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Archive for the ‘Pearls’ Category

M&M Tips March 2010

Tips from your diligent peer review committee.
1. When a patient has copious ongoing bleeding, and is hypotensive, consider giving blood. The blood bank can provide un-crossmatched blood very quickly if necessary.
2. When a patient who has a very low blood pressure requires intubation, consider improving the blood pressure prior to performing intubation, as the transition to positive pressure and pharmacologic sympatholysis that accompanies RSI often further depress blood pressure. Intravenous fluids and pressors are two strategies. Phenylephrine 10 mg/1 cc vials, are now available in both the adult and pediatric med rooms at Sinai.
3. In patients who require intubation but cannot be preoxygenated effectively, or in patients who require high minute ventilation to maintain physiologic pH, consider maneuvers to improve oxygenation/ventilation around RSI if an awake approach is not predicted to be successful. These maneuvers include BVM or NIV before, during, and after induction, perhaps using an LMA (after induction). Short laryngoscopy times and first pass success are more important in these patients – choose your approach and intubator accordingly.
Thanks to Dr. Holland Yang for her expertly-presented M&M yesterday.
Key points from the discussion:
* Aortic dissection is an uncommon but lethal, treatable disease associated with a steadily increasing mortality with every hour the diagnosis is delayed.
* Aortic dissection can be very hard to diagnose. 1 out of 3 cases do not have chest pain, and 1 out of 20 cases have no pain anywhere. 1 out 3 cases are first diagnosed on autopsy.
* Key risk factors include abnormalities of the aorta (connective tissue disorders, syphilitic aortitis, Takayasu arteritis) and aortic valve abnormalities (bicuspid aortic valve, valvuloplasty). The disease is also associated with hypertension (especially stimulant use and weightlifting) and pregnancy.
* The most important clinical presentations are pain in the chest and back, migratory chest/back/abdominal pain, and chest pain with a neurological deficit.
* Unusual combinations of symptoms, such as back or abdominal pain with a neurological deficit and symptoms on both sides of the diaphragm, should raise suspicion of the disease. Although not as well described, we have seen several cases at Sinai/Elmhurst where diarrhea (from bowel ischemia) was a prominent component of the presentation.
* In cases where the diagnosis is entertained but not ruled out with a definitive study (usually CT aortography), clinical decision-making to that effect should be documented. Charting a normal neuro exam and peripheral pulse exam implies thoroughness, though absence of findings with these maneuvers does not exclude the diagnosis.

Written by reuben

March 11th, 2010 at 3:12 pm

Posted in Pearls

Q Tips – March 2010

Tips from your diligent peer review committee.
1. When a patient has copious ongoing bleeding, and is hypotensive, consider giving blood. The blood bank can provide un-crossmatched blood very quickly if necessary.
2. When a patient who has a very low blood pressure requires intubation, consider improving the blood pressure prior to performing intubation, as the transition to positive pressure and pharmacologic sympatholysis that accompanies RSI often further depress blood pressure. Intravenous fluids and pressors are two strategies. Phenylephrine 10 mg/1 cc vials, are now available in both the adult and pediatric med rooms at Sinai.
3. In patients who require intubation but cannot be preoxygenated effectively, or in patients who require high minute ventilation to maintain physiologic pH, consider maneuvers to improve oxygenation/ventilation around RSI if an awake approach is not predicted to be successful. These maneuvers include BVM or NIV before, during, and after induction, perhaps using an LMA (after induction). Short laryngoscopy times and first pass success are more important in these patients – choose your approach and intubator accordingly.

Tips from your diligent peer review committee.

1. When a patient has copious ongoing bleeding, and is hypotensive, consider giving blood. The blood bank can provide un-crossmatched blood very quickly if necessary.

2. When a patient who has a very low blood pressure requires intubation, consider improving the blood pressure prior to performing intubation, as the transition to positive pressure and pharmacologic sympatholysis that accompanies RSI often further depress blood pressure. Intravenous fluids and pressors are two strategies. Phenylephrine 10 mg/1 cc vials, are now available in both the adult and pediatric med rooms at Sinai.

3. In patients who require intubation but cannot be preoxygenated effectively, or in patients who require high minute ventilation to maintain physiologic pH, consider maneuvers to improve oxygenation/ventilation around RSI if an awake approach is not predicted to be successful. These maneuvers include BVM or NIV before, during, and after induction, perhaps using an LMA (after induction). Short laryngoscopy times and first pass success are more important in these patients – choose your approach and intubator accordingly.

Written by reuben

March 11th, 2010 at 2:13 pm

Posted in Pearls

Scale for patients >350 pounds

is available on 10 East. Very portable, easy to use.


ED CT holds up to 450 pounds.

Written by reuben

August 4th, 2009 at 5:12 pm

Posted in Pearls

Corrective Action Plans

We have had several ED cases with poor outcomes over the past year that triggered root cause analysis and resulted in corrective action plans.  The following corrective actions directly or indirectly involve our ED practice. The department may be monitored by the state for compliance with these plans.

• New onset adult seizures, syncope, and chest pain will all be treated as if potential cardiac ischemia:  ECG within 15 minutes.

• Initial dosing of hydromorphone is 0.5 -1.4 mg, initial dosing of Morphine is 4 mg.

• Higher doses of pain medications may be given if there is a note in the chart documenting the medical reasoning for choosing a higher dose.

• More than 3 doses of IV pain medication in 3 hours should prompt a pain consult for consideration of PCA pump, or medical reasoning why there is no consult.

• All transfers of patients with thoracic aneurysm or dissection should be discussed with the MSH ED attending before transfer from another institution.

• CT surgery will use AMION for on call and chain of command contacts.  Non-compliance should be reported to Scot Hill.

• Consultants should respond by phone within 10 minutes, and be present within 30 minutes.  Non-response should trigger a call to the next higher level in the chain of command.

