3-day Rule Research Articles

A Novel Use of the "3-Day Rule": Post-discharge Methadone Dosing in the Emergency Department.

Methadone is a medically necessary and lifesaving medication for many patients with opioid use disorder. To adequately address these patients' needs, methadone should be offered in the hospital, but barriers exist that limit its continuation upon discharge. The code of federal regulations allows for methadone dosing as an inpatient as well as outpatient dispensing for up to three days to facilitate linkage to treatment. As a quality initiative, we created a new workflow for discharging patients on methadone to return to the emergency department (ED) for uninterrupted dosing. Our addiction medicine team changed hospital methadone policy to better allow hospitalization as a window of opportunity to start methadone. This necessitated the creation of a warm-handoff process to link patients to methadone clinics if that linkage could not happen immediately on discharge. Thus, our team created the "ED Bridge" process, which uses the "3-day rule" to dispense methadone from the ED post hospital discharge. We then followed every patient we directed through this workflow as an observational cohort for outcomes and trends. Of the patients for whom ED bridge dosing was planned, 40.4% completed all bridge dosing and an additional 17.3% received at least one but not all bridge doses. Established methadone patients made up 38.1% of successful linkages, and 61.9% were patients who were newly started on methadone in the hospital. Improving methadone as a treatment option remains an ongoing issue for policymakers and advocates. Our ED bridge workflow allows us to expand access and continuation of methadone now using existing laws and regulations, and to better use hospitals as a point of entry into methadone treatment.

A diagnostic stewardship approach to prevent unnecessary testing of an enteric bacterial molecular panel.

After stool culture was replaced by an enteric bacterial panel (EBP) at the Johns Hopkins Hospital (JHH), many EBPs were ordered >3 days after admission (EBP >3 days) with low yield. To reduce unnecessary testing, a hard stop for ordering EBP >3 days was established with the option to override the restriction. The present study retrospectively evaluates the usefulness of overriding that restriction. A retrospective chart review was performed on all patients with an EBP >3 days at the JHH from November 2021 to October 2022. The override provided only one new diagnosis of Salmonella infection in a patient who developed diarrhea within 3 days of admission but was not tested by EBP until day 5. There were no positive EBPs >3 days in patients without diarrhea or who developed diarrhea >3 days after admission (diarrhea >3 days). Most patients with requests to override the restriction were also tested for Clostridioides difficile. All patients positive for C. difficile received treatment and their C. difficile positive test resulted >1 day before the EBP was run. There were no differences in yield in patients >65 years of age with significant comorbidities or associated with neutropenia, leukocytosis, human immunodeficiency virus status, or lactoferrin positivity. There were no positive tests in patients receiving stool softeners within the previous 48 hours of testing. Overriding the hard stop should not be approved in patients without diarrhea or with diarrhea >3 days, who received stool softeners within the previous 48 hours or have not been tested for more common causes of hospital-acquired diarrhea.IMPORTANCETesting for enteric bacterial pathogens in patients hospitalized for more than 3 days is almost always inappropriate. Our study validates the utility of the 3-day rule and the use of clinical decision support tools to decrease unnecessary testing of enteropathogenic bacteria other than C. difficile. Overriding the restriction was very low yield. Our study highlights the importance of diagnostic stewardship and further refines the criteria for allowing providers to override the restriction while monitoring the impact of the interventions.

Exposing the Care Conundrum of Low-Energy Pelvic Ring Fractures in Older Adults: A Review of 322 Patients.

A care conundrum for low-energy pelvic ring fracture patients in which they face financial burden after not qualifying for an inpatient stay of 3days or more has been noted in the literature. The purpose of this study was to identify factors that lead to inpatient length of stay (IP LOS) ≥3days in older adults with nonoperative pelvic ring fragility fractures and to highlight the challenging financial decision-making of those with IP LOS <3days in the context of the Medicare 3-day rule. This was a retrospective review of 322 patients aged ≥65 presenting from March 2016 and February 2019 to either of 2 emergency departments (EDs) after a ground-level fall resulting in a pelvic ring fracture. Patient demographic, IP LOS, and mortality data were extracted. Case management notes were analyzed to summarize financial decision-making for patients with IP LOS <3days. Multivariate logistic regression analysis was conducted to identify factors that predicted IP LOS ≥3days and mortality. IP LOS ≥3days was associated with presentation to level I hospital (OR .30 [.19, 0.50]) and being single (OR 2.50 [1.10, 5.68]). 70.3% required a post-acute skilled nursing facility (SNF) stay. Of patients with LOS <3days, 25.0% were financially responsible for their SNF stay, while 7.9% elected home care due to financial reasons. Overall 30-day, 90-day, and 1-year mortality were 2.5%, 8.1%, and 20.8%, respectively. For patients with LOS <3days, returning to assisted living compared to discharging to a SNF increased 90-day mortality risk (HR 8.529, P = .0451). Having Medicare trended towards increased 90-day mortality risk compared to commercial insurance (HR 4.556, P = .0544). The current system is failing older adult patients who sustain nonoperative low-energy pelvic ring fractures in terms of financial coverage of necessary post-acute treatment. This care conundrum has yet to be solved.

