Adult Surgical Clinical Reviewer: Discussion of Complex Clinical Scenarios and Variable Review

Transcription

1 Adult Surgical Clinical Reviewer: Discussion of Complex Clinical Scenarios and Variable Review

2 Disclosures The following individuals have no actual or potential conflicts of interest in relation to this presentation: Jesus Diaz, BSN, RN; Jakob Lapsley, BSN, RN; Sue Kim-Navabi, BSN, RN

3 Agenda Q&A after each question Review comments from Adult Variable Survey from March Follow-up webinar in August to review questions

4 3 You are Question reviewing Number a video-assisted on SurveyMonkey thoracic surgery Quiz (VATS) left lower lobectomy as a principal operative procedure. The patient was discharged home on postoperative day 4. On postoperative day 6 the patient returned to your hospital's emergency room complaining of chest pain when taking deep breaths. The patient's temp was 101 F and the bloodwork collected in the emergency room showed a WBC of A chest X-ray demonstrated empyema and a chest tube was placed at bedside in the emergency room. Purulent drainage was noted to be collecting in the chest tube. The infectious disease physician was consulted and documented, early septic picture developing; source empyema." What postoperative occurrence would be assigned to this case? A B C D Sepsis Septic Shock Unplanned Reoperation Pulmonary Embolism

5 3 ANSWER A Sepsis Sepsis SIRS WBC of 12.2 and a temperature of 101 F Purulence was noted in the chest tube and the infectious disease physician correlated the source purulence to the septic picture. Septic Shock No organ or circulatory dysfunction. Unplanned Reoperation Chest tube was placed bedside, not the operating room Pulmonary Embolism No new diagnosis of a new blood clot in a pulmonary artery.

6 Sepsis Correlation: Practitioner documentation correlating that purulence or positive culture was thought to be from a site causative of Sepsis or systemic infection MD notes: Sepsis likely from VAP PNA Patient with Urosepsis Cannot use iatrogenic injury during principal operative procedure to assign preoperative sepsis or PATOS

7 10 You are reviewing a total knee arthroplasty as a principal operative procedure. Upon discharge, the patient was scheduled for 12 weeks of physical therapy. The physical therapist s documentation from the postoperative week 6 visit notes that the patient has achieved full range of movement and can now walk approximately 4-5 blocks without any difficulty. True or False: This documentation from the visit with PT at postoperative week 6 is sufficient to satisfy full 30-day follow-up. T F True False

8 10 ANSWER T True You may utilize clinic follow-up visits at or beyond 30 days with a physical therapist or occupational therapist to satisfy complete 30 day follow-up if the need for therapy is directly related to the principal operative procedure. This guidance can be found in the 30-day follow-up policy.

9 Full 30-Day Follow-Up PT/OT documentation can be utilized if directly related to principal operative procedure Home health nurse documentation can be utilized if signed off/reviewed by advanced provider Due Diligence - 3 attempts

10 19 You are reviewing a case where a patient had a laparoscopic lower anterior resection for rectal cancer as the principal operative procedure. During the procedure, there was an unintended enterotomy with gross spillage of enteric contents into the operative space. The enterotomy was repaired and the lower anterior resection was completed with all layers of the incision closed by some means. On postoperative day #2, the patient began to have abdominal pain with fevers. A computed tomography (CT) scan revealed a contained intraabdominal abscess. The patient was taken back to the operating room for an incision and drainage of the abscess with an abdominal washout. You have assigned the postoperative occurrence of Organ/Space SSI to the case. Would you assign Organ/Space SSI PATOS to the case? Y N Yes No

11 19 ANSWER N No Iatrogenic injuries causing spillage of enteric contents would not meet PATOS criteria, as the patient did not enter the operating room with the injury or defect.

