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Emily Parrish
6 years ago
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The Emergency Department: How CDI in the ED Is Crucial to a Successful CDI Program Victor Freeman, MD, MPP, AHIMA Approved ICD 10 CM/PCS Trainer Regional Medical Director JA Thomas

(a part of Nuance Communications) Burlington, Massachusetts 2 Learning Objectives At the completion of this educational activity, the learner will be able to: List three key CDI

1 The Emergency Department: How CDI in the ED Is Crucial to a Successful CDI Program Victor Freeman, MD, MPP, AHIMA Approved ICD 10 CM/PCS Trainer Regional Medical Director JA Thomas & Assoc. (a part of Nuance Communications) Burlington, Massachusetts 2 Learning Objectives At the completion of this educational activity, the learner will be able to: List three key CDI concepts that need to START in the ED Describe the importance of the ED as the site of first (hospital) patient presentation and documentation Explain the importance of the ED in documenting medical necessity for the admission Discuss how ED care often changes the diagnostic picture Identify special ED issues related to managing MCOtargeted diagnoses 3

2 Successful CDI Ideally STARTS With Capturing ALL the ACTIVE diagnoses that are POA: ALL the acute and chronic diagnoses; ALL the surgical and medical diagnoses; That are active at the time of the decision to admit PLUS capturing ALL those active diagnoses Using codable terminology (i.e., as ICD 9/ 10 codes); Supported by clinical criteria/judgment documentation; Followed by appropriate treatment (or monitoring) And having active AND resolved Dxs consistently carry through the medical record, to the discharge summary 4 Successful CDI Ideally STARTS With Partnering with utilization review To ensure documentation of medical necessity Partnering with quality reporting To capture severity of illness Partnering with patient safety To identify preexisting (POA) conditions and risks 5 Successful CDI Ideally STARTS With A good transition from ED to inpatient bed Documentation flow from ED to attending doc A good transition between attendings Documentation consistency and follow up Mutual clinician support in documentation From consultants, nurses, dietitians, therapists 6

3 WHY the ED Is Crucial to CDI 7 ED: First Patient Presentation Site Need caregiver pre arrival clinical info If patient = poor historian, dementia, speech issues May have to rely on EMS report First responders, who assess & treat May have to rely on facility report Nursing home, assisted living, rehab site 8 ED: First Patient Presentation Site The most important pre arrival information for patients with dementia/cognitive/speech issues Is the patient at their mental baseline? If the patient is NOT at their mental baseline, do a workup for encephalopathy ED nurse AND physician/pa/rnp MUST be trained to ask and ALSO to do the follow-up 9

4 ED: First Patient Presentation Site Other important pre arrival info for patients Medications/drugs Toxic encephalopathy(?) Drinking Hx Wernicke s encephalopathy(?) Blood pressure Hx HTN encephalopathy(?) Diabetes Hx Metabolic encephalopathy(?) Renal disease Also metabolic due to Ca/Mg/Phos derangements Commonly, the most reliable/accurate clinical information comes from direct caregivers 10 ED: First Patient Presentation Site Altered mental status = common doctor speak Nothing more than a clinical descriptor Encephalopathy = Diagnosis (MCC) Comes with an etiology AND treatment plan Remember: Encephalopathy is a new term SOUNDS scary! (like encephalitis ) 11 ED: First Patient Presentation Site Is the patient at their mental baseline? Key question in ED nurse/clinician protocol EMS should be trained to ASK caregivers Remember: Cognitive status may change en route Should be standard in facility transfer report Provides a clear clinician s assessment of patient 12

