Grand Rounds Recap 8.8.18

ED Billing : Level V Charting and Critical Care Time WITH DR. Ryan

Reimbursement varies based upon the charge level assigned to the chart.

Four reasons to work towards improving your chart documentation:

  1. Improves communication between providers leading to better patient care.
  2. It is a requirement from JCAHO, hospital administration, and insurance companies.
  3. Real time documentation avoids implications of fraud.
  4. Helps you to stay out of court.  Improved documentation removes doubt of care provided when adverse outcomes occur.

Requirements for a level V chart:

History of Present Illness

  • Level IV and V chart requires at least four of the following qualifiers of the HPI:  location, duration, quality, severity, context, timing, modifying factors, associated signs and symptoms.
  • Ex. Level V HPI:  50 yo male presents with aching 10 over 10 chest pain that started one hour ago and is constant with associated numbness in the his shoulder.  His symptoms started while lifting a box at work and is improved with rest.

Review Of Systems

  • Level I chart does not require a review of systems
  • Level II and III chart requires one pertinent system covered
  • Level IV requires two to nine pertinent systems covered
  • Level V requires ten + pertinent systems covered

Past Medical, Family, and Social Histories

  • Level I - III chart does not require any documentation of these histories
  • Level IV chart requires one item from any history
  • Level V chart requires one item from two separate histories

Physical Exam

  • Level I chart requires one system examined and documented
  • Level II - III chart requires two to three systems examined and documented
  • Level IV chart requires five to seven systems examined and documented
  • Level V chart requires eight + systems examined and documented
  • It is considered sufficient to document that a system is "normal"; however, all abnormalities must be clarified in detail.

Medical Decision Making

  • The level assigned to the chart is not easily quantified.
  • The key to success is to always document all things you performed or assessed.  This includes labs reviewed, imaging studies personally assessed, considerations in your differential diagnosis, and ultimate number of issues addressed during the visit.

Critical Care Time:

  • It is important to document what made you consider the patient critically ill, what you did for the patient, and the cumulative critical care time you spent on direct and indirect patient care.

Top Practice Changing Articles of 2017-2018 WITH DR. Benoit

Dr. Benoit gives a run down of his top articles of the academic year - click on the title as a link to the abstract

Bhatt, JAMA Peds 2018

Clinical Question: In healthy pediatric patients, does following fasting duration guidelines for procedural sedation, versus not following fasting duration guidelines, decrease the risk of aspiration or serious adverse events, in the ED?

Study Design: Prospective observational cohort study

Sample Size: 6,183 patients

Results: No difference

Aycock, Annals of Emergency Medicine 2018

Clinical Question:  In patients receiving a CT scan, does the addition of IV contrast, versus no IV contrast, increase the risk of acute kidney injury, need for renal replacement therapy, or all cause mortality, in any setting?

Study Design: Meta-analysis of observational studies

Sample Size: 28 studies with 107,335 patients

Results: No difference


Costantino, JAMA IM 2018

Clinical Question: In patients who present with syncope, what is the prevalence of pulmonary embolism, at ED or hospital discharge?

Study Design: Retrospective cross-sectional study

Sample Size: 1,671,944 patients

Results: Very low (<1%)

Chu, Lancet 2018

Clinical Question: In critically ill patients, does providing liberal supplemental oxygen, versus conservative oxygen, increase in-hospital or 30-day mortality, in the ICU?

Study Design: Meta-analysis of RCTs

Sample Size: 25 studies with 16,037 patients

Results: Conservative oxygen is superior


Daum, NEJM 2017

Clinical Questions: In adult and pediatric patients with an uncomplicated small abscess undergoing incision and drainage, does the addition of clindamycin or bactrim, versus placebo, improve clinical cure rate at 10 days, in outpatient clinics and the ED?

Study Design: RCT

Sample Size: 786 patients

Results: Antibiotics are superior

Crowell Academic Emergency Medicine 2017

Clinical Question: In patients with suspected globe rupture being evaluated by ophthalmology, what is the sensitivity of a CT scan in making the correct diagnosis, in the ED?

Study Design: Retrospective diagnostic accuracy study

Sample Size: 114 patients (35 with open globe)

Results: Not good enough (51-77%)


Friedman, Annals of EM 2017

Clinical Question: In patients with acute, non-traumatic, non-radicular low back pain receiving naproxen, does the addition of valium, versus placebo, improve functional disability and pain scores at 1 week, in the ED?

Study Design: RCT

Sample Size: 114 patients

Results: No difference

Driver, JAMA 2018

Clinical Questions: In experienced providers performing direct laryngoscopy on patients with a predicted difficult airway, does a bougie, versus stylet, increase the first-pass success rate, in the ED?

