4 Goals Exceptional Care Customer Loyalty Financial Strength
Comprehensive, acute care hospital including emergency, heart, and women’s services Established in 1982 Member of St. David’s HealthCare and Hospital Corporation of America (HCA) 5
South Austin Medical Center was built in 1982 Many people did not see the need for a hospital “south of the river” Original planning meetings held at Hill’s Café The Goodnight family, local business owners, were very supportive and instrumental in the construction of the hospital 6
Blood Cancer Treatment &Bone Marrow Transplant Robotic Surgery Freestanding Emergency Departments Urgent Care Clinics Wound Care/Hyperbaric Services Sleep Lab Transfer Center 7 Hospital Services
Currently has approximately 40 beds Observation area (called Fast Track) In 2008, a helipad was constructed immediately adjacent to the ED to receive critically ill and/or injured patients 8
In 2010, SAMC had the busiest ED in Austin, with over 73,000 visits annually Patients receive care based on a triage system The majority of hospital admissions come through the ED Major SAMC goal is to reduce wait times in ED and the time to release or admit patients 9
Triage stationWalk-in and ambulance entrances
Several areas dedicated to surgical patients Orthopedic patients Post surgery patients Oncology patients Patients with illnesses All floors have telemetry or heart monitor capability if required by patients (except L&D) 12
Levels of care ICU – Intensive care unit (2 nd floor) IMC – Intermediate care unit (7 th floor) Full telemetry monitoring is done on these patients, according to their needs 14
Patient room with telemetry equipment
Nurses stationFamily waiting area
Heart–related areas include Cardiac cath labs and Outpatient Heart Center Special procedures area and EP Lab CVRU (Heart-related ICU) on 4 th floor Two open-heart operating rooms This unit has 8 beds 17
Procedure room & telemetry
Digital Mammography SuiteX-Ray Machine
27 Chief Medical Officer: Al Gros, MD Chief of Staff: Robert Northway, MD Chief of Staff-Elect: Alex Esquivel, MD Secretary: David Savage, MD Medical Staff Leadership Dr. Al Gros CMO, South Austin Medical Center Office: (512) 816-6112 Mobile: (512) 294-7064 Fax: (512) 816-7278 Email: Albert.Gros@stdavids.com
Physician PI Coordinator Variance Reports Patient Complaints Failed Measures Fall-out from Screens Prof. Liability Actions Employee Complaints Compliance Issues Action Clinical Issue: Competence, Core Measures, Outcomes Indicator 'Fall-outs' Department Compliance / Social Issue: (i.e., Complaints, Non-compliance, Behavior) Egregious Event: (incl. Sentinel Events, In-House Physician Quality Issues) Rapid Review Team Medical Director / Vice Chief of Staff MCEC (Chief Medical Officer) MEC (Chief of Staff) BOT Triage (Med Dir & PIC) Sentinel Events Peer Review Process Approved by MEC 2/08
31 OPPE & FPPE Review
Core Measures AMI (Acute Myocardial Infarction) HF (Heart Failure) PN (Pneumonia) SCIP (Surgical Care Improvement Project)
SCIP Core Measures SCIP INFECTION QUALITY INDICATORS Prophylactic Antibiotic Received within 1 Hour of Incision (2 hrs for Vancomycin or fluoroquinolones) Recommended Prophylactic Antibiotic Selection for Surgical Patients Prophylactic Antibiotics Discontinued within 24 Hours After Surgery End Time (48 hrs for Cardiac Surgery) Cardiac Surgery Patients with Controlled 6 A.M. Post-op Serum Glucose (<200 mg/dL) post-op day 1 & 2 Surgery Patients with Appropriate Hair Removal (no razors) Urinary Catheter Removed on Post-op Day 1 or 2 Surgery Patients with Perioperative Temperature Management (active warming intraoperatively or one body temp. > 96.8o within 30 min. prior to 15 min. after Anesthesia End Time) 33
SCIP Core Measures SCIP VTE QUALITY INDICATORS Recommended Venous Thromboembolism Prophylaxis Ordered anytime from hospital arrival to 24 hrs after Anesthesia End Time Recommended Venous Thromboembolism Prophylaxis within 24 Hours Prior to Anesthesia Start Time to 24 Hours After Anesthesia End Time SCIP CARDIAC QUALITY INDICATOR Surgery Patients on Beta Blocker Therapy Prior to Admission Who Received a Beta Blocker During the Perioperative Period SCIP HEART FAILURE QUALITY INDICATOR ACEI or ARB Prescribed at Discharge for Patients with <40% LVEF 34
35 Physician and Patient Communication
36 Why Should You Care? A 2004 Harris Interactive poll of 2,267 U.S. adults showed that “patients place more importance on doctors’ interpersonal skills than their medical judgment or experience, and doctors’ failings in these areas are the overwhelming factor that drives patients to switch doctors.” Physician conduct and communication, not necessarily clinical outcomes, appear to be the principle predictors of malpractice risk.
