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New protocol slashes PCI-to-balloon time
Mortality rate 50% lower than that of 'walk-ins'
A new program in Houston that involves tight teamwork between The University of Texas Medical School at Houston, the Memorial Hermann Heart and Vascular Institute — Texas Medical Center, and the Houston Fire Department EMS, as well as an experimental "cocktail" given in the ambulance to patients meeting certain criteria, has dramatically reduced Percutaneous Coronary Intervention (PCI)-to-balloon time and improved survival rates.
The program is named the Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization (PATCAR). When patients with cardiac symptoms call 911 and the fire department responds, they are asked these quick questions: Do you have cardiologist? If so, at which hospital do they practice? Do you have a provider preference?
"If the patient has a long-standing relationship with another hospital or they prefer another, they are not brought to ours," explains James McCarthy, MD, medical director of emergency services at Memorial Hermann — Texas Medical Center. "But if that facility does not have a cath lab and they have STEMI [ST segment elevation myocardial infarction], they do not go there." If the EKG is positive, he continues, one paramedic does a complete assessment and the second one calls the ED's number on a cell phone and sends the EKG.
"A light flashes on my computer and it makes a noise at my receiving station, which is centrally located in the ED," McCarthy says. "I click a mouse, and up pops the screen, and it is either STEMI or not."
How long? About 5 seconds
This process typically takes about five seconds, he says. McCarthy's dedicated phone rings like a siren. "I talk with the paramedic about the patient; they tell me the symptoms, I confirm that I am looking at the right EKG and that it is consistent with STEMI, and review the symptoms and history to see if there is anything that excludes the patient from receiving fibrinolytics," McCarthy says. "If not, we give the patient a loading dose of heparin, clopidogrel, and retavase." (The retavase is given at only half the usual dose, per the Food and Drug Administration's approval after the researchers developing the protocol filed an Investigational New Drug application.)
As soon as McCarthy gives that order, he turns to his secretary and says, "Activate heartbeat," at which point a multipager goes to an interventional cardiologist fellow, a cardiology research nurse, a cath lab nurse and other staff, the business office, the cardiac care unit (CCU), a CCU fellow, the CCU charge nurse, resident, and the operations administrator.
Explaining the importance of contacting the business office, McCarthy says, "nothing happens in a hospital without a medical number. The patient hits the door and is pre-registered."
Staff often wait for patient
McCarthy estimates that about 40% of the time, he and his team get things moving fast enough so that the cardiology staff are actually waiting for the patient. "We take a quick look to make sure they do not need be intubated — that they are awake and talking — and they go straight to the cath lab and are transferred to the table by the Houston fire department," he says. "By the time we are done with paperwork, the case is over."
This process has dramatically reduced the time it takes to treat the patient, says Richard Smalling, MD, PhD, head of the PATCAR initiative. "Right now, the typical time from primary PCI onset to balloon is four hours; with us, [the artery is] opened in 165 minutes or less," says Smalling, who is also professor of medicine at UT Medical School at Houston and director of interventional cardiology at Memorial Hermann — Texas Medical Center.
In addition, says McCarthy, "For patients we do this for, there is a 50% reduction in mortality compared to folks who just walk in the ED or who are brought in by an ambulance service that has not called us."
For more information on Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization (PATCAR), contact:
Inservice given for new protocol
Before the successful implementation of the PATCAR (Pre-Hospital Administration of Thrombolytic Therapy with Urgent Culprit Artery Revascularization) process at Memorial Hermann — Texas Medical Center, a good deal of preparation was required, says James McCarthy, MD, medical director of emergency services.
It was the brainchild of Richard Smalling, MD, PhD, professor and director of interventional cardiovascular medicine, University of Texas Medical School at Houston, director of interventional cardiology at Memorial Hermann Memorial Hermann — Texas Medical Center, Houston, and head of the PATCAR initiative. "But we were brought into it early on — in the planning stages," McCarthy recalls. "The initial concerns were what could be done in the back of the ambulance and how to treat a patient we have not seen yet." As soon as he and his staff stepped back from that initial reaction, he says, they realized that in certain cases, it made sense.
"We had to do an inservice on what the protocol was, what the plan was, what testing was required, and technical stuff on setting up with the staff on how we would be receiving the EKGs from the field, a protocol for making it safe to administer pre-hospital therapy, and working out kinks with the paramedics," McCarthy says. "Then, we worked intensively with the transmission staff, because initially we did not have a strong-enough data line for 12-lead EKGs. We had to switch to cell phone carriers."
