Transcript Capturing Shock in the ICU Setting

Capturing Shock in the ICU Setting
Cindy Pritchett, RN, BSN, CCDS
CDI Specialist
Medical City Dallas Hospital – HCA
Dallas, TX
Objectives
• Participants will be able to:
– Differentiate shock types and treatment
modalities
– Identify clinical indicators and treatments for
shock that trigger queries
– Review specific “shock” cases that resulted in
successful query generation
– Review the importance of relationship building
with intensivists
– Discuss strategies to capture mid-level
involvement in CDI programs
Shock: What Does It Look Like?
• The main symptom of shock is low blood
pressure
Shock Types
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Anaphylactic
Cardiogenic
Hemorrhagic
Hypovolemic
Neurogenic
Septic
Anaphylactic Shock
• Cause
– Allergic response
• Treatment
– Antihistamines
– Epinephrine
– Steroid
– Severity
– CC
See sample at: http://anaesthesiatoday.blogspot.com/2010/03/anaphylaxis-extreme-hypersensitivity.html
Cardiogenic Shock
• Cause
– Damaged heart
• Treatment
– Address underlying
cause
• IABP
• Vasopressors
– Severity
– MCC
Courtesy of 3DScience.com
Hemorrhagic Shock
• Cause
– Blood loss
• Treatment
– Blood/blood products
– Severity
– MCC
Courtesy of 3DScience.com
Hypovolemic Shock
• Cause
– Fluid loss
• Treatment
– Fluid replacement
– Severity
– MCC
Neurogenic Shock
• Cause
– Spinal cord injury
• Treatment
– Immobilization
– Anti-inflammatories
– Severity
– MCC
• Cause
– Anxiety
• Treatment
– Anti-anxiety/psychotropic
medications
– Severity
– None
Understanding Sepsis
Terminology
• Infection
• Bacteremia
• SIRS (systemic inflammatory response
syndrome)
• Septicemia
• Severe sepsis
• Septic shock
SIRS
• Systemic disease manifested by 2 or more of
the following conditions:
– T >100.4ºF or < 96.8ºF
– HR > 90
– Resp > 20 or CO2 < 32
– WBC >12,000 or < 4,000 or > 10% immature
(band) forms
SIRS
• SIRS (systemic inflammatory response
syndrome) 995.90 due to:
– Infectious processes 995.91
– With organ dysfunction 995.92
– Noninfectious process 995.93
– With acute organ dysfunction 995.94
SEPTICEMIA
• Acute illness associated
with pathogens in blood
– Positive blood cultures
not required
– Does not mean sepsis
Courtesy of 3DScience.com
Sepsis
• Documented infection with 2
or more SIRS indicators
present without organ
dysfunction
– T > 100.4ºF or < 96.8ºF
– HR > 90
– Resp > 20 or CO2 < 32
– WBC >12,000 or < 4,000
or > 10% immature (band)
forms
Courtesy of 3DScience.com
Severe Sepsis
Sepsis with
Organ dysfunction
– ARDS
– ARF
– Encephalopathy
– Hepatic Failure
– CHF
– DIC
Hypoperfusion
– Oliguria < 30 cc/hr
– Hypoxemia PaO2 < 75 mm
Hg on room air
– Lactic acidosis pH < 7.35
Or Hypotension
– SBP < 90
Courtesy of 3DScience.com
Septic Shock
• Sepsis-induced
hypotension in the
presence of perfusion
abnormalities
Courtesy of 3DScience.com
Septic Shock
• Cause
– Bacterial agent(s)
• Treatment
– Antibiotics
– Fluids
• Clinical indicators
– Temperature > 100.4ºF or <
–
–
–
–
–
96.8ºF
Leukocytosis > 12,000
Leukopenia < 4,000
Tachycardia
Hyperventilation
Metabolic acidosis (pH < 7.35)
Courtesy of 3DScience.com
Coding Clinic Q2 2000, p. 3
Sepsis ‘Progression’
SIRS (CC)
Systemic disease with at least 2
clinical indicators – can be
noninfectious cause
SEPTICEMIA (MCC)
SEPSIS (MCC)
SEVERE SEPSIS (MCC)
SEPTIC SHOCK (MCC)
Acute illness associated with pathogens
in blood
Documented infection with 2 or more
SIRS indicators present
Sepsis with organ dysfunction,
hypoperfusion, or hypotension
Sepsis-induced hypotension in the
presence of perfusion abnormalities
Other Shock Types
Type
Severity
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Hypotensive
Circulatory
Electrical
Hypoglycemic
Postoperative
Unspecified shock = CC
MCC
None
DM II w/ coma = MCC
non-DM w/ coma = CC
• Following trauma and
surgery specific = MCC
nonspecific postop = CC
Shock as the PDx
Shock should not be
coded as PDx when a
related definitive
condition is present.
Symptom code can be
sequenced first if it is
followed by 2 or more
comparative/contrasting
diagnoses.
Screen capture of the 3M™ Coding and Reimbursement System provided with
written permission from 3M. © 3M 2011. All rights reserved.
Septic Shock Coding Guidelines
For all cases of septic shock, the code for
the systemic infection should be sequenced
first.