HCAHPS Hospital Consumer Assessment of Healthcare Providers and Systems 37
38 HCAHP Survey Questions
39 Key Stakeholders The physician/patient interaction influences the patient’s experience and perception of care CMS surveys patient on physicians: –Treating with courtesy and respect –Listening carefully –Explaining things in a way patients can understand
40 Management Best Practices AIDET and Key Words Consistent approach to communication Acknowledge Introduce Duration Explanation Thank You Employee Forums Global communication and education Senior Leader visibility
41 Case for Service Communication skills can heavily influence patient compliance and will impact clinical outcomes Studies have demonstrated that when a physician is approachable, gives serious consideration to the patient’s concerns, and communicates well, better patient compliance is likely.
42 Case for Service Exceeding expectations with exceptional service keeps patients coming back. Loyal patients are greater revenue producers than acquiring new patients
43 Case for Service Physicians can improve staff morale, performance, and retention through: Investing in relationships Clear, constructive, respectful communication Specific reward and recognition Modeling behaviors consistent with the mission
44 RX Tool #1 – First Impressions Knock, then pause two seconds prior to entry Smile, shake hands, and introduce yourself to the patient and everyone in the room Sit and sustain eye contact LOOK as though you ENJOY what you do! Use a consistent opening dialogue for established and new patients that creates comfort and approachability with you. Tell patients about your training, your experience, and your personal approach to patient care.
45 RX Tool #2 – Exam Room Preparedness What you know and don’t know when you enter the exam room creates or undermines the confidence patients will have in you. Review interval events, consults, and what you did last prior to entering the exam room. Specifically reference your “plan” that was established during the prior visit. Communicate your awareness of interval medical events. Leverage the information available to convey you are attentive and aware of every element of their care.
46 RX Tool #3 – The Physician Exam Providing information on physician exam findings conveys thoroughness and a diligent effort to find the cause of a problem. Review your physical exam findings as you perform the exam. The more information you provide to patients about themselves, the greater value for the visit in the eyes of patients.
47 RX Tool #4 – Providing Patient Information Explanation of diagnosis and treatment is the most important element of the patient visit Effective communication improves recall of directions, compliance, and patient satisfaction. Every condition and plan must include a simple explanation. All explanations must be followed by query of the patients for their understanding. Ask patients to repeat the plan as they understand it to ensure their understanding and identify areas needing further explanation.
48 RX Tool #5 – Collaboration with Patients Establishing collaboration with patients improves compliance, outcomes, and patient satisfaction. Collaboration can be established by asking patients if they have any reservations or concerns in regard to a treatment plan. Collaboration is about specifically soliciting patient input regarding the treatment plan going forward.
49 RX Tool #6 – Patient Follow-Up All patients must leave a visit understanding exactly what it is that will happen next. Provide clear follow-up on the timing and purpose of patients’ upcoming visits. Provide information regarding the timing of laboratory and radiographic tests and how the results will get to the patient. Explain the purpose and timing for specialty consultation in terms of when, why, and who. Position specialty physician colleagues well.
50 Steps in Effective Service Recovery 1.Apologize 2.Let the patient speak 3.Validate 4.Correct the issue 5.Take action 6.Follow up with the patient
52 Medical Staff Meetings Monthly meeting calendars are posted on the MedWeb site, faxed, and e-mailed to members. Monthly meeting calendars are posted on the MedWeb site, faxed, and e-mailed to members. There is a 50% meeting attendance requirement for Active members in the departments of Medicine, Surgery, and Cardiology. There is a 50% meeting attendance requirement for Active members in the departments of Medicine, Surgery, and Cardiology. There is a 25% meeting attendance requirement at the quarterly General Medical Staff meetings for all Active members. There is a 25% meeting attendance requirement at the quarterly General Medical Staff meetings for all Active members.
53 Credentialing and Medical Staff Services St. David’s and HCA structure regarding credentialing St. David’s and HCA structure regarding credentialing Standardized market forms Standardized market forms Individual facility approvals Individual facility approvals Qualification: Board certification or obtained within 5 years of initial appointment. Certification must be maintained. Qualification: Board certification or obtained within 5 years of initial appointment. Certification must be maintained.
