ACPA Update
October 2021
In this Update
Editor's Note
Rising Pediatric Behavioral Health Admissions and Associated Challenges Faced by Physician Advisors and Pediatric Hospitals
The Outliers’ Conundrum 
Surviving Sepsis Campaign 2021: Updates Are In
Observation Committee Questions of the Month Responses 
President's Corner
Editor's Note
Ronald Hirsch, MD, FACP, CHCQM-PHYADV, CHRI
Member, ACPA Advisory Board 
Editor, ACPA Update
NPAC, the National Physician Advisor Conference, is just a few weeks away as I write this. Last week, the ACPA Government Affairs Committee held their first Town Hall, following in the footsteps of the ACPA Observation Committee’s successful Town Hall in June. Each month, ACPA releases this newsletter with articles from our members with topics of interest to the membership. The ACPA website keeps getting better, with new guidance from the CDI Committee to help PAs understand how to translate the often incomprehensible Coding Clinic guidelines into a usable form that can be taught to doctors. When I became a PA in 2006, I had few resources to guide me. It seems like I was appointed the physician advisor and then told to go to work. When I asked what I was supposed to do, they simply told me to “be a physician advisor.” We are so fortunate to have so many resources now.

This month we have an article on the challenges face by physician advisors with pediatric behavioral health. It seems that the issues are in some ways similar to the challenges of behavioral health in adults, with staffing shortages, post-acute planning, and payment barriers. Dr Sterner provides a great commentary and proposes solutions that can work for both children and adults. 

In another article, we hear about the issue of length of stay and the effect of outliers from Dr. Gore. His article is unique in that it summarizes the findings of a journal article published by Dr. Locke, the past president of ACPA. It is certainly worth reading this article and the article from Dr. Locke at the link provided by Dr Gore. It is always exciting to see an ACPA member be published in a peer-reviewed journal. I know there are others and we’d love to feature your work here. Write a summary of your study and send it to me. 

And finally we get to see the results of the August Observation Committee cases. As in previous surveys, the results show that we don’t all agree with the correct response. Why is that? Aren’t the rules very straightforward and we should all have the same answer? Now I would sure love to see better participation; under 40 people took the 5 minutes necessary to click the link and answer the questions. Imagine if you sent a CDI query to 100 of your doctors and only a few responded. Don’t make me deactivate your physician’s parking lot key card!  

Finally, want to expand your curriculum vitae? Write an article for the newsletter. Email me at signaturedoc@gmail.com for the submission guidelines.   
Rising Pediatric Behavioral Health Admissions and Associated Challenges Faced by Physician Advisors and Pediatric Hospitals 
Sophia Sterner, MD FAAP   
Member, ACPA Pediatric Physician Advisor Committee
We are in a pandemic – access to care is challenging, stress levels for caregivers and patients are high, families are home more and have less outlets for stress 

  1. We are in a pandemic – access to care is challenging, stress levels for caregivers and patients are high, families are home more and have less outlets for stress 
  2. Mental health resources are lacking – though this is not new, with COVID it is amplified 
  3. Patients with co-morbidities or medical conditions PLUS a behavioral problem are difficult to find placement for.  Some common examples are patients with autism, developmental delays, those with DME equipment such as NG or G-Tube feeds.   
  4. Patients with child protective services (CPS) involvement create an added layer with difficulty for placement  

The health system has had to react and shift to address the rise in this patient population. Many organizations have seen a rise in staff harm, an exponential increase in avoidable days specifically related to difficulty with placement may it be for acute psychiatric care or residential facilities, and the most important problem – these patients are not in the correct facility to address their underlying behavioral health issue(s).    

What are organizations doing to address these issues? Some ideas I have heard from other organizations or have seen in my own include: 

  1. Training frontline staff on how to care for behavioral patients, such as formal de-escalation training 
  2. Cohort behavioral health patients to a specific area or unit 
  3. Using technology such as video capability to address the shortage of staffing when 1:1 is needed 
  4. Working with security on how they can be involved in the care of these patients 
  5. Implementation of a “code strong” – a way to get the right people to the bedside for behavioral escalations. This includes the provider, nursing, social work, security, pharmacy with medications that may be useful for behavioral patients. 

