1. Title of Presentation Arial Regular 22pt
Single line spacing
Up to 3 lines long
Date 20pts
Author Name 20pts
Author Title 20pts
Guidelines to the Guidelines
2. Objectives:
• Participant will understand the purpose of medical
guidelines
• Participant will understand importance of evidence
based medicine in relation to medical guidelines
• Participant will be able to use Interqual guidelines as
designed
• Participant will be able to utilize Interqual guidelines in
their every day practice of case management
3. Guidelines to the Guidelines
Clinical Guidelines
• Clinical guidelines are defined as: Medical
interventions based on medical practice
that has been proven to be best practice.
It is commonly termed “evidence based
medicine”.
4. Guidelines to the Guidelines
Guidelines
• There are two distinct companies that produce
medical/acute guidelines
– Milliman
–Focus is on how the patient presents. They focus on
symptom rather than treatment
For example, if a patient comes in with pneumonia, they
will focus on the patients respiratory status versus
what treatment is being given.
5. Guidelines to the Guidelines
Interqual
- Interqual guidelines
Interqual’s focus is on the intensity of which the
patient is being treated.
If we take the same patient with pneumonia, they will
focus on what treatment is being done, such as
antibiotics, respiratory treatments etc.
6. Guidelines to the Guidelines
Interqual
• Interqual breaks down the information in two ways
– 1. Level of care guidelines. These guidelines are to make sure
that the patient is in the correct level of care.
– 2. Body systems. The guidelines are then broken down by
systems such as GI and ID
7. Guidelines to the Guidelines
Further Breakdown
Interqual breaks it down further into two additional
subsets
Severity of Illness or SI
This is used on admission/preadmission only. Patient
must meet severity of illness before you can review for
intensity of service. This is done upon admission.
Intensity of service
These are basically physician orders. What is being
done for the patient. It must be met initially and with
continued stay
8. Guidelines to the Guidelines
Severity Of Illness
• This criteria consist of objective, clinicals indicators of
illness which focus on the patient’s clinical presentation
and/or diagnosis
• Time requirements vary based on the level of care
• Grouped by reason for admission and alphabetized
9. Guidelines to the Guidelines
Continued
• Most Severity of Illness or SI are organized into
subsets
– Clinical Findings
– Imaging Findings
– ECG findings
– Laboratory findings
10. Guidelines to the Guidelines
Intensity of Service
• This criteria consists of monitoring and therapeutic
services, either by themselves or together, that can
only be administered at a specific level of care.
• Intensity of service criteria is broken down again into
two sections
– One IS This means you only need to meet one of these clinical
to meet criteria
– Three IS This mean the patient has to have at least three of
these interventions to meet criteria
IS EXCLUDES PO MEDICATION UNLESS INDICATED
11. Guidelines to the Guidelines
Interqual basics
• Interqual contains the five basic review types
–Preadmission review. This is for planned
admission for a procedure
–Admission review. This is done upon the
patient’s admission to the hospital. It includes
Observation and Inpatient admissions
12. Guidelines to the Guidelines
Types of review continued
–Discharge review. This is to determine the
safety of discharge or transfer from one level of
care to another
–Continued Stay review. This is performed to
determine if the level of care is still appropriate.
Only intensity of service criteria is used.
–Secondary review. This review occurs when
the primary reviewer does not find that patient
meets criteria. It is up to the individual
originations to determine who does those
reviews
13. Guidelines to the Guidelines
Admission Review Process
• This is done when the patient is admitted to a level of
care to determine if that level of care is appropriate. If
the patient is transferred from a lower level of care to a
higher level of care, an admission review is also
required. Both the Severity of Illness (SI) and the
Intensity of service (IS) rules from the same criteria
subset must be met.
14. Guidelines to the Guidelines
Steps
• Identify the level of care based on the patients current
level
• Select the most appropriate criteria subset based on
the patient’s predominant clinical findings
• Review specific clinical information derived at the time
of admission. ER data can be utilized.
• Apply the SI rule – pt must meet severity of illness
criteria
• Apply the IS rule – pt must meet intensity of service
criteria
15. Guidelines to the Guidelines
Admission review findings
• When the SI and IS rules are met.