Written by phil

April 8th, 2009 at 7:16 pm

IV Flow Rates

standard pink IV:
20 gauge (.8 mm) x 30 mm angiocath
max flow rate = 60 ml / minute

standard green IV:
18 gauge (1 mm) x 30 mm angiocath
max flow rate = 105 ml / minute

standard grey IV:
16 gauge (1.3 mm) x 30 mm angiocath
max flow rate = 220 ml/min

procedural IV:
18 gauge x 64 mm angiocath
max flow rate = 85 ml/min

medial (blue) & proximal (white) lumen of triple lumen catheter:
18 gauge x 190 / 180 mm
max flow rate = 26 ml/min

distal (brown) lumen of triple lumen catheter:
16 gauge x 200 mm
max flow rate = 52 ml/min

cordis / introducer:
8.5 french (2.8 mm) x 100 mm
max flow rate = 126 ml / minute
max flow rate with pressure bag @ 300 mmHg: 333 ml / minute

Written by phil

January 7th, 2009 at 4:04 am

Posted in Pearls

December M&M Tips

Teaching points summary:

* Testing the gag reflex is no longer thought to be an appropriate maneuver for assessing airway reflexes as it is neither sensitive nor specific and can provoke vomiting.

* Patients likely to desaturate quickly after pre-oxygenation include the obese, kids, pregnant women, and any patient with an oxygenation insult (pneumonia, pulmonary edema, asthma/COPD, pneumo/hemothorax, pulmonary contusion, etc).

* Although RSI with conventional laryngoscopy is safe and effective for most intubations, its appropriateness must be explicitly considered in every case. The less urgent the intervention, and the more difficult airway features present (difficult laryngoscopy, difficult bag-valve-mask, difficult cricothyrotomy) the more suitable is an awake technique.

* When in the midst of an intubation, the response to hypoxia is ventilation, not repeat laryngoscopy.

* Bag-valve-mask ventilation should routinely be performed with nasal and oral airways in situ as well as a two hands-down technique.

* If BVM ventilation is ineffective, the response should not be repeat laryngoscopy but rather the optimization of BVM ventilation. The most important interventions to perform are to re-position the patient, insert two nasal airways and an oral airway if not already placed, replace dentures if out, use a larger mask size, and change to a more experienced BVM operator. The use of airway adjuncts that may be blindly and quickly inserted, such as an LMA or combitube, is also appropriate to effect ventilation in an otherwise difficult to bag patient.

* Continuous capnography should be used as a tube confirmation technique when possible. If colorimetric capnography is used, a bright yellow response should be sought after six breaths.

* Have a low threshold to use the gum elastic bougie.

* Think of laryngoscopy as epiglottoscopy, as the purpose is to first control the tongue and then to find and control the epiglottis. Perform bimanual laryngoscopy by using your right hand to manipulate the thyroid cartilage to optimize glottic view.

* Patients being bagged with high FiO2 require surprisingly little ventilation to fully oxygenate. Bag slowly and gently to minimize gastric insufflation.

* For all intubations, consider using the intubation checklist, overflowing with handy reminders and pearls. Use the Sinai EM Updates page and click on “airway.”

Process Results:

* The glidescope handle, previously behind a key, is now in an easily-opened drawer and should be immediately available when needed.

* Airway equipment, including difficult airway adjuncts and implements for performing awake intubation, will soon be organized on a cart so as to provide immediate and reliable access.

* Airway management strategies were reviewed this morning and residents were trained in the two-hands down method of bag-valve-mask ventilation.

Written by reuben

December 24th, 2008 at 11:48 pm

Posted in Airway,Pearls

Q Tips

Greetings from the Peer Review Committee:

Here are the some “Q”uality tips from our recent meetings:

  • When you have a STEMI patient, use AMAC to activate the MI team.  The call should be initiated by either an attending or senior resident only.  If you choose to call the cath lab directly, be sure to document the time of notification in the chart.  This will help us ensure that STEMI cases are being identified & treated appropriately .
  • In reviewing sepsis cases, we found several patients that meet EGDT criteria but do not get all the indicated interventions in the pathway; most commonly, patients are appropriately getting central lines but CVP or ScVo2 are not being documented.
  • In patients with hemodynamically significant PE (documented or suspected), consider initial therapy with unfractionated heparin instead low molecular weight heparin – we have unfractionated heparin the department so there is no delay in medication administration; whereas lovenox needs to be sent from pharmacy thus adding significant delay in administration.
  • Be sure to wait for results of any tests that you order; seems obvious but there were several cases where an official urinalysis was ordered & the patient was discharged prior to results being obtained – in both of these cases they were positive & the patient was never treated.
  • If the CT scan that you are ordering is EMERGENT, call CT scan or the radiologist to facilitate the study.  Of course, all of our CTs are emergent but there are some that need to be done much more urgently than others so use your discretion.
  • When ordering lovenox, remember to document the patient’s weight in the notes section.  Pharmacy will not dispense lovenox until they confirm patient weight so this will decrease the turnaround time for getting the medication.
  • And lastly … always, remember to document any progress of the case in the doctors notes section of the chart.  This includes anything from “patient was seen by pmd” to “patient feels better after hydration, will d/c home”, etc.  If it’s not documented on the chart, then it didn’t happen.

Thanks for your attention!

Written by phil

December 11th, 2008 at 7:05 pm

Posted in Pearls

Q Tips August 2008

“Q”uality tips from recent months:

CVP can be measured off femoral lines with relative accuracy if the patient is lying flat.
When ordering medications, “time” is no longer a mandatory field.
When giving fluids to patients, please be sure to remember to actually enter an order.  In addition, if the patient receives more than 1 liter, please remember to re-order it so there is a clear reflection of how much fluids the patient actually got.
A low B-hcg does not eliminate the possibility of ectopic pregnancy – in fact, low B-hcg are more common in these cases.
If you have an elevated lactate on a patient with presumed sepsis (or in any case actually), be sure to get a repeat value to show either normalization or a trend.
Be sure to document your initial EKG interpretations – especially in pts with STEMIs or USA.
When you talk to the ME regarding a death in the ED, if you do not agree with their interpretation of etiology of death – you can refuse to sign the death certificate & the ME will then have to take the case.