Study Design: RCT

Sample Size: 757 patients

Results: Bougie is superior


Gayet-Ageron, Lancet 2018

Clinical Question: In patients with acute traumatic or post-partum hemorrhage who received TXA within 3 hours, does the timing of administration, decrease mortality, in multiple settings?

Study Design: Patient-level meta-analysis of RCTs

Sample Size: 2 studies with 40,138 patients

Results: 10% drop in survival per 15 minute delay

Fuller, Annals of EM 2017

Clinical Question: In recently intubated patients, does a 4-part lung-protective mechanical ventilation protocol, versus no protocol, decrease the incidence of ARDS, ventilator-free days, or mortality, in the ED?

Study Design: Before-and-after study

Sample Size: 980 patients

Results: Lung-protective protocol is superior


Self, NEJM 2018

Clinical Question: In patients admitted to a non-ICU, does administration of lactated Ringers, or Plasma-Lyte, versus normal saline, reduce the number of hospital-free days, in the ED?

Study Design: Cluster-randomized crossover trial

Sample Size: 13,347 patients

Results: No difference

Nogueira, NEJM 2018

Clinical Question: In ischemic stroke patients with a last known normal of 6-24 hours and a LVO and a small infarct volume, does endovascular thrombectomy, versus standard of care, improve neurological outcome at 90 days, in the ED?

Study Design: RCT

Sample Size: 206 patients

Results: Endovascular thrombectomy is superior


Shackelford, JAMA 2017

Clinical Question: In military patients with severe traumatic injuries, does prehospital administration of blood products, versus delayed or no administration, improve 24-hour and 30-day survival, in a combat zone?

Study Design: Retrospective observational cohort study

Sample Size: 502 patients

Results: Prehospital blood products is superior

Semler, NEJM 2018

Clinical Question: In patients admitted to an ICU, does administration of lactated Ringers or Plasma-Lyte, versus normal saline, reduce the incidence of a composite end-point of death and/or new renal replacement and/or AKI, in the ED and ICU?

Study Design: Cluster-randomized crossover trial

Sample Size: 15,802 patients

Results: LR or Plasma-Lyte


Stephens, Chest 2017

Clinical Question: In mechanically ventilated patients, does deep sedation, versus non-deep sedation, increase in-hospital mortality, in the ED?

Study Design: Retrospective observational cohort study

Sample Size: 414 patients

Results: Non-deep sedation is superior

Shaikh, JAMA Peds 2018

Clinical Question: In pediatric patients age 2-23 months, does "UTICalc", compared to the American Academy of Pediatrics algorithm, improve the diagnostic accuracy of urinary tract infections, in the ED?

Study Design: Nested cast-control study

Sample Size: 2070 patients

Results: UTICalc is superior


Thomalla, NEJM 2018

Clinical Question: In ischemic stroke patients with an unknown onset time who are not getting endovascular thrombectomy but have a favorable MRI, does tPA, versus placebo, improve neurological outcome at 90 days, in the ED?

Study Design: RCT

Sample Size: 503 patients

Results: tPA is superior 

Stern, Cochrane 2017

Clinical Question: In adults and pediatric patients with severe community acquired pneumonia with or without health-care associated pneumonia, do steroids, versus placebo, reduce mortality and treatment failure rates, in hospitalized patients?

Study Design: Meta-analysis of RCTs

Sample Size: 17 studies with 2,264 patients

Results: Steroids are superior


Waldman, Annals of Emergency Medicine 2018

Clinical Question: In patients with a simple corneal abrasion, does prescribing 24 hours of topical tetracaine, versus standard treatment, increase the risk of ocular complications, in the ED?

Study Design: Retrospective cohort study

Sample Size: 1,980 patients

Results: No difference

van der Hulle, Lancet 2017

Clinical Question: In patients with suspected pulmonary embolism, does the YEARS algorithm (higher D-dimer cut-off if no signs of DVT, no hemoptysis, and PE not most likely diagnosis), versus Well's criteria, safely reduce CT imaging, in the out/in-patient setting?

Study Design: Prospective diagnostic accuracy study

Sample Size: 3,465 patients

Results: YEARS does safely reduce CT imaging need


Weisbord, NEJM 2018

Clinical Question: In patients high risk for kidney injury undergoing elective angiography, does administration of sodium chloride IV, versus sodium bicarb IV, and NAC PO, versus placebo, decrease the rate of kidney injury, in the angiography suite?

Study Design: RCT with 2x2 factorial design

Sample Size: 5,177 patients

Results: No difference

R4 Capstone Lecture : Learning from Failure WITH DR. Colmer

Despite our best efforts, failure is a part of the practice of medicine. Clinicians tend to deal with failure in one of three ways:

  • "Self-Flagellation" is a maladaptive behavior where we beat ourselves up after a failure.  Shifting the focus away from self-improvement and instead dwelling our short-comings prevents the ability to grow from the experience.
  • "Putting your head in the Sand" is also a maladaptive behavior where we make excuses for the poor outcome and try to shift blame away to preserve our ego.  
  • A third option exists where we embrace the failure as an opportunity for growth and focus on analyzing the scenario for learning opportunities that ultimately will make us a more successful provider in the future.