54 Physician Health Forms of Impairment Alcoholism and other drug use Other psychiatric disorders Addressed by the TCMS Physician Health and Rehabilitation committee
55 RED FIRE Hazardous Mat GRAY Tornado WHITE Disaster GREEN Evacuation Pull station/Extinguisher locations refer to safety charts/maps posted Rescue if possible Call Security with location of fire Activate alarm pull station Close doors & windows Identify fire doors & exits Evacuate if necessary If fire is in an adjacent department or above or below, respond with available staff with fire extinguisher Remain alert for further instruction or “ALL CLEAR” R.A.C.E. – rescue alarm, contain/confine and extinguish P.A.S.S. – pull pin, aim, squeeze and sweep the base of the fire Internal Clear the area/close doors Stop the leak/spill if it can be done safely Pull MSDS sheet Secure the area Call security with information Response team activated If there are victims, call ED Notify Director or supervisor Await further instructions External Direct patients to outside of ED – NO entry to facility Possible lockdown of facility Patients triaged and decontaminated Remain alert for further instruction or “ALL CLEAR” WATCH Directors/Supv alert all staff Check for supplies (flashlights, blankets, etc) Close blinds and drapes Ensure critical eqpt is plugged into red plugs Remain alert and listen for further instruction WARNING Close all doors Move away from windows, as much as possible Move patients to inner hallway Evacuate if necessary Remain alert for further instruction or “ALL CLEAR” Report back to your department PBX will page directors with instructions Assess staffing needs Hand carry staffing form to HR Assess bed availability & other resources (blood, food, water, etc) Refer to staffing chart and assume your assigned role Remain alert for further instruction or “ALL CLEAR” Partial Evacuation Supervisor completes quick head count of staff Report to your department if able. If not evacuate down, never go up Remain alert and listen for further instruction Total Evacuation Supervisor completes quick head count of staff All available staff report to nearest clinical area to assist evacuate to designated staging area, ambulatory patients go first Take medical records if possible Do not re-enter unless told to BLACK Bomb PURPLE Threatening Person YELLOW Person Down CODE ADAM Abducted Infant DR. LEO/CODE BLUE Cardiac Arrest Get all info you can from caller Try to keep caller on line while someone else calls Security Refrain from alarming patients and visitors DO NOT use cell phones or radios Search areas for anything suspicious, if found DO NOT TOUCH – call Security with exact location of object If object found, evacuate area When area has been searched and cleared, call Security Remain alert for further instruction or “ALL CLEAR” Call Security DO NOT attempt to challenge or disarm individual Remain calm and maintain eye contact and talk to individual NEVER attempt to physically restrain or remove by yourself When response team arrives relay information Remain alert for further instruction or “ALL CLEAR” Call Security with exact location of person down Remain with the person until response team arrives Relay information Assist as needed Remain alert for further instructions Go to closest exit and prevent anyone from leaving until help arrives Report suspicious people to security If you see a person with an infant that looks suspicious, STOP THEM, or follow them and call for help If possible check outside doors Remain alert for further instruction or “ALL CLEAR” Call the Code based on your Facility (Dr. Leo/ Code Blue) Call Security Bring the Crash Cart to the site If properly trained, begin CPR (check patient for consciousness etc.) Each facility has a designated Code Team If not assigned to Code Team, clear the area and manage traffic Have patient’s chart available SPECIFIC SIGNALS - ISOLATED EVENTS SPECIFIC SIGNALS - GENERAL SIGNALS SAFETY CODES
Physician Satisfaction Team The SAH Physician Satisfaction Team commits to partner with the medical staff to improve the environment in which they work. We will strive to ensure that the highest level of service is consistently provided to the physicians. We will act as a liaison to foster open communication and will recognize our physicians as valued partners in the delivery of healthcare. MVP of the Quarter Doctors’ Day Celebration Veterans’ Day Celebration Direct Physician Concerns to appropriate leaders 56
Clinical Information Systems Information Systems Access: Meditech hCare Portal Decide which type of training will work for you Web-based training (WBT) One-on-one sessions Or a combination of training methods Collect all of your clinical system passwords Plan to attend a training session to set up your account 57
Electronic Medical Record (EMR) What is the Clinician Portal? Physician electronic access point for clinical information Integrated systems Simplified sign-on—one username, one password Simplified Remote Access – no more tokens User-friendly, intuitive interface Access to complete patient list Resources section Clinical references Training modules Facility-specific information Accessible from hospital, home, office, or while traveling 58 For questions about Incomplete Deficiencies- please contact Health Information Management at 816-6308 For questions about Portal or access- contact the help desk at 901-HELP or Ryder Bodoin at 632-1618
59 Meditech (Clinical Patient Care System) √ PCI (Patient Care Inquiry) LAB, RAD, PATH and HIM reports √ Demographic/Insurance Info. √ Access from hospital, office or home √ Physicians MUST write Consult Orders so consulting physician will have access to the patient √ Electronically sign dictated reports remotely √ Software provided by the hospital for remote installation Physician Help Desk #: 901-4357 (HELP) Physician Help Desk #: 901-4357 (HELP) Obtain Access, Schedule Training, & Report Problems 24/7 service
60 Health Information Management Hours of Operation Hours of Operation Monday-Friday 8:00 am to 4:30 pm. Dictation Dictation Timeliness Requirements Electronic Health Record and Chart Completion for Physicians Select Dictation
Privacy and Security Terms and Definitions PHI -Protected Health Information (Any information that can be linked to a patient) Name Address Dates (i.e. birth date, admission date, discharge date, etc.) Phone numbers; Fax numbers; Social security number; Medical record number; Health plan beneficiary number; Account number; Certificate/license number; Vehicle identifier and serial number; Device identifiers and serial numbers; URLs; Internet protocol addresses; Biometric identifiers (e.g.; fingerprints); Full face photographic and any comparable images; Any other unique identifying, characteristic, or code; and Any other information about which you have actual knowledge that could be used alone or in combination with other information to identify the individual 61 Health Information Management HIPAA – Heath Insurance Portability & Accountability Act (est. 1996) HITECH – Health Information Technology for Economic & Clinical Health (est. 2009).
