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

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. 4 However, emergency physicians rely on gestalt to predict outcomes well. Dr. Koo is faculty and an emergency physician at MedStar Washington Hospital Center in Washington, D.C., 1999;21(10):974.

Emergency Department 59

Emergency Department Mass Casualty Incidents Documentation/Coding Sepsis 59

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

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. AE and PPP have equivalent outcomes. You can feel comfortable that outcomes will be the same as AE.

Fractures 113

Fractures Radiology Radiology Documentation/Coding 113

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Draft Guidance Document Wong et al.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. Clinical Outcomes Associated With Overestimation of Oxygen Saturation by Pulse Oximetry in Patients Hospitalized With COVID-19. Nature (news).

Academics 81

Academics Documentation/Coding Administration Research 81

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. A cluster randomized trial using all-cause mortality as an outcome was always needed to determine whether EMR alerts improve outcomes for suspected severe infection.

Sepsis 45

Sepsis Documentation/Coding Hospitals Outcomes 45

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 105

Documentation/Coding Emergency Department Federal Emergency Management Agency Best Practices 105

Don't Forget the Bubbles

JULY 3, 2023

This time we have our first group of colleagues from Birmingham Children’s Hospital Emergency Department. This data relies heavily on the coding, which we know is not standardized across healthcare sites- and, therefore may not be truly reflective. This retrospective cohort study compared pre- and post-guideline outcomes.

Emergency Department 105

Emergency Department Hospitals Domestic Violence Pediatrics 105

Dr. Smith's ECG Blog

MARCH 14, 2024

Written by Jesse McLaren Three patients presented with acute chest pain and ECGs that were labeled by the computer as completely normal, and which was confirmed by the final cardiology interpretation (which is blinded to patient outcome) also as completely normal. The reliability of these ECGs should be based on patient outcome.

EKG/ECG 119

EKG/ECG Documentation/Coding Patient Safety Outcomes 119

EMDocs

SEPTEMBER 26, 2024

This story, while unlikely to reflect the standards of most readers, has a somewhat surprising outcome. An unknown EP reviews the report, determines that there is no reason to notify the patient, and documents nothing. Even if we don’t know who the second EP was, he was an agent of the hospital, so the hospital is also liable.

Radiology 98

Radiology Radiology EKG/ECG Documentation/Coding 98

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 105

Seizures Dehydration Documentation/Coding Infectious Diseases 105

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 98

Documentation/Coding Hospitals Sepsis Infectious Diseases 98

The Skeptics' Guide to EM

JULY 27, 2024

Ann Emerg Med 2024 Date: July 25, 2024 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: Your hospital is running Morbidity and Mortality (M&M) rounds after a few recent cases in which the diagnosis of sepsis was identified late, and antibiotics were delayed.

Sepsis 99

Sepsis Outcomes Documentation/Coding Hospitals 99

RebelEM

JANUARY 29, 2024

in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 in the paper but 2.7% to ≈0.99 (p<0.001) Mean MPI/Tei Index≈ 0.47 to 4.0mg/hr typically given in EKOS therapy (See Below).

Stroke 136

Stroke Outcomes Hospitals Administration 136

RebelEM

NOVEMBER 30, 2023

PMID: 37597449 Clinical Question : In sepsis patients with CHF, does a restricted volume resuscitation strategy of less than 30mL/kg IV crystalloid initiated within the first three hours of sepsis identification, compared to volume resuscitation with 30 mL/kg IV crystalloid, decrease in-hospital mortality? 2.89, p = 0.01.

Sepsis 122

Sepsis Fluid Resuscitation Resuscitation Administration 122

EMDocs

SEPTEMBER 30, 2024

Primary outcome: Prescription of ICS on ED discharge from the index visit Secondary outcomes: ICS prescription rates in high-risk subgroups Rates of outpatient follow-up within 30 days of an ED visit for asthma Variation in ICS prescription rates among attending ED physicians. The primary outcome was hospital admission rates.

Outcomes 105

Outcomes Academics Documentation/Coding Emergency Department 105

PulmCCM

JUNE 12, 2023

TTM2 found no improvement in survival or neurologic outcome among patients randomized to cooling to a target of 33 °C, as compared to controls receiving fever prevention (e.g. Use code PULMCCM15 and get 15% off when you register online.

