PulmCCM

SEPTEMBER 17, 2023

The Centers for Disease Control and Prevention formally called on hospitals to develop robust sepsis care programs to systematically identify and treat sepsis, track outcomes, and improve care delivery. ” What is that, a sepsis Stasi? Unlike strokes and STEMIs, sepsis has no gold standard for diagnosis.

CDC 98

CDC Sepsis Hospitals Documentation/Coding 98

ACEP Now

MARCH 10, 2025

ACEP has summarized these issues in its Code of Ethics: Emergency physicians shall communicate truthfully with patients and secure their informed consent for treatment, unless the urgency of the patients conditions demands an immediate response. National Hospital Ambulatory Medical Care Survey: 2021 Emergency Department Summary Tables.

Documentation/Coding 52

Documentation/Coding Emergency Department Psychiatric Risk Management 52

ACEP Now

DECEMBER 11, 2023

The wave of increasing hospital closures and service line cutbacks continues to sweep the U.S. A recent article documents 56 additional U.S. hospitals that are closing clinical departments or ending or reducing services. 2 Of these 56 additional hospitals, many are not rural; thus, this specter is expanding. AMA website.

Hospitals 98

Hospitals Administration Documentation/Coding Research 98

ACEP Now

DECEMBER 17, 2024

In a public letter, he highlighted the pressures of residency and stigma surrounding mental health, warning that there are other residents fighting a true life-and-death battleone that is waged both inside and out at the clinic/hospital. Elmhurst doctors’ strike ends as hospital, union reach deal. Thompson SL, Salmon JW.

Burns 105

Burns Hospitals Documentation/Coding Emergency Department 105

EM Literature of Note

JANUARY 16, 2025

Literally every practicing physician working in a hospital environment knows there is a broad spectrum of skill, approach to acute illness, and level of risk-tolerance. These attributes manifest in different ways, and, in emergency physicians, one is the differing likelihood two clinicians might have to admit same patient to the hospital.

Outcomes 77

Outcomes Radiology Radiology Emergency Department 77

Ken Grauer, MD

JUNE 22, 2024

During my decades of working with residents when hospital Attending — by far, the most commonly overlooked vital sign was respiratory rate. Initial assessment of the patient for possible acute PE begins by counting the respiratory rate. KEY Point: The respiratory rate that is written on the chart does not count!

EKG/ECG 433

EKG/ECG Stroke Documentation/Coding Wellness 433

Emergency Live

DECEMBER 21, 2023

The Importance of Color Codes in Hospital Emergency Situations and on Rescue Vehicles Color Codes in Hospital Emergencies In hospital settings, color codes are used to communicate specific emergency situations quickly and effectively.

Documentation/Coding 105

Documentation/Coding Hospitals 105

Mind The Bleep

FEBRUARY 2, 2025

In some hospitals, there is an infection ward round and MDTs for selected patients, however elsewhere your phone call may be all the information micro receive about the patient whose samples they are processing. Also, in larger hospitals, virology may be a separate department with its own advice system.

Radiology 98

Radiology Radiology Documentation/Coding Hospitals 98

Ken Grauer, MD

FEBRUARY 28, 2023

Figure-2: I've color-coded P waves from Figure-1 according to P wave morphology ( See text ). NOTE: For clarity — I've color-coded P waves in the long lead II rhythm strip according to morphology. Microvascular dysfunction — cardiac vasculitis — intravascular thrombosis.

EKG/ECG 195

EKG/ECG Documentation/Coding Sepsis COPD 195

PDC Healthcare

AUGUST 17, 2023

Key Takeaways from a Recent Pharmacy Survey PDC surveyed 6,400 Hospital Pharmacy Managers and Directors to get feedback on their priorities and challenges. Below we explore the results and key takeaways of the PDC survey, along with some helpful tips for pharmacy professionals.

Hospitals 98

Hospitals Patient Safety Documentation/Coding 98

Mind The Bleep

FEBRUARY 2, 2025

Hospital/NHS number is 1234. If the aim is for someone to take over care then an explanation of why they can provide better care often works better than why you can’t look after them Outline the purpose of your referral early. Ronan is a 12yr old boy who has a suspected diagnosis of leukaemia.

Radiology 96

Radiology Radiology Sepsis Documentation/Coding 96

EMDocs

JUNE 13, 2024

An attorney is consulted, and a lawsuit is filed against the EP, the hospital, the pharmacy, and the dentist. We just don’t document it. Result : Pre-trial settlement against the hospital and EP for a minimal amount. Documenting our warnings should be standard care. difficile enterocolitis. difficile colitis.

Documentation/Coding 98

Documentation/Coding Patient Safety Emergency Department Hospitals 98

ACEP Now

NOVEMBER 7, 2024

Elizabeth Wharff was the director of emergency psychiatry at Boston’s Children’s Hospital in the late 1990s when she became concerned about what was, then, a new problem. They would be the least difficult and disruptive, the least strain on the hospital staff,” Dr. Wharff explained.