Need to Know (Only access information that is needed for your job and only sharing sensitive and confidential information with other that’s have a need to know and are directly involved in the care of the patient.) Minimum Necessary (access, use or disclose the minimum information necessary to perform his or her designated role regardless of the extent of access provided to him or her.) De-Identify (Health information that does not identify an individual and with respect to which there is no reasonable basis to believe that the information can be used to identify an individual) Pass code Policy (Release of information to a patient’s immediate family member, other relative, or a close personal friend of the patient, or any other person to whom the patient has given his or her password (numeric code provided to patient at Registration). Sensitive Information: information that poses a significant or financial harm/risk to the patient. Examples: protected health information, social security numbers, employee human resources files) and restricted data (e.g., cardholder information, company passwords Breach: Unauthorized acquisition, access, use, or disclosure of unsecured, unencrypted protected health information which compromises the security or privacy of such information and poses a significant risk of financial, reputational, or other harm to the individual. Wrongful Disclosure – wrongful release of protected health information (PHI) to an unattended recipient outside of our covered entity. Example: Faxing records to a church fax line instead of the attended physician office. Office of Civil Rights – OCR (Governing body for HIPAA & HITECH) 62 Health Information Management Privacy and Security Terms and Definitions
Health Information Management Privacy and Security Safeguarding Information Safeguarding= (Reasonable steps to protect PHI) Following ‘need to know’ guidelines Employing ‘Minimum Necessary’ standards Verify documents are for the correct individual prior to providing services or releasing documentation. Not removing PHI from the facility Releasing of PHI = (Appropriate means for disclosing PHI) Utilization of the Pass code Policy Obtaining a valid authorization for uses and disclosures outside of treatment, payment, and healthcare operations. Refer these requests to the Health Information Management Department. (also see SAMC authorization on e-demand ) Verbal Disclosure Verifying appropriate audience (i.e. receive patient consent prior to discussing PHI in front of family members). * Clinicians should not assume the patient has agreed to have PHI verbally shared in front of their family members, friends or other visitors just because the patient did not request these individuals to leave when the clinician began speaking. Closing Curtains in semi-private locations Use low voices & do not discuss PHI in public areas Verifying identity when speaking via phone When leaving messages do not disclose PHI or diagnostic information. You can however leave your name, callback number, purpose for the call (e.g. “to discuss his or her treatment results”) 63
Health Information Management Privacy and Security Safeguarding Information Accessibility Chart handling Chart must not be left unattended in public areas Chart must not be readily available for unauthorized viewing (i.e. any customer, employee or physician without need to know) Electronic Access Screens/Monitors must be positioned away from direct view of general public Privacy screens should be used in areas accessible to the public Passwords must not be displayed or viewable Must log-out or lock workstation when leaving unattended (especially in public areas such as corridors and patient rooms) Disposing securely Documents must be shredded or disposed of in designated container. FISO – Facility Information Security Officer = Covers Security (“Access to”) – e.g. Passwords, Encryption, Portable Media, etc. SAMC FISO is Richard Lear – firstname.lastname@example.org; 816-7336 FPO – Facility Privacy Officer = Covers Privacy (“Appropriateness of Access”) – e.g. ‘Need to know’, ‘Minimum Necessary’, Confidentiality, SAMC FPO is Barbara Howard – email@example.com 816-7138 Custodian of Medical records – HIM Director/FPOrichard.firstname.lastname@example.org@stdavids.com 64
65 Health Information Management Notification ProcessNotification Process Deficiencies color coordinated in portal for your convenienceDeficiencies color coordinated in portal for your convenience BLUE: Incomplete 0-15 daysBLUE: Incomplete 0-15 days RED: Warning 16-29 daysRED: Warning 16-29 days YELLOW: Delinquent 30+ daysYELLOW: Delinquent 30+ days Notification and Suspension letters are faxed to physician offices every Wednesday, as a courtesy only.Notification and Suspension letters are faxed to physician offices every Wednesday, as a courtesy only. Coding Query ProcessCoding Query Process Process Incompletes by selecting Process or Process All Process Incompletes by selecting Process or Process All Queries are presented as Missing Text deficiencies Press the PgUp key or click Page 1 to reference the coding question
66 Unacceptable Abbreviations Intended Meaning Misinterpretation Expected Action UUnits O, “4” Write out entire word “Units” IU International units Misread as IV (intravenous) or the number 10 Use the word “units” Trailing Zero (i.e. 1.0 mg) 1 mg Misread as 10 Do NOT use trailing zeros after a decimal point Lack of a leading zero 0.1 mg Misread as 1 or 11 mg ALWAYS use a zero before a decimal point MSMSO4MgSO4 Morphine sulfate or magnesium sulfate Confused for one another. Can mean morphine sulfate or magnesium sulfate Write “morphine sulfate” or “magnesium sulfate” Q.D., q.d., qd Q.O.D, q.o.d, qod “Daily” and “every other day” Mistaken for each other. The period after Q can be mistaken for an “I” or the “O” can be mistaken for an “I” Write “daily” and “every other day”
Insufficient, Incomplete, or Illegible Documentation How ’ s this patient doing? Good! Dated & Timed Understand the Plan? What is the medical complexity of this visit for billing?