12 SSIs Can only be assigned at or below the level of closure If the wound is left open at time of principal operative procedure and subsequently closed, an SSI can be assigned Always assign the deepest level Cannot use intraoperative information from principal operative procedure to assign an SSI Multiple SSIs can be assigned

13 18 You are abstracting an open appendectomy for a ruptured appendix as the principal operative procedure. The fascia was closed but the skin was left open with packing. On postoperative day 1, a wound VAC was placed. On postoperative day 6 the surgeon documents: "His wound VAC was changed, small amount of purulent drainage noted in the subcutaneous layers of the wound, wound not ready for closure. Fascia is free of infection." Would you assign the postoperative occurrence of Superficial Incisional SSI to the case? Y N Yes No

14 18 ANSWER N No An SSI can only be assigned at or below the level of closure. As the superficial layers of the incision were not closed, you would not assign the SSI

15 Superficial Incisional SSI

16 Deep Incisional SSI

17 5 You are reviewing an abdominal perineal resection as a principal operative procedure. On postoperative day 4, the perineal incision was noted to be draining foul smelling pus from the superficial layers. Fascial and deep layers appeared to be intact. That same day, an abdominal CT scan demonstrated a possible abscess in the lower left quadrant. The CT scan showed no communication between the abscess and perineal incision. Later that day, a CT guided drainage was performed and the fluid was cultured. The culture returned positive for E. coli. The surgeon started the patient on a course of antibiotics to treat the abscess. From the information provided, which occurrences would be assigned? (Select all the apply) A B C D Superficial Incisional SSI Deep Incisional SSI Organ/Space SSI No SSI would be assigned

18 5 ANSWER A C Superficial Incisional SSI Organ/Space SSI An Organ/Space SSI would be assigned. Abscess identified in the organ/space Positive culture from the organ/space. A Superficial Incisional SSI would be assigned. Pus was noted in the superficial layers of the perineal incisional The CT scan demonstrated that there was no communication between the organ/space infection and the superficial incisional infection. As such, both SSIs would be assigned.

19 Organ/Space SSI

20 7 You are reviewing a total colectomy for colon cancer as a principal operative procedure. The patient is a 71-year-old man with a past medical history significant for alcohol abuse. The patient has no underlying pulmonary or cardiac disease. On postoperative day 1, the patient develops a low-grade temperature of F, shortness of breath, and rhonchi. The patient exhibits altered mental status which the surgeon attributes to alcohol withdrawal. An alcohol withdrawal protocol is initiated. Chest X-rays on postoperative day 2 demonstrate, "opacities seen throughout the lung bases". On postoperative day 3, the patient develops a new productive cough with purulent sputum. The patient s WBC are Would you assign the postoperative occurrence of Pneumonia to the case? Y N Yes No

21 7 ANSWER N No Criteria are not met. Although there was documentation of a chest X-ray showing opacities, shortness of breath, rhonchi, and a new productive cough with purulent sputum, there was no documentation of fever, leukopenia (<4000 WBC/mm3) or leukocytosis. Although the patient was greater than 70 years old and had altered mental status, the surgeon attributed the altered mental status to another cause, the alcohol withdrawal.

22 Pneumonia Requires two radiologic exams to assign if patient underlying pulmonary or cardiac disease (e.g. congestive heart failure, bronchopulmonary dysplasia, pulmonary edema, or chronic obstructive pulmonary disease) No specific timeframe for symptomology criteria If all criteria are met, you assign

23 11 You are reviewing an emergent colectomy for toxic megacolon as a principal operative procedure. The patient is diagnosed with sepsis. A preoperative chest X-ray taken just before surgery demonstrates the following: IMPRESSION: 1) VAGUE, ILL-DEFINED OPACITY IN THE LEFT LOWER LOBE. 2) MINIMAL SUBSEGMENTAL ATELECTASIS LEFT LUNG BASE. 3) BORDERLINE CARDIOMEGALY WITHOUT OBVIOUS CONGESTIVE FAILURE PATTERN. On postoperative day 1, the patient develops shortness of breath, elevated temp 38.6 C and decreased O2 saturations which required CPAP via a face mask. Postoperative X-ray shows opacity concerning for Pneumonia. You have assigned the postoperative occurrence of "Pneumonia" to the case. Would you assign "Pneumonia PATOS" to this case? Y N Yes No