Finally, he said, he worked on a multidisciplined approach for the hospital. "We addressed how to get the ball moving once we were notified," he explains. "For example, we had to work with cardiology to relinquish the decision about whether to go to catheterization. That decision now solely rests in our hands."
Now, when McCarthy hits his "panic button" indicating a patient with ST-segment elevation myocardial infarction (STEMI) is coming in, "Smalling just asks how long he has to get to the cath lab," says McCarthy. "I tell him to either go straight to the ED or to the lab."
Improve your understanding of decision making's impact
[Editor's note: This is the first in a two-part series on the relationship between decision making and documentation. This month, we cover the key components of medical decision making. Next month, the column will address risk as an element of decision making. This quarterly column on coding in the ED is written by Caral Edelberg, CPC, CCS-P, CHC, president of Edelberg Compliance Associates in Baton Rouge, LA. If there are coding issues you would like to see addressed in this column, contact Edelberg at (225) 454-0154. EFAX:(225) 612-6904. E-mail: email@example.com.]
It's funny how things change. This year marks 14 years since the implementation of the Medicare/American Medical Association documentation guidelines. Looking back at that point in time, it seemed a long shot that emergency medicine records could ever contain all of the elements needed for most of the levels, particularly 99284 and 99285.
To a large extent, the guidelines have made the job of coding easier. Coders know what to look for to score each level. Vendors offering documentation tools were given a remarkable opportunity, and many survive to this day with constant upgrades to products to help physicians with the arduous task of documenting each and everything they do.
Physicians have come a long way, too. Their documentation today exceeds our expectations by miles and, more significantly, most emergency physicians today really want to learn the ins and outs of documentation to ensure they are paid properly for their hard work. They often look to coding and billing staff to keep them current on coding and documentation rules.
Of late, more medical records provide documentation for the essential components of the history and physical examination. When missing information, most coding professionals would agree that missing elements of the history most often results in down-coding from the level illustrated by medical decision making. Why? ED physicians don't often understand the intricate rules and correlation between the history/physical and the importance medical decision making. Understanding how medical decision making affects overall level of service within the ED goes a long way toward understanding what to document, with the understanding that documentation merely supports the efforts of the ED practitioner; however, in doing so, it allows coding staff to code at the level of service actually provided.
Docs undervalue their services
If ED physicians have an understanding of the level of complexity of medical decision making they are providing through the case, the checks and balances in place for determining the level of the history and physical examination might easily function properly. Truly, many emergency physicians do what comes naturally when treating ED patients and don't recognize the high complexity of many of the day-to-day services they provide. In doing so, they routinely undervalue their services.
Medical decision making (MDM) was gifted to us by the Centers for Medicare & Medicaid Services and the American Medical Association. It's a label placed on something physicians start the minute they pick up a chart and walk into a patient's examining room. With the documentation guidelines, MDM was put into a format that has now become standard thinking for coding and billing professionals but doesn't always make sense to the physician.
MDM consists of:
If we break each element down, we see components that are essential to documentation and coding appropriately. (See graphic.)
Of note, the content of the diagnoses and management options component clearly recognize many of our ED patients at the multiple or extensive level that correlates to a 99284 or 99285. Most ED patients present to the ED with problems new to the ED physician. Don't think of it as chronic problems being managed appropriately; think of it as acute exacerbation of chronic problems — many poorly managed — and most being new to the ED physician examining the patient.
Definition of 'work-up'
The definition of "work-up" planned has never been clearly defined as it relates to the documentation guidelines. However, some payers define it as a work-up by the examiner during the current visit. Others define it as a scheduled work-up following the visit. Either way, our ED patients typically score at the 99284 or 99285 level on this element, as ED problems are either new to the examiner but not requiring a work-up, or new to the examiner who is planning a work-up.
Clearly, diagnostic studies and referrals to consultants for further work-up and treatment constitute a planned, additional work-up. I tend to think that following the history and physical, the emergency physician either plans an additional, more in-depth work-up or determines that no additional work-up is required. If the work-up — generally defined as lab, X-ray, EKG, or additional diagnostic tests — is performed in the ED, it should qualify as "additional work-up planned." If referred to another provider, it definitely qualifies. Check with your major payers to see how they define "additional work-up."
The amount and complexity of data to be reviewed are clearly an objective determinate, and the level of complexity should be clearly documented. The ordering of lab tests, X-rays, and EKGs is generally easy to identify from the physician notes. However, when the physician fails to document discussion/review of test results with the radiologist or cardiologist or fails to record the personal review of diagnostic tests, the review of old records, or the personal interpretation of diagnostic tests, the documentation fails to provide the higher level of complexity managed by the ED physician.