5 ED: First Patient Presentation Site ED clinicians need to know KEY clinical criteria SIRS criteria >>> Sepsis (early, severe, shock) RIFLE (KDIGO) criteria >>> Acute kidney injury egfr criteria >>> Chronic kidney disease Hypoxia/hypercapnia >>> Acute resp. failure (or the documentation clinical signs/symptoms) Home O 2 >>> Chronic respiratory failure Train the ED clinicians to recognize key diagnoses or POST the criteria to remind/prompt documentation 13 ED: First Patient Presentation Site Key CDI diagnoses need to become the standard language of the entire ED staff Nurses, ED clerks, allied health providers Key CDI diagnoses need to become the standard language of EMS reports First responders are an extension of the ED staff Key CDI diagnoses need to become the standard language of the community MDs 14 ED: First Patient Presentation Site (EMS) Hospitals need a working relationship w/ EMS First responder reports: Key for capturing Dxs EMS needs to assess/report initial observations Initial signs & symptoms point to specific Dxs EMS needs to report all treatments/responses Treatments can change ED clinical presentation 15

6 ED: First Patient Presentation Site (EMS) Key initial signs & symptoms Sweats/lethargy Infection? Fever, hypotension, tachy HR/RR SIRS? SOB Acute respiratory failure? Unable to get up Acute kidney injury? CP/sweats Acute coronary syndrome? Ideally, ED staff will teach EMS to report using codable terms, signs, & symptoms 16 ED: First Patient Presentation Site (EMS) Key conditions that change w/ EMS treatment Acute respiratory failure Oxygen Sepsis/septic encephalopathy IV fluids Acute renal failure IV fluids Acute coronary syndrome Nitroglycerin Insulin shock (Severe hypoglycemia due to insulin overdosing) EMS Rx = IV / SL dextrose/sugar Ideally, ED staff will learn to document the EMS vitals/reports and treatment to support acute diagnosis capture 17 ED: First Patient Presentation Site (Other) Ideally, the ED, CDI, discharge planning staffs will collaborate to work with the community to standardize Rx/prob lists With other local hospitals (uniformity) For local ICE initiatives (uniformity) For patients/families (discharge forms) For clinics/medical offices (direct admits) Facilities (for patient transfers) 18

7 ED: First Patient Presentation Site (Other): Special Notes on Facility to ED Transfers 19 ED: First Patient Presentation Site (Other) Working relationships with facilities is KEY Need standardized acute diagnosis reporting Need standardized chronic diagnosis reporting Need standardized risks/injuries reporting Ideally, standardization is done with other hospitals and is communitywide 20 ED: First Patient Presentation Site (Other) Standardize acute condition reporting Sxs, oxygen sat > Acute resp. failure Fever/hypothermia, elev. HR/RR > Sepsis (Sxs ABOVE +) hypotension > Severe sepsis Drop in urine output > Acute kidney injury Acute (abnormal) signs/symptoms checklist: Nausea/vomiting, acute pain/tenderness, redness, bruising, motor/sensory deficits 21

8 ED: First Patient Presentation Site (Other) Standardize chronic condition reporting Dx, O 2 suppl., CO 2 ret. > Chronic resp. failure Base BUN/creat., GFR > Chronic kidney disease Diastolic/systolic/combo > Chronic heart failure Vasc. vs. non vasc. > Dementia (aggress/depress) Chronic (abnormal) Sxs vitals labs checklist: Breathing patterns, RR, HR (P Afib) [EKG], BNP, electrolytes, glucose, Hct/Hgb, LFTs, pancr. tests 22 ED: First Patient Presentation Site (Other) Standardize risks/injuries reporting Aspiration precautions > Aspiration pneumonia Fall precautions > Injury, stroke, infection Wander precautions > Dementias/sundowning Periodic straight urinary catheterization > UTI Chronic/known injuries or physical issues: Functional quadriplegia (!), plegias, pareses, bruises/tender areas, ulcers (sites types/stages) 23 ED: First Patient Presentation Site (Other) Learn SNF/rehab documentation needs for making an ED to SNF/rehab transfer Short term (IV antibiotics, ADL support) Medium term (strengthening, ADL support) Long term ( Failure to thrive admission) (Also called admit for placement ) Be sure to talk with clinical leaders AND the CFO about any transfer barriers 24

