Excela Health reduces observation waits

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Excela Health System's Westmoreland Hospital, like most U.S. medical centers, saw a precipitous rise in outpatient "observation" cases beginning in 2010 as insurers, including Medicare, tightened criteria for what qualified as an inpatient admission.

The immediate implication was financial -- hospitals saw revenues slip since observations cases are typically reimbursed at about one-third the rate of an admission, while patients' out-of-pocket costs went up because their insurance provided less coverage for outpatient treatment.

Hospitals everywhere have scrambled to adjust to the new revenue landscape, looking to become more efficient without skimping on patient care. Excela Health was no different -- in some instances, its outpatient stays exceeded 80 hours, or more than three days.

But in an initiative that's drawn national attention, Westmoreland Hospital has cut average outpatient stays from 27.5 hours in August 2010 to a low of 20 hours this April. Its sister hospital in Latrobe has seen the average stay go from a high of 26 hours to a low of 19 hours in the past three years.

The hospitals have also found that shorter stays have made for happier, healthier patients.

"We want to provide the patient the right level of care. Period. The whole point is to get it right," said Holly J. D'Amico, a nurse and director of medical resources at Excela.

She believes the clinical benefits of shortening outpatient stays have even outweighed any financial savings.

With everyone from the unit secretaries to the chief medical officer on board, the Excela initiative starts with making sure patients are quickly identified and placed on the appropriate unit.

Typically, patients who end up in the observation unit first came to the emergency room complaining of chest pain, or stomach pain, or perhaps an asthma attack.

Using specific criteria, Excela case managers can quickly determine if the patient should be admitted or sent to an observation unit until the condition is stabilized. With this initiative, Excela has reduced its conversion rate -- the rate that observation patients ultimately have to be admitted -- by 40 percent.

If patients go to the 16-bed observation unit at Westmoreland or the 12-bed unit at Latrobe, their treatment and discharge plan are checked multiple times each day. Observation patients have priority over non-urgent inpatients when it comes to lab and diagnostic work, their test results get expedited, and their conditions are regularly updated.

If an observation patient's test results are not back within an hour, a call is made to find out why -- and subsequent calls made every 15 minutes after that until the information arrives. If a patient's stay hits 18 hours, the staff meets to determine what still needs to be done.

Unless clinical indications require patients to be admitted, the goal is to discharge them within 23 hours.

Rather than feeling rushed, patients are glad to be heading home and getting back to their daily routine, said Eric Kreinbrook, who oversaw the initiative at Latrobe as clinical nurse coordinator. It's also better for them, since research has shown the chances of developing an infection grow the longer someone is in the hospital.

"It's safer for the patient if there's nothing wrong with them," he said, "and if there is something wrong, we can admit them."

The Excela program has prompted inquiries from across the United States, said Ms. D'Amico. Last year, she was asked to present at the World Congress on Observation in Florida, while Mr. Kreinbrook has been invited to speak at conferences in Chicago and Las Vegas. Locally, the Fine Foundation and the Jewish Healthcare Foundation have honored Excela for its success in shortening outpatient observation stays.

Even more than following specific criteria, Ms. D'Amico and Mr. Kreinbrook say the key to the program's success has been communication and holding one another accountable.

"We look at every patient who goes over 23 hours," said Mr. Kreinbrook. "Why did they do it and how do we prevent it?"

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Steve Twedt: stwedt@post-gazette.com or 412-263-1963.


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