Coding Clinic Q2 2000, p. 3
Ex: Septic shock due to bacterial peritonitis
Assign 038.9 for unspecified Septicemia as PDx
Assign 567.29 for Other suppurative peritonitis
Assign 995.52 for Severe Sepsis
Assign 785.52 for Septic Shock
Coding Sequencing
POA – septic shock, respiratory failure, influenza,
pneumonia
– 038.9 Unspecified Septicemia (PDx)
– 482.2 Pneumonia due to H. influenzae
– 995.92 SIRS due to infectious process
– 785.52 Septic Shock
– 518.81 Acute respiratory failure
– 96.72 Other continuous mech vent > 96 hours
– 410.71 AMI
– 96.04 Insertion of ET tube
Coding Septic Shock
Coding sequence for septic shock & E. coli
septicemia:
• 038.42 Septicemia due to other gram-neg orgs,
E. coli as PDx
• 995.92 for SIRS
• 785.52 Septic Shock as secondary diagnosis
Other ‘Shocked’ Organs
Shock kidneys
Shock liver
Shock lung
ATN – acute tubular
necrosis
Severity = MCC
Alll images courtesy of 3DScience.com
↑ AST & ALT
Severity = MCC
ARDS – adult respiratory
distress syndrome
Severity = CC
Case Study
• 78/M s/p balloon aortic
valvuloplasty
– Pleural effusion
– Atelectasis
– CKD III
– Metabolic alkalosis
– Pulmonary edema
• Respiratory distress 4
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•
•
•
days postop –
reintubated
IV antibiotics initiated/
pan-cultured
SBP dropped 80s–90s
Levophed initiated
CXR “moderate right
and mild left basilar
atelectasis/edema/pneu
monia present”
Documented after intubation
Respiratory failure
? PNA
Shock Query
“Based on your clinical judgment, can you specify the
diagnosis (cardiogenic shock, septic shock,
hypovolemic shock, unspecified shock, other more
appropriate diagnosis) for the below abnormal clinical
findings and associated treatment plan?”
Clinical indicators:
•
•
•
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SBP 80–90s
Initiation of Levophed
HR 100s
WBC 12.0
DRG Impact
With CC
Screen capture of the 3M™ Coding and Reimbursement System provided with
written permission from 3M. © 3M 2011. All rights reserved.
DRG Impact
With MCC
Screen capture of the 3M™ Coding and Reimbursement System provided with
written permission from 3M. © 3M 2011. All rights reserved.
Mortality Rate Impact
To Query or Not to Query
67/M admitted with:
• PICC infection
• Chronic systolic heart
failure
• SBP 40–50s day #3
• Vasopressin/dopamine
initiated
• Catheter tip + SC Neg
• WBCs 13.5
MD documented “suspect
cardiogenic vs.
hypovolemic shock.”
Screen capture of the 3M™ Coding and Reimbursement System provided with
written permission from 3M. © 3M 2011. All rights reserved.
Case Review
74/F with aortic stenosis s/p
balloon aortic valvuloplasty
dropped SBP into 70s on
POD #3. Vasopressin
initiated. All cultures negative.
WBCs normal. Temp 100.2.
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–
–
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Chronic resp failure
Acute blood loss anemia
Hyponatremia
Bilateral infiltrate – on
Cefthiazone
Post-event MD documented
– Hypotensive shock
– Pneumonia
Screen capture of the 3M™ Coding and Reimbursement System provided with
written permission from 3M. © 3M 2011. All rights reserved.
Case Review
75/M admitted with AF/RVR who underwent a
cardiac catheterization. Subsequently developed
ischemic bowel requiring an exploratory lap.
Patient dropped SBP into 70–80s leading to
initiation of vasopressin.
“Suspect drop in BP is volume related.”
Query MD for shock
Case Review
67/M admitted with pneumonia, confusion, and
hypotension (SBP 70s) received Levophed in the
emergency department. Attending queried for
shock based on above.
CDIS
Case Review
91/F admitted with hypotension, bradycardia, and
acute bronchitis. BP on admit in ED was 62/37.
Dopamine was initiated. Urine culture showed +
Citrobacter freundii > 100K. IV antibiotics initiated.
Blood cultures negative. Patient afebrile with
normal WBCs.
Relationship Building –
Intensivists
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Physician champion
Rounding/one-on-one education
Tools
Onboarding education
JIT training
Sharing data
Case-specific improvement opportunities
Medical staff meetings
Praise/edification
Successful Investment
76/M with aortic stenosis underwent BAV with IABP
insertion. SBP 70s with initiation of vasopressin. Med
weaned after IABP inserted. Patient remained on vent.
Cardiogenic shock and respiratory failure
Patient experienced postop bradysystolic arrest
cardiac arrest
What the Future Holds
3 codes
• 038.9
• 995.92
• 785.52
ICD-9-CM
Unspecified septicemia
Severe sepsis
Septic shock
2 codes
• A41.9
• R65.21
ICD-10-CM
Septicemia, unspecified
Severe sepsis with septic shock
References
• Haik, MD, William, Understand Clinical Terminology and Indications of
Sepsis, HCPro, Inc., 2008.
• Wedro, Benjamin, MD, FACEP, FAAEM, “Shock.” Available online at
www.emedicinehealth.com/shock/article_em.htm
• Heligan, MD, Patrick, Critical Care Medicine Tutorials: What is infection,
sepsis, SIRS, septic shock, septicemia, MODS? Available online at
www.ccmtutuorials.com/infection/sepsis/page3.htm
• Coding Clinic, Fourth Quarter 2003, pp. 79–81, Septicemia and Septic
Shock Guidelines.
• Wiedemann, Lou Ann “Coding Sepsis and SIRS.” Journal of AHIMA 78, No.
4 (April 2007): 76.
• AHIMA audio seminar/webinar, December 11, 2008, “Coding Septicemia,
SIRS, and Sepsis.”
Questions?
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