Thanks for your attention.

Written by reuben

August 16th, 2008 at 1:41 am

Posted in Pearls

Q Tips

  • Remember that you can use succinylcholine intramuscularly if you cannot obtain iv access in a timely manner — the dose is 3-4 mg/kg (with a max dose of 150mg).
  • When discharging patients, be sure to write a reevaluation note documenting improvement in symptoms when appropriate. When signing patients out AMA, document reasons for patient leaving & your discussion with them. This is much more important than the patient actually signing the AMA form.
  • We’ve had several arrests 2′ hypoxia during intubation attempts — in a patient with low saturations on arrival, the 1st intubation attempt should be by a senior EM resident, followed rapidly by the attending to ensure rapid airway establishment.
  • In patients who present with hypoglycemia, remember that you should start them on a D5 drip after treating the initial value with D50. Or feed them!
  • In patients that are HIV+ & present with a headache – be sure to document an opening pressure when doing the LP. This is an important result in helping to diagnose the etiology of the headache.
  • Remember that if a patient expires in the ED – even if they are admitted – change the dispo to “expired”. This is how we capture charts for review.
  • On the other hand, if admitted patients are discharged from the ED by the medicine team – do not change the disposition. This will falsely lower our admission statistics.
  • When medical students are ordering medications, remind them that they must change the “ordering physician” name to the attending’s name they are working with – pharmacy will not fill the order if it is done by a medical student which results in a delay of the patient getting their meds.
  • When ordering medications, please DO NOT FREE TEXT! Pharmacy tracks this & we have to review these. In addition, you will not get any drug interaction or allergy prompts. This includes all drips – pressors, heparin, nitroglycerin, etc. If you cannot find what you are looking for … ask Kevin or Neal where to find it (or anyone else who’s around!).
  • When ordering lovenox, be sure to type in the patient’s weight in the comments area … you can save yourself a phone call from pharmacy inquiring about the weight.


Written by reuben

March 23rd, 2008 at 1:58 am

Posted in Pearls

Q Tips (Sepsis)

Overall Sinai is doing much better in regards to care of the septic patient in 2008.  In January, our MICU admits with sepsis had lactates drawn 100% of the time (vs. 66% in Dec 2007).  However, only 50% (5/10) of patients eligible for the EGDT protocol (lactate >4 or hypotension) went through the protocol.  The following management suggestions were culled from the 10 MICU admits with severe sepsis:
  • EGDT Eligibility: Septic patients with low BP or lactate over 4 should be considered for Early Goal Directed Therapy.  The inclusion criteria and pathway are available in copies, or at  Anyone unfamiliar with our protocol, please print a copy out and check it out.
  • Pressors: Dopamine vs. Levophed.  Both remain in the surviving sepsis campaign recommendations as first line agents for hypotension in sepsis.  Levophed is the pressor of choice in our protocol.  From the SSC 2008 recommendations: Norepinephrine is more potent than dopamine and may be more effective at reversing hypotension in patients with septic shock. Dopamine may be particularly useful in patients with compromised systolic function but causes more tachycardia and may be more arrhythmogenic (78). It may also influence the endocrine response via the hypothalamic-pituitary axis and have immunosuppressive effects.
  • Initial Hypotension in Sepsis:  Our protocol flows from fluids, to pressors, to steroids, to blood products to dobutamine, to intubation, to yet more fluids.  These elements are in sequence on the protocol, and will remain as they are for clarity, however, there is one instance when they may need to be instituted in parallel.  If your patient’s MAP is very low initially, start pressors even if no fluid has been given yet.  Although there is no data to support a specific cutoff, a MAP<50 is reasonable.  Fluid resuscitation ought to begin at the same time.  Give the empiric 20 cc/kg bolus as part of the EGDT protocol.  Pressors will affect your CVP measurements, so the key is to get the CVP up to >8 while on pressors, and then titrate down as MAP stays > 65. As you titrate down, you’ll see the CVP will drop–give more fluids.  If the patient’s blood pressure is > 65 with low dose pressors and CVP > 8, turn off the pressors for a few minutes and see where the CVP goes.
  • Documentation: Please document.  HPI should be something related (not the STD HPI).  Attendings can document Critical Care time for patients requiring EGDT.  If you go through the EGDT protocol document your CVPs as they may not be recorded by the resus RN.  We are working on a more complete EGDT documentation record.
  • Steroids: Cortisol stimulation testing has gone by the wayside s/p the recent CORTICUS trial.  Our protocol has dropped Dexamethasone in favor of Hydrocortisone to be given only in patients with septic shock refractory to vasopressor therapy.
  • Lactates: Every septic patient going to the MICU had a lactate drawn.  Excellent.  Fewer had them repeated.  You should repeat a lactate (as easy as drawing a GEMM) to evaluate oxygen delivery in the prbc/dobutamine/intubation part of the EGDT protocol – and a declining lactate at 6 hours is an important prognostic marker.
  • Cardiac Biomarkers in Sepsis: Watch out for confounding +Troponins in your septic patient.  If they have no story or EKG changes, the + troponin that the lab called you about may be leak related to their sepsis, rather than a primary coronary/myocardial event.  If you still suspect severe sepsis is the prime mover, don’t forget to continue EGDT if you have a lactate over four or hypotension.


Written by reuben

March 23rd, 2008 at 1:55 am

Posted in Pearls,Sepsis


1. Medical Decision Making: Coders look for MDM first… They use a point system that adds up based on how many tests you order AND documentation of your gathering of information and analysis of information. In other words use the “DOCTORS NOTES” section. The more boxes you check in this section, (greater that 4 is “high”) the more MDM points you get. Below in addendum A is the coding specialist discussion of this topic

2. We document Critical Care on 1.38% of our patients. The national average is 2-4%. In order for our coders to bill out a case as critical care you need: (for those of you who wanted “the written definition”)

a. Clinical Condition Criterion-There is a high probability of sudden, clinically significant, or life-threatening deterioration in the patient’s condition that requires the highest level of physician preparedness to intervene urgently. (An acute allergic reaction, or severe asthma attack, or bad CHF, or Acute MI, or CNS bleed, etc… all count…..)
b. Treatment Criterion-Critical Care services require direct personal management by the physician. They are life and organ supporting interventions that require frequent, personal assessment and manipulation by the physician. Withdrawal of or failure to initiate these intervention on an urgent basis would likely result in sudden, clinically significant or life-threatening deterioration in the patient’s condition.