Hyperthermia / Hypothermia 105

Hyperthermia / Hypothermia Academics Documentation/Coding Outcomes 105

ACEP Now

OCTOBER 3, 2023

This document is an update of guidelines first published in 2000, and then updated in 2007. These guidelines present the best available evidence to support clinical decision making in the prehospital setting when TBI care may have the most significant impact on outcomes; they also establish a research agenda for future investigations.

Fluid Resuscitation 98

Fluid Resuscitation Documentation/Coding Resuscitation EMS 98

PulmCCM

JUNE 5, 2023

veterans’ hospitals did not show a mortality reduction from low-dose methylprednisolone. Patients receiving hydrocortisone required more insulin, but did not have higher observed rates of hospital-acquired infections or gastrointestinal bleeding. iatrogenic or hospital-acquired) were excluded. In the U.S.,

Advances Cardiac Life Support (ACLS) 96

Advances Cardiac Life Support (ACLS) Documentation/Coding CPR Shock 96

PulmCCM

JANUARY 29, 2024

Read the document for all the details (it’s not long). A randomized trial showed improvement in ROSC with 20 IU vasopressin + 40 mg methylprednisolone after the first dose of epinephrine for in-hospital arrests, without any survival or neurologic benefit seen. PulmCCM is not affiliated with the American Heart Association.

Seizures 115

Seizures CPR Documentation/Coding Hyperthermia / Hypothermia 115

RebelEM

JULY 3, 2023

What They Did: Researchers conducted a multicenter, retrospective cohort study in three community hospitals and two freestanding emergency departments. Secondary outcome All secondary outcomes were found to be similar (Not statistically significant) between groups (See table above). received CaCl 89.3%

Administration 96

Administration Outcomes Documentation/Coding Emergency Department 96

Dr. Smith's ECG Blog

JUNE 13, 2024

Her first set of vitals were documented: BP 116/57 Pulse 94bpm Respiratory rate 24/min O2 sat 90% on room air Temp 97F She had been cleaning a Jeep in the sun, and was sunburned. The physician documented “normal sinus rhythm”. The physician documented that she was “improved” and the patient was discharged. CK MB was 1.9

EKG/ECG 92

EKG/ECG Documentation/Coding EMS Burns 92

The Skeptics' Guide to EM

FEBRUARY 3, 2023

Temperature Control After In-Hospital Cardiac Arrest: A Randomized Clinical Trial. September 2022 Guest Skeptic: Dr. Justin Morgenstern is an emergency physician and the creator of the #FOAMed project called www.First10EM.com Case: You are working an overnight shift at a small rural hospital. Circulation. Circulation.

Hyperthermia / Hypothermia 52

Hyperthermia / Hypothermia Hospitals Documentation/Coding CPR 52

EMDocs

JUNE 8, 2023

and 9 hours after onset of symptoms, with non-infarcted brain tissue, does the administration of alteplase improve functional outcome at 90 days? Subsequently reduced enrollment to 310 patients because no patients had been lost to follow-up or had insufficient data documented. Intervention: Alteplase 0.9 in alteplase group versus 0.9%

Stroke 98

Stroke Administration Documentation/Coding Outcomes 98

Dr. Smith's ECG Blog

MARCH 19, 2024

This case was sent by Amandeep (Deep) Singh at Highland Hospital, part of Alameda Health System. The patient presented to an outside hospital An 80yo female per triage “patient presents with chest pain, also hurts to breathe” PMH: CAD, s/p stent placement, CHF, atrial fibrillation, pacemaker (placed 1 month earlier), LBBB.

EKG/ECG 111

EKG/ECG Hospitals Documentation/Coding Outcomes 111

RebelEM

AUGUST 22, 2024

hours of symptom onset appears to be the most promising approach for improving visual outcomes, supported by multiple studies and meta-analyses. Finally, most hospitals lack the necessary protocols and processes to coordinate the complex interdisciplinary care patients with RAO may require. Paper: Lema GMC, De Leacy R, Fara MG, et al.