Accurate Documentation Precise and detailed documentation reflects the complexity of our patients and the excellent care we provide Helps prevent HAC and RAC recoupment Improves physician and hospital profiles (MEDPAR, Healthgrades, CMS, etc.) Comply with CMS rules and regulations Receive proper reimbursement through correct MS DRG assignment
Physicians Note DRG classification is not only for purposes of reimbursement… But captures the documentation necessary for quality of care analysis and mortality predictions for both you…and the hospital!
Keep in Mind: Accurate representation of patients helps to justify cost, length of stay, and mortality statistics Coders have rules to follow. They cannot assume anything – they must code from what the physician has actually documented. Coders cannot use information from telemetry strips, lab reports, radiology reports, pathology, diagnostic reports, or nursing/ancillary notes for coding. The physician must address these findings in the medical record.
Clinical Documentation Liaisons’ Role Concurrently review Medicare charts and query physicians for documentation clarification prior to patient discharge Provide education to physicians and appropriate clinical staff about documentation improvement methods as indicated Bridge the gap between clinical language and coding language
Physician Role Focus on patient care Review any education from CDLs and apply to documentation Respond to all inquiries from CDLs - Appropriate, timely responses will prevent post-discharge queries from the coders - Physicians do not need to agree with the inquiries, just respond
Clinical Language vs. Coding Language
APR DRG Medical diagnoses and procedures are used to determine a patient’s APR DRG (All Patient Refined Diagnosis Related Group) – includes Severity of Illness (SOI) and Risk of Mortality (ROM) sub-classes There are 4 sub-class levels for SOI and ROM: - Level 1: Minor- Level 3: Major -Level 2: Moderate- Level 4: Extreme SOI and ROM are driven by secondary diagnosis.
Secondary Diagnoses Definition – conditions that are monitored, evaluated and/or treated during the hospital stay. Three classes: ▪ Major complications and comorbidities (MCC) ▪ Complications and comorbidities (CC) ▪ Non-complications and comorbidities (NCC) MCCs and CCs affect the DRG assignment The difference between an MCC, CC and NCC can be the specificity of documentation
Be as specific as possible… ● Congestive Heart Failure Acuity – acute, chronic, acute on chronic Type – systolic, diastolic, combined Please indicate both the type and acuity of CHF, if it is unknown please indicate that it is unknown. When type and acuity is determined, after testing, please make this note the chart. ● Malnutrition Acuity – mild, moderate, severe Type – protein, protein calorie, marasmus, other unspecified ● Anemia Specific type and cause – acute blood loss anemia, iron deficient anemia, chronic blood loss anemia, anemia due to chronic disease, aplastic, etc. ● Hypertension Essential, benign, accelerated, malignant FYI – hypertension “urgency” or “emergency “ both code to plain hypertension
More Tips… ● Home medications Please provide corresponding diagnoses for ordered home medications. Remember that secondary diagnoses show the complexity of each patient and can affect SOI/ROM. ● Catheter associated UTIs (CAUTI) Coders and CDLs are instructed to query for CAUTI anytime a UTI is diagnosed after a Foley catheter has been placed. This applies both to newly placed Foleys and chronic Foleys/suprapubic catheters. Please document whether or not the UTI is associated with the Foley. ● T he attending physician is the one who will be queried for clarification even if the conflicting documentation originated from a consultant or partner. Once discharged, the coder will query the discharging doctor. ● Positive cultures (e.g. blood, urine, wound, respiratory) Please link the organism to the infection (e.g. E coli UTI, MRSA sepsis, Pseudomonas pneumonia). Please indicate the location of pressure ulcers and wounds as well as their etiology. Coders can take stages of wounds from nursing documentation.
Tips to Prevent a Renal Failure Query ACUTE: ARF = acute renal failure AKI = acute kidney injury ARF = AKI to coders ARI = acute renal insufficiency = disorder of kidney and ureter to coders ARI ≠ ARF to coders ARI ≠ AKI to coders CHRONIC: CRI = chronic renal insufficiency CRF = chronic renal failure CKD = chronic kidney disease CRI = CRF = CKD to coders If possible, please provide the stage of kidney disease. If not possible, please document that staging is being deferred at this time. CKD stage V = ESRD to coders Please document the stage of CKD. If unknown-document unknown and later when determined document stage.
