75 yo male with multiple cardiac risk factors presents with acute dyspnea and new onset fatigue. Echo within the last 12 months WNL. Patient was seen in the office and diagnosed with 3rd degree heart block. Decision made to send to ED. Complete heart block confirmed and decision made to admit to cardiology under observation status. Hospital day 2 patient has pacemaker placed without incident. Patient noted to have a slight reduction in hemoglobin, possibly dilutional, and cardiology elects to keep patient in the hospital crossing a second midnight. 

Would you keep this patient in Observation for monitoring even though it is second midnight or would you convert this patient to Inpatient stay?

Committee Discussion

We received a total 24 responses with 58% supporting inpatient status while 42% would recommend continuing observation services. Much debate can be had regarding the decision to keep the patient in the hospital following the pacemaker placement with an incidental finding of a small reduction in hemoglobin. However, the crux of the decision on appropriate status hinges on the following: 1. The patient had an acute finding necessitating hospital admission and intervention. 2. This admission did occur over 2 midnights of medically necessary care based on reasonable medical judgment. 

It is the committee’s opinion that this patient would be best served by conversion to inpatient status on hospital day number 2. This would be done following the decision by cardiology that patient could not be safely discharged to home post procedure on hospital day number 2. 

Select Responses: 

"Due to high risk of adverse outcome with complete heart block, I would advocate for inpatient status from beginning. Given that patient spends 2 MN receiving medical care, definitely inpatient. Per MSN Matters MM 10080, For hospital stays that are expected to span less than 2 midnights, an inpatient admission may be payable under Medicare Part A on a case-by-case or individualized basis if the medical record supports the admitting physician/practitioner’s judgment that the beneficiary required hospital care on an inpatient basis despite the lack of a 2- midnight expectation. Medicare contractors will consider, when assessing the physician’s decision, complex medical factors including but not limited to: • The beneficiary history and comorbidities • The severity of signs and symptoms Current medical needs • The risk of an adverse event."

"Patient stable after pacemaker placement. Patient could reasonably be discharged in pm of hospital day 1. Observation overnight is a judgement call and the level of required care and risk is low for 2nd midnight."

"Level of care and intensity of service not there after PPM placed."