Inpatient and Outpatient

The complexity of hospital capacity management does not end with bed assignment. Another factor to consider when admitting patients is that they must be categorized as either an inpatient or outpatient. Categorizations vary with insurance policies, Medicare rules, changing medical needs, and various other factors. And for both the patient and the medical facility, mistakes can be costly, causing higher out-of-pocket expenses, potentially for both the patient and the hospital. To understand how the classification and admission process actually works— and where it sometimes breaks down—it is necessary to look more closely at how Surgery, Cardiology and the Emergency Department each classify and handle admissions, as each area handles its patients in different ways.

Surgery

Surgical patients come from the ED, the floor, Transfers from another facility or have been scheduled for an elective procedure. A list of scheduled electives is generally available a week or more in advance (Figure 3-1).

Figure 3.1 Reference from a Western New York 500-bed hospital.

Commercial insurers often determine whether an elective procedure is categorized as in-patient or outpatient through their approval process. Medicare also influences whether a procedure is considered inpatient or outpatient. Medicare publishes a yearly updated list on the CMS.gov website of which surgical procedures are deemed outpatient only.

But what is the definition of inpatient versus outpatient Surgical procedures? In practice, it varies from one insurer to the next. The most used definition is that: “...if a procedure is done without complications and the patient is expected to be discharged after their recovery period then they are considered an outpatient.” The sticky part here is “without complications.” What if the patient has refractory vomiting, hypoxia, hypotension, or any other issues? A surgeon is likely to make a clinical decision to keep that patient in the hospital. This type of unanticipated short-term hospital stay is what many facilities refer to as “extended recovery.” It is still categorized as an outpatient stay. The hospital now needs additional beds to manage the short stays of this unanticipated group of outpatients. Although the number of these patients can vary, some extended recovery cases are actually scheduled, as surgeons sometimes know full well that the patient is not going home after the procedure and will need an inpatient bed and the hospital will be denied inpatient reimbursement.

The reason for this is the difficulty in obtaining prior authorization by a commercial insurer for an inpatient surgical procedure. There are significant hurdles to overcome, often involving time on the phone and filling out paperwork, and there is seldom time to build a case and win authorization for the inpatient stay. Subsequently, patients are placed in elective outpatient status on the Operating Room schedule. This impacts overall bed management for the organization when an unanticipated number of patients thought to be going home now need a bed.

Managing the Operating Room population starts with these elective procedures but gets more complex when the ED surgical cases like appendicitis or cholecystitis are taken into account. Both, if done laparoscopically without complications, are considered outpatient procedures, but if done by open incision are classified as inpatient. This has serious future repercussions with the utilization of robotic surgery and the significant increase in laparoscopic procedures.

There has been a profound increase in surgical cases being done as an outpatient. I recently read of cardiothoracic bypass surgery being done laparoscopically. In the future, these cases may transition to ambulatory outpatient surgical suites with significant financial consequences to hospitals margins.

Then there are surgical specialties. The hospital clusters groups of similar-type patients in specialized areas for a lot of very good reasons. They all require the same specialty skills, specialty equipment, and specialty services like physical therapy for the orthopedic floor. Keeping these patient types together aids in their efficient movement through the system and ensures they all access the services they need.

The units themselves are a challenge for bed assignment. Procedures which send patients to any given specialty unit are not leveled during the week, so beds are occupied in waves. A high volume of Orthopedic cases on Monday and Tuesday then reduced caseload Wednesday through Friday with virtually zero cases scheduled Saturday and Sunday.

Then a full unit on Wednesday but deficient volume for the unit on Thursday or Friday. This creates significant bed utilization problems for bed assignment. Most places prefer to send only orthopedic cases to the orthopedic floor, but if additional beds on the orthopedic unit are available, they are assigned to “stable medical patients.” This results in varying numbers of orthopedic patients occupying the unit, which is backfilled with a mix of medical cases. On the weekend, when a significant number of orthopedic cases have left, ED medical admissions are placed in the unit’s available beds. Then on Monday morning, we have an orthopedic unit functioning as a medical unit (Figure 3.2).

Suddenly, the operating room, which is now very busy, is desperate to move all the medical patients off their specialty unit because it’s orthopedic Monday.

Figure 3.2 Bed shortage of an Orthopedic unit when the number of beds and Length of Stay (LOS) of Ortho cases are not used to implement a leveled surgical schedule. Shows impact on patients/unit of an unconstrained Surgical Schedule.

Cardiology

This area functions much like the surgical arena. Portals of entry again are the ED, Transfers, floor patients, and direct elective admissions. Some facilities do not offer full cardiac services such as catheterizations and EP studies. Those that do usually want the patients in a specific area for the same reasons surgical specialty units were created. Cardiology has come a long way from the 10-day LOS for acute Myocardial Infarction which was common 30 years ago. Today, it is common for a patient undergoing a significant interventional procedure to stay less than 48 h. Elective procedures that require intervention are considered now to be outpatient procedures similar to the extended recovery cases that surgery manages. Here again, we find the use of inpatient beds for patients considered to be in the outpatient world. Complications such as chest pain, arrhythmias, or bleeding can clearly move a patient into an inpatient status, but this is a minority of these patients.

The same issues described for surgery happen with cardiac catheterizations. Since elective scheduled procedures are the lion’s share of cardiac procedures done, there is again a Monday through Friday scheduling issue—Heavy Monday and Tuesday and light Thursday and Friday. This non-leveled schedule results in the cardiac specialty floor again being utilized by ED medical admissions on the weekend and screams from the unit to “move these medical patients” come Cath-lab Monday (Figure 3-3).

Cardiology is unique in the management of potential cardiac patients because they have two types of outpatients to manage. The elective outpatient procedural patients and the “observation” patients. Observation is a status created by CMS to manage patients who don’t have an immediately identified acute medical problem but whose presentation may evolve into one. There are a number of cardiac-type cases that fall

Figure 3.3 Unconstrained Cath Schedule leads to front loading of cases Monday through Wednesday, resulting in "non-cardiac" occupancy of the Cardiac floor Thursday through Sunday.

into this category including but not limited to chest pain, syncope, congestive heart failure and arrhythmias.

So how is the observation status identified and why is it important to bed assignment? Here again is a patient whose services are paid for on an outpatient reimbursement structure even though the patient may well be in an inpatient bed. The majority of these “observation” admissions come from the ED. One would think that this would be of benefit in optimizing the use of the cardiac specialty unit and maintaining its occupancy but remember the primary priority patient for the unit is the post cardiac procedure patient—not the ED admission. Many of these observation cardiac patients are simply scattered to the winds in most hospitals resulting in significant loss of efficiency and increases in LOS. We'll take a closer look at “observation” patients and their care in a later section.