Case Management denying admission

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This question is directed more towards those in post-residency life.

I'm the ED Medical Director of a busy suburban ED (50K visits). Our hospital has hired a new Director of Case Management who has an entirely new approach to ED case management.

While the old Case Manager would sit side by side with us in the ED, and request better documentation to justify an admission or admission vs. obs decision, the new lady has blocked several admissions because they "don't meet criteria".

Case 1 was a lady with new, severe hemorrhoids that couldn't poop, obs for pain control and surgery c/s.

Case 2 was a schizophrenic off meds, on her period, with an asymptomatic anemia (Hgb 7.5). Psych facility wouldn't take her without a transfusion, so obs for transfusion and psych dispo.

Case 3 was similar to 2 (psych vs organic, obs for drugs to wear off and psych eval)

All three stayed in the ED for hours (up to 24), and 1 and 2 were eventually admitted after the Case Manager's meddling plans fell through.

I have a meeting with her and my ED leadership team next week. Are there any laws/rules which I could use to stop this practice? I'm all for a collegial discussion and adding documentation to support an admission or level of care decision, but as you can imagine blocking my docs' admissions doesn't go over very well with me or the nurses.

You and your docs are MDs here.
If it does not meet some criteria, let her get creative and find something to meet the requirement.
On rare occasions if I run into this, I just politely ask them if they would like to discharge the pt, and somehow the pt gets an obs bed!

Ours dont block admits but rather change them to/from obs status. Anemia requiring a blood transfusion needs a workup. IMO you can find a reason to admit ANYONE. have a complaint? I can find a way to admit it. That being said im more a wall than a revolving door.

I imagine your meeting will be fruitful. Keep in mind the hospital wants you to move patients through the system so they should be in your favor. Your new hire might have done things differently from where they came.

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After ruminating on this last night. It is one of the most frustrating parts of my job. Not exactly this nor the Case manager asking if the patient should be obs and not inpt or remote tele vs tele.. but more the larger issue. Non physicians making me do things I dont want to.

The nursing home who wont accept the patient until x, the psych facility who wont take the patient until the BAL is under 200. The group home who wants something stupid done. Being told what to do my non medical types drives me nuts. I have learned not to fight it anymore cause it frustrates me so much.

...only run into it once or twice, and my response was the same as above "okay, you discharge them and be sure to document why.."

We have a case worker from 8a-midnight that reviews all admissions and determines if they should be obs or inpatient. She also advises us of any readmissions, and is great at arranging hospice, walkers, wheelchairs, home O2, etc.

Originally Posted by Birdstrike

I'm not a director, but if these were my patients this is what I'd tell them, "As a licensed physician, I have determined this patient is sick enough to be admitted anywhere from 24-72 hr. Either we "admit him" or he sits in this ED bed getting treated HERE, until he gets better, gets sick enough for you to stop obstructing his care, or he dies. It will also be documented with each re-exam, and with each shift change why, and because of whom (insert list of all hospital administrators on duty), his proper care and disposition is being prevented. If his condition worsens, I will promptly and without notification transfer him to a hospital that may NOT be a higher level of care and flag all administrators on call as triggering the EMTALA violating transfer".

It then becomes well documented who is at fault for any poor outcomes (hospital X) and who was fighting for the patient. This is great example of a hospital administration being completely at odds with the treating ED physicians and it is, in my opinion, the job of the ED director to stand up to them in these cases, and "have the ER doc's backs". Since ED directors usually depend on the hospital administration for their jobs, not the ER doc's, this is not an easy thing to do.

Sounds great, it also would lead you to be fired from pretty much any community shop in the country.

our case managers go home at 5. If I can swing it I don't call for the admission until 5:15 if I know they would try to be obstructive...same deal with the surgeon who accepts no one. wait until shift change when a reasonable surgeon takes the pager...

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These administrators rarely have any power or teeth.

Im an intern so take this fwiw, but i was told by case management one time that if you just document unsafe to discharge, this gets them an obs bed.
case management at our program is great, always there 24 hours a day and always willing to dig through that book to find a reason to admit if none is clear.

Our case management usually will help us meet criteria. If they need to stay and I know its a weak case I diagnose as many things as I can, intractable pain, anemia, hypokalemia (even if incredibly mild...3.5 etc), hypomagnesemia, dehydration, etc. Also send a urine and get a CXR as there is a reasonable probability that one or the other will be (falsely) positive. Also if not dangerous put them on IVF at a set rate, make NPO (can't go home NPO, need iv hydration) get peak flows in asthma and COPD (the patients never do it right so the numbers are always abysmal). An extra dose of zofran makes that nausea "intractable" even if it wasn't needed.

Ultimately we have a physicians over-ride if none of that works which may be a solution to the OPs problem but it means that the hospital is going to eat at least some of the stay.

Ultimately you have to do what is best for the patient and if that means playing the system a little bit then so be it.

Our case manager kept trying to get me to admit people who didn't need to be admitted.

"But he meets criteria doctor!"

"I'm sure he does. But I'd still be too embarrassed to call a hospitalist to admit him for that, and the patient doesn't want to come in anyway."

Originally Posted by logos

Our case management usually will help us meet criteria. If they need to stay and I know its a weak case I diagnose as many things as I can, intractable pain, anemia, hypokalemia (even if incredibly mild...3.5 etc), hypomagnesemia, dehydration, etc. Also send a urine and get a CXR as there is a reasonable probability that one or the other will be (falsely) positive. Also if not dangerous put them on IVF at a set rate, make NPO (can't go home NPO, need iv hydration) get peak flows in asthma and COPD (the patients never do it right so the numbers are always abysmal). An extra dose of zofran makes that nausea "intractable" even if it wasn't needed.

Some of that sounds potentially fraudulent.