405 IAC 5-33-1 Adult medical surgical criteria

Sec. 1. Day of admission appropriateness shall be as follows: (1) Severity of illness criteria: (A) sudden onset of unconsciousness or disorientation (coma or unresponsiveness); (B) pulse rate: (i) less than fifty (50) per minute; or (ii) greater than one hundred forty (140) per minute; (C) blood pressure: (i) systolic less than ninety (90) or greater than two hundred (200) millimeters mercury; or (ii) diastolic less than sixty (60) or greater than one hundred twenty (120) millimeters mercury; (D) acute loss of sight or hearing; (E) acute loss of ability to move body part; (F) persistent fever equal to or greater than one hundred (100) (p.o) or greater than one hundred one (101) (R) for more than five (5) days; (G) active bleeding; (H) severe electrolyte/blood gas abnormality, including any of the following: (i) Na < 123 mEq/L Na > 156 mEq/L (ii) K < 2.5 mEq/L K > 6.0 mEq/L (iii) CO2 combining power (unless chronically abnormal) < 20 mEq/L CO2 combining power (unless chronically abnormal) >36 mEq/L (iv) Blood pH < 7.30 Blood pH > 7.45; (I) acute or progressive sensory, motor, circulatory, or respiratory embarrassment sufficient to incapacitate the patient (inability to move, feed, or breathe); must also meet intensity of service criterion simultaneously in order to certify; do not use for back pain; (J) EKG evidence of acute ischemia; must be suspicion of a new MI; or (K) wound dehiscence of evisceration. (2) Intensity of service: (A) intravenous medications and/or fluid replacement (does not include tube feedings); (B) surgery or procedure scheduled within twenty-four (24) hours requiring: (i) general or regional anesthesia; or (ii) use of equipment, facilities, or procedure available only in a hospital; (C) vital sign monitoring every two (2) hours or more often (may include telemetry or bedside cardiac monitor); (D) chemotherapeutic agents that require continuous observation for life-threatening toxic reaction; (E) treatment in an intensive care unit; (F) intramuscular antibiotics at least every eight (8) hours; and (G) intermittent or continuous respirator use at least every eight (8) hours. (3) Criteria of appropriateness of day of care shall include the following: (A) Medical services: (i) procedure in operating room that day; (ii) scheduled for procedure in operating room the next day, requiring preoperative consultation or evaluation; (iii) cardiac catheterization that day; (iv) angiography that day; (v) biopsy of internal organ that day; (vi) thoracentesis or paracentesis that day; (vii) invasive CNS diagnostic procedure, for example, lumbar puncture, cisternal tap, ventricular tap, or pneumoencephalography, that day; (viii) any test requiring strict dietary control for the duration of the diet; (ix) new or experimental treatment requiring frequent dose adjustments under direct medical supervision; (x) close medical monitoring by a doctor at least three (3) times daily (observations must be documented in record); or (xi) postoperative day for any procedure covered in item (i) or (iii) through (vii). (B) Nursing/life support services: (i) respiratory care–intermittent or continuous respirator use and/or inhalation therapy (with chest PT, IPPB) at least three (3) times daily; (ii) parenteral therapy–intermittent or continuous intravenous fluid with any supplementation (electrolytes, protein, or medications); (iii) continuous vital sign monitoring, at least every thirty (30) minutes, for at least four (4) hours; (iv) IM and/or SC injections at least twice daily; (v) intake and output measurement; (vi) major surgical wound and drainage care (chest tubes, T-tubes, hemovacs, Penrose drains); or (vii) close medical monitoring by nurse at least three (3) times daily, under doctor's orders. (C) Patient condition: (i) within twenty-four (24) hours before day of review inability to void or move bowels (past twenty-four (24) hours) not attributable to neurologic disorder; (ii) within forty-eight (48) hours before day of review: (AA) transfusion due to blood loss; (BB) ventricular fibrillation or ECG evidence of acute ischemia, as stated in progress note or in ECG report; (CC) fever at least one hundred one (101) degrees rectally (at least one hundred (100) degrees orally), if patient was admitted for reasons other than fever; (DD) coma–unresponsiveness for at least one (1) hour; (EE) acute confusional state, not due to alcohol withdrawal; (FF) acute hematologic disorders, significant neutropenia, anemia, thrombocytopenia, leukocytosis, erythrocytosis, or thrombocytosis yielding signs or symptoms; or (GG) progressive acute neurologic difficulties; and (iii) within fourteen (14) days before day of review, occurrence of a documented, new acute myocardial infarction or cerebrovascular accident (stroke).