Low-Energy Pelvic Ring Fractures: A Care Conundrum.

Introduction:A need exists for improved care pathways for patients experiencing low-energy pelvic ring fractures. A review of the current literature was performed to understand the typical patient care and post-acute rehabilitation pathway within the US healthcare system. We also sought to summarize reported clinical outcomes worldwide. Significance: Low-energy pelvic ring fracture patients usually do not qualify for inpatient admission, yet they often require post-acute rehabilitative care. The Center for Medicare and Medicaid Services’ (CMS) 3-day rule is a barrier to obtaining financial coverage of this rehabilitative care.Results:Direct admission of some patients to post-acute care facilities has shown promise with decreased cost, improved patient outcomes, and increased patient satisfaction. Secondary fracture prevention programs may also improve outcomes for this patient population.Conclusions:Post-acute care innovation and secondary fracture prevention should be prioritized in the low-energy pelvic fragility fracture patient population. To demonstrate the effect and feasibility of these improved care pathways, further studies are necessary.

156 Centers for Medicare and Medicaid Skilled Nursing Facility 3-Day Waiver Pilot: Evaluation of Emergency Department Length of Stay for Direct Admission to Skilled Nursing Facilities

The Skilled Nursing Facility (SNF) 3-Day Rule requires that Medicare beneficiaries have an inpatient hospital stay of three consecutive days within the past 30 days to be eligible for coverage of SNF admission. However, there is opportunity within the Centers for Medicare & Medicaid Services (CMS) Shared Savings Program for waiver of this rule for eligible beneficiaries who are prospectively assigned to an Accountable Care Organization (ACO) and who receive care from an eligible SNF. The objective of this pilot study was to evaluate the emergency department (ED) length of stay (LOS) of participating Cleveland Clinic Ohio ED ACO patients who were discharged directly to an eligible SNF under the waiver.

The 3-day rule for stool cultures: should all patients with haematological malignancies be excluded?

ObjectivesThe ‘3-day rule’ for stool culture ordering suggests that only selected inpatients with nosocomial diarrhoea should have stool cultures for enteropathogenic bacteria (EPBs). Patients with haematological malignancies are not included in this group. We have analysed the ordering of stool cultures at Laikon Hospital to investigate whether all patients with haematological malignancies should be excluded from the 3-day rule. MethodsWe have retrospectively analysed all inpatient stool specimens sent to the microbiology laboratory for enteropathogenic bacteria culture at Laikon Hospital, Athens, Greece, between January 1, 2014 and December 31, 2014. We classified stool cultures sent after the third day as ‘appropriate’, ‘excluded’ with standard rule, ‘excluded’ with haematological malignancies, and ‘inappropriate’. ResultsDuring the study period, 1101/1593 inpatient stool cultures (69.1%) had been ordered after the third day of hospitalization. The total yield for inpatient EPB stool cultures was 0.7% (11/1593). The yield for ‘appropriate’ cultures was significantly higher than the yield of all ‘excluded’ specimens (3.7% (3/81) versus 0.3% (2/585), p 0.018) and to ‘inappropriate’ orders (3.7% (3/81) versus 0.0% (0/485), p 0.0028). There was no difference in the yield between specimens ‘excluded’ with the standard rule and ‘excluded’ with haematological malignancies. ConclusionsIn our hospital, the yield of stool cultures from patients with haematological malignancies is similar to that of patients ‘excluded’ from the standard 3-day rule. If patients with haematological malignancies were not excluded from the rule, we would reduce the inpatient stool cultures by 13.6% (217/1593) at the cost of missing one positive stool culture.

The yield of stool testing in hospital-onset diarrhea: Has evidence changed practice?

