Conference Notes 4-2-2013

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EM-Peds Case Review

Protected Discussion but the following were take home points:

Don’t be squeamish about putting in an IO line.  Tell parents it is an IV in the bone.  If the kid is sick and no IV in 2 sticks then put in an IO.  Easy/safe/effective.

Also consider hydration through G-tube if one is present until you have IV access.

Give kids their maintenance meds while in the ER if their stay is prolonged. 

Contact PICU early and be careful to effectively convey the acuity of the situation.  The physician on the recieivng end of the  phone naturally tends to interpret the acuity as lower than it actually is.  You can always have the ED attending contact the PICU attending to ask for evaluation/help managing  the patient in the ED.

Parents of chronically ill kids may downplay the severity of the child’s illness. They are so used to recurrent problems they may underestimate the level of their child's acuity.  Be cautious of this phenomenon and  stick with your instincts and carefully consider the patient’s vital signs. 

Be very attentive to a patient with a heart rate over 180 or with grunting respirations.   These are two of Dr. Roy’s red flags.  

In ill appearing febrile kids, give empiric antibiotics early and often.

Give stress dose IV steroids  for ill kids with risk for adrenal insufficiency. 

 Fort/Herron                    Oral Boards

Case 1:  Near Drowning/Hypothermia   Critical actions: External rewarming, CXR to eval for aspiration, Observe for developing pneumonia.   Initial CXR in these situations can be normal and evolve. 

Case 2:  Pt with non-specific complaints who is found to be a victim of Domestic Violence    Critical actions:  Wade through patient's nonspecific complaints and Ask patient about possible domestic violence, check UCG, recognize depression, give tetanus shot, consult social services.    Domestic violence can affect all socio-economic groups.   Common presenting times are nights and when male partner is distracted by things like super bowl and march madness.   Need to offer social worker services. Pt can refuse.  In Illinois, You don’t need to report to police if pt does not want her case reported.    Elise comments: Very controversial issue.  Reporting can cause harm to patient.  In California EP’s are mandated reporters  and this can be problematic. It can potentially leave patient in a very vulnerable situation.  In Illinois, don’t report If patient does not want you to.  We are not mandated reporters in Illinois. For Oral boards, 2 rules of thumb: all kids have been abused and all women are pregnant or abused.

Case 3:  Ecclampsia resulting in low speed MVC    Critical actions: Identify that the patient is pregnant, give Magnesium for seizures, Evaluate for traumatic injuries. 

Collander/ Barounis comment: Ecclamptic patients should all probably get CT scans of the head.

Harwood comment:  If a patient is shivering then they have mild hypothermia and they will be fine. If they aren’t shivering they have severe hypothermia and need more aggressive warming.   Neuromuscular blocking with paralytics will stop the muscular manifestations of a seizure but they will still be seizing in their brains.  You can’t just treat patient with paralytics.  Gotta  give them some anti-epileptic and probably also monitor with an EEG tracing to make sure seizure has been halted.  

Barounis/Collander comment: In a hypothermic patient, if tachycardia is present you have to consider some other pathologic process in addition to hypothermia ,like toxic ingestion.  Isolated hypothermia should make a patient bradycardic.  

Sayger /Katiyar/McGurk  Critical Care Billing and Coding

85% of EP pay comes from level 1-5 codes.

We generally are under-documenting critical care time.

Critical care is defined by medicare as patients that are hypotensive, Impairment of one or more vital system functions ,require prolonged bedside physician care, or are dying or at risk of dying.   Examples: afib with rvr, stroke, sepsis, ICU admits.  ICU admission is not required for critical care billing.  Examples of non-icu admitted  critical care would be severe asthma or CHF that has improved to the point of floor admission.  McGurk comment: If patient is discharged home it is unlikely they will bill for critical care.  Harwood and Katiyar comment: STEMI’s should be billed as critical care.   Mistry comment: You have to document clearly how you provided critical care.  You have to be do this right in case you get audited.  Your % of critical care patients should probably not exceed 5%.  Altman comment: Medicare can clawback your billings and potentially prosecute you criminally for potential jail time.   So you gotta make sure you are doing this right.   

Katiyar comment: we should be billing critical care better because critical care is the core of our specialty and what we feel is the most important.  The RVU’s for critical care are much more than the levels 1-5.

A lot of EP’s don’t bill critical care because we consider much critical care we do routine care.

Key documentation: critical illness/injury, high complexity decision making, total critical care time exclusive of billable procedures.   Sayger comment: you can’t just list results.  You have to document some analysis and interpretation of results and clinical care provided.

Mcgurk comment: Say in your note, “I spent X minutes providing critical care for this patient”

Discussing care decisions with family members of an unresponsive patient can be included in critical care time.  This discussion needs to be documented.  Simple updates of patient’s status do not count for critical care.  Harwood comment: discussion of a LET form would count as critical care.

Medicare Audits of charts look at severity of illness, documentation, high complexity decision making and time claimed.

 History limitation on top of first net charts, in effect, acts as EM caveat for the chart.

Permar    5 Slide Follow Up

12 day old male infant with HR=250.  EKG with narrow complex tachycardia.  Vagal maneuvers: ice, rectal temp had no effect.    Adenosine worked only transiently.    Echo at bedside showed structurally normal heart.  IV Amio drip started and pt converted within 30 minutes.  Pt had recurrent SVT in ICU and a procainamide drip was started in addition.  Next step would have been cardioversion but this wasn’t needed. Dose for cardioversion is 1-2J.  Dose for defibrillation is 2-4J.  Dx was persistent junctional reciprocating tachycardia.   This arrhythmia can be troublesome to convert.  Pt dc’d home on oral amiodarone.

SVT usually has a heart rate >220. 

Hemming  5 Slide Follow Up

34 yo male with back pain.  Urinary incontinence.  Pt had weakness and decreased sensation in bilat lower extremities.  

Main diagnosis considered was Cauda equina syndrome : urinary retention, saddle anesthesia (buttocks/perineum),  60-80% of patients have decreased sphincter tone.  Pt’s have variable motor  findings in lower extremites.

 

Pt had no canal stenosis on MRI.  His symptoms resolved spontaneously within 2 days. 

Signs of Non-organic back pain: inappropriate tenderness, pain with simulated axial loading, distraction signs, neuro findings not corresponding to neuro disease, over-reaction during physical exam.  

Girzadas comment: Be very cautious chalking findings up to psychiatric disease.  The EP’s job is to evaluate for organic cause of back pain.

Harwood comment: This patient should have gotten a psychiatric consult for this second visit. 

Herrmann comment: Check for urinary retention with ultrasound when considering cauda equina syndrome.

Altman comment: Use the Illinois narcotic prescription history online.   It is very helpful to decide how to manage the patient.