/policies/,/policies/administrative/,/policies/administrative/uwhc/,/policies/administrative/uwhc/department-specific/,/policies/administrative/uwhc/department-specific/nursing-administrative/,/policies/administrative/uwhc/department-specific/nursing-administrative/patient-charges/,

/policies/administrative/uwhc/department-specific/nursing-administrative/patient-charges/906.policy

201608216

page

100

UWHC,

Policies,Administrative,UWHC,Department Specific,Nursing Administrative,Patient Charges

Criteria for Inpatient Daily Care Level 5 Charge - Patients who have sustained a Neurological Insult (Includes traumatic brain injury and other) (9.06)

Criteria for Inpatient Daily Care Level 5 Charge - Patients who have sustained a Neurological Insult (Includes traumatic brain injury and other) (9.06) - Policies, Administrative, UWHC, Department Specific, Nursing Administrative, Patient Charges

9.06

POLICY & PROCEDURE





Effective Date:
August 1, 2016

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
9.06

Original
Revision

Page 1
Of 5

Title: Criteria for Inpatient Daily Care Level
5 Charge Patients Who Have Sustained a
Neurological Insult (Includes traumatic brain
injury and other)




I. PURPOSE
A. Patients will be charged a higher daily care rate when they are admitted to selected
inpatient units and meet certain criteria as specified in the Policy section below.
II. POLICY
A. This Daily Care Level 5 Neurological Insult charge applies only to the following units:
Surgical Trauma (93460), Neurosciences 93380 and 93390, Cardiothoracic Surgery
(93570), General Surgery (93660), Gynecology, Urology, Plastics and Otolaryngology
(93610) and Orthopedics (93430).
B. To receive this charge, the patient would need to have sustained a neurological injury and
must meet any 2 criteria listed below.
1. Vital Signs, Neuro checks, or Suctioning every 2 hours would automatically
qualify the patient for the charge without any additional criteria being applicable.
2. Neurological Monitoring. Neuro checks every 4 hours or more frequently
3. Hemodynamic Monitoring
a. Serial Hematocrit monitoring
b. Vital signs every 2 hours or more frequently
c. Lumbar drainage requiring every 2 hours drainage or more frequent
monitoring
4. Respiratory. Tracheostomy requiring suctioning every 2 hours or more frequently
and /or Compromised ability to protect airway relating to cognitive impairment
5. Behavioral/Safety needs
a. Safety checks every one-hour
b. Cognitive impairment (e.g. traumatic brain injury, alcohol/drug related, or
dementia) SEE RANCHO LEVEL DEFINITIONS BELOW FOR
NEUROLOGICAL INSULT.
6. Functional Limitations
a. Unstable C-spine (MD has not cleared spine secondary to patient's
inability to participate in exam)
b. Initial Halo placement
c. Unstable thoracic or lumbar spines (patient does not have brace)
d. External fixators in place limiting patient's ability to participate in basic

POLICY & PROCEDURE





Effective Date:
August 1, 2016

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
9.06

Original
Revision

Page 2
Of 5

Title: Criteria for Inpatient Daily Care Level
5 Charge Patients Who Have Sustained a
Neurological Insult (Includes traumatic brain
injury and other)




cares (feeding, bathing)
C. Definition of Rancho Levels III through V for Neurological Insult Patients. The Inpatient
Daily Care Level 5 Neurological Insult charge applies to Rancho Level IV or V, or Level
III patients that are rapidly progressing and require frequent monitoring as they move
toward a Level IV. Definitions of each level are as follows:
1. Level III - Localized Response
a. Patient reacts specifically but inconsistently to stimuli.
b. Responses are directly related to the type of stimulus presented as in head
turning toward a sound, or focusing on an object being presented.
c. The patient may withdraw extremity and/or vocalize when presented with
a painful stimulus.
d. Patient may follow simple commands in an inconsistent, delayed manner,
such as closing his eyes, squeezing or extending extremity. Once external
stimuli are removed he may lie quietly.
e. The patient may also show a vague awareness of self and body by
responding to discomfort by pulling at NG tube, catheter or resisting
restraints.
f. The patient may show a bias towards responding to some persons,
especially family or friends, but not to others.
2. Rancho Level IV - Confused, Agitated Phase
a. Heightened state of activity with severely decreased ability to process
information
b. Agitated or aggressive behaviors that are not related to any specific stimuli
c. Intense behavior attempts to remove tubes or restraints, or crawl out of bed
d. Performs functional activities with maximum assist or cueing
e. Gross attention to the environment is short and attention span is poor or
non-existent
f. Poor short term memory and often unaware of present events
g. Verbalization is frequently incoherent and/or inappropriate to the
environment
h. Repeated attempts to wander if physically mobile

