Acute Care Archives

Good morning, we have a patient that had a CT in the hospital as an outpt and was then sent to the ED. He went for emergent crani and another CT was not done until after..So for CT head done during resuscitative phase, can we answer, yes? And for data/information from an outside facility, can we count that as yes and pick up the CT if it was our facility, but prior to ED encounter?

Since the head CT was completed at an outpatient facility, not a transfer in, the answer would be no for CT head done during resuscitative phase. Per the manual, Yes …

Continue reading “Good morning, we have a patient that had a CT in the hospital as an outpt and was then sent to the ED. He went for emergent crani and another CT was not done until after..So for CT head done during resuscitative phase, can we answer, yes? And for data/information from an outside facility, can we count that as yes and pick up the CT if it was our facility, but prior to ED encounter? “

Hello, please help me understand how to answer the question for the below scenario “Did patient require a laparotomy that was not performed within 2 hours of arrival at your facility.” The patient arrives to hospital 2/27 2221 and goes emergently to the operating room. The first slice is at 2/27 2344 with specifically the Ex Lap beginning during the same OR visit at 2/28 0024.

Since the initial laparotomy began > than 2 hours of arrival to your hospital, the appropriate answer would be Yes-the patient required a laparotomy/laparoscopy and had the procedure performed greater …

Continue reading “Hello, please help me understand how to answer the question for the below scenario “Did patient require a laparotomy that was not performed within 2 hours of arrival at your facility.” The patient arrives to hospital 2/27 2221 and goes emergently to the operating room. The first slice is at 2/27 2344 with specifically the Ex Lap beginning during the same OR visit at 2/28 0024.”

On the Acute Care ED Response screen: If Trauma is consulted in the ED/Resus phase we are marking that as a Trauma Consult on this screen. If Trauma has not been consulted during the ED/Resus phase and does not see the patient in this phase of care- BUT gets consulted later in the hospital stay- when the patient is already inpatient/admitted (say there was a late find injury)- are we to go back to this Acute Care screen and change the status there to Trauma Consult? I have not been doing this for the inpatient consults- just recording them appropriately on the Inpatient Consult screen.

No, if Trauma is not called in ED, you would enter NO for “was alert called”, and just enter trauma consult call/arrive on the consults side. This is similar to …

Continue reading “On the Acute Care ED Response screen: If Trauma is consulted in the ED/Resus phase we are marking that as a Trauma Consult on this screen. If Trauma has not been consulted during the ED/Resus phase and does not see the patient in this phase of care- BUT gets consulted later in the hospital stay- when the patient is already inpatient/admitted (say there was a late find injury)- are we to go back to this Acute Care screen and change the status there to Trauma Consult? I have not been doing this for the inpatient consults- just recording them appropriately on the Inpatient Consult screen.”

If a total GCS is documented within 30 minutes of patient arrival, but the individual components of the score are not documented, can the total GCS be recorded in Collector?

Yes, if an incomplete GCS is documented, record as many of the GCS items as are available. This includes the Total GCS. You may record individual scores with a GCS …

Continue reading “If a total GCS is documented within 30 minutes of patient arrival, but the individual components of the score are not documented, can the total GCS be recorded in Collector?”

Patient comes in with a known GI bleed (so this will not be a HE). He goes for a scope to see where his bleed is and ends up getting the bleed cauterized and he also receives blood products because of this blood loss. Would you suggest picking up the scope, cauterization and admin of blood products considering none of this was done to treat or diagnosis an injury? I know the procedures (other than blood) are not required to be picked up based on the guideline book even if it were for the injury but we pick up all procedures used to treat/diagnosis injuries. Just looking for some input to see what you’d think especially with the blood products.

You are correct that you do not need to capture procedures for coexisting medical conditions. Only procedures related to evaluation and treatment of injury are required to be included in …

Continue reading “Patient comes in with a known GI bleed (so this will not be a HE). He goes for a scope to see where his bleed is and ends up getting the bleed cauterized and he also receives blood products because of this blood loss. Would you suggest picking up the scope, cauterization and admin of blood products considering none of this was done to treat or diagnosis an injury? I know the procedures (other than blood) are not required to be picked up based on the guideline book even if it were for the injury but we pick up all procedures used to treat/diagnosis injuries. Just looking for some input to see what you’d think especially with the blood products.”

If you have a patient whose initial VS are documented at 14:59 and that included the oxygen saturation level but at that time the supplemental oxygen was not documented and then at 15:00 you had another set of VS documented and this time it did include the supplemental oxygen as room air noted, what would you suggest. Would you take unknown for the supplemental oxygen since it was not marked with the original O2 sat or would you take room air since this was documented within 30 minutes of arrival?

I recommend recording unknown as the determination of supplemental oxygen should be made during the assessment of the initial ED/hospital oxygen saturation level. In this situation the initial O2 sat …

Continue reading “If you have a patient whose initial VS are documented at 14:59 and that included the oxygen saturation level but at that time the supplemental oxygen was not documented and then at 15:00 you had another set of VS documented and this time it did include the supplemental oxygen as room air noted, what would you suggest. Would you take unknown for the supplemental oxygen since it was not marked with the original O2 sat or would you take room air since this was documented within 30 minutes of arrival?”

On page 95 of the guidelines for was patient monitored during CT studies during the resuscitative phase are you to take all studies done within the resuscitation phase or just the initial study? Thanks for clarifying!

That is for all studies, yes.

If our facility screens for both opioids and fentanyl specifically, do we capture a patient who tests positive for both only under opioids or also under other and manually type in fentanyl?

Fentanyl is recorded under opioids and should not be captured separately.

Question about radiology studies performed in resuscitative phase- (under acute care section)- If there is a portable chest x-ray done and also x-ray of foot (does not say portable) – can I still put “1” yes, for was patient monitored during radiology? Or do ALL of the plain films need to be monitored for a yes response? The book is not specific or should I assume it means all radiology studies done in the resuscitative phase?

If the patient has multiple x-rays performed, there needs to be documentation of portable for all or documentation of the presence of the RN or CRNA, patient vital signs, and/or …

Continue reading “Question about radiology studies performed in resuscitative phase- (under acute care section)- If there is a portable chest x-ray done and also x-ray of foot (does not say portable) – can I still put “1” yes, for was patient monitored during radiology? Or do ALL of the plain films need to be monitored for a yes response? The book is not specific or should I assume it means all radiology studies done in the resuscitative phase?”

Patient was a TX out of our ER to XYZ Hospital, except the patient stated they wanted to stop home before going to XYZ Hospital. Do I count this as an ER discharge and not a TX-out?

If there is documentation and/or an order that the patient is a transfer out and is to report to a receiving facility, PTSF recommends this patient be captured as a …

Continue reading “Patient was a TX out of our ER to XYZ Hospital, except the patient stated they wanted to stop home before going to XYZ Hospital. Do I count this as an ER discharge and not a TX-out?”