To determine the impact of standardized critical care documentation tools on charge capture by intensive care unit (ICU) advanced practitioners (APs). Design: Prospective charge capture analysis of AP critical care charges (Current Procedural Terminology codes 99291 or 99292). Setting: Neurosurgical, general surgical, and cardiothoracic ICUs in a level I, 800-bed hospital. The AP provider to patient ratio was 1:6, with 24-hour surgical intensivist oversight. Participants: Advanced practice registered nurses and physician assistants in the ICU. Interventions: Standardized templates were developed to simplify documentation and optimize billing of critical care. All APs participated in comprehensive educational sessions on billing compliance and documentation. Main Outcome Measures: Charge capture was collected for 3 years, and comparisons were made between the first quarter before (fiscal year [FY] 2008), during (FY 2009) and after (FY 2010) implementation. The number of ICU patient-days, length of stay, and of beds was collected. Results: During the implementation/education phase (FY 2009), there were no differences in charge capture compared with FY 2008. Each unit demonstrated an increase in charge capture after implementation, and an overall increase of 48% for all 3 ICUs was seen. The number of admissions and length of stay were not statistically different. The total number of ICU beds increased from 42 to 45 during the evaluation period. The salary offset for APs increased from 62% to 80%. Conclusions: Advanced practitioners represent an important component of the critical care services provided to patients in high-acuity surgical ICUs. Standardized critical care documentation and comprehensive education on evaluation and management guidelines significantly increased charge capture.
To quantify midlevel practitioner (MLP) staffing requirements based on the volume and complexity of patient care and the duty-hour constraints of the Accreditation Council for Graduate Medical Education 80-hour workweek.Design: Data extracted from Eclipsys Sunrise Decision Support Manager, the hospital financial budget, and census reports; and MLP, resident, and subspecialty fellow clinical, operative, and on-call schedules, and educational curriculum. Fiscal year 2005 patient census and hours of required care were defined by attending physician service and/or patient care location. Volume of patient care activity for MLPs, residents, and subspecialty fellows were established by verified self-reporting methodology.Setting: Urban teaching hospital with 867 beds, of which 116 are surgical beds (which include 36 intensive care unit beds and 12 step-down beds).
Providing high quality team-based palliative care in rural settings, in small hospitals, outpatient clinics, and homes presents economic and workforce challenges. Simply following an algorithm or copying blueprints from larger, academic centers may not be feasible in smaller communities with unique histories, smaller stakeholder groups, and thinner economic margins. The solutions are as complex as the individuals we are trying to care for: resources are scarce, education is essential, and sustainability is paramount. In this session, we share examples of palliative care program development in rural America, citing data and the unique narratives that describe common challenges and successes. This session will compare and contrast the palliative care programs arising from rural and under-resourced communities. A panel of palliative care physicians, administrative champions, and program developers will share their perspectives on the challenges and rewards of building more with less. We will highlight programs that include two California-based efforts to leverage technology to bring palliative care support to small hospitals and to the Karuk Tribe, as well as a single-hospital health system in southwestern Pennsylvania utilizing administrative and community supports to overcome the barriers for palliative care program development.
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