Introduction: Aside from examination for Clostridium difficile, the yield of stool testing in hospital-onset diarrhea is poor. Clinical practice guidelines discourage overzealous stool testing in patients with diarrhea that develops after the third hospital day. However, the adoption of this recommendation into clinical practice is limited. Furthermore, the effect of microbiology laboratory improvements on hospital-onset diarrhea testing is largely unknown. Methods: A retrospective cohort study was conducted in a university-affiliated community-hospital and included all adult inpatients who developed diarrhea after hospitalization. Results: 132 adult patients (53% female) developed diarrhea after hospitalization in 2013. The cohort’s mean age was 55.6 years. 46.2% of patients developed diarrhea in the first 3 days of hospitalization. Testing for parasites was negative in all examined 67 samples. Testing for C. difficile was positive in 13 cases (10.8%) out of 120 tested samples. Testing for other pathogens was positive in 1 sample (Campylobacter) out of 129 samples. Stool samples tested in the first 3 days of hospitalization were more likely to be positive (64.3 vs 35.7%, p = 0.1). Change in management was reported in 9 out of 14 patients (64.3%) with positive stool testing compared with 31 out of 118 patients (26.3%) with negative stool testing, p = 0.01. Conclusion: Despite improvements in stool samples’ testing, the yield continues to be low, especially in hospital-onset diarrhea past the third hospital day. Physicians’ embracement of the ‘3-day rule’ continues to be poor.

Does the Medicare 3-Day Rule Increase Length of Stay?

Medicare will only cover a stay in a skilled nursing facility (SNF) after TKA if the patient stays for at least 3 days at the inpatient hospital. The 3-day stay rule was instituted in 1965, to prevent over utilization of Medicare. We retrospectively reviewed 800 consecutive TKA, identifying patients that were discharged to rehab after surgery. 322 patients were discharged to SNF after surgery (209 Medicare, 113 private insurances). The LOS was 2.3 days for privately insured patients and 3.02 for Medicare recipients (P<0.05). No difference was found with regard to age, BMI, and ASA score. The Medicare 3-day rule independently increased the LOS in patients who required inpatient rehab, leading to increased cost. We suggest that this rule must be revised.

Bundle Up for Savings

Bundle Up for Savings

Next Generation ACOs: CMS Increases Risks, Rewards

Next Generation ACOs: CMS Increases Risks, Rewards

Medicare’s 3-Day Rule: Time for a Rethink

A pilot study was undertaken to examine the impact of Medicare’s 3-day rule on length of stay (LOS). One hundred consecutive patients who underwent primary total joint arthroplasty and were discharged to extended care facilities were retrospectively reviewed. Based on readiness for discharge criteria, delaying discharge until the third postoperative day increased LOS by 1.1days (P<0.001). 60.6% of patients were ready for discharge by the second postoperative day, none of whom required re-admission within 30days of discharge. There were no rehabilitation gains by staying an additional hospital day beyond readiness for discharge (P=0.092). This pilot study calls into question the value of Medicare’s 3-day rule and demonstrates the feasibility and need for further research to address this seemingly antiquated policy.

ACOs Turn Up the Heat Among Skilled Nursing Facilities

ACOs Turn Up the Heat Among Skilled Nursing Facilities

Tracing Temperature Patterns of Cut Leafy Greens during Service in North Carolina School Food Service

Contaminated fresh produce has been increasingly identified as a cause of foodborne illnesses. Because of concerns about pathogen growth on these food items at retail, the 2009 U.S. Food and Drug Administration Food Code established that cut leafy greens (lettuce, spinach, spring mix, cabbage, arugula, and kale) must have time and temperature controls for safety and hence should be kept at refrigerated temperatures (5°C or lower). The purpose of this study was to determine the temperature profiles of cut leafy greens in single-serving clamshell containers provided as part of the North Carolina School Lunch Program and to compare the two policies that North Carolina has in place to control the temperature of these products (the 3-day rule and time in lieu of temperature). Temperatures were recorded with data loggers in 24 schools during a 3-day period. In all cases, substantial temperature variability was found for these products, including temperatures above 5°C for at least 1 h on each of the 3 days. In some cases, temperatures reached above 5°C for more than 3 h throughout the serving time. The results demonstrate the importance of developing a protocol for continuous temperature monitoring of leafy greens served in school lunch programs.