More Sepsis Tips “Urosepsis” codes as “UTI.” The coder will query to clarify the doctor’s meaning of “urosepsis.” Septicemia or sepsis with a urinary tract source will code as sepsis as Pdx. Bacteremia due to a UTI will code as a UTI as Pdx. Please be specific-If a patient has a diagnosis of sepsis and a positive blood culture, link the sepsis to the organism – ex. Staphlococcal sepsis. Definitions of sepsis terms (in regards to coding): Bacteremia – positive blood cultures; there are no significant clinical symptoms; it will code to the underlying infection (not sepsis); physician can chart “bacteremia with sepsis (or septicemia or SIRS)” Septicemia – systemic disease associated with the presence of pathological microorganisms in the blood; the coder is advised to query for “sepsis” when the physician documents “septicemia” SIRS – systemic response to infection or trauma; not assumed to be sepsis Sepsis is SIRS due to infection
Up/Down Arrows From AHIMA Coding Clinic 1 st Quarter 2011: It is not appropriate for the coder to report a diagnosis based on up and down arrows. Diagnosing a patient’s condition is solely the responsibility of the provider. Up and down arrows can have variable interpretations and do not necessarily mean "abnormal." They could simply be indicating change (including improvement) over past results. Therefore the provider should be queried regarding the meaning of the arrows and request that the appropriate documentation of a condition or diagnosis be provided. For example, the coder cannot assume that “ ↑Na” refers to “hypernatremia” or “↓Mg” refers to “hypomagnesemia.” The entire word must be written at least once in the record. Subsequent documentation can contain up/down arrows.
End of Life Issues Please clearly state the cause of death in your final progress note and/or death summary. Please document “comfort care”, “hospice,” “end of life care,” or “palliative care” when further aggressive treatment is no longer appropriate and treatment is focused only on relieving pain and discomfort. Please document secondary diagnosis such as coma, malnutrition, agonal respirations, shock, malnutrition, pressure ulcers. These require nursing care and monitoring and very often will affect the patient’s SOI and ROM calculation.
Malnutrition Malnutrition is most simply defined as any nutritional imbalance. People can suffer from overnutrition or undernutrition. Malnutrition is a major contributor to increased morbidity and mortality, decreased function and quality of life, increased frequency and length of hospital stay, and higher health care costs.
On admission many critically ill patients, especially elderly patients, already are, or may be at significant risk of developing malnutrition and its related complications due to inflammation and or infectious process.
Old Malnutrition Query Form. The old malnutrition query form focused on protein / albumin levels. “Research analysis indicated that these acute phase proteins do not consistently or predictably change with weight loss, calorie restriction, or nitrogen balance. They appear to better reflect severity of the inflammatory response rather than poor nutritional status. These lab tests, while probable indicators of inflammation, do not specifically indicate malnutrition and do not typically respond to feeding interventions in the setting of active inflammatory response; therefore, the relevance of these acute phase proteins as indicators of malnutrition, is limited. “ A.S.P.E.N.
New Malnutrition Query Effective September 2013 Since there is no single parameter that is definitive for adult malnutrtion, identification of two or more of the following six characteristics is recommended for diagnosis: Insufficient energy intake Wt loss Loss of muscle mass Loss of subcutaneous fat Localized or generalized fluid accumulation that sometimes masks weight loss Diminished functional status as measured by hand grips. A.S.P.E.N. Albumin and prealbumin may still be used as an “other clinical indicator”.
Questions? Please feel free to contact a Liaison. We are onsite Monday through Friday. Betsy Woodhouse RN 512-816-6357 Betsy.Woodhouse @StDavids.com Shawnalee Huskey RN 512-816-6043 Shawnalee.Huskey@StDavids.com Juan Patino, RN 512-816-6422 Juan.email@example.com
Infection Prevention Hand Hygiene – Most important tool in preventing infections. We follow WHO guidelines for Hand Hygiene: Both before and after touching patient Before performing clean/aseptic procedure After touching patient’s surroundings After body fluid exposure Can use alcohol based hand sanitizer except in following circumstances: Hands visibly soiled or patient has/or is suspected of having C. difficile infection. MUST use soap and water. Mechanical action removes spores from hands.
Isolation Precautions Standard Precautions used for all patients. Contact precautions for those entities spread by direct or indirect contact: MRSA, VRE, C. diff, and other MDRO’s including ESBLs, localized Shingles, MDR Pseudomonas and MDR Acinetobacter baumanii. Must wear gown and gloves when entering patient room. Droplet precautions for patients suspected or infected with diseases spread by large particle droplets: Meningococcal (Neisseria) meningitis, influenza, Pertussis, and Mumps. Must wear surgical mask. Airborne precautions prevent the spread of infectious droplet nuclei which remain suspended in the air: TB, Chicken Pox, disseminated Shingles and Measles. N-95 mask and negative pressure room.
Preventing Device Related Infections Bundles help ensure care on a consistent basis IHI (Institute for Healthcare Improvement) Bundles *Central line Bundle includes use of insertion checklist* 1. Hand Hygiene 2. Maximum barrier precautions during insertion 3. Use of CHG 4. Optimal site selection-AVOID femoral in adults 5. Daily review of necessity- REMOVE unnecessary lines
Preventing Device Related Infections Ventilator Associated Pneumonia 1. Elevate head of bed 30 degrees, if possible maintain during transport. 2. Daily sedation vacation-assess readiness to extubate. 3. Peptic ulcer prophylaxis 4. DVT prophylaxis unless contraindicated 5. Oral care- including tooth brushing and CHG rinse
Preventing Device Related Infections Foley Catheter Associated Urinary Tract Infections 1. Daily review of need-OUT as soon as possible 2. Sterile technique for insertion. 3. Maintain closed drainage system. 4. Drainage bag below level of bladder at all times, even during transport. 5. Secure catheter to prevent migration. 6. Daily catheter care.