Physician Advisors then have the challenge – how do we get this care reimbursed?  Unfortunately, the increased need for these resources do not necessarily equate to medical necessity if it is an issue with lack of placement. As with all things in pediatrics, what can be done will vary by state and local regulations. Things to keep in mind include:
 
  1. Consider what options you have for a status that payers will agree with – some have shared that they bill as outpatient in a bed or use custodial care codes 
  2. Understand what your contract language is with payers and know if there is anything within your contract that you can leverage regarding social stays or patients with difficulty in placement 
  3. Collaborate with your payers – they may have contacts for placement that may be helpful  
  4. In some cases, billing state agencies or Children’s Division may be appropriate 

Like many I hope that the numbers of cases decrease, and patients can be in a facility that is equipped to treat and handle their behavioral health needs. Physician Advisors play an important role in supporting our facilities and frontline staff during this challenging time. 

Dr. Sterner is a pediatric hospitalist at Children’s Mercy Hospital in Kansas City, MO. She is a clinical associate professor at the University of Missouri- Kansas City School of Medicine and serves as the Medical Director for Care Management and Patient & Family Services.
The Outliers’ Conundrum 
Alvin Gore, MD  
Vice President – Operations, ACPA 
Issues of utilization management stand at the top of daily functioning of every US hospital. However, the formal studies that deal with these topics are not common. Therefore, it was especially nice to see the publication in the online journal BMC Health Services Research by a group of authors that investigated the increasing impact of LOS “outliers” in the academic hospital, which was co-authored by the immediate past President of the ACPA, Dr. Charles Locke1. Prior to this publication two of the authors — Drs. Hughes and Locke — presented the findings of this study at the Grand Rounds at my hospital, so I was able to see the ‘early preview’.
 
The topic of outliers is certainly not new to anyone who is reading this newsletter. While various institutions define outlier patients differently, the main issue remains unchanged:  the impact of the outlier population on the LOS metric (whether or not one agrees with the use of this metric) is profoundly significant. Despite their relatively small numbers (about 1.5% of total discharges in the study, and about 3% in my institution), these patients impact another metric in a major way — that is of a combined ‘outlier patient-days product’ (outlier patient volume X average outlier LOS). For instance, at my UM Committee we now provide regular updates to the ‘outlier patient-days’ metric – when it is presented as a percentage of the entire hospital’s patient-days number, the impact could be quite significant. This issue is not limited only to major academic centers, but is just as relevant to traditional community hospitals as well.

We can certainly debate the reasons for the increasing impact of this patient subgroup. As was shown in this study, both the number of cases and their LOS have increased from 2014 to 2019. The reasons could be varied — some related to the society in general, such as an aging population, numerous socioeconomic factors particularly affecting more vulnerable patients, homelessness, the unwavering substance abuse epidemic, etc. Others relate to structural issues within the healthcare delivery system itself, such as the decreasing numbers of PCPs leading to reduced access for primary care follow-up after a hospital stay, flat numbers of skilled nursing facilities that frequently struggle to keep their doors open, access to long-term care beds and so on.   

Despite the incredible technological advances in healthcare, at the end of the hospital stay it frequently comes down to very basic needs that cannot be met, leading to these patients remaining in the acute care setting.

I certainly hope that more studies like this one will come out from our midst in the future highlighting this crucial but underappreciated issue.