24 11 ANSWER Y Yes PATOS is met: As opacity was noted in the preoperative chest X-ray Even if the opacity is described as vague or ill-defined Could represent early developing Pneumonia

25 PATOS Postoperative occurrence criteria must be met Strong suggestion or suspicion Removes occurrence from most online reports Occurrence will not count on the SAR

26 2 You are reviewing a total abdominal hysterectomy as a principal operative procedure. The patient was discharged to their home on postoperative day 3. At 11:00 PM on postoperative day 3, the patient returned to your hospital's emergency room with complaints of abdominal pain. At 2:30 AM on postoperative day 4, an order was written to admit the patient under observation status to an acute care bed at your hospital. The patient remained admitted under observation status while tests were run until the next morning. The patient was discharged home from the observation acute care bed that morning on postoperative day 5. Would you assign a Hospital Readmission to the case? Y N Yes No

27 2 ANSWER N No For readmissions under observation status, the stay must cross over at least two midnights to be considered a readmission. Time spent in the your hospital s ER would not count when determining the hospital stay length. In this scenario, the observation stay began at 2:30 AM on postoperative day 4 and the patient was discharged the next morning.

28 16 A patient fell about 4 feet from a ladder and was seen in the ER. The ER physician diagnosed the patient with a fractured wrist, which was splinted and the patient was sent home to follow-up with Ortho 5 days later. He was scheduled for a wrist open reduction internal fixation (ORIF) 8 days after being discharged from the ER. The ORIF appears in your operative log for your current cycle. Would you exclude the case as a trauma? Y N Yes No

29 16 ANSWER N No As the patient was discharged from the initial trauma visit, and had a scheduled surgery 8 days later you would not exclude the case as a trauma.

30 13 A patient underwent an aortic valve replacement. The patient was placed on a heparin IV drip and then bridged to oral warfarin to prevent valve thrombosis. The patient was subsequently discharged on postoperative day 5. On postoperative day 8, the patient was readmitted with gastrointestinal bleeding and a bleeding duodenal ulcer. The patient s INR value was 4 and fresh frozen plasma was administered. The patient was taken to the operating room for an exploratory laparotomy with lysis of adhesions, and pyloromyotomy with over-sewing of duodenal ulcer beds. The patient has a history of gastrointestinal bleeding. You did not abstract the aortic valve replacement in NSQIP. You have identified the pyloromyotomy (CPT code 43520) as the potential principal operative procedure to abstract. Would you include the pyloromyotomy from postoperative day 8? Y N Yes No

31 13 ANSWER N No As the patient's anticoagulation regimen from the heart value surgery may have exacerbated or precipitated the subsequent gastrointestinal bleeding, you would exclude the pyloromyotomy with over-sewing of duodenal ulcer beds.

32 12 You are reviewing a colectomy which was performed due to perforated diverticulitis as a principal operative procedure. On postoperative day 2, a surgical incision assessment reads: "There is a subcutaneous fluid collection deep to the skin staples which may represent a superficial infected seroma. A scant amount of purulent drainage was expressed from the incision." The surgeon prescribes a course of antibiotics. There is no indication of involvement of deeper layers of the incision. You assigned the postoperative occurrence of "Superficial Incisional SSI" to this case. Would you be able to assign PATOS to this "Superficial Incisional SSI" occurrence? Y N Yes No

33 12 ANSWER N No No signs of infection in the superficial layers at the time of the principal operative procedure. Although perforated diverticulitis intraoperatively, this occurred in the organ/space and not the superficial layers. PATOS for a Superficial Incisional SSI would not be met from those findings.