Psychiatric 59

Psychiatric Pediatrics Hospitals Emergency Department 59

The Trauma Pro

AUGUST 15, 2023

MTP logistics include details such as who will be delivering the blood, what actually goes in each cooler, what ratios should be used, limitations imposed by the use of frozen plasma, and documentation. One of the most creative solutions I’ve seen is the use of a hospital security officer. Think about it.

Documentation/Coding 130

Documentation/Coding Best Practices Resuscitation Emergency Department 130

The Trauma Pro

JULY 5, 2024

If the specialist insists on the emergency physician providing care because they do not want to come to the hospital, the specialist opens themselves up to major problems if any actual or perceived problem occurs afterwards. Be sure to fill out a consent as soon as practical, and document any attempts that were made to obtain it.

Documentation/Coding 113

Documentation/Coding Fractures Emergency Department Wellness 113

PDC Healthcare

MAY 1, 2023

But in mass-casualty incidents and large-scale hazards, chaotic scenes […] The post PDC Partners with Pulsara to Streamline Communication Between EMS, Hospital Personnel, and Emergency Management appeared first on connectID - PDC Healthcare Blog.

Mass Casualty Incidents 98

Mass Casualty Incidents EMS Hospitals Documentation/Coding 98

EMDocs

JULY 25, 2024

The brother’s wife calls the airport police who are able to locate him and send him to a nearby hospital. The nurse completes the Columbia-Suicide Severity Rating Scale (C-SSRS) and documents that the patient’s recent thoughts of killing himself and his detailed plan makes him “High Risk” for suicide.

Documentation/Coding 104

Documentation/Coding Hospitals Patient Safety Emergency Department 104

PEMBlog

MARCH 4, 2025

Garcia T, Florin TA, Leonard J, Shah SS, Ruddy RM, Wallihan R, Desai AP, Alter S, El-Assal O, Marzec S, Keaton M, Yun KW, Leber AL, Mejias A, Cohen DM, Ramilo O, Ambroggio L; Childrens Hospitals Initiative for Research in Pneumonia (CHIRP). Studies supporting antibiotic treatment of documented mycoplasma pneumoniae in children are limited.

Pediatrics 94

Pediatrics Military CDC Hospitals 94

The Trauma Pro

MARCH 14, 2024

They can range from very spacious… to very tight… Most trauma bays that I have visited were somewhere between 225 and 300 square feet (21-28 sq meters), although some were quite large (Rashid Hospital in Dubai at nearly 50 sq meters!). Related link: Facilities Guidelines Institute documents

Resuscitation 162

Resuscitation Documentation/Coding Hospitals 162

ACEP Now

OCTOBER 29, 2024

Our nurse did not study Paul Ekman’s Facial Action Coding System for Action Units to code “fear” in the patient’s face. Passively, I watch another clinician’s cursory examination of a critically ill patient to determine how they deem a patient “toxic-appearing” or their bedside neurological assessment to activate a code stroke.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

EMDocs

AUGUST 22, 2024

3,4 Notably, institutions receiving federal funding (such as hospitals receiving Medicare reimbursement) must abide by Title VI of the 1964 Civil Rights Act, which entitles persons with NELP to language assistance. Utilizing certified interpreters and documenting their use. Educating patients on their rights.

Documentation/Coding 104

Documentation/Coding Emergency Department Federal Emergency Management Agency Best Practices 104

The Trauma Pro

MAY 3, 2024

They separated all patients with acetabular and pelvic ring fractures using ICD-10 codes. Various hospital outcomes were tabulated, including hospital charges, mortality, and discharge location. They further narrowed their dataset to patients with angioembolization (AE) or peri-pelvic packing (PPP) as their primary procedure.

Fractures 113

Fractures Radiology Radiology Documentation/Coding 113

EB Medicine

SEPTEMBER 13, 2024

Eckler, MD discuss the September 2024 Emergency Medicine Practice article, Elder Abuse and Neglect: Making the Diagnosis and Devising a Treatment Plan in the Emergency Department Introduction and Announcements Elder Abuse and Neglect: An Overview Risk Factors and Reporting Pre-Hospital and Emergency Department Considerations Screening Tools and (..)

Elder Abuse 87

Elder Abuse Emergency Department Documentation/Coding Hospitals 87

PulmCCM

JANUARY 15, 2025

Draft Guidance Document Wong et al. Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19. References Pulse Oximeters for Medical Purposes - Non-Clinical and Clinical Performance Testing, Labeling, and Premarket Submission Recommendations. January 2025.

Academics 81

Academics Documentation/Coding Administration Research 81

EMDocs

SEPTEMBER 26, 2024

An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. An attorney is consulted and a lawsuit filed against the hospital, the first ED physician, the EM group, and the PCP. It wasn’t, so you weren’t called, nor did the doc need to document anything.

