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