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If you’re interested in this topic, my guess is you probably want to know staffing implications for progressive care and intensive care.
But first thing’s first. It’s important for you, as a nurse, to be clear on the difference between progressive care and intensive care before we dive into staffing.
ICU is critical care and PCU, or progressive care, is considered an intermediate level of care based on The Centers for Medicare and Medicare Services definitions.
Telemetry is a technology, not a level of care. Telemetry could include any level of patient for a variety of reasons — it does not classify a patient at a higher level of care just because a provider ordered it.
Telemetry services are typically built within the room-and-board charge. Many private insurances do not allow cardiac monitoring to be billed separately as the technology is seen as a fixed asset of the facility, used multiple times by multiple patients.
The Centers for Medicare & Medicaid Services (CMS) coupled with your state department of health determine and enforce levels of care. Most professionals might refer to CMS as “Medicare” and use these two terms interchangeably.
Even if your patient doesn’t have Medicare or Medicaid as a payer, if your hospital takes any federal funding (Medicare and/or Medicaid dollars) then they must follow CMS rules. CMS is a regulatory body.
Organizations like The Joint Commission and DNV are accrediting bodies, and they have “deemed” status granted by CMS. This means as accrediting bodies they can survey healthcare organizations on behalf of and/or instead of CMS.
The CMS definition of critical care includes the direct delivery of medical care by a physician for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such as there is a high probability of imminent or life threatening deterioration in the patient’s condition.
Additionally, CMS states critical care is usually but not always given in areas such as the emergency department, ICU or critical care units. Payment for critical care can be made in any location as long as the care meets the definition above.
From this, it can be extrapolated that nursing services would be needed at a higher intensity as well (not just from the physician).
The level of care determination is something that is continuously being assessed and can change day to day.
Intermediate level of care is defined as: Hemodynamically unstable patient (or those with the potential to become unstable) who require treatment, assessment or intervention every 1-2 hours.
Acute level of care (in the hospital) is defined as: Hemodynamically stable patient who requires treatment, assessment or intervention every 2-4 hours.
Differences in billing to consider
In order to bill for the different levels of services, typically a utilization review nurses evaluates the physician’s clinical documentation to determine which level of care the patient meets and he or she should be reviewing and documenting this daily.
Only physician documentation counts in determining level of care and billing for the inpatient stay. However, nursing and ancillary documentation, such as the use of a dietician and various therapies, can be used by the provider. The provider needs to carry ancillary documentation forward in his or her own documentation to demonstrate the medical complexity of a patient.
The interesting part about having levels of care, particularly documenting the intermediate level, is it usually doesn’t make that much difference in payment. Medicare, most Medicaid payers and private payers pay based on a diagnosis-related group methodology.
Diagnosis-related groups are classifications of diagnoses and procedures in which patients demonstrate similar resource consumption and length of stay patterns, which is why hospitals are always benchmarking length of stay.
A payment rate is set for each diagnosis-related group and the hospital’s reimbursement for inpatient stay is based on that.
Why staffing levels matter so much
What does this have to do with staffing levels? Keep in mind that critical care is critical care and intermediate care, such as progressive care, is intermediate care regardless of facility type and ability.
As you can imagine, an ICU in a 900-bed inner city hospital admits very different patients and has a very different capacity for critical care than an ICU in a 100-bed community hospital.
Yet that same definition above is applied for determining level of care. And payment-wise, your organization is not getting paid much, if anything, for that intermediate level of care because of the diagnosis-related group payment system.
If you are looking for data that equates higher hospital payment in progressive care unit settings to higher staffing levels, you won’t find the needed supporting documentation.
What this means for staffing intermediate, acute, critical or observation level of care is that there is not just one answer for you to take and run with.
Yes, there are states that have a ratio cap of 1:1/1:2 in the ICU setting for nurse staffing. But in my example of the 900- vs. 100-bed hospital, that is the reason you need an acuity system in place.
The average ICU patient in that 900-bed hospital will be much more complex than the most complex patient the 100-bed community hospital. The larger hospital has greater resources, including physician specialists, equipment and so on to care for the most critically ill patients.
Patient acuity goes hand in hand with nurse intensity
What you need to do will be somewhat time intensive at first. It is an absolute must to arrive at the right staffing levels to document the nursing intensity required to take care of an intermediate patient.
As noted in the two different sized hospitals, this will be different in each organization. Nurse staffing needs to be determined locally within each hospital and unit based on a variety of factors.
A staffing committee for each unit should be comprised largely of bedside nurses with unit managers. Unit level outcomes should be monitored monthly in relationship to staffing levels and should be adjusted as needed to patient outcome targets are being met.
It is important as nurses each of you understand the payment system in which you work.
Ultimately, this drives all decisions, patient care and staffing levels. It is imperative to know the difference in levels of care, and to help ensure patients obtain the outcomes they deserve with the appropriate RN staffing regardless of level of care.
Take these courses to learn more about intensive care:
ICU Alert: Worsening Respiratory Function Can Signal ARDS
(1 contact hr)
Despite progress in managing acute care disease, acute respiratory distress syndrome (ARDS) continues to pose challenges for critical care clinicians. Respiratory failure that characterizes ARDS is a common cause of morbidity and mortality, with mortality rates of 40% to 50%. ARDS is associated with injury to the alveolar-capillary membrane of the lungs, which alters oxygenation status and results in a reduced concentration of oxygen in the blood. A variety of conditions that predispose the lungs to injury can cause ARDS, and both direct and indirect injuries can lead to it. Prompt recognition of the distinct signs and symptoms of acute lung injury, often a harbinger of ARDS, can set a targeted treatment plan in motion. Likewise, early recognition of the progressively worsening respiratory function seen in ARDS can alert the team that the patient will need special types of mechanical ventilation to preserve and improve oxygenation.
Evidence-Based Practice for ICU Sedation, Central Line Infections and Early Feeding
(1 contact hr)
Advances in technology give us easy access to a wealth of information to support evidence-based practice. By accessing these resources, nurses can provide patients with the best evidence-based interventions and treatments. This continuing education module reviews the evidence behind three practices: breathing trials for patients on mechanical ventilation, preventing CLABSIs and early feeding of critically ill patients.
Treatment and Prevention of Anemia of Critical Illness
(1 contact hr)
Anemia of critical illness (ACI) is present in a majority of patients admitted to ICUs and is a leading cause of inadequate oxygen delivery. With this diagnosis, the patient’s hemoglobin level can be expected to decrease an average of 0.5 gm/dL per day. By the third day of an ICU admission, 95% of ICU patients are anemic. This module reviews the overall pathophysiology of ACI and examines the risk factors of and treatment options for this condition. It also addresses the recommendations on the use of blood transfusions in trauma and critically ill patients, complications of blood transfusions, the use of erythropoiesis-stimulating agents (ESAs) and the nurse’s role in caring for the patient with ACI. The critical care nurse and other healthcare team members must recognize that ACI is a distinct clinical entity that can be prevented through a multifaceted approach, which includes early detection, improvement in the nutritional status of ICU patients and reduction in phlebotomy-related blood loss.