Dr. Alvin Gore is Physician Advisor and Director of Utilization Management at St. Joseph Health in Sonoma County, California. 
Surviving Sepsis Campaign 2021: Updates Are In
Erica E. Remer, MD, FACEP, CCDS  
Member, ACPA Board of Directors
Co-Chair, ACPA Clinical Documentation Integrity Committee
Editor’s Note: While Dr Remer normally talks to us about CDI, she is an Emergency Medicine physician so the treatment of sepsis is second in her heart after the coding and clinical validation of the diagnosis of sepsis. She took the time to summarize the new guidelines on sepsis for ACPA members. Take the time to read it and then ensure your facility is going with the guidelines. 

Surviving Sepsis Campaign (SSC) updated their guidelines last week (early October 2021), and they were simultaneously published in Critical Care Medicine and Intensive Care Medicine (Surviving sepsis campaign 2021) . The definition of sepsis is still expressed as “life-threatening organ dysfunction due to dysregulated host response to infection.” The update is of the treatment of sepsis and septic shock, and the revisions are based on research studies available since the previous iteration in 2016. 

Some of the revisions seem semantic and do not seem to impart significant changes to the recommendations or protocols. I strongly suggest anyone interested in sepsis should review Table 1 which lays out the table of current recommendations and changes from the previous 2016 recommendations. The rationales for the changes and recommendations follow in the narrative of the SSC 2021 article. I am summarizing the current recommendations for the approach to sepsis and septic shock in adults in this article. They use the word “recommend” for strong recommendations and “suggest” for weak recommendations, so I will, too. 

They moved the screening section up to the top of the recommendations. They recommend the use of a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients and standardizing treatment. Acknowledging some inconsistency, a 50-study meta-analysis seemed to demonstrate that PI programs were associated with better adherence to sepsis bundles with a reduction in mortality. Surprisingly, they note that the specifics of the program were not as important as its existence and focus on screening and treatment. I interpret this to mean that just the rigor of attending to the potential for sepsis and following a standard protocol improved outcomes, although Dr. Edward Hu had a different take (you’ll have to ask Eddie for his opinion!). 

SSC 2021 notes that “a variety of clinical variables and tools are used for sepsis screening,” including systemic inflammatory response syndrome (SIRS) criteria, vital signs, Sequential Organ Failure Assessment Score (SOFA) or qSOFA, and other predictive scores. They postulate that machine learning may improve performance of screening tools. qSOFA is not recommended as a sole screening tool. Although there is variation in sensitivity and specificity of sepsis screening tools, there is agreement that it is important to identify “sepsis early for timely intervention.”  

There is a weak recommendation (i.e., suggestion) to use lactate level as an adjunctive but not diagnostic test to modify the pretest probability of suspected sepsis in patients. Later on in the paper, they note that “serum lactate is an important biomarker of tissue hypoxia and dysfunction but is not a direct measure of tissue perfusion.” 

In terms of initial resuscitation, SSC makes a “best practice statement” that “sepsis and septic shock are medical emergencies, and we recommend that treatment and resuscitation begin immediately.” The administration of at least 30 mL/kg of crystalloids in the case of sepsis-induced hypoperfusion or septic shock has been downgraded to a suggestion. They note this recommendation is from observational studies, and there have been no prospective interventional studies investigating what precise volume is optimal. They note that failure to receive 30 mL/kg within 3 hours of sepsis onset is associated with worse outcomes, even if a patient has comorbidities which might constitute a risk to assertive fluid resuscitation. Interestingly, SEP-1, the CMS sepsis bundle, as of January 1, 2022, will allow dispensation to patients who are deemed at risk of fluid overload (e.g., heart failure, renal failure) and permit a smaller volume of fluid resuscitation. 

Tools to provide guidance of resuscitation with weak recommendations/suggestions include dynamic measures (e.g., passive leg raising combined with cardiac output measurement and actions to effect increases in stroke volume), lactate levels, and new in 2021, assessment of capillary refill time. SSC 2021 continues to recommend a target mean arterial pressure (MAP) of 65 mmHg. 

