Sinai Hospital Baltimore
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Patient Status Decision Center

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Welcome Future Doctors! 🎉

Today we're mastering the art of patient status determination!

Inpatient vs. Observation - Let's make it fun and memorable!

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The Big Picture 🖼️

As a resident at Sinai Hospital, your status decision impacts:

  • 💰 Patient's financial responsibility
  • 🏥 Hospital reimbursement
  • 📋 Documentation requirements
  • 🏠 SNF eligibility

📥 Inpatient

Formally admitted, expecting ≥2 midnights

Medicare Part A

Single deductible

👀 Observation

Monitoring to determine disposition

Medicare Part B

20% copay per service

The Two-Midnight Rule ⏰

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🤔 The Key Question:

At admission, do you reasonably expect the patient will need hospital care for ≥2 midnights?

💡 Remember: It's about EXPECTATION at admission, not actual length of stay!

Remember SI/IS with SICK-HELP! 🧠

Severity of Illness (SI) - "SICK"

Stable vital signs? (No = High SI)
Immediate risk of deterioration?
Critical lab values?
Kidney/organ dysfunction?

Intensity of Service (IS) - "HELP"

Hourly monitoring needed?
Emergent IV medications?
Life support (NIV, telemetry)?
Procedures requiring hospital setting?
💡 Quick Tip: If a patient is SICK and needs HELP, they likely need inpatient care!

SI/IS Framework Challenge! 🎮

Drag the clinical findings to the correct category!

Patient: 78-year-old with UTI and sepsis

BP: 88/50 HR: 120 Temp: 102.5°F Mental Status: Confused

Available Clinical Findings:

Hypotension (88/50)
Altered Mental Status
IV Fluid Boluses
Immunosuppressed
Q1h Neuro Checks
IV Antibiotics

Severity of Illness (SI) ✅

"How sick is the patient?"

Intensity of Service (IS) 🛠️

"What are we doing for them?"

The Golden Sentence ✨

"This patient is admitted as [STATUS] due to [DIAGNOSIS] with a high Severity of Illness manifested by [SI FINDINGS]. They require an Intensity of Service including [IS INTERVENTIONS]. Based on this, I reasonably expect a medically necessary hospital stay of at least two midnights to achieve clinical stability."

🎯 Pro Tips from Sinai Veterans:

  • Be specific with objective findings
  • Link SI/IS to expected length of stay
  • Document your clinical reasoning
  • Avoid "social admission" language

Clinical Decision: ADHF 💙

Acute Decompensated Heart Failure

Drag each patient finding to the appropriate status bucket:

SaO2 85% on RA
Cardiorenal syndrome
SaO2 96% on 2L
Need for BiPAP
Good response to ED diuresis
Hypotension
Stable vitals
Failed aggressive ED diuresis

🏥 Clear Inpatient

High SI / High IS

👀 Appropriate for Observation

Lower SI / Lower IS

Clinical Decision: COPD 🫁

COPD Exacerbation

Categorize these COPD findings:

pH 7.25, PaCO2 65
Altered mental status
Normal pH/PaCO2
Needs NIV
SaO2 92% on 2L
Pneumonia on CXR
Expected improvement <48hrs
Failed initial ED treatment

🏥 Clear Inpatient

High SI / High IS

👀 Appropriate for Observation

Lower SI / Lower IS

Clinical Decision: Cellulitis 🦠

Cellulitis

Sort these cellulitis presentations:

Sepsis criteria met
Non-toxic appearance
Rapidly progressing
Failed oral antibiotics
Concern for necrotizing fasciitis
Needs 3 doses IV antibiotics
Uncontrolled pain
Hemodynamically stable

🏥 Clear Inpatient

High SI / High IS

👀 Appropriate for Observation

Lower SI / Lower IS

Clinical Decision: Chest Pain 💔

Chest Pain

Classify these chest pain scenarios:

Positive troponins
Ruled out ACS in ED
Dynamic EKG changes
Needs stress test
Hemodynamic instability
Diagnosis unclear
Needs urgent cath
Stable, needs monitoring

🏥 Clear Inpatient

High SI / High IS

👀 Appropriate for Observation

Lower SI / Lower IS

Knowledge Check Time! 🧩

🤔 Quick Question 1:

A patient with cellulitis has failed oral antibiotics but is hemodynamically stable and non-toxic. What's the appropriate status?

🤔 Quick Question 2:

What does the "reasonable expectation" in the Two-Midnight Rule refer to?

🤔 Quick Question 3:

A COPD patient has pH 7.30 and needs NIV. Status?

Clinical Pearls from Sinai 💎

Top 5 Documentation Pearls:

Always document your "reasonable expectation" clearly
Use objective findings (vitals, labs) not subjective descriptions
Link SI/IS directly to expected length of stay
Avoid phrases like "social admission" or "placement issues"
If status changes, document why (new findings, deterioration)
💡 Remember: Good documentation today prevents denials tomorrow!

Clinical Decision Matrix 📊

Condition 🏥 Clear Inpatient 👀 Appropriate for Observation
ADHF • Hypoxia (SaO2 <90%)
• Cardiorenal syndrome
• Need for NIV/BiPAP
• Failed aggressive ED diuresis 		• Stable vitals
• Good response to ED diuresis
• Expected stay <48 hrs
• No hypoxia
COPD • Respiratory failure (pH <7.35)
• Altered mental status
• Pneumonia complication
• Need for NIV 		• No respiratory failure
• Mild hypoxemia
• Expected improvement <48 hrs
• Failed initial ED management
Cellulitis • Sepsis criteria
• Rapidly progressing
• Concern for necrotizing fasciitis
• Uncontrolled pain 		• Non-toxic appearance
• Failed oral antibiotics
• Need brief IV therapy
• Hemodynamically stable
Chest Pain • Positive troponins (NSTEMI/STEMI)
• Dynamic EKG changes
• Hemodynamic instability
• Needs urgent cath 		• Ruled out ACS in ED
• Needs stress test
• Diagnosis unclear
• Stable, needs monitoring

Avoid These Pitfalls! ⚠️

🚫

❌ DON'T

  • 📅 Just count midnights
  • 🏠 Admit for social reasons
  • 📊 Rely only on InterQual/MCG
  • 📝 Forget to document reasoning

✅ DO

  • 🧠 Use clinical judgment
  • 🏥 Focus on medical necessity
  • 📊 Apply SI/IS framework
  • ✍️ Write that golden sentence!

"Your documentation is your defense!" 🛡️

Final Challenge! 🏆

Lightning Round - Pick the Status!

1️⃣ Total knee replacement (on IPO list), goes home next day?

2️⃣ Stable cellulitis, needs 3 doses IV antibiotics?

3️⃣ NSTEMI with dynamic EKG changes?

Congratulations! 🎉

🎓 🏥 💪

You're now a Patient Status Expert!

Remember: Great documentation protects patients AND providers!

Key Takeaways from Sinai:

  • 🧠 Clinical judgment + SI/IS = Success
  • ⏰ 2-midnight expectation at admission
  • 📝 Document like your attending is watching (they are!)
  • 💡 When in doubt, think medical necessity
  • 💎 Use the SICK-HELP mnemonic

Go forth and make great status decisions! 🚀

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Copyright 2025 Carol Scott, MD