34 15 A patient underwent an exploratory laparotomy as the principal operative procedure. Upon entering the operating room, the patient was intubated with an endotracheal tube and general anesthesia was administered. The patient was discharged from the operating room and remained on ventilator support following the procedure. The patient left the operating room from the principal operative procedure on postoperative day 0 at 1500 and remained intubated and on the ventilator until postoperative day 2 at The patient did undergo a return to the operating room for an additional exploratory laparotomy on postoperative day 1 from Would the occurrence of "On Ventilator > 48 Hours" be assigned to this case? Y N Yes No

35 15 ANSWER N No Although the time from postoperative day 1500 to postoperative day is 49 hours, you would not count the 3 hours the patient spent on the ventilator during the reoperation in the cumulative time for this variable. Criteria not met 49 hours 3 hours (reoperation) = 46 hours cumulative time.

36 4 A patient arrives at your hospital s emergency room escorted by his daughter. The daughter states that he fell from a standing position at home after developing acute shortness of breath and fainting. The patient has no underlying cardiac or pulmonary diseases. In the ER, the X-ray revealed a right hip fracture. This fracture required a right hip pinning which you are assessing as the principal operative procedure. Preoperatively, on the day of surgery, the patient has a productive cough, acute shortness of breath, rhonchi, and tachypnea. There were no preoperative X-rays of the lungs. Postoperatively, the patient went on to develop acute delirium, need for BiPAP, a WBC of 14 cell/mm3, and continued tachypnea and rhonchi. A chest X-ray was ordered which demonstrated infiltrates and the patient was diagnosed with pneumonia. You assigned the postoperative occurrence of "Pneumonia" to this case. Would you be able to assign PATOS to this "Pneumonia" occurrence? Y N Yes No

37 4 ANSWER Y Yes As the patient met criteria to assign postoperative Pneumonia, you would then assess for PATOS. Although there were no chest radiological exams performed preoperatively, the patient displayed productive cough, acute shortness of breath, rhonchi, and tachypnea. These signs and symptoms are highly suggestive of pneumonia at the time of surgery.

38 21 A patient is admitted for an elective mitral valve replacement which you select for abstraction. On postoperative day 1, the nurse notices dysarthria and right arm weakness. The speech and motor dysfunction resolved with 2 hours. The neurologist diagnosed a transient ischemic attack (TIA). The patient is then discharged to an acute rehab facility on postoperative day #5. On postoperative day #28, the patient is admitted back at your facility with a left middle cerebral artery occlusion seen on the MRI scan. The patient is totally unresponsive, flaccid, and areflexic. The patient dies later that night. Would the postoperative occurrence of "Stroke/Cerebral Vascular Accident (CVA)" be assigned to the case? Y N Yes No

39 21 ANSWER Y Yes Criteria are met on postoperative day 28, as a left middle cerebral artery occlusion was identified and there was no resolution of the motor, sensory, or cognitive dysfunction (patient died), Stroke/Cerebral Vascular Accident (CVA) criteria are met. The transient ischemic attack on postoperative day 5 would not met criteria.

40 20 A 55-year-old Caucasian male presents to your facility s gastrointestinal laboratory (GI lab) for a planned outpatient sigmoidoscopy due to a positive fecal occult blood test. During the sigmoidoscopy, the gastroenterologist removes one polyp from the sigmoid colon to send to pathology. In the recovery area, the patient begins complaining of sharp abdominal pain. The gastroenterologist orders a CT scan of the abdomen and pelvis which revealed a moderate amount of free air in the peritoneum. General surgery is consulted and takes the patient emergently to the operating room for an exploratory laparotomy. A perforation of the sigmoid colon is found and a subsequent repair of sigmoid colon perforation is performed. What procedure would you capture as the principal operative procedure? A Sigmoidoscopy (CPT Code 45338) B Exploratory laparotomy (CPT Code 49000) C Repair of sigmoid colon perforation (CPT Code 44604) D No procedure would be selected as a principal operative procedure as the trip to the operating room was necessitated due to a complication or occurrence from the sigmoidoscopy.