9 ED: Most Common Site for Admission: Discharge vs. Observation vs. Admission 25 ED: Most Common Site for Admission With the new (dreaded) TWO midnight rule, good documentation for medical necessity AND the ED to admitting clinician report becomes a crucial intra hospital transfer Problems: Special issues: Who decides pt. disposition? ED physicians tend to document, order, report using chief complaint or simple diagnoses Tensions between ED physicians and admitters (ED = Liability if DC d vs. admitter = Why inpt.???) 26 ED: Most Common Site for Admission Who decides the patient s disposition? ED physician? Writes holding orders/sends pt. Admitting clinician? Comes to ED to see pt. Partnership? Discuss and agree on plan ED physician decides if the patient needs hospitalization vs. discharge? Admitting clinician decides if the patient needs observation vs. admission? 27

10 ED: Most Common Site for Admission ED physician language: Chief complaint Part of physician TRAINING = Patient s words Often is just a symptom (e.g., chest pain, SOB) or a simple diagnosis (e.g., UTI, cellulitis) Gets carried through to reason for admission, orders, report to admitting physician Ideally, ED physicians will put greater emphasis on reporting the worrisome manifestations of the chief complaint or the simple diagnosis 28 ED: Most Common Site for Admission Examples of manifestations of disease Acute respiratory failure due to pneumonia Toxic encephalopathy due to medication reaction Sepsis due to cellulitis REMEMBER: Probable, likely, & presumptive are acceptable terms = Definitive coding 29 ED: Most Common Site for Admission Manifestations + diagnoses is much more compelling in ED report to admitting doc Highlights severity of illness as POA Becomes FIRST location for coder ID of diagnosis Prompts admitter to include BOTH diagnoses REMEMBER: Documenting manifestations + clinical criteria/judgment + treatment plan = Best way to capture medical necessity (also dangers of DC/why hosp. needed/risks) 30

11 ED: Provides Stabilization/Initial Care: How the ED Changes the Diagnostic Picture 31 ED: Provides Stabilization/Initial Care Admitting clinicians do NOT want to use the ED physicians diagnoses May feel that the diagnosis was never present May feel the diagnosis is something else May feel the diagnosis is resolved Admitting physicians must learn that their documentation MUST include all care from the ED until time of patient discharge 32 ED: Provides Stabilization/Initial Care Diagnosis was NEVER present The ED probable, likely, presumptive diagnosis should have clinical criteria/judgment support, BUT if it is something else, simply document: Eliminated [ED diagnosis] based on these NEW [clinical findings/interpretations of old findings] Admitting physicians should keep track of these diagnosis changes to give constructive feedback to the ED medical staff it s OK to change a Dx 33

12 ED: Provides Stabilization/Initial Care Diagnosis is something else The ED probable, likely, presumptive diagnosis should have clinical criteria/judgment support, BUT if it is something else, simply document: Eliminated [ED diagnosis] and now believe the Dx to be [new diagnosis] based on these NEW [clinical findings/interpretations of old findings] Admitting physicians should keep track of these diagnosis changes to give constructive feedback to the ED medical staff it s OK to change a Dx 34 ED: Provides Stabilization/Initial Care Diagnosis is now resolved I didn t see it, so I am NOT documenting it! The ED probable, likely, presumptive diagnosis should have clinical criteria/judgment to support, AND if Dx was active at time of the DECISION to admit the patient, it needs to be documented Admitting physicians must learn to document Per ED physicians, THEY saw [active ED Dxs] and did [ED treatments] [Resolved/ing Dxs] are resolved/ing, and I will do [X] to follow up 35 ED: Provides Stabilization/Initial Care ED diagnoses can be key in capturing coding for medical necessity/severity of illness ED diagnoses should be carried through the medical record and listed in the DC summary ED treatment does NOT negate ED diagnoses Remember: A patient who looks comfortable on a 100% non rebreather mask after nebulizer Rx is STILL an acute respiratory failure patient 36

