InterQual Level of Care Acute Pediatric Criteria 2013 Clinical Revisions

Transcription

1 InterQual Level of Care Acute Pediatric Criteria 2013 Clinical Revisions The Clinical Revisions provide details of changes to InterQual Clinical Criteria. They do not provide information on changes made to CareEnhance Review Manager software. For information on Review Manager software changes, see the Review Manager Release Notes and the What's New topic in CareEnhance Review Manager Help. Review and Incorporation of Recent Medical Literature McKesson Health Solutions is committed to keeping the InterQual product suite current and accurate. Criteria are continually reviewed and updated, with new editions of every product released annually. McKesson Health Solutions staff of physicians, nurses, and other licensed healthcare professionals, and its extensive array of primary care and specialty consultants, participate in ongoing criteria revision as new medical information emerges. Each annual release of the criteria reflects a thorough review of new medical literature, society guidelines, and current practice standards and incorporates consultant and user feedback. MHS Customer Hub The MHS Customer Hub ( provides interactive support, answers to commonly asked questions, and links to other resources. For a user ID and password, contact your MHS Customer Hub site administrator or MHScustomerhub@mckesson.com Potential Care Impact This Clinical Revisions document outlines the updates McKesson Health Solutions has made to the criteria to reflect the latest changes in the clinical evidence. Whether content has been added or updated, a level of care changed or a new condition added that did not exist before; certain criteria changes may affect your organization s care management approach. Listed below, McKesson Health Solutions has designated the major criteria updates that may impact your organization with a () symbol. Page 1 of 204

2 Review Process Changes Revision Rationale Potential Care Added: An episode day is a calendar day, which begins at 12:00 a.m. regardless of the time of admission. However, the exception to this would be admissions in the evening (e.g., after 6 p.m.); in which case, episode day one may be used for admission day and the next hospital day NOTE: Regulatory or contractual agreements may dictate other specifics concerning when the "new day" begins. Added: If conducting a retrospective review, use data from the episode for the day that the review is being conducted. This includes information that may have been pending or incomplete at the time the decision to admit was made. To clarify the intent of the criteria To clarify the intent of the criteria Global / General Criteria Changes Revision Rationale Potential Care Added the following subsets: Acetaminophen Overdose Carbon Monoxide Poisoning Cellulitis Cystic Fibrosis Diabetes Mellitus Diabetic Ketoacidosis Hypoglycemia Meningitis Pancreatitis Pyelonephritis Sickle Cell Crisis Criteria for these conditions, previously found in the General Medical and Extended Stay subsets, have been removed. Based on the condition specific model Page 2 of 204

3 Revision Rationale Potential Care In an attempt to enhance the usability of the criteria, some criteria have been restructured. Where possible, criteria have been alphabetized Categories have been streamlined, added, modified, or removed Responder criteria have been revised to include only clinical stability criteria related to the condition and common complications and comorbid conditions. An example follows: Responder, discharge expected today if clinically stable last 24h, All: T 99.4 F (37.4 C) PO O 2 sat 91% (0.91), PEF or FEV 1 70% (0.70) or within acceptable limits Wheezing resolving Complication or comorbidity, One: No complication or active comorbidity relevant to this episode of care BS mg/dl ( mmol/l) New onset infection, One: WBC < 12,000/cu.mm (12x109/L) Bands < 6% (0.06) Pneumonia, Both: T 99.4 F (37.4 C) PO O 2 sat 94% (0.94) or within acceptable limits Tolerating PO Exceptions to this rule occur in cases where complications or comorbid conditions are not included under Partial responder. At the OBSERVATION, ACUTE, and INTERMEDIATE levels of care under Responder, or baseline or within acceptable range is now stated as within acceptable limits. The note reads: When criteria state "within acceptable limits" it refers to either the patient's normal baseline, newly established baseline, or to parameters which the medical practitioner determines are acceptable. and clarifies the intent of the criteria Page 3 of 204

4 Revision Rationale Potential Care At the ACUTE level of care changed: "Oxygen to maintain O