One of the keys to remember is that the provider has to be immediately accessible to the patient. (We are always in the Department!) Critical Care is not time spent exclusively at the bedside of the patient, but time spent in work directly related to the patient’s care

Critical Care time cannot be requested if the patient is not yet in the ER, such as en-route in the ambulance or if the patient is deceased as the Critical Care time ends when the patient is no longer alive. The patient does not have to be admitted to a CCU or ICU in order to request Critical Care, and can in rare instances be sent home with Critical Care performed during the patient’s ER course.

PLEASE NOTE: Our billing company is unable to return charts for provider documentation of Critical Care when none is requested in the cases where the documentation would have supported it. That means: please respond to Tiffany’s imail request to review a case for potential critical care documentation. She reviews that charts of all patients that physically went to the resus room, every day. If it was not a potentially life, limb or organ if danger… just imail her back “no”. If it may have been critical care, review the chart, “buff it if needed, choose the drop down for critical care and imail her back.

CPR: When CPR is performed the time requested for Critical Care must be time not spent in the direction of the CPR as this is a separately billable procedure which needs to be subtracted from the Critical Care time. Finally, if the provider documentation does not support the requested Critical Care time an EM level will be assigned in place of the Critical Care.

3. IV Hydration: In order for a coder to bill out a separate charge for hydrating a patient they need to see:

a. Reason for the IV Hydration
b. Direct supervision of IV Hydration
c. Amount of time it took to hydrate
d. Post infusion assessment of the patient

HINTS: If you use the box in the attending note section you can cover b and c. If your primary or secondary diagnosis is dehydration, then a is covered. If your condition is “improved” then d is covered…..

I supervised the administration of IV hydration which required minutes to completely infuse.

(see addendum B for further explanation)

4. Procedures: All procedures performed should be fully documented so that they can be billed separately as appropriate. Intubations, Central Lines, Chest Tubes, etc are separately billable, however they have to be documented in order to bill separately. USE THE TEMPLATES (addendum C)

a. Splints- use the ORTHO SPLINTING template even if the ortho resident applied the cast or splint!

5. . Medical student documentation is considered invisible with the exception of Review of Systems and/or Past, Family, Social Histories. The ROS and PFSH may be used to supplement the attending’s documentation when the attending checks the appropriate boxes in the ATTENDING NOTE section.

6. ROS: Our billing company considers the statement “All relevant systems reviewed and all negative except for the above” unacceptable. One or two ROS need to be documented and then the statement “All other systems reviewed and negative” if reviewed or at least 10 of the 14 systems listed in order to support High MDM or EM level 99285. This means that you need to make yourself a macro that says “All other systems reviewed and negative”, use this with 2 other systems OR you need to document at least one element (or negative) in 10 systems.

7. RVU’s. An RVU is a numeric ranking assigned to a CPT procedure relating it to other CPT procedures in terms of the time, work and costs associated with the procedure. If you document high levels of care and many procedures then you will have higher RVU’s. More RVU’s is good!

I hope that helps…. Feel free to contact me if you have any questions or concerns. If you would like to speak directly to our billing companies coding specialist, email her (Deb Grieve) at the email below. and


Medical Decision Making is determined by the documentation of the Data, Risk and Problem Categories. In order to have consistency with our coders, we utilize a coding tool based on a tool created by the Marshfield Clinic in Wisconsin that has been approved by CMS. In this system, the Data elements, Risk and Problem Categories are assigned points and those points are added together to come up with the EM level
a. Data- The amount and/or complexity of medical records, diagnostic tests, and/or other information that must be obtained, reviewed and analyzed. The data points are as follows: 1-Review and/or order lab tests, 1-Review and/or order radiology tests, 1-Review and/or order tests from the Medicine section of CPT (EKG, EEG, etc.), 1-Discussion of test results with performing physician (ex. review radiology report with radiologist), 1-Decision to obtain old records and/or obtain history from someone other than patient, 2- Review and summarize old records and/or history from someone other than patient and/or discussion of case with another health care provider, 2-Independent visualization of image tracing or specimen. Please note that 4 or more points scored for data equates to High Medical Decision Making for the Data sub-component.

b. Risk-The CMS table of risk is used to help determine the level of MDM by the Nature of Presenting Problem(s), Diagnostic Procedure(s), Possible Management Option(s). 1-Minimal risk is usually one self-limited or minor problem such as cold or insect bite with management options such as rest and gargles or superficial dressings, 2-Low risk is two or more self-limited or minor problems, one stable chronic illness, or acute uncomplicated illness or injury with management options such as over the counter drugs, IV fluids without additives, 3-Moderate risk is one or more chronic illness with mild exacerbation, progression or side effects of treatment, two or more stable chronic illnesses, undiagnosed new problem with uncertain prognosis, acute illness with systemic symptoms, or acute complicated injury with management options such as prescription drug management, IV fluids with additives or closed treatment of fractures/dislocations, 4-High risk is usually one or more chronic illnesses with severe exacerbation, progression or side effects of treatment, acute or chronic illnesses or injuries that may pose a threat to life or bodily function, or an abrupt change in neurologic status with management options such as Parenterally controlled substances given IV, IM or SubQ, drug therapy requiring intensive monitoring for toxicity or decision not to resuscitate or to de-escalate care because of poor prognosis. Please note that the highest level of Risk is chosen based on documentation.

c. Problem Categories-Points are assigned based on the outcome of the patient’s status or the work up performed in the ED. 1/2-Self limited or minor (stable, improved, worsening)(max 2), 1-Established problem to examining physician/group;stable, improved, 1/2- Established problem, worsening, 3-New problem (to examining physician/group), no additional work-up planned (max 1), 4-New problem (to examining physician/group), additional work-up planned. Please note that additional work-up planned includes admitting a patient to the hospital, transferring to another facility, making an appointment for the patient with date and time documented, and/or the amount of diagnostic tests being performed in the ED.