41 20 ANSWER D No procedure would be selected as a principal operative procedure as the trip to the operating room was necessitated due to a complication or occurrence from the sigmoidoscopy. The perforation of the sigmoid colon was likely caused by the sigmoidoscopy. This case would be excluded

42 17 The principal operative procedure you are abstracting is a uneventful femoral-popliteal bypass graft for intermittent claudication. On postoperative day 5, the patient is noted to have severe abdominal pain. The white blood cell count that morning was Later that day the patient became tachypneic (RR-29), tachycardic (HR-115) and hypotensive, which required the initiation of vasopressors. The patient was immediately taken back to the operating room. The surgeon s operative report notes ischemic large bowel secondary to a sigmoid volvulus. A sigmoid colectomy was subsequently performed. You have assigned the post-operative occurrence of Septic Shock to the case due to the intraoperative findings of ischemic bowel requiring resection, SIRS within 48 hours of the return to the operating room and circulatory dysfunction requiring vasopressor support. Would you assign Septic Shock PATOS? Y N Yes No

43 17 ANSWER N No No evidence suggesting that the patient was in Septic Shock at the time of the principal operative procedure. Intraoperative findings from a reoperation cannot be utilized as PATOS criteria.

44 8 A 74-year-old man was taken to the operating room for the diagnosis of a sigmoid volvulus. The patient had a sigmoid colectomy with Hartmann's pouch and end sigmoid colostomy which you are abstracting as a principal operative procedure. Intraoperatively, there was a small portion of the sigmoid colon which the surgeon noted as being obviously gangrenous. There was no evidence of perforation and no significant free fluid within the abdomen. No abscesses were noted. He returned to the operating room on postoperative day 20 with a diagnosis of an abscess in the pelvic cavity. Which post-operative occurrences would you assign? A B C D Superficial Incisional SSI Deep Incisional SSI Organ/Space SSI No SSI would be assigned

45 8 ANSWER C Organ/Space SSI An abscess was identified during a reoperation in the organ space manipulated during the principal operative procedure.

46 6 You are reviewing a laparoscopic gastric bypass as a principal operative procedure. A Jackson-Pratt (JP) drain was placed into the abdominal cavity during the principal operative procedure through a separate stab wound. All layers of the incision were closed and no signs of infection were noted at the time of the principal operative procedure. On postoperative day 3, the surgeon documented purulent drainage in the JP bulb. An abdominal CT scan demonstrated a rim-enhancing collection of fluid in the right aspect of the pelvis measuring 8.5 x 4.9 x 4.0 cm, which was concerning for an abscess. Would this case be assigned as an "Organ/Space SSI"? Y e s N Yes No

47 6 ANSWER Y Yes Purulent drainage was identified postoperatively from a drain that was placed through a stab wound into the organ/space. The possible abscess identified on the CT scan would also meet criteria.

48 9 A patient comes to the emergency room with ruptured gangrenous appendicitis. There are numerous traumas requiring emergent surgery that take precedence and the appendectomy must wait for surgery later that day. You are reviewing an appendectomy as a principal operative procedure. The anesthesiologist documented the case to be emergent on the anesthesia form. What would you answer for the variable of Emergency Case? Y N Yes No

49 9 ANSWER Y Yes If a case assigned as an emergency case by the surgeon and/or anesthesiologist you would assign "yes" to the Emergency Case variable, even if there is a backlog for operating room cases. The patient must be kept in the hospital and cannot be sent home

50 14 You are reviewing the case of a patient who underwent an incision and drainage of a vulvar abscess. An incision was made into the abscess cavity and the abscess was drained. The abscess cavity was explored and it was noted to be contained to the subcutaneous tissue. The abscess cavity was sharply excised with no entry into the deep layers. Hemostasis was achieved with pressure and cauterization. The wound was irrigated, packed, and a sterile dressing was applied. The patient tolerated the procedure well. What would you assign for Surgical Wound Closure? A B C All layers of incision (deep and superficial) fully closed by some means. Only deep layers of incision are closed; superficial layers are left open. No layers of the incision are surgically closed.

51 14 ANSWER B Only deep layers of incision are closed; superficial layers are left open As only superficial layers were entered and deeper layers remained intact, "Only deep layers of incision are closed; superficial layers are left open" would be selected for wound closure.