POLICY & PROCEDURE





Effective Date:
August 1, 2016

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
9.06

Original
Revision

Page 3
Of 5

Title: Criteria for Inpatient Daily Care Level
5 Charge Patients Who Have Sustained a
Neurological Insult (Includes traumatic brain
injury and other)




i. May require a patient safety attendant
3. Rancho Level V Confused, Inappropriate, Non-Agitated Phase
a. Appears alert but responses are non-purposeful or inconsistent
b. Agitated or aggressive behavior that is related to a specific stimuli
c. Gross attention but lacks ability to focus attention without frequent re-
direction
d. Memory impairments with confusion of past and present events
e. Perform functional activities with moderate assistance
f. Repeated attempts to wander if physically mobile
g. May require a patient safety attendant
III. PROCEDURE
A. Upon Admission:
1. If patient meets the criteria section listed above then they should receive an
Inpatient Daily Care Level 5 – Neurological Insult charge until such time as the
charge criteria is no longer met. The admitting nurse will communicate to the
Health Unit Coordinator (HUC) the need to implement the Level 5 daily care
charge. The HUC will enter the Level 5 accommodation code into Health Link
(HL) in order to change the daily care charge. The correct accommodation code
must be entered into the HL system before midnight on the day of admission in
order for the patient to receive the charge applicable to the first day of the stay.
2. It is the responsibility of each Nurse Manager to specify which staff member is
accountable for charge entry when a HUC is not working. Generally, the task of
assuring correct charges are reflected in the system will be assigned to either the
Care Team Leader or the admitting Nurse when a HUC is not available. The
assigned staff member is responsible for entering the Level 5 accommodation
code into Health Link.
3. The defining criteria for a level 5 Neurological Insult charge will be available 24/7
on uConnect for use by staff.
B. Days following admission date:
1. The Level 5 Neurological Insult charge will be evaluated for appropriateness on
each Day shift following admission, and will be discontinued when the patient no

POLICY & PROCEDURE





Effective Date:
August 1, 2016

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
9.06

Original
Revision

Page 4
Of 5

Title: Criteria for Inpatient Daily Care Level
5 Charge Patients Who Have Sustained a
Neurological Insult (Includes traumatic brain
injury and other)




longer meets the charge criteria listed above. The nurse assigned to the patient
will communicate with the Health Unit Coordinator (HUC) when the Level 5
Neurological Insult charge should be discontinued. To discontinue the Level 5
charge will require changing the accommodation code to General Care.
2. It is the responsibility of each Nurse Manager to specify which staff member is
accountable for charge entry when a HUC is not working. Generally, the task of
assuring correct charges are reflected in the system will be assigned to either the
Care Team Leader or the admitting nurse when a HUC is not available. The
assigned staff member is responsible for entering the Level 5 accommodation
code into Health Link.
C. Daily Patient Charge Review
1. On a daily basis, the Manager or Manager’s delegate (e.g. Care Team
Leader/Senior Team Member (STM) or Health Unit Coordinator) is responsible
for reviewing all active charges before midnight and for assuring that all patient
charges are correct for the midnight charge capture. Data pertinent to the daily
care patient charges can be found in either the home page patient list or the unit
census snapshot report in Health Link.
2. On a daily basis, the Manager or Manager’s delegate (e.g. Care Team
Leader/STM or Health Unit Coordinator) must review the Daily Activity Journal
report (DAJ) which lists all charges posted for a patient the previous midnight. A
comparison of the DAJ with the unit census snapshot run for the previous 24
hours will be conducted. Any patient charge errors discovered as a result of this
review will be corrected immediately. If the patient is not yet discharged,
corrections can be made in Health Link by the unit staff. If the patient has been
discharged by the time the error is discovered, the unit staff will notify the
Admissions Department. Admissions will then correct the charge error when
feasible to do so.

IV. AUTHORED BY
A. Director, Nursing Finance & Staffing Effectiveness


POLICY & PROCEDURE





Effective Date:
August 1, 2016

Administrative Manual
 Nursing Manual
 Other _______________

Policy #:
9.06

Original
Revision

Page 5
Of 5

Title: Criteria for Inpatient Daily Care Level
5 Charge Patients Who Have Sustained a
Neurological Insult (Includes traumatic brain
injury and other)




V. REVIEWED BY:
A. Director of Nursing Finance and Staffing Effectiveness, June 2016
B. Nurse Managers F8/4 Neuro ICU, D6/4 Neurosciences, & F4/4 Surgical Trauma, June
2016
C. Director of Surgical & Psych Nursing, June 2016
D. Director of Pediatric Nursing, June 2016
E. Nursing Administrative Policy & Procedure Committee, July 2016

SIGNED BY:
Beth Houlahan, DNP, RN, CENP
Senior Vice President Patient Care Services,
Chief Nursing Officer