In order to establish the Medical Decision Making based on the providers documentation, Data, Risk and Problem Categories are added up and then 2 of the 3 must meet or exceed to support the appropriate level of EM.

IV Hydration service codes 90760 – 90761 are intended to report a IV Hydration infusion which consists of a fluid and/or electrolyte solution (i.e., normal saline, 30mEq KC1/liter) but are not used to report infusion of drugs or other substances. There is no doubt that start and stop times for each IV infusion, piggyback, etc., should be documented in order to bill the most appropriate code(s) as these are time based codes and would require distinct start and stop times should the procedure be performed greater than 1 hour, since the initial code description is “up to one hour”. Poorly documented accounts (where the hydration was greater than one hour) and no stop times are documented – the code may default to the lowest code for the range. It should also be noted that concurrent infusions may occur during an encounter, and this is another indication of the importance of being able to separate out the services as documented. IV Hydration for hydration of prepackaged fluid and electrolytes – not for infusion of drugs or other substances, typically require direct supervision for purposes of consent, safety oversight, or intrasupervision of staff. Documentation should clearly indicate:

a. Reason for the IV Hydration
b. Direct supervision of IV Hydration
c. Amount of time it took to hydrate
d. Post infusion assessment of the patient
The CPT codes that are assigned when documentation supports billing of IV Hydration:
a. 90760 – intravenous infusion – initial – up to one hour
b. 90761 – each additional hour up to 8 hours


In order to accurately assign CPT codes for procedures, the documentation must clearly state what type of procedure was performed, if applicable the location and length and the description of the procedure performed. When a procedure has to be repeated, documentation of the additional steps should be documented as a procedure may be billed separately every time it is performed. An example is the chart we reviewed that had documentation of the patient who was intubated once and then when the ET tube came out, the attending had to re-intubate the patient. Both of the intubations are billable. Attendings should clearly document their supervision of procedures when performed by Residents in order to bill separately for the procedures. When a Medical Student is involved, the attending must re-document the entire procedure in order to bill separately for the procedure. If a PA performs a procedure and the attending documents a face to face encounter with the patient, the PA will be credited with the procedure and the attending with the EM level.

Splinting documentation must support that the splint was placed by the ER provider if the patient has a governmental insurance such as Medicare. For all other insurances, the ER provider can document a post splint placement examination when applied by a nurse or tech and the splint can be billed separately. This can be as simple as a statement such as “splint placed by tech in good alignment with neurovascular status intact”.

Written by phil

January 18th, 2007 at 1:25 pm

Posted in IBEX,Pearls

Q Tips

· Gloves do not replace the need for hand washing! Please be sure to wash your hands (or use Purell) before and after every patient encounter. The Infection Control department is collecting observational data as to our practices in the ED for the hospital. Please do your best to comply.

· There are new ACIP guidelines which recommend the usage of Tdap rather than Td for patients requiring tetanus prophylaxis. There has been an increased incidence of pertussis in recent years which has prompted the change in protocol. The pharmacy is now stocking Tdap. Please adjust your orders to reflect these new recommendations.

· In reviewing ED mortalities, we have found intermittent usage of D50 in the resuscitation of cardiac arrest patients. Per ACLS guidelines, there is no role for D50 in these patients.

· While resuscitating cardiac arrest patients, please remember that the new ACLS guidelines stress the importance of continuous CPR with as few & limited interruptions as possible. We are re-stressing this as there was an instance where CPR was halted for an EKG to be done during a code for VF.

· If there is any concern or suspicion of foul play in an ED death, in addition to calling the ME, please call social work to evaluate the case.

Written by phil

October 12th, 2006 at 1:45 am

Posted in Pearls


Starting July 1 AMAC will check on call schedules, age of
patient and code 11 as listed in complaint column.

If it is weekdays between 8A and 6 PM they will call the
social worker for adult or peds code 11s and connect to the
charge nurse in the area.

Off these hours and on weekends they will page the SAVI
advocate on call and connect to the charge nurse in the
area. SAVI can also be activated thru AMAC for domestic
violence cases off hours. Advocates provide information to
survivors and are present to provide emotional support,
encourage follow up. They do not perform exams or evidence

We have some shifts covered for the forensic portion of the
sexual assualt exam and evidence collection. For patients
listed as code 11 in the triage complaint, AMAC will call
the SAFE if there is one on the schedule and connect to the
Attending in the area. They will also notify the Attending
if there is NOT a SAFE so that the Attending can designate
the appropriate HCW to perform the exam. We are working to
expand this program.

Thank you for your support.
Barbara Richardson, MD, SAFE
Deb Travis, RN, SANE-A

ADDENDUM: from Dwayne Raymond, RN

Both photographs and NON-IBEX documentation of the physical
exam, Comprehensive Sexual Assault Form (CSAF) usually
found in the SAVI packets – SHOULD BE SECURED IN THE LOCK

The logbook can be found in the lockbox of the SAVI cabinet.
PLEASE, do not leave anything in the metal cabinet of the
medication room.

Written by phil

June 30th, 2006 at 6:13 pm

Posted in Pearls

Prevention of Unrecognized Arterial Cannulation

The possibility of arterial cannulation during attempted central venous access is well recognized. Classic findings of arterial cannulation such as pulsatile bright red blood are notoriously unrelieable markers of catheter location. When unwanted arterial cannulation is suspected, the catheter should be removed and a new attempt at venous cannulation made. To reduce the possiblity of unrecognized arterial cannulation, the following guidelines must be adhered to:

1. Use ultrasound guidance where possible to minimize the risk of arterial puncture.

2. Confirm placement of internal jugular or subclavian central line placement with chest radiograph. Three key features should be assessed.
a. First, the catheter should lie in the vena cava, outside of the cardiac silhouette.
b. Second, the catheter should be relatively parallel to the walls of the vena cava.
c. Third, the catheter tip should not abut the wall of the vena cava.