Radiology 97

Radiology Radiology EKG/ECG Documentation/Coding 97

PDC Healthcare

APRIL 2, 2024

Every year the ISBT 128 publishes labeling standards for essential items that hospital lab professionals use, including blood bags. The ISBT 128 is the “global standard for the terminology, identification, coding and labeling of medical products of human origin (including blood, cell, tissue, milk, and organ products).

Documentation/Coding 81

Documentation/Coding Hospitals Patient Safety 81

Emergency Medicine Journal

NOVEMBER 28, 2023

Accordingly, this pilot study aimed to test whether clinician-assigned ED discharge diagnosis coding could be implemented in an Irish ED, and whether coded data would be of sufficient quality to support operational needs and the proposed model of activity-based funding (ABF). 67% of available codes were used.

Documentation/Coding 40

Documentation/Coding Emergency Department Operations Administration 40

ACEP Now

JANUARY 11, 2024

The wave of increasing hospital closures and service line cutbacks continues to sweep the United States. A recent article documents 56 additional U.S. hospitals that are closing clinical departments or ending or reducing services. 2 Of these 56 additional hospitals, many are not rural; thus, this specter is expanding.

Hospitals 52

Hospitals Administration Documentation/Coding Research 52

ACEP Now

OCTOBER 26, 2023

One of the HCFA letters, written by then Medicaid Director Tim Westmoreland (the Westmoreland Letter) specifically cited that the CPT 9928X codes should be reimbursed under federal PLP unless the Medicaid plan believed there were program integrity issues with the claim. The provision similarly downcoded hospital facility fees.

Documentation/Coding 124

Documentation/Coding Hospitals Emergency Department Administration 124

ACEP Now

JANUARY 13, 2024

The 2,414-page final rule is the document that informs what Medicare payments will be for the following year. Physician Fee Schedule Conversion Factor As expected, the conversion factor, a dollar amount which, when multiplied by the relative value units assigned to a code, determines the payment amount, is expected to drop by 3.39

Documentation/Coding 52

Documentation/Coding Hospitals 52

Ken Grauer, MD

JULY 29, 2023

The ECG in Figure-1 was obtained from an 18-year old woman — who moments before been resuscitated from out-of-hospital cardiac arrest. An ICD ( I mplantable C ardiac D efibrillator ) was inserted — and the patient was discharged from the hospital. QUESTIONS: In light of the above clinical history. MRI confirmed ARVC.

EKG/ECG 370

EKG/ECG Resuscitation Documentation/Coding Hospitals 370

PulmCCM

JANUARY 6, 2025

With financial penalties coming for noncompliance with the new rule, hospital administrators rapidly deployed the alerts to fire on all eligible inpatients. The SCREEN Trial SCREEN was a stepped-wedge cluster randomized trial of an EMR alert for organ failure, conducted at 45 wards of 5 hospitals in Saudi Arabia from 2019 to 2021.

Sepsis 45

Sepsis Documentation/Coding Hospitals Outcomes 45

The Trauma Pro

OCTOBER 18, 2024

To take some of the variability out of the decision-making process for admitting service, two surgical groups on Long Island created a scoring system that incorporated several parameters described in the ACS Optimal Resource Document (Orange book). The only gray zone is the score of 4 or 5.

Documentation/Coding 147

Documentation/Coding Emergency Department Hospitals 147

EMDocs

OCTOBER 10, 2024

Exam is normal except for tenderness as documented in the diagram. Hospital Inpatient : R thigh is indurated and blistered but abdomen is all but ignored. On the 2nd hospital day, she becomes obtunded and is intubated. She only gets worse, and by the 4th hospital day she is unresponsive. I just failed to document it.

Documentation/Coding 97

Documentation/Coding Hospitals Sepsis Infectious Diseases 97

EMDocs

JUNE 28, 2023

EMS report includes concern for CVA, with variable documentation of face and extremity weakness. Nursing documentation includes the presence of a facial droop. He is transported to a different hospital as possible trauma. A lawsuit is filed against the first hospital and ED physician.

Documentation/Coding 94

Documentation/Coding EMS Stroke Patient Safety 94

ACEP Now

JANUARY 4, 2025

1 Just one year prior, Dr. Clarke had begun an emergency medicine residency at what was then known as LA CountyUSC Hospital, Los Angeles. Firsthand Account An ambulance bay at the LA County-USC Hospital in 1978. Dr. Clarke was then hired as assistant director in the emergency department (ED) at Pomona Valley Hospital, Pomona, Calif.

Forensics 52

Forensics Urgent Care Hospitals Emergency Department 52

EMDocs

MAY 9, 2024

Exam documents that he is alert and oriented but “tired appearing” and “not appearing post-ictal.” The patient is transferred to a tertiary care hospital where an MRI reveals bilateral mastoiditis with bony erosion. Defense : The EP did address the seizure when he documented “not post-ictal.” VS are normal with a temp of 97.3.

Seizures 104

Seizures Dehydration Documentation/Coding Infectious Diseases 104