Association's Policy Focus Is on New Quality Measures

Association's Policy Focus Is on New Quality Measures

Validation of the 3-Day Rule for Stool Bacterial Tests in Japan

Stool cultures are expensive and time consuming, and the positive rate of enteric pathogens in cases of nosocomial diarrhea is low. The 3-day rule, whereby clinicians order a Clostridium difficile (CD) toxin test rather than a stool culture for inpatients developing diarrhea >3 days after admission, has been well studied in Western countries. The present study sought to validate the 3-day rule in an acute care hospital setting in Japan. Stool bacterial and CD toxin test results for adult patients hospitalized in an acute care hospital in 2008 were retrospectively analyzed. Specimens collected after an initial positive test were excluded. The positive rate and cost-effectiveness of the tests were compared among three patient groups. The adult patients were divided into three groups for comparison: outpatients, patients hospitalized for ≤3 days and patients hospitalized for ≥4 days. Over the 12-month period, 1,597 stool cultures were obtained from 992 patients, and 880 CD toxin tests were performed in 529 patients. In the outpatient, inpatient ≤3 days and inpatient ≥4 days groups, the rate of positive stool cultures was 14.2%, 3.6% and 1.3% and that of positive CD toxin tests was 1.9%, 7.1% and 8.5%, respectively. The medical costs required to obtain one positive result were 9,181, 36,075 and 103,600 JPY and 43,200, 11,333 and 9,410 JPY, respectively. The 3-day rule was validated for the first time in a setting other than a Western country. Our results revealed that the "3-day rule" is also useful and cost-effective in Japan.

Medicare and the 3‐Day Rule

Medicare and the 3‐<scp>D</scp>ay <scp>R</scp>ule

Hospitalists, Too, Seek to Change Medicare's 3-Day Rule

Hospitalists, Too, Seek to Change Medicare's 3-Day Rule

Performance of stool cultures before and after a 3-day hospitalization: fewer cultures, better for patients and for money

We evaluated retrospectively the yield of stool culture (SC) depending on the length of hospitalization, and we characterized the patients missed by the 3-day rejection rule. SC detects bacterial enteric pathogens (Campylobacter spp., Salmonella enterica, Yersinia spp., Shigella spp.). During this 5-year study period, 13,039 SCs were requested, and 376 were positive (2.9%). The yield of SC dropped from 11.7% before 3 days of hospitalization to 0.7% after 3 days in children and 4.3% to 0.3% in adults. Finally, only 13 clinically relevant cases (0.2% of SC prescribed after 3 days) were undiagnosed by strict application of the 3-day rule. In conclusion, rejection of SC prescribed after 3 days of hospitalization allows to reduce workload by 37.8% for children and 65.7% for adults, representing a cost of €12,500 ($16,250) per year in our hospital.

ACOs, 3-Day Rule, Team Roles Are Top Issues

ACOs, 3-Day Rule, Team Roles Are Top Issues

Understanding the Medicare “Extended Care Benefit” a.k.a. the 3-Midnight Rule

The purpose of this article is to discuss the overall features of the "Extended Care Benefit," also known as the 3-midnight rule for post-acute skilled nursing facilities (SNF) coverage. The goal is to support case managers in the effort to gain a better understanding of how the benefit applies to the Medicare beneficiaries with whom they are working. (1) Give a brief history of the purpose of the "extended care benefit," (2) describe the circumstances under which a patient may be eligible for coverage of skilled nursing or rehabilitation services following a hospitalization, and (3) apply new knowledge to practice by incorporating case management tips into practice. The primary setting for case managers who need to know this information is in acute care and in postacute care facilities that admit patients for extended care services. The eligibility of Medicare beneficiaries for this benefit may be broader than is commonly known by case managers. 1. Case managers should not "assume" that the patient does not meet criteria for this benefit. For example: Even if the patient is not ready for rehabilitation services at the time of discharge, a case manager can advocate for deferred admission when the patient is ready. 2. Case managers should include in the patient's admission assessment, the history of previous hospitalizations, particularly in the past 30 days. The patient may have met the 3-midnight requirement prior to admission. 3. Hospital-based case managers must work closely with intake staff, case managers, or liaison staff from the SNF level of care to do a comprehensive assessment of the patient's continuing care needs. 4. Delivering the message to Medicare beneficiaries and their families that the patient does not meet criteria for "extended care services" is a very difficult task and should be done in collaboration with other team members, particularly social workers. 5. With 43% of all admissions of patients being in the "short-stay" category, early intervention is critical to determine the possibility of the patient's postacute needs. It is the short-stay patient who does not meet medical eligibility for 3 days who needs more attention early in the stay. 6. Keeping a patient in the hospital, who does not meet medical necessity standards, even for 1 day with the purpose of meeting the 3-day rule may be considered to be "fraudulent," and is a serious matter. Acute care setting is intended to provide acute care services and not to be used to help "needy" individuals meet criteria for extended care benefits.