13 Setting Up a CDI Program in Your ED: Special Issues to Consider 37 Setting Up CDI in Your ED Requires key leader buy in and a good plan: C suite support: Are the CEO/COO, CNO/CMO, CFO all on board for the investment time/money? Key groups: Are HIM, utiliz. review, case mgmt. all on board for coordination/snf outreach? Plan: Behavioral change model = Awareness, knowledge, skills, motivation, reinforcement 38 Setting Up CDI in Your ED Awareness: Hosp/physician profiling + value based purchasing requiring physicians do a better job of capturing ALL acute & chronic Dxs in codable terminology ED is NOT doing all that it can to help the hospital and fellow medical staff capture key diagnoses With CDI training, protocols, and partnerships with EMS/SNFs the ED can actually LEAD the way! (And without a lot of added staff time/effort) 39

14 Setting Up CDI in Your ED Motivation: Message must come from medical staff leaders: ED physicians, we NEED you to lead the way we need to have medical staff protocols BOTH for better Dx capture and mgmt of key pt types! We want to foster better communication/coor. between ED docs and admitting docs. We want to ensure that your needs/perspectives (e.g., liability, ED throughput, cooperation, respect) are fully acknowledged/addressed in this process. 40 Setting Up CDI in Your ED Knowledge/skills: ED physician training: What works best for THEM? Overview/intro CDI training, posters/pocket cards, real time EMR CDI alert on (pending) admits. ED nurse + social worker/utiliz. rev., case mgmt.: Key CDI issues in working with families & SNFs. EMS and SNF collaboration: Meet their needs too! EMS loves clinical educ. to improve communication AND SNFs have financial, staffing, communication concerns regarding transfers to and from SNF. 41 Setting Up CDI in Your ED Reinforcement: ED physician training: What works best for THEM? Clinical feedback on presumptive diagnoses, ED group feedback on successes/opportunities, recognition & praise for their CDI contributions. ED nurse + social worker/utiliz. rev., case mgmt.: Recognition & praise for their CDI contributions. EMS and SNF collaboration: They are people too! Recognition & praise for their CDI contributions. 42

15 Special Issues: How the ED Is Crucial to Hospital CDI 43 ED: Special Issues With the throughput pressures in many EDs, it is important to establish protocols to ensure followup on key diagnoses: While the ED can call heart failure acute/chronic, the admitting team may need to determine if it is systolic vs. diastolic vs. combined Acute kidney injury does need follow up orders, e.g., I&Os, repeat renal labs, hydration (Mod. sev.) protein calorie malnutrition does need consult by dietitian (special documentation/plan) 44 ED: Special Issues With payers targeting many Dxs for denials, it is important for the medical staff to develop internal protocols for managing targeted Dxs: Syncope/dizziness: Hydration, rapid W/U, in OBS Chest pain: Low risk + TWO neg troponins OR low HEART score for maj. cardiac event >>> DC Ambul. care sensitive Dxs/freq. re admitters: Next morning appointments with clinics/offices (especially the homeless, mental health pts.) 45

16 ED: Special Issues With payers targeting many Dxs for denials, it is important for the hospital to develop protocols for managing targeted Dxs: Weakness/FTT: Identify 2 MNs of treatable diagnoses or develop protocol ED to SNF placement UTI needs IV antibiotics: Develop protocol ED to SNF short term transfer Do your local SNFs take evening/weekend (afternoon) transfers? WHY NOT? What documentation do the SNFs NEED? 46 Special thanks to Heritage Valley Health System (Beaver/Sewickley, Pennsylvania) It was my study of CDI in their emergency departments that became both the insight and inspiration for this ACDIS presentation. 47 Thank you. Questions? Victor.Freeman@Nuance.com In order to receive your continuing education certificate(s) for this program, you must complete the online evaluation. The link can be found in the continuing education section at the front of the program guide. 48

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