There is an increase in mortality reported in multiple studies when there is a delay in transferring a patient to the intensive care unit (ICU) from the emergency department. SSC 2021 responds by recommending patients who require ICU admission be admitted within 6 hours. From the emergency physician perspective, it is our intention to get patients to the unit as soon as we humanly can get the patient out of our department! Perhaps this directive will be helpful in facilitating that. 

There are some subtle changes and new emphasis in the Infection section. There seems to be more recognition that all that appears to be sepsis may not turn out to be and that continuous reassessment is indicated. If a noninfectious cause is determined for clinical presentation, antibiotics are to be discontinued. If there is a low likelihood of infection, antibiotics may be deferred while rapidly investigating and closely monitoring.  

Patients with possible septic shock or a high likelihood of sepsis should receive antimicrobials “immediately, ideally within 1 hr of recognition,” and the empiric broad-spectrum therapy should cover all likely organisms, even potentially resistant bacteria, fungi or viruses as clinically indicated. Sustained double gram-negative coverage is discouraged except in patients for whom there seems to be no other choice, to minimize undesirable side effects and complications. After a loading dose of beta-lactam antibiotics when appropriate, prolonged infusion (as opposed to conventional bolus therapy) is recommended if the necessary equipment is available. 

There does not seem to be substantive change in source control from 2016. The recommendation is to determine if there is an infection amenable to source control measures (e.g., drainage, debridement, explantation of an infected device), and to promptly remove intravascular access devices that could represent sources for sepsis, unless impractical. Medical therapy instead of source control when indicated is not advised. 

To minimize adverse effects, de-escalation, targeting, and discontinuation of antibiotics is recommended. The suggestion is to assess daily rather than having a fixed duration of course. The shortest effective course of therapy is less costly and has fewer undesirable effects. Procalcitonin is suggested as an adjunct to decide when to discontinue antibiotics, when available. 

Crystalloids are the clear fluid of choice, being least expensive and widely available. Balanced solutions are suggested over normal saline, which is new since 2016. Albumin can be included for large volume resuscitation. Hydroxyethyl starch (HES) and gelatin are discouraged. 

For septic shock, norepinephrine is the clear front-runner for vasopressor choice. If the MAP is not responding, in their experience, once the norepinephrine dose is in the range of 0.25-0.5 μg/kg/min, the suggestion is to add vasopressin. If that doesn’t do the trick, they recommend epinephrine. For patients with septic shock and cardiac dysfunction, an inotrope such as dobutamine is suggested. Invasive monitoring and central access is suggested. New to 2021, if central venous access is not immediately feasible, peripheral vasopressor administration is suggested. With ongoing requirement for vasopressor therapy, IV corticosteroids are suggested. 

No recommendations were made as to whether restrictive or liberal fluid management is preferable in the first 24 hours following the initial fluid bolus.  

They felt there was insufficient evidence to make a recommendation (or even a suggestion!) regarding conservative oxygen therapy. If high-flow nasal oxygen (HFNC) therapy is possible in the setting, it is suggested as preferable to non-invasive ventilation (NIV) [new suggestion since 2016], but the patients must be closely monitored to see if intubation becomes necessary. No recommendation as to use of NIV as opposed to full-fledged invasive ventilation was made. There is a recommendation to use lung-protective low tidal volume ventilation (6 mL/kg) as opposed to high tidal volume (>10 mL/kg) in sepsis-induced acute respiratory distress syndrome (ARDS), and it is suggested in patients without ARDS. Higher positive end expiratory pressure (PEEP) is suggested especially for adults with moderate to severe ARDS. Prone positioning was recommended for moderate-severe ARDS. Neuromuscular blockade is suggested to be administered intermittently as opposed to by continuous infusion and should be utilized with adequate patient sedation and analgesia. Venovenous extracorporeal membrane oxygenation (ECMO) is suggested in severe ARDS when conventional mechanical ventilation fails if the facility can provide it [new since 2016 – I bet COVID-19 helped facilitate this recommendation]. 