What are Hospital Acquired ConditIons (HACs)? Required by the Deficit Reduction Act (DRA) of 2005. The Hospital-Acquired Conditions payment provision is a step toward Medicare VBP for hospitals Conditions that are: high cost or high volume or both; result in the assignment of a case to a DRG that has a higher payment when present as a secondary diagnosis, and could reasonably have been prevented through the application of evidence based guidelines. Infection RelatedPatient Safety Mediastinitis after coronary artery bypass graft (CABG) surgery Falls and fractures, dislocations, intracranial and crushing injury and burns Vascular catheter-associated infectionsPressure ulcers Catheter-associated urinary tract infection *Surgical site infections*Glycemic Control *Ventilator-associated pneumonia*DVT/Pulmonary embolism
“Serious Preventable Adverse Event” Policy Intra operative or immediate post operative death of ASA Class I patient Wrong site/ body part surgery Wrong patient surgery Wrong procedure surgery Death or disability associated with device use other than as intended Death or disability associated drugs, devices, or biologics contaminated during use Suicide or attempted suicide with disability while in facility Death or disability due to elopement Discharge of infant to wrong person Death or disability due to spinal manipulative therapy Stage 3 or 4 pressure ulcers, not present on admission or a result of multi-system organ failure Death or disability due to kernicterus Retained foreign object during surgery Death or disability from hypoglycemia with onset while a patient Maternal Death or disability associated with labor and delivery Death or disability due to hemolytic transfusion reaction Death or disability due to medication error Death or disability related to restraints Death or disability from fall Death or disability due burn Wrong gas delivered to patient Death or disability due to electric shock Death or significant injury of patient or staff member due to physical assault Physical or sexual assault within or on facility grounds Abduction of patient Care ordered by or provided by person impersonating a licensed healthcare provider
Vascular Catheter-Associated Infection Diagnosing Short Term Catheter Infections in AdultsCDC/NHSN Surveillance Criteria CLABSI For patients with suspected CRBSI: Collect blood cultures prior to initiating antimicrobial therapy. Two peripheral venous blood cultures (separate sticks) are preferred over paired blood samples drawn from the catheter and a peripheral vein. Do not routinely culture catheter tips on removal unless there are clinical signs and symptoms for infection. Interpretation of Culture Results A definitive diagnosis of CRBSI requires: The same organism grow from at least 1 percutaneous blood culture and a quantity of >15 colonies from the catheter tip. Paired blood cultures, either from two peripheral separate sticks or one drawn from a catheter hub and the other from a peripheral vein, growing the same organism in a patient with clinical signs and symptoms and no other recognized source. Growth of >15 colony-forming units (cfu) from a 5-cm segment of the catheter tip by semiquantitative (roll-plate) culture from short-term nontunneled catheters, without a positive peripheral blood culture, is not diagnostic by itself, and likely a contaminant. If a catheterized patient has a single blood culture that grows coagulase-negative Staphylococcus species, then draw additional paired blood cultures from the catheter and peripheral site to be certain that the patient has a true bloodstream infection and that the catheter is the likely source. If any organism, pathogen or skin contaminant grows from the line only and the venous culture is negative, this probably represents hub contamination. Treatment for CRBSI Empiric antimicrobial coverage should be reevaluated when culture and susceptibility data are available and de-escalation of the antibiotic regimen can be done. Criteria 1: Patient has a recognized pathogen cultured from one or more blood cultures (at least one bottle), and organism cultured is not related to another site of infection. Recognized pathogen excludes organisms considered common skin contaminants Criteria 2: Patient has at least 1 of the following signs or symptoms: fever (>38 o C), chills or hypotension AND signs and symptoms and positive laboratory results are not related to an infection at another site AND common skin contaminant is cultured from 2 or more blood cultures (at least one bottle from each set) drawn on separate occasions within two days of each other. Organism sameness is defined by speciation or descriptive name, with or without antimicrobial susceptibility results Purulent phlebitis confirmed with a positive semi-quantitative culture of a catheter tip, but with either negative or no blood culture is considered a vascular infection CVS-VASC, not a BSI.
Catheter-Associated UTI (CA-UTI) Diagnosing Catheter-Associated Urinary Tract InfectionsCA-UTI in Adults Patient has at least one of the following signs or symptoms with no other recognized cause: Fever (>38°C or 100.3°F) new onset or worsening Altered mental status Malaise or lethargy Flank pain Pelvic discomfort / costovertebral tenderness Acute hematuria Or where catheters have been removed within the previous 48h: Urgent or frequent urination Dysuria Suprapubic pain or tenderness AND Patient has a positive urine culture, that is >=10 3 microorganisms per cc of urine of one or more bacteria species. ADDITIONAL TREATMENT INFORMATION Neither presence of pyuria nor cloudy or odorous urine, in a catheterized patient, should be interpreted as a need for urine culture or antimicrobial therapy. Absence of pyuria in a symptomatic patient suggests a diagnosis other than CA-UTI. 7 day tx duration for CA-UTI when symptoms promptly resolve. 14 day tx duration for CA-UTI with a delayed response Consider 5 days of Levofloxacin in CA-UTI when patient is not severely ill Consider 3 day tx duration in women age 65 years and less that develop CA-UTI without upper urinary tract symptoms after an indwelling catheter has been removed. Antimicrobial prophylaxis with systemic or irrigation agents is not recommended Important: Accurate documentation helps to assure correct coding and billing. Please use these guidelines to assist with documentation and treatment.
