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You don’t want to be accused of harming your patients.

But if you have a high rate of complications, you might raise some eyebrows.

Quality is becoming a bigger focus each passing year. In medicine, “Quality” doesn’t just mean providing consistently good care that is at least average if not better than average… It also means hitting certain “Quality Metrics.”

Now whether or not these metrics actually result in better patient outcomes is not a discussion I’m going to get into right now.

I want to teach you how to excel in the system as it is now.

I’m going to focus on Hospital Associated Infections (HAI’s) and Patient Safety Indicators (PSI’s). Going into detail about each individual HAI and PSI is outside of the scope of this newsletter, but I’m going to go through some general documentation tips to avoid accidentally documenting yourself into complications.

Check out this dizzying graphic. It’s CMS’s Hospital Value Based Purchasing Program (HVBPP). (This is actually outdated. PSI’s still exist but are under a different program now… But I include this just to have them both in the same place visually.)

Here’s a list of the PSI’s:

And just so you don’t have to squint your eyes too hard, here’s a list of the Hospital Associated Infections:

So, my recs:

Present on Admission

In EPIC, there’s this annoying little “POA Y or N” button. This is asking if the diagnosis was present on admission or not. As these metrics track HOSPITAL complications, many will not count (“exclude”) the complication if it was present on admission. So, take that little button seriously and make sure your documentation is clear about POA status or not.

Additionally, you may get a query about POA or not. But the options are not just Yes (Y) or No (N). They also include:

• U = Documentation is insufficient to determine if condition is present on admission

• W = Provider is unable to clinically determine whether condition was present on admission or not

“W” will exclude many conditions from a complication, just as “Y” does. “U” will not exclude it. I could never remember the difference until my friend Erica Remer said, “U means Uh oh!”

Remember that sometimes things can be present, but not necessarily identified, at the time of admission. Example: you treated a patient for COPD exacerbation and did further work-up when they didn’t respond to treatment; you ultimately found them to have a pulmonary embolism that was probably present on admission. You can say that was POA, although you didn’t identify it at the time.

Anticoagulants and Coagulopathies

If a patient has an underlying coagulopathy or is on an anticoagulant, then you shouldn’t get dinged with a post-op hemorrhage (PSI-09). Makes sense. But… It’s not that easy (of course 😔 ).

Coders can’t capture that connection if you just say “on eliquis” or “due to xarelto.” You have to capture the coagulopathy caused by the anticoagulant. The actual code is a weird one: “Hemorrhagic disorder due to extrinsic circulating anticoagulant.”

Ain’t nobody going to document that.

(I mean… You can document it now that you know… But I don’t blame you if you don’t.)

So, many CDI’s will query for (and doctors often feel more comfortable with) “coagulopathy due to anticoagulant.” THAT will link the bleed and the anticoagulant, and *poof* the complication goes away.

While we’re here, don’t get scared to document acute blood loss anemia after surgery. You only trigger PSI-09 Perioperative hemorrhage or hematoma if an additional procedure is required to address the hemorrhage or hematoma.

Shock

Shock present on admission is an exclusion for some complications. However, you have to say “shock.”

“Infection with encephalopathy and persistent hypotension despite IVF requiring vasopressors” is not “shock.”

“Septic shock” is shock.

Same goes for the other types of shock. Gotta say it outright. Coders aren’t allowed to assume or “read between the lines.”

Post-op

I mentioned this last week, but it’s worth repeating 👇️ 

This is a big one for PSI-11: Postoperative respiratory failure.

PSI-08: In-hospital fall with hip fracture

I will specifically mention PSI-08 here because many indirectly hate it without knowing it by name. SOME people (me) have strong feelings about how this has negatively impacted our patients

But I’m not here just to rant. Check out the exclusion list for this one:

Yeah. Those diagnoses (some must be the reason for admission) will mean you and your hospital don’t get dinged with that complication.

Notice “poisoning” on there? Remember what I said last week that poisoning isn’t how you would generally think of it? (Like an angry ex-lover poisoning someone’s drink.) It includes when a patient incorrectly took their medication and had problems (such as toxic encephalopathy) from it.

Rapid Fire Recs

• Some of the complications, such as pressure ulcer and CLABSI, have exclusions for dermatologic disorders such as exfoliative disorders, severe burns or Epidermolysis bullosa. Make sure to document those when present. (NHSN Source + AHRQ Source)

• CAUTI’s are for indwelling foley catheters. They do not include condom catheters and suprapubic catheters, but I’ve seen these incorrectly called foley catheters in documentation. So, be careful with that. (NHSN Source)

• Midlines are not considered central lines for CLABSI’s. Make sure you don’t accidentally describe a midline as a central line. (NHSN Source)

• Surgical Site Infections are actually risk adjusted. Meaning it’s not just the flat rate, but is impacted by patient characteristics that put them at increased risk of getting those infections. It’s limited but includes diabetes and BMI. So, make sure to document those. (ACS / CMS Source)

• I’ve seen the fact that a patient has a solitary kidney go unnoticed and undocumented quite a bit but that’s an exclusion criteria for PSI-10 Postoperative acute kidney injury requiring dialysis. (AHRQ Source)

Sepsis

LOL. Not even going to touch this with a 10 foot pole right now.

Check out my previous issue on it here. Trigger warning if you have strong opinions on sepsis.

I recently posted about “How we got here” with the sepsis dumpster fire, and oh boy did it generate some comments:

Angry tweets and questionable hospital tactics…

I’ve seen angry tweets from doctors saying their hospitals “aren’t allowing them to get the appropriate tests or give appropriate treatment” because their hospitals don’t want to get dinged with a HAI or PSI. If hospitals are truly doing that, then they need to take a step back and remember the ultimate goal: patient safety and care.

I review my hospital’s complications for documentation opportunities but if the documentation is solid and we still have a high number of complications?

Great.

We’ve identified a process and care problem that we can now help fix (and have data to support that initiative).

That’s all for now. Don’t forget to use YOUGOTTHIS!24 at checkout to get 10% off either of my courses. It expires Monday at midnight CST.

Cheers,

Robert

Thanks to Laura Samson, RN BSN CCDS, and my wife Kara (for grammar - yes I need that) for editing this newsletter!

When you’re ready, there are two ways I can help you:

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