1. Approve stay and schedule a continued stay review
• SI and IS rules not met.
1. Obtain additional information from admitting MD or
other caregivers
2. If additional information does not meet SI or IS,
discuss alternate levels of care with attending md.
3. Facilitate transfer if the attending physician is
agreeable
16. Guidelines to the Guidelines
Continued Stay Review
Continued stay review is performed to determine the
appropriateness of continued stay at a level of care.
Apply the intensity of service criteria (one IS/*three IS)
The patient has to meet criteria on a daily basis
17. Guidelines to the Guidelines
Steps
• Begin at the same criteria subset used during the
Admission review unless
– Pt has been transferred to a lower level of care
– Pt has been transferred to a higher level of care – then it would
be an admission review
– Pt remains at the same level of care but their medical condition
has changed. You do not need to meet severity of illness.
18. Guidelines to the Guidelines
Steps continued
• Review patient specific clinical information
• Apply IS by selecting the IS criteria based on
treatments, medication or interventions making sure
they meet all the rules for duration, time frames and
number of criteria
19. Guidelines to the Guidelines
Continued stay review actions
• If IS is met, approve level of care for that day and
schedule a continued stay review
• Three *IS met, approve level of care for that day.
Review the discharge screens and document the
discharge plan. Schedule a continued stay review.
• IS or three*IS not met or IS and discharge review
criteria are selected, obtain additional information from
the attending MD or other caregivers. If IS is not met,
perform discharge review.
20. Guidelines to the Guidelines
Discharge Review
• Discharge reviews are done when criteria for continued
stay are not met, an IS criteria is selected that states
“and discharge review”, or to assist in determining the
next appropriate level of care within the facility or
transfer to another facility.
21. Guidelines to the Guidelines
Steps
• Select the same criteria subset used for the admission
or continued stay review and apply the DS rule the
appropriate level of care
– One IS that states “and discharge review”
22. Guidelines to the Guidelines
Discharge Review Actions
• If the discharge screen is NOT met, approve the day
and schedule the next review within 24 hours.
• On the next review, if DS is still not met, it should go to
secondary review.
23. Guidelines to the Guidelines
Discharge review actions continued
• If the discharge screen is met and discharge is
scheduled, no action required
• If discharge not scheduled, contact the attending
physician to discuss the d/c plan and ALOC options
• Facilitate discharge or transfer if the attending
physician agrees
24. Guidelines to the Guidelines
Secondary Review
• This review is completed by a supervisor, specialist or
a physician may conduct a secondary review.
• Organizational policy should determine the
qualifications of the reviewer as well as the extent to
which the reviewer has oversight
• The secondary reviewer determines the medical
necessity of admission or continued stay based on
review of the medical record, discussions with nursing,
discharge planner and attending physician and by
applying clinicals experience.
25. Guidelines to the Guidelines
Interqual Tips
• Don’t be afraid to use the reference materials
– The index can assist in identifying the appropriate criteria
subset
– Inpatient list identifies procedures that are appropriate for the
inpatient setting
– Abbreviation and symbols list
– Drug list
26. Guidelines to the Guidelines
Process Tips
• Review all notes attached to criteria. They are in
parentheses and are numbered.
• PRN medication can be used to meet the IS criteria
during an admission review but only if the required
frequency is met
• Oxygen saturation is based on room air measurements
unless otherwise noted.
• Treatments or services that are only given once while
in the ED cannot be used for IS criteria
27. Guidelines to the Guidelines
Process Tips continued
• If there is no IS on an admission review, this does not
meet criteria. You can use the discharge screen to
determine an alternate level of care
• A 24 hour grace period can be given, one time only,
when DS are not met and the IS rule (one IS/*three IS)
is not met. For example:
– A therapeutic pause of medication is needed.
28. Guidelines to the Guidelines
Tips
• It is acceptable for a patient to be in observation even
if they meet acute criteria. This can occur when the
expected length of stay is less than 24 hours
• Don’t confuse patient status issues with billing issues.
Some payers contract with facilities to provide
observation level of care when it could be either
inpatient or outpatient