Stroke 85

Stroke Administration Outcomes Documentation/Coding 85

Sensible Medicine

AUGUST 21, 2023

Administrative data sets are often collected for the purpose of billing, or costing, or administrative organization, and thus are extremely vulnerable to up coding or intentional or accidental omissions. ” For example, mortality is a patient outcome—provided it can be reliably ascertained.

Administration 97

Administration Outcomes Research COPD 97

RebelEM

JUNE 8, 2023

Assessed clinical practice, outcome, length of stay, safety, and efficacy of both phenylephrine and epinephrine peripherally administered through a push dose.

Administration 98

Administration Emergency Department Outcomes Documentation/Coding 98

ACEP Now

DECEMBER 6, 2024

1 Relatively little literature on the clinical characteristics and outcomes of out-of-hospital cardiac arrest (OHCA) patients complicated by coronary vasospasm exists beyond anecdotal reports, however. Cardiac arrest secondary to myocardial ischemia from coronary vasospasm is well documented. Angina pectoris. 1959;27:375-388.

Resuscitation 98

Resuscitation EKG/ECG Documentation/Coding COPD 98

Taming the SRU

DECEMBER 8, 2023

EMS had reported she had coded en route. ED providers should be familiar with several extraction techniques for foreign bodies in the external auditory canal including the use of manual extractors, irrigation, and other methods such as adhesives and acetone. She regained pulses with warming on arrival.

Hyperthermia / Hypothermia 88

Hyperthermia / Hypothermia Head Injuries Resuscitation Documentation/Coding 88

RebelEM

AUGUST 12, 2024

What They Did: Double-blind, randomized, placebo controlled trial that ran from October 2019 through January 2024 Multinational study conducted at 22 centers in three European countries 3512 patients were enrolled and before surgery eligible patients were randomly assigned to one of the following two groups Amino Acid Group: 10% Isopuramin at a dose (..)

Outcomes 81

Outcomes Hospitals Operations Shock 81

The Skeptics' Guide to EM

DECEMBER 2, 2017

Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival. DISCLAIMER: The views and opinions of this podcast do not […] The post SGEM#197: Die Trying – Intubation of In-Hospital Cardiac Arrests first appeared on The Skeptics Guide to Emergency Medicine. Reference: Andersen et al.

Hospitals 40

Hospitals CPR Resuscitation Documentation/Coding 40

ACEP Now

JULY 7, 2024

My current practice is a hybrid of academic and community sites, and I have worked in myriad community hospitals from busy ones to single coverage critical access hospitals. If you have a difficult outcome, it is helpful to know what risk management support you have at your hospital. The past is the past.

Resuscitation 98

Resuscitation Risk Management Hospitals Critical Access 98

Don't Forget the Bubbles

JUNE 19, 2024

This may limit the generalisability of the results in regional/community hospital settings. A proportion of the patients who were initially missed using the CDR were found to actually have risk factors documented in EMS reports or the medical record. Were the predictor variables and the outcome evaluated in a blinded fashion?

CPR 124

CPR Research Documentation/Coding Outcomes 124

The Trauma Pro

MAY 10, 2024

And its correlation with outcomes varies. It also standardizes comparisons between hospitals that use STAT. This fills in the code on the second tab which will be added to TraumaBase. The most important one is that it relies only on the Injury Severity Score (ISS) to judge whether some type of mistriage occurred.

Blood Transfusions 113

Blood Transfusions Radiology Radiology Documentation/Coding 113

Don't Forget the Bubbles

MAY 10, 2023

Then you hear the words coming out of the speaker, “ Paediatric code black. Paediatric code black ”. You’ve heard the phrase code black before – it’s a traumatic cardiac arrest. You know a paediatric code black means paediatric traumatic cardiac arrest. As you arrive in resus, so too do half the children’s hospital.

Emergency Department 91

Emergency Department Resuscitation Documentation/Coding Teamwork 91

American Medical Compliance

AUGUST 7, 2024

For example, CMS requires accurate and timely documentation of patient care to ensure proper billing and reimbursement. Adhering to CMS quality measures, such as reducing hospital readmission rates and improving patient safety protocols, helps maintain high standards of care.

Hazardous Materials 105

Hazardous Materials Documentation/Coding Legal Issues Patient Safety 105