3. If obtaining a cxr is not feasible for any reason or there is any doubt regarding location after cxr, the critical care committee recommends confirmation by:
a. Manometry (transduce waveform)
b. Comparative Blood Gas Analysis – draw samples from the catheter and an artery
c. Contrast Dye Study


1. Scott WL. Complications associated with central venous catheters. A survey. Chest. 1988; 94:1221-1224.
2. Brandt RL, Foley WJ, Fink GH, et al. Mechanism of perforation of the heart with production of hydropericardium by a venous catheter and its prevention. Am J Surg. 1970; 119:311-316.
3. Sheep RE, Guiney WB. Fatal cardiac tamponade: Occurrence with other complications after left internal jugular vein catheterization. JAMA. 1982; 248:1632-1635.
4. Bar-Joseph G, Galvis AG. Perforation of the heart by central venous catheters in infants: Guidelines to diagnosis and management. J Ped Surg. 1983; 18:284-287.
5. Collier PE, Ryan JJ, Diamond DL. Cardiac tamponade from central venous catheters — A report of a case and review of the English literature. Angiology. 1984; 35:595-600.
6. Maschke SP, Rogove HJ. Cardiac tamponade associated with a multilumen central venous catheter. Crit Care Med. 1984; 12:611-613.
7. Tocino IM, Watanabe A. Impending catheter perforation of superior vena cava: Radiographic recognition. Am J Roentgenol. 1986; 146:487-490.
8. Jiha JG, Weinberg GL, Laurito CE. Intraoperative cardiac tamponade after central venous cannulation. Anesth Analg. 1996; 82:664-665.
9. Bunegin L, Albin MS, Helsel PE, et al. Positioning the right atrial catheter: A model for reappraisal. Anesthesiology. 1981; 55:343-348.
10. Jobes DR, Schwartz AJ, Greenhow DE, et al. Safer jugular vein cannulation: Recognition of arterial puncture and preferential use of the external jugular route. Anesthesiology. 1983; 59:353-355.

Written by phil

June 25th, 2006 at 4:55 pm

Posted in Pearls

Resuscitation Room Supplies

with 2 comments

The MSH Emergency Department Resuscitation Room has the following supplies available by cabinet:

Equipment Location

HD Monitoring Setup Storage cabinet bottom shelf

EtCO2 supplies Airway cart bottom drawer

Central Line Dressings ??

Written by phil

June 21st, 2006 at 1:15 pm

Posted in Pearls

MSH Women’s Health Services Referral Guidelines

Indications for Referral
Threatened abortion
Dysfunctional uterine bleeding (H/H>30)
Post-partum patients
Urinary tract infection
Pelvic inflammatory disease
Sexually transmitted diseases
Contraception (all forms)
Routine Gyn exam
Pelvic pain

Refer to Specialty Clinics
Colposcopy (Abnormal PAP) -> Pt with abnormal PAP smear
Cystometrics (Urinary Incontinence) Speciality clinics

Refer to JMF Clinic not GYN
Sexual assault patients

Refer to Gyn Surgery Clinic
Possible ectopic pregnancy (ASAP or send to ER)
Missed ab confirmed (ASAP)
Bartholin cyst/abscess (1 week//use Word Catheter)
Ovarian cyst premenopausal pt (>5 cm) (1-2 wk)
Ovarian cyst postmenopausal pt (any size) (1-2 wk)
Pt requiring elective surgery (1-2 wk)
Fibroids(symptomatic or >12 wk) [3-4 wk; If H/H <30, w/in 1 wk]
DUB unresponsive to treatment [3-4 wk; If H/H <30, w/in 1 wk]
Cysto/rectocele 3-4 wk (needs neg urine C&S)
Uterine prolapse 3-4 wk
Other Gyn pathology 3-4 wk

Refer to Infertility Clinic
Gyn endocrine disorder

Written by phil

June 12th, 2006 at 7:39 pm

Posted in Pearls

Critical Care Documentation and Billing

This info graciously borrowed from AAEM Dollars and Sense. Thanks Shkelzen.

Critical Care Codes

Many emergency physicians still struggle with what type of patient presentations constitute critical care. The average ED patient is very ill compared to the average patient in the big house of medicine. I tell my physicians to picture the scenario as if the patient were presenting to an office-based practitioner’s office. What would the management feel like to that physician?

The fact that you knew what to do, that it was easy for you to take care of the patient and that the patient got better doesn’t mean you weren’t providing critical care services.

You should develop the habit of asking yourself about critical care time on all patients that go to a unit bed, or would be going to a unit bed if you hadn’t intervened emergently, and all patients with significantly abnormal vital signs (pending organ failure) or significant mental status changes. Remember your time intervals (30-74 minutes) and to subtract time for any separately billable procedures performed and time spent supervising residents.

Author: Andrea Brault, MD, FAAEM, MMM

Dr. Brault is President of Emergency Groups’ Office, Arcadia, CA and is Co-Chair of the AAEM Reimbursement Committee

Critical care is the service that defines emergency medicine to many patients and most payers. There is great value in having this life-saving service immediately available to any patient at any time, without regard for the ability to pay. Emergency medicine ought to ” own” this code but its definition has changed seven times since 1991, so it is not surprising that this is one of the more under-reported services in emergency medicine.

Key Elements Defining Critical Care

The most recent changes have given the clearest and most beneficial definition to emergency care. Three key elements of critical care are now defined as follows:

” … there is a high probability of sudden, clinically significant, or life threatening deterioration…” Critical care no longer requires unstable vital signs.