97 Case Management Department In existence at since early 1996 In existence at SAMC since early 1996 Drives the discharge process Drives the discharge process Coordinate the care across the continuum, services and resources for patients/families Coordinate the care across the continuum, services and resources for patients/families Education of patient/family regarding continuum of care Education of patient/family regarding continuum of care Conduct concurrent insurance reviews Conduct concurrent insurance reviews Plans and implements discharges with the interdisciplinary team Plans and implements discharges with the interdisciplinary team Consists of both RNs & Social Workers Consists of both RNs & Social Workers
98 Your Role in Case Management Interqual Criteria Interqual Criteria Code 44 Code 44 Keeping the case manager informed of plans for the patient Keeping the case manager informed of plans for the patient Communication with case manager is key to timely discharge/movement to next level of care Communication with case manager is key to timely discharge/movement to next level of care Daily discharge of patients by 11:00 a.m. Daily discharge of patients by 11:00 a.m. Case Management Office. 816-6260 Blackberry. 517-4342
99 Spiritual Care – Ethics Mark Elder, Director Mark Elder, Director SDSAMC employs professional chaplains SDSAMC employs professional chaplains Available 24/7 Available 24/7 Provide information and assistance with Advance Directives Provide information and assistance with Advance Directives Bioethics Committee is co-chaired by a physician and chaplain. Meets quarterly. Bioethics Committee is co-chaired by a physician and chaplain. Meets quarterly. Responsible for bioethical consults, education, and policy recommendation. Responsible for bioethical consults, education, and policy recommendation. Texas Organ Sharing Alliance Texas Organ Sharing Alliance DNR Order Sheets DNR Order Sheets Digital Pager #512-205-1881, Office #512-816-7198
Nursing Structure Led by the Chief Nursing Officer – Sally Gillam Over 700 nurses employed Each nursing unit consists of a Nursing Unit Director, Nursing manager, Unit Supervisors, and unit shift charge nurses Support staff to include Patient care Technicians and unit clerks on each unit
Service Lines SAMC consists of major service lines: Emergency Department Surgical Services Medical Surgical/Telemetry Women Services Oncology
Nursing Units/Representation 2 North/Post partum Labor & Delivery NICU Tina Mendiola 2 Central Noel DeSapio 3 Central 5 Central Rick Claycamp
3 South 4 Central Tricia Casler ICU CVRU IMC Toni Fuller 6 th Floor - Oncology Nursing Units/Representation
24/7 Nursing Representation The House Supervisor is available 24/7 by calling 68888 The House Supervisor is the Air traffic controller, aka Bed Czar, and is responsible for all patient placement and transfers All incoming and outgoing will be through the House Supervisor The House Supervisor in addition to each nursing floor charge nurse is available to assist with anything
105 Physician Relations The Physician Relations Director is here for you! To help you get to know the facility, where things are and how processes work Help you with special requests, issue resolution, answer questions Help you meet other physicians in the area Physician Referral Line CME/Grand Rounds Kathryn Scoblick, Physician Relations Director 512-816-6113 512-897-0661 (cell)
106 Educational Programs Medical Grand Rounds Medical Grand Rounds Ethics Credit Ethics Credit CPR/ACLS Education CPR/ACLS Education Tumor Board Conferences Tumor Board Conferences
107 Admissions & Central Scheduling Hospital‘s Main Number 447-2211 Central Scheduling Main 816-7340 Central Scheduling Physician's Line 816-7464 Hours: 7:30 to 5:30 pm (After hours, contact the Operating Room or House Supervisor) Registration/Admissions 24hrs/7day #816-7116 Director of Patient Access: Beverly McFarland 816-7112 House/Nurse Supervisor 816-7109 Physician's Direct Line to PBX operators 816-7497
One Call Patient Transfer Center OneCall Patient Transfer Team is comprised of Registered Nurses, Paramedics, and EMTs, all with critical care experience available 24 hours a day St. David’s HealthCare OneCall Patient Transfer Center is your one stop, one call resource for: Emergency Transfers or Direct Admits Specialty Consults IP admissions from physician office and/or referring hospitals for patients who need a higher level of care Facilitation of ground and air transport Housed at SDM at East 30 th St. 108
One Call Patient Transfer Center To Transfer a Patient: 1)Call 1888-989 8985 2)The One Call Patient Transfer Team will ask for basic patient information including: Patient’s Name Referring Doctor/Hospital Reason for Transfer 109
110 Thank you for taking the time to view this orientation program. We want your experience at St. David’s South Austin Medical Center to be the best in the city and we want to be your #1 facility of choice for your patients.