Additional strategies: Restrictive transfusion strategy at 7 g/dL is recommended over liberal threshold (i.e., 10 g/dL). IV immunoglobulin is discouraged. Stress ulcer prophylaxis is suggested in patients who have risk factors for GI bleeding. Venous thromboembolism (VE) prophylaxis is recommended, and low molecular weight heparin (LMWH) is recommended over unfractionated heparin (UFH). Mechanical VTE prophylaxis is not felt to confer any additional benefits over pharmacologic. 

This next one is kind of funny to me: If there is no definitive indication for renal replacement therapy (RRT), don’t use it. However, if a patient does require RRT, the panel does not have a preference for continuous or intermittent. 

If a patient is hyperglycemic (> 180 mg/dL), the recommendation is to initiate insulin therapy with a typical targe range of 144-180 mg/dL. Skip the vitamin C [new since 2016]. Only use sodium bicarbonate for severe metabolic acidemia (pH ≤ 7.2) and AKI. Enteral feeding is suggested early (within 72 hours) for those who can tolerate it. 

The consensus panel recognizes that there is wide variation in ICU and post-ICU management of heterogeneous critically ill patients, but they feel there are overarching best practice concepts for goals of care. There is no recommendation for specific criteria to initial a goals of life discussion, and there are many factors to take into consideration, such as premorbid condition, prognosis, response to therapy, and receptiveness of family to have the discussion. However, it is felt that having a quality of life discussion is recommended. Formal palliative care consultation is recommended when appropriate but not as a routine practice. 

Peer support groups for survivors are suggested. Competent transition of care is suggested, but there was no specific structured format or tool for hand-off. Screening for need and referral for economic and social support is recommended. Sepsis education including common impairments such as post-intensive care/post-sepsis syndrome is suggested prior to discharge. Shared decision making in discharge planning is recommended. Medications should be reconciled (this needs to be a recommendation?!). Discharge summary and patient information should include details of the ICU stay and sepsis. 

The final recommendations/suggestions deal with post-discharge. Although on their radar, they claimed insufficient evidence to make a recommendation on early cognitive therapy for adult survivors of sepsis/septic shock. They recommend some mechanism to assess and follow-up for post-discharge physical, cognitive, and emotional problems stemming from the admission. They suggest referral to a post-critical illness program if available and rehabilitation as needed. 

I think it is really helpful for these authoritative pundits to review the medical literature for us and condense it into actionable items. There may be some changes that your facility’s sepsis protocol should undergo as a result of this publication. If you are interested in the studies they reviewed and the data, read the whole article. If not, I hope this summary will be helpful to you! 

Dr. Remer is the founder and president of Erica Remer, MD, Inc., icd10md.com  
Observation Committee Questions of the Month Responses 
Provided by the members of the ACPA Observation Committee
An 83yom with atrial fibrillation on anticoagulation presents to the ED after a fall. She is unable to provide consistent history, but denies any complaints; per her son, she lives alone and has been increasingly struggling to perform iADLs, but she seems acutely worse over the last week or so. She fell, and EMS reported that the house was in a state of squalor. She is hemodynamically stable, and a trauma survey (performed because of a fall on anticoagulation) did not reveal any musculoskeletal injuries. Her urinalysis showed 5-10 WBCs per LPF and bacteria, but nitrites were negative. Hospitalization is requested, because family cannot care for her. As it is Friday evening, you expect that she will be in hospital for several days. 

What status is appropriate?

  1. Inpatient 
  2. Observation 
  3. Outpatient in a bed 

A: 23 of 28 respondents indicated “observation” for question one, with 5 choosing “outpatient in a bed” and zero choosing inpatient.  Comments note the borderline UA, possibility of oral treatment, and non-coverage of custodial care. However, since there is a possibility of infection and the apparent acute change in her overall condition, I think a period of observation to allow for appropriate medical decision-making and further determination is reasonable. Given the clear custodial overtones I could not justify an inpatient status from presentation.  If I were reviewing the morning after she was admitted to inpatient, I would likely recommend a CC44-to-outpatient status change. 

