Patient with Compromised Medical Condition
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Aggressive Active Intervention by EDMD
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Request for Critical Care Time by provider
CRITICAL CARE TIME
Compromised Medical Condition:
v There is a high probability of sudden, clinically significant, or life threatening deterioration in the patient’s condition that requires the highest level of physician preparedness to intervene urgently. Document the fragility of the presenting condition.
v The patient may present in stable condition but unexpectedly deteriorate while in the department. For these instances, it is extremely beneficial to document the change in status in the Provider Notes. Depending on the template in use at your facility, this may take place on a Critical Care Continuation Sheet, Progress Note, Addendum, etc.
Aggressive, Active Intervention:
v Withdrawal of, or failure to initiate these interventions on an urgent basis would likely result in sudden, clinically significant or life threatening deterioration in the patient’s condition.
v A course of action that includes titrated meds, antiarrhythmics, vasodilators, cardioversion, central line placement or an intubation can be indicative of a critical care event.
v Active intervention can include close monitoring of the patient’s condition in the form of repeat vital signs, continuous cardiac monitoring, etc. This demonstrates concern for the patient’s current status and implies that the possibility exists that either a rapid or unexpected deterioration could occur.
Request for Critical Care Time:
v Time must be requested by the provider in an amount greater than 29 minutes in order to assign.
v Time may include but is not limited to:
• Direct personal management by physician
• Time spent at bedside
• Reviewing test results or imaging studies
• Discussing patient’s care with other medical staff
• Documenting in the medical record
• Time spent with family members or surrogate decision makers to obtain medical history, discuss condition or prognosis, or treatment options/ limitations when patient is unable.
v Time spent performing separately billable procedures, i.e. CPR, intubation, central line placement, etc. must be deducted from the amount of time requested.
Examples of Compromised Medical Conditions (List is not all inclusive):
Consider documenting Critical Care Time when ordering/performing these services:
Examples of Aggressive Intervention (List is not all inclusive):
The following are considered high risk management when given intravenously:
• Thrombolytics – TPA, Streptokinase
• Anticonvulsants – Dilantin, Valium, Phenobarbital, Tegretol,
• Vasodilators – Nipride, Nitroglycerine
• Pressors – Dobutamine, Dopamine, Epinephrine, Isuprel, Levophed
• Anti-Arrhythmics – Adenocard, Atropine, Bretylium, Lidocaine, Procainamide, Verapamil
• Insulin, Labetolol, Lopressor, Cardiozem, Apresoline, Amiodarone, Diltiazem, Hydralazine, Sodium Bicarb, Vasopressin, Heparin….
Other aggressive measures:
• Triple Lumen Catheter if unstable vital signs*
• Chest tube insertion
• Endotracheal intubation
• External pacemaker application
• Internal pacemaker insertion
• BiPap or CPAP
• Cardioversion
• Pericardiocentesis
• Thrombolytic injection/infusion and/or immediate catheterization lab for acute MI
• Thrombolytic injection/infusion for acute thrombotic stroke
• IV fluid bolus > 2 L in adult or 20cc/kg in Pediatric patient
• Aggressive fluid resuscitation
• Repeated breathing treatments due to SOB (1 hour continuous nebulizer tx)
• Blood or blood products if unstable vital signs
• To OR from ED for medical or traumatic condition w/ unstable vital signs
• Care before and after successful CPR