Utilizing Utilization Management Nurses for Length of Stay Management

Alvin Gore, MD

Like many health systems nationwide, mine has also struggled with managing our patients’ length of stay (LOS). By now, multidisciplinary or interdisciplinary rounds have become the de facto standard for more efficient LOS management. These rounds usually include attending physicians, case managers, social workers, nursing (either bedside or lead/charge nurses), as well as representation of other disciplines such as physical/occupational therapy, pharmacy, palliative service, chaplains, etc. On occasion, even Clinical Documentation Integrity nurses join, as well. However, one glaring segment that has been absent from the rounds is participation of utilization review nurses (UM RNs).

Following the COVID-19 pandemic, many services have moved off-campus into remote domain or have centralized their services into a single hub serving a number of facilities. Similarly, our UM RNs moved offsite and began working remotely. The idea of creating virtual huddles using UM RNs was born as an additional tool in our LOS management arsenal. Our rationale takes into consideration the unique perspective UM RNs provide compared to unit-based case management nurses. Specifically, UM RNs zero-in on patients’ medical management needs as they typically know the medical record in greater depth than the case managers, who frequently are too busy with a multitude of phone calls and other duties as related to the discharge planning process and care transitions.

Our rounds began initially as a daily, one-hour virtual call run by a Utilization Management manager along with the Case Management director and physician advisor participating in the call. We decided to concentrate on the Diagnosis-Related Group (DRG) payors’ cohort with actual length of stay (ALOS) > 5 days. This cutoff was chosen arbitrarily, and other institutions may come up with their own filters and cutoffs. The UM RNs succinctly present their patients using a scripted template, concentrating on the medical needs and the discharge barriers from the UM perspective. Real-time escalations take place during the huddles – usually the Case Management director reaching out to the unit-based case managers and physician advisors reaching out to the appropriate clinicians (physicians, nurse practitioners, physician assistants, etc.).

Our experience with these rounds has been positive for uncovering unique barriers which case managers might not notice, such as need for a prompt antibiotic plan from an infectious disease physician, testing which could be performed as an outpatient following discharge from the hospital, delays in surgery schedules, needs for simplifying parenteral medication regimens, and others. Many of these issues can either be addressed definitively in real-time or discussed for further consideration and resolution.

As our UM rounds have evolved and their impact has been proven, we decided to reduce the frequency to a Monday/Wednesday/Friday cadence. However, all participants agree that these rounds have resulted in a meaningful impact on LOS reduction.

Dr. Alvin Gore is Director of Utilization Management at St. Joseph's Health System and Physician Advisor Survey Champion for the American College of Physician Advisors.