The following day, the urine culture is no growth and no other abnormalities have presented. The patient is cooperative and pleasant but not oriented to place, time, or situation. Nurses are concerned about her gait stability. No post-hospitalization services have been arranged and thus she will stay in hospital and cross a second midnight. What is the appropriate status? 

  1. Change to inpatient 
  2. Remain in observation 
  3. Change to “Outpatient in a bed” 

A: Of 28 respondents, 21 continued observation, 4 changed to “outpatient in a bed”, and 3 changed to inpatient. While CMS’ 2-midnight policy indicates that as an inevitable second midnight approaches, a patient should generally be changed to inpatient or discharged. However, a patient needs medical necessity to justify hospital care; while this does NOT mean they need to meet inpatient based on a commercial tool, it is clear that logistical or custodial issues do not justify midnights for purposes of an IP claim. In this case, I do not see an indication for a change to inpatient status, as there is no “medical necessity” for hospital care at this point, whether she needs to stay in hospital for lack of disposition or not.  In my practice, we would leave in observation and not submit a claim beyond the 24 hours of observation. Changing to “OP in a bed” may be appropriate if your organization has such a status. 

On Sunday, the patient becomes agitated and not redirectable; she strikes at staff and requires sedation. Does this merit change to inpatient status? 

  1. Yes 
  2. No 
  3. Maybe 

A: 19 of 28 respondents changed to IP, 2 did not, and seven indicated that their decision would depend on documentation and situation of the agitation. In my opinion, a change to inpatient depends on the intervention(s) needed, persistence of symptoms, and documentation. If the patient required serial assessments and interventions, with active medical decision-making and documentation of same, an inpatient status and claim is likely supportable. If the agitation was a one-time event and/or was not documented, then my initial determination would stand. I would also count one of her two midnights to date towards her 2-midnight total. 
American College of Physician Advisors
President's Corner
October 2021
How many times have we heard or read about innovative ways to care for patients in the hospital and work with families in preparing for discharge? How many man-hours have been spent on process investigations, programs, and education on new methods aimed toward more efficient performance, faster turn-around times, and optimized patient safety? Not to poo-poo these efforts over the last decade, but I have another suggestion: 

HIRE MORE PEOPLE. 
 
Hire more people. That’s it. For the most part, our teams are composed of qualified, highly-functional individuals who are devoted to their roles caring for patients. They desperately want to do the best job possible – whatever that job entails. If there is a new safety protocol, they want to implement it. New tracking study to advance a quality initiative? Yes, please tell them what is needed so they can participate and advance toward the goal.  But, this all takes time. Time, and manpower. If your glass is already full, changing from tap water to a fancy sparkling brand isn’t going to make the glass larger. You’re just going to overflow onto the table.   
 
At the very end of last month, my mother almost died. Within 24 hours we went from being “overly cautious” – driving to a local COVID-19 testing spot after relatively mild symptoms developed – to me notifying my sister and my mother’s siblings sprinkled across the country that if they wanted to say goodbye, they should fly out immediately.  I had a whole eight days to watch the mechanisms of in-hospital care from the common vantage point of an ever-present family member but with the uncommon background of a physician advisor and former hospitalist.  Oftentimes, it was not pretty. 
 
I plan on taking a number of weeks to sift through my notes and formulate further thoughts to share but ubiquitous to all of my musings is a single conclusion: our health systems need to hire more people.  We need to stop applying heat with a blowtorch in an attempt to stretch and mold our water glasses into a form which holds more volume.  We need to look at our household budgets, cut the extras as needed (I’m looking at you, front entrance waterfall), and purchase more goblets. 
Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV
(Pronouns: She/Her)
President, ACPA

Dr. Juliet B. Ugarte Hopkins is Physician Advisor for Case Management, Utilization, and Clinical Documentation for ProHealth Care, Inc. in Waukesha, WI.
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