Archive for March, 2012

Transferring Patients in an ASC

March 17, 2012 Leave a comment

One of the Quality Measures CMS has identified that ASCs will have to start tracking, collecting data and reporting on is in the transferring of patients from the ASC to an institution of higher care.  Surgery centers have maintained documentation regarding such transfers from their initial Medicare and accreditation surveys.

The Transfer Log, Incident Report Log and an incident report, itself, are completed for all transfers.  Furthermore, through the Incident Report and Log, the Quality Improvement Coordinator and Risk Manager Designee track any trends.  Such trends are reported to the QI, the MAC and the Board.  Where trending with a particular physician is noted, peer review is conducted.  This all sounds like we, in the industry, are doing everything we should be doing.  Right?  This may be in question.

In the late fall of 2011, The ADA Group conducted a benchmark study amongst 36 clients collecting data identified in the Quality Measures CMS wants tracked.  Out of 36 centers there were 113 reported transfers; however, this is not a pure report, as this included 24 hour admits.  We decided to have them do this, as CMS is looking at hospital re-admissions, and, while, these patients, on the whole, are not being re-admitted to the centers, and while CMS is not requiring ASCs to track such data, The ADA Group believes it bears tracking.  In a future article, we will separate this data to report transfers vs. hospital admissions within 24 hours post discharge from the ASC.  Not all centers reported their volumes; however, with those reporting their caseload ytd for 2011 we tallied a total volume of 55, 357 with a percentage of transfers/24 hour admits of .002 percent.

CMS believes ASCs may not be enforcing their admission criteria, thus inflating the number of hospital transfers that are occurring.

Greater issue is the process that is taking place in the ASCs transferring patients.

As a group of 3 licensed risk managers, we have cause to review incident reports beyond just reviewing logs for trending.  What we are finding is alarming.  As recent as 2010 most charts of patients who were transferred to the hospital had no physicians’ orders advising the staff  TO  arrange for a hospital transfer.  In addition,  many incident reports where patients were discharged from the ASC and sent to the hospital with their care person driving them.

We researched regulations.  It is true that there are no regulations requiring patients be transferred in an ambulance or medical transport service van.  However, in discussing the issue with the State of Florida Agency for HealthCare Administration, Department of Risk Management, we got total support for our stand that ANY patient being transferred to the hospital ER for a HIGHER LEVEL of CARE should be transferred by ambulance.  We are aware that this is an additional cost to the patient, but the risk, the vulnerability of the organization, is just too high to do otherwise.

Recently, we had two occurrences reported to us.  In one, the surgeon came into the recovery with anesthesia following the patient and ordered the staff to send the patient to the hospital once discharged with her care person by private car.  The anesthesia provider argued that he did not want the patient going by private car, but felt an ambulance needed to be called.  Imagine “the day in court”.  The lawyer for the plaintiff asks the nurse manager, CEO or Medical Director, “Did you send the patient by ambulance? No?  …even with the anesthesia provider demanding that mode of transportation?  What WAS your rationale?”

In another instance, the gastroenterologist reports that he believes the patient’s esophagus may have been torn during the EGD when the patient started waking up and coughing.  Consequently, he wanted the staff to advise the patient’s husband that, upon discharge, he needed to take the patient over to the hospital for admission to the ER.  The husband followed these orders, but now things get cloudy.  We have no idea how much time elapsed from the time the patient and her husband left the center and were subsequently admitted to the hospital’s ER.  Did they stop to get the patient (who, after all, had been NPO for hours) a little something to eat or drink on the way?  ….or, maybe, the patient had some sips of the husband’s coffee that was in the car…

When the ORS/QI Coordinator called the hospital the next day for a report from the nurse in charge of the unit to which the patient was admitted, she was advised the patient wasn’t admitted, and, in fact, they did no tests at that particular hospital.  She was advised that they had sent the patient on to a hospital two (2) hours away where there were throat and thoracic surgeons.  When she called that hospital, she was told no report could be given because of  HIPAA (not true as the ASC is part of the patient care continuum). ADAcontacted the hospital’s risk management department and could only learn the patient was to be fed the next day prior to discharge.  The ORS contacted the gastroenterologist who had not been notified by the original hospital OR the final hospital of admission.  Again, this leaves the center so vulnerable, as to be beyond discussion.

The ADA Group’s licensed risk managers discussed this topic of transferring patients with several other licensed risk managers to include the State of Florida.  One risk manager believed that letting the patient go to the ER in a private car was perfectly fine—especially if the hospital is on the same campus.  But, let’s look at this.  The patient belongs to the ASC as long as they are on the ASC property which includes the parking lot.  The hospital parking lot and ASC parking lot are one of the same.  Now, ANYTHING can happen in a parking lot—accidents—and what if the patient had an “episode” enroute?

Always err on the side of patient safety:

  1. Develop a comprehensive policy regarding patient transfers and submit this to the medical staff committee and the Board for approval and revision, clarification, as needed.  In this policy determine the difference between hospital referrals and direct transfers.
  2. Circulate the policy to the medical staff.
  3. Inservice the Center staff.
  4. Document all transfers and referrals on an incident report.
  5. Maintain the incident report log.
  6. Track and report trends.  Note whether or not the patient met the organization’s admission criteria on scheduling.
  7. Follow up all transfers with the nurse in charge at the admitting unit.
  8. Procure a copy of the hospital discharge note.  (You may have to get this from the transferring physician.)
  9. Track and report 24-hour hospital admits to the hospital and re-admits to the ASC.
  10. Report all trending as discussed above.
  11. Inservice staff, monitor and conduct competencies on pre-operative patient instructions that include post-operative instructions.
  12. Conduct QI studies on the effectiveness of post-operative instructions and admission criteria deviations.
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