain without contrast did not show an acute stroke.

The patient was placed in observation for TIA. Telemetry was ordered and low dose aspirin administered. Overnight, the patient remained asymptomatic and in sinus rhythm. Blood pressure ranged from 178/92 to 166/88. Neurological consultant the following morning recommended brain MRI to rule out an acute stroke. The MRI and carotid Dopplers ordered by the hospitalist were scheduled for later in the afternoon. 

The MRI was negative. Carotid Dopplers showed bilateral carotid stenosis, the right side was estimated at 50-60% and the left was 70-75%. There was no evidence of thrombus or ulcerated plaque. A transthoracic echocardiogram showed mild left ventricular hypertrophy, an ejection fraction of 60% and good wall motion, with no evidence of vegetations, atrial thrombus, or mass.

At 5:30 P.M. the neurologist received the reports and ordered bilateral carotid angiograms, which were scheduled for the next available time slot, which was the next morning. At this point, as observation approached the second midnight, the hospitalist considered admitting the patient. He was concerned that although the patient was clinically stable and unlikely to require an angioplasty or surgery, he did not think he was safe for discharge because the angiogram hadn’t been done. What if it indicated the need for a procedure or surgery? He knew he was not going to release the patient, but what should the status be? Should it be extended observation because the patient was stable and likely to go home after the procedure the next morning or inpatient because of the 2-midnight rule?

The physician consulted a case manager, who informed the physician that Medicare might deny an admission and consider this a hospital delay: They might ask, “Why wasn’t the angiogram done the second day? Was it just a scheduling problem? Since the patient had been asymptomatic, why couldn’t he be released on medical therapy and return for an outpatient angiogram?” The hospitalist conferred with one of the other hospitalists, who said, “You can’t send him home. Are you nuts? What if he has a stroke? What if you get sued?” The hospitalist decides to keep the patient and calls you for status advice. What do you recommend?

ACPA Observation Committee Review:

We appreciate everyone’s response on this case. Out of 28 responses, 17 (60%) felt patient should be left in Observation status while 11 (40%) of responders felt patient should be admitted to Inpatient status. 

Majority of the comments in this case circled around delay in ordering imaging. Delays were categorized by some as avoidable vs unavoidable. Many of the comments focused on the medical necessity of obtaining further diagnostic testing in the hospital setting. Comments favoring observation highlighted patient/doctor convenience as the reason for further testing in an otherwise asymptomatic patient whereas comments favoring inpatient felt results of carotid angiogram could alter treatment plan with vascular surgery involvement. Some of the comments favoring inpatient status focused on the high risk of recurrent neurologic episodes given the stuttering nature of patient’s initial presentation. Additional emphasis was also placed on the importance of documentation of high-risk factors like ABCD2 score, plan for telemetry and continued neurological assessments to help support medical necessity for a second midnight for inpatient status. 

This case highlights the importance of factoring in delays as well as documentation when making a recommendation for Observation vs Inpatient status.