Pediatric Behavioral Emergencies WITH DR. Zamor

ED visits for psychiatric or behavioral complaints account for approximately 5% of annual PED visits.
1 in 15 youth presenting to the ED with psychiatric complaints require restraint during the course of the ED stay.

There are identifiable risk factors for agitation:

Non-modifiable factors:

  1. Male gender
  2. Low family income
  3. Traumatic brain injury
  4. History of physical or sexual abuse, disciplinary action at school, interpersonal violence

Psychological factors

  1. Negative world view
  2. Lack of empathy
  3. Limited insight

Physical factors

  1. CNS disorders
  2. Acute or chronic pain
  3. Poor sleep
  4. Infection


  • Environmental Alterations
    • Remove distracting, risky, or clutter items from their environment
    • Introduce yourself, explain procedures and time course
    • Offer comfort items (blankets, food)
    • Allow them to make discrete choices (lights on/off, parents in/out)
  • Verbal De-escalation
    • Involve child-life specialist, family members, etc in attempt to calm the patient.
    • Remove individuals who are contributing to the patients stress
  • Chemical Restraints
    • PO > IM > IV
    • If patient already has a prescription of a medication give a PRN of that med to avoid polypharmacy
    • Check to see if patient has missed a dose of a normally scheduled medicine 
    • Identify why the patient may be agitated and use a medication targeting the cause:
      • Anxiety: benzos
      • Psychosis/aggression: Anti-psychotics
  • Physical Restraints
    • Final resort if the above are unsuccessful or if the patient represents an acute risk of harm to self or others
    • Physical restraints require chemical restraint as well.

R3 Small Groups : ENT Topics WITH DRs. Golden, Jarrell, and Nagle

Epistaxis in the ED


  • Anterior (90%) vs. Posterior
  • Etiology
    • Trauma
    • Dry mucosa
    • Rhinitis/sinusitis
    • Polyps/neoplasm
    • Systemic Disease
  • Anticoagulation
  • Bleeding Dyscrasias


  • Resuscitate as needed
  • Apply direct pressure
  • Vasoconstriction
    • Blow clots out of nose
    • Oxymetolzone 
    • 4% cocaine solution
  • Packing/Hemostatsis
    • Analgesia
      • 4% atomized lidocaine
    • Hemostasis
      • Silver Nitrate
      • TXA
    • Packing
      • Rapid Rhino
      • Foley 
  • Disposition
    • Anterior: Follow up in 24-72 hours if packed
    • Posterior: Admission

Ear Lacerations

Traumatic Ear Lacerations

  • Step 1: Numb - Field block of the ear/auricular block
  • Step 2: Close the cartilage.  Use 5-0 or 6-0 vicryl simple interrupted sutures
    • Cartilage is avascular with all blood supply coming from the overlying skin
    • Approximating the cartilage - especially in the helix/anti-helix - will help maintain the anatomy of the ear
    • If there is exposed cartilage (that skin will not cover after repair), it is reasonable to perform a wedge resection
      • Up to 5 mm of cartilage can be removed without disrupting the anatomy
      • If >5mm of cartilage is exposed/will need to be removed, consider specialist consultation
  • Step 3: Close skin.  Use 5-0 or 6-0 non-absorbable suture
    • Approximate the anatomy as closely as possible.  Use staging sutures if needed
    • Skin sutures can go through cartilage as well if necessary to approximate anatomy
  • Step 4: Bolster to prvent auricular hematoma (and subsequent cauliflower ear) formation (keep in place for 24-48 hours)
    • Classic technique: Xeroform in front of laceration, gauze behind ear, wrap in ACE or coband

Ear Lacerations Secondary to Earrings

  • It is reasonable to repair this in the ED but these do not require emergent repair
  • If the patient is very concerned about cosmesis or if the laceration is complicated (ex. gauges with large defect) discharge and have the patient follow up with plastic surgery.
  • If repairing primarily in the ED:
    • Use simple interrupted sutures with non-absorbable suture material
    • If the skin edges are healed you need to excise those before repair
    • If you have a partial laceration (earring did not pull all the way through the earlobe) you need to excise the skin to the inferior portion of the earlobe.
    • Biggest cosmetic concern is the inferior border of the lobe creating a ''notch''
      • Treat this repair like a vermillion border repair.  Alignment is critical to cosmetic result
      • Do NOT close the laceration with portions of the old earring tract inside as this will cause a inclusion cyst.
      • Remind patient that they should no re-pierce their ear for 12 weeks