” … which requires the highest level of physician preparedness to intervene urgently.” There is no physician more prepared to intervene urgently in any patient’s care than the emergency physician. This defines the specialty.

Involving “direct personal management”, the absence of which “would likely result in sudden, clinically significant or life threatening deterioration…” If you did nothing for the patient, what is the potential that they could have a sudden unwelcome result? If that probability is high, critical care is in order.

Thus, vital signs can remain stable and the patient still have the immediate potential for life threatening organ failure, even when that failure has been prevented by your intervention. It is not uncommon that patients presenting critically ill receive care that prevents deterioration such that the patient can later be safely discharged. Patients with respiratory complaints associated with asthma, CHF, croup or severe allergic reactions all receive critical care at times and may occasionally be discharged after a stay in the ED.

Saving the patient’s life, then saving the need for an admission, is an exceptionally valuable service.

Examples abound of critically ill patients. If withholding aggressive nebulizer treatments, racemic epi or other drugs of aggressive management would likely result in “a high probability of imminent or life threatening deterioration”, critical care is being performed by their administration. Those with various arrhythmias, unstable angina, or active chest pain not easily relieved by sublinqual nitro who must be treated aggressively with IV medications and observed over time are candidates for reporting critical care.

Asthmatics with a recent history of admission for asthma, who are not responding quickly to treatment and require aggressive IV medication management, commonly meet this definition of critical care. The November 2, 1999 Federal Register even noted that “many patients with an acute exacerbation of congestive heart failure, regardless of severity, could meet the new definition of critical illness.” CFR 64 No 211, p.59423.

“Constant Attention”

The old critical care term “constant attendance ” has been replaced with the term “constant attention”. Attendance implied a physical place, like the bedside; “attention” indicates the true value of critical care, it is a cognitive service rendered when the physician is thinking about how to resolve the patient’s potential for crisis.

Historically, proceduralists have defined the payment system; surgeons pioneered the health insurance industry in the 1920s (the Baylor University Plan for it’s faculty later extended to the community and lead to the founding of Blue Cross). Payment was for ” doing” something to the patient. With Medicare’s Physician Payment Reform in 1991, the emphasis now is on paying physicians for thinking, or for doing the right (quality-oriented) things. Complex thinking about possible life-threatening outcomes is principally in the domain of the ED visit level, but thinking about how to prevent the patient from crashing right now is the domain of critical care.

Critical Care RVU Value

By Medicare’s calculation, 30-74 minutes of critical care pays 37% more than a 99285 with fewer documentation requirements. However, in the relative scheme of things, critical care is still much under-valued. Consider that the work value of a simple cataract removal that can take 7-10 minutes to do, has a Medicare work value of 8.19, more than twice the 4.0 work value assigned to critical care.

No amount of HPI, ROS, medical, family or social history, or exam content is specified to support the claim for critical care; only that the chart supports the time the physician claimed was spent performing critical care and that the patient had the immediate potential for clinically significant deterioration.

This can be a subjective condition; the physician should describe concerns about the patient’s potential imminent decline.

CPT Time Analysis

CPT clarifies more of what is included in critical care time:

Time spent with the individual patient should be recorded in the patient’s record. The time that can be reported as critical care is the time spent engaged in work directly related to the individual patient’s care whether that time was spent at the immediate bedside or elsewhere on the floor or unit. For example, time spent on the unit or at the nursing station on the floor reviewing test results or imaging studies, discussing the critically ill patient’s care with other medical staff or documenting critical care services in the medical record would be reported as critical care, even though it does not occur at the bedside. Also, when the patient is unable or clinically incompetent to participate in discussions, time spent on the floor or unit with family members or surrogate decision makers obtaining a medical history, reviewing the patient’s condition or prognosis, or discussing treatment or limitation(s) of treatment may be reported as critical care, provided that the conversation bears directly on the management of the patient.

Time spent in activities that occur outside of the unit of off the floor (eg. telephone calls, whether taken at home, in the office, or elsewhere in the hospital) may not be reported as critical care since the physician is not immediately available to the patient. Time spent in activities that do not directly contribute to the treatment of the patient may not be reported as critical care, even if they are performed in the critical care unit (eg, participation in administrative meetings or telephone calls to discuss other patients). Time spent performing separately reportable procedures or services should not be included in the time reported as critical care time.
Code 99291 is used to report the first 30-74 minutes of critical care on a given date. It should be used only once per date even if the time spent by the physician is not continuous on that date. Critical care of less than 30 minutes total duration on a given date should be reported with the appropriate E/M code.

Code 99292 is used to report each additional 30 minutes beyond the first 74 minutes. It also may be used to report the final 15-30 minutes of critical care on a given date. Critical care of less than 15 minutes beyond the first 74 minutes or less than 15 minutes beyond the final 30 minutes is not reported separately.

Time flies when you are absorbed in your work and it is common that emergency physicians forget what commonly goes in to their care of the patient with the immediate potential for medical crisis. The following figure identifies several of these time-consuming critical care services.

CPT Time Analysis Chart and Examples

Medicare and CPT have provided exact instructions for how to count and report time. The first 30 – 74 minutes of critical care is to be reported using code 99291. Less than 30 minutes is to be reported with the appropriate E/M code. Each 30 minutes beyond 74 minutes is reported with an additional one-half hour code 99292.

Time spent when the physician is not immediately available to the patient does not count towards critical care, for example, phone calls from home/office, or radio command in the ED. Time spent performing other procedures that will be billed in addition to critical care and time spent by residents who are performing critical care are also not reportable.

Time is also defined specifically by date, not by 24-hour periods. In 1994, time in the CPT methodology was changed from “day” to “date” so that the critical care clock starts over at midnight .


Critical care started at 11:35pm with the episode continuing until 12:30am.

Report: Use an E/M service on first date of service because less than 30 minutes was performed on that date and report 99291 (First hour) on the second date of service.


Critical care started at 11:30pm with episode continuing until 12:30am.

Report: Report 99291 (First hour) on first date of service and 99291 (First hour) on the second date of service. Two different dates represent two different services.

Include in the chart a statement of the aggregate time of attention spent on the patient throughout their ED stay but discount the time spent performing separately reportable procedures. This time statement is an estimate. There is no precise proxy that can stand in place of your time of attention because critical care is mental work done when you are immediately available to the patient. Make a mental note of the time spent on procedures and deduct that time from your total attention to the patient.

Check the CPT manual to see exactly which procedures are bundled into critical care. They include only the following codes: 93561, 93562, 71010, 71015, 71020, 94760, 94761, 94762, 99090, 43752, 91105, 92953, 94656, 94657, 94660, 94662, 36000, 36410, 36415, 36600. These are all minor procedures, like reading a chest film, placing an NG tube, starting an IV, and ventilation management. Anything not listed above is separately billable, including EKGs and rhythm strip interpretations, which many payers wrongly try to bundle into to critical care payment.

Definition of “Critical”

The chart must meet two tests:

First, the condition of the patient must clearly involve a “high probability of sudden, clinically significant, or life threatening deterioration which requires the highest level of physician preparedness to intervene urgently” or unambiguously indicate an unstable medical condition or potential for life-threatening condition.

Second, the physician must actually intervene by providing “frequent personal assessment and manipulation”. The physician’s intervention must be documented. You should document performance of “direct personal management” as a form of intervention.

Documentation of Critical Care

Specifically, state your personal management of the patient during his/her critical period, by describing what the period involved. Write a sentence describing that the “high probability of _________ required my full and direct attention, intervention and personal management for ___ minutes while the patient was critical.”

The entire chart is necessary to support critical care time, as nursing assessment notes, procedure notes, medication rates and routes of administration, etc. substantiate the patient’s critical status. To fully support the claim for critical care the chart should note the time of both physician and nursing events (initial physician exam, re-exams, IV order times, dosage and medication changes.) The picture is clearer when both nursing and physician notes are available for review.

A good critical care procedure note would include comments about the patient’s progress throughout their ED stay, specific responses to each intervention as well as comments about multiple vital sign or exam assessments. Drug therapy start times, routes and rates of administration, along with the results of diagnostic tests and procedures should be clear in the chart. These are a means of supporting the patient’s clinical condition and help to reflect the time spent in the patient’s care.

Medicare’s documentation standard is the physician’s own note regarding total time spent in patient care. It is best to conclude critical care documentation with a ” procedure note” describing your activities and decision making while the patient was under your care. Note here how long pain lasted or vital signs were unstable, what was tried to alleviate it and at what time the patient no longer needed critical care attention.

By CPT’s definition, critical care is now clearly not an exclusive E/M service and can be billed in addition to an E/M service in some cases, because:

It has no history, exam or MD M component
Only E/M services of the same type must be combined on the same day.
CPT clearly does not bundle 9928x codes in with critical care.

Critical care and other E/M services may be provided to the same patient on the same date by the same physician… Any services performed which are not listed above should be reported separately.
(‘01 CPT, p. 18)

[An] emergency department code may be reported in addition to the critical care service code(s) if both services are provided by the same physician on the same day.
Medicare is more restrictive. Only when a patient receives an evaluation and management service first, then later in the same visit becomes critical, can you report both an E/M service and critical care on the same date of service.

Physicians should always note in the chart when critical care started after the initial evaluation.

Written by phil

June 8th, 2006 at 12:33 pm

Posted in Pearls

Airway Management of the Septic Patient

Very Abbreviated conversation between Matt Denny and Scott Weingart:

Matt: I’ve been reading a few articles arguing against using etomidate, even as a single dose for induction, on the grounds that it suppresses cortisone production. The alternatives were giving steroids to all such patients post etomidate, or using alternative agents such as thiopental or dexmedetomidine. What’s your take on all of this?

Scott: dex not a good induction agent. thoipental induces hypotension, so you must dose accordingly. i use ketamine for my sepsis inductions. etomidate is fine if the patient is going to get empiric steroids anyway, i.e. your patient already on vasopressors. etomidate may result in a patient getting placed on pressors a few hours earlier than they would without it. does this have clinical relevance now that we supplement all patients on pressors, who knows. It is a confounder for all of Annane’s work on the value of steroids in septic shock.

Etomidate in Sepsis:

Written by phil

May 30th, 2006 at 8:02 pm

Posted in Pearls

Sinai ED Clinical Resources

Sinai specific resources that we use both frequently and infrequently to make your shift go a little bit smoother.

Resus Room
– Resus Criteria
Critical Care Supplies
Ultrasound Documentation
– MI Team Activation: see info here. When in doubt, call AMAC.
– STROKE Team Activation: Call AMAC who will notify Stroke, CT, Lab.
Central Line Documentation: be sure to document Maximal Sterile Barrier use.

Methadone Clinics
– Harlem East Life Plan 2369 2nd Avenue (212) 876-2300

Disposition and Follow-Up
– (800) MD SINAI: Physician Referral Service to Faculty Practices and the following:
Settlement Health: Sliding Scale
Boriken Neighborhood Health: Sliding Scale
EHOPP: No health insurance, >22 yo, and Residents of East Harlem
– Metropolitan Psych Clinic
GYN Referral Guidelines
LWBT AMA and ELOPED Patients

Specific Patient Issues
– Sickle Cell -> Page Heme Fellow on admission/ ?every visit
– Hemophilia PTs -> Masterlist of Factor deficiencies in Attg Office
– Sexual Assault (Code 11): Call SW and then AMAC to reach SAVI and the SAFE examiner on call.

Expediting Admissions
– surge criteria
– TO BE CLEAN –> Call transport at 44443 to ensure they know bed needs to be cleaned

Phone Numbers
– AMAC – 43611

ID Approval
– Hours: 9 am – 6 pm. (Fill out form after 6pm)
– If ID unavailable -> call pharmacy to release drug

What About…
– When do I send a patient to Psych ED?
– ED Policy Manual

Written by phil

May 23rd, 2006 at 2:40 pm

Posted in Pearls