Hospital Admissions

[dhageremtp]

I just received an email from the director of nursing from my facility stating it is a CMS rule that I as a PA need to notify a physician within 4 hours of a hospital admission, and furthermore that FNPs do not have the same requirement. I have asked her to state the CMS rule so I can read it, anyone else familiar with this?

[burnpac]

Bullsh*t. There is no such rule. The facility rules that govern a physician assistant in the hospital are set by the medical staff and found in the medical staff bylaws and rules. CMS has many broad guidelines regarding medical staff practice, but there is nothing specific that dictates to a hospital what privileges they can or can't extend to PAs. Second, the DON has no place in the medical staff chain of command. You need to follow state law, and your facility's medical staff bylaws and rules. You answer to your physician partner, the department chair, and the medical COS. There may very well be a medical staff rule that the patient has to be physically examined within 4 hours of admission by the admitting physician, but at our facility, they don't differentiate between MDs or PAs when it comes to admission PE. If I do the admission, or discharge, it is the same as if he performed it.

 

We have gone through a recent CMS nightmare at are facility, and the nursing "false authority" syndrome runs rampant at times like that. When ever a nurse comes up to me and states it a "CMS rule" that I or the medical staff has to do something, I tell them, "Show it to me in writing." 99.9% of the time, they can't because they made it up, misinterpreted it, or just heard someone else say it.

 

I would politely e-mail her back, ask for a specific reference to the CMS rule in question, and copy the medical COS.

[burnpac]

That said, I would never think of admitting a patient to my surgeon partner's service without discussing it with him either before or immediately after the admission. There are times when I'm on call and my surgeon is exhausted from a long day in the OR where he extends the authority to me "to just handle it" over night or over a weekend. But still, he is the surgeon and must be part of any admission decision-making.

 

My point is that these decisions are best made at the local level by physician - PA teams.

[ATCLATEMTB]

Could not have said it better! For some reason CMS / whatever scary agency is coming next tends to give nurses a "false authority" syndrome and it does runs rampant!!

 

I have to admit I'm tired of seeing RN's in white coats and clipboards telling all sorts of tales / rules / policy etc. You can usually spot these a mile away....clean white coat, far from a patient, and skilled in e-mail warfare.

 

To the original poster: proof in writing from official CMS source. I have had CMS rules summarized in a document given to me from an authority source, when I researched the actually CMS policy it was entirely different then "official" summary given out as law of the land. It took time and effort to sort out the actual truth, but in a big system everyone has a steak in something....not to mention a knife in both hands.

[dhageremtp]

Refer to CQI/Peer Review of the CAH regs C-0339 – “MD/DO evaluates quality and appropriateness of midlevel providers”

This she states is more like a CQI study where we set up criteria and review a number of charts according to policy and Bylaws. They expect to see follow up and an increase in number of charts reviewed if problems are noted. This would be like our Peer Review that we do with Dr’s, except that is states the review has to be done by an MD/DO.

If a PA admits a patient to Inpatient – a Physician must be notified within 4 hours. This is not a requirement for a FNP. That is about the only difference in the review of care for the 2 types of mid-levels. I don’t believe this is always documented with our current PA’s.

 

I believe if the FNP were to admit patients to the hospital and the care is provided in conjunction with an MD/DO so that there is definite review of care – we would be OK.

That's the email I that I received, I have tried to find this in actual CMS documentation and cannot find anything........of course she wont give me anything more than this.

[True Anomaly]

I'm a little confused- are you working in the ER and are admitting patients to an inpatient service, or are you a hospitalist PA doing admission H&P's/orders?

[sbellin]

I have been through this recently in regards to whether whenI’m on call for admissions that an MD/DO needs to be personally available tosee the patient if needed. Our CAH hascontacted our state department of health (Washington State) and they state thatthere is no requirement for an MD/DO to be personally available to seeinpatients. This though may vary fromstate to state.

CMS states in CFR 485.631that mid-levels (PA’s and NP’s)may admit to a CAH but a physician needs to be notified (no time stated) of theadmission and discharged and if there are any major therapeuticinterventions. CMS does notdifferentiate between NP and PA supervision. Although there may be a statespecific law CMS does not place an hourly limit on when an MD/DO should be madeaware of an admission or discharge. Iusually will talk to the docs once a day about who I have in-house.

With all that said, the biggest glitch may be hospital by-laws. They are many times archaic andrestrictive. If there is within yourfacility an hourly restriction then it is probably there.

[KMD16]

I've ran into similar situation in the past where this folks dictate how we do things. This folk are not your friends!

[LIPPER]

DON's of skilled facilities are nothing as it pertains to telling PA's how to do anything.. Hell they can't administer Tylenol without your written order. I'd just say "OK and walk away".... ....Unless of course she was simply mentioning this to you to be polite/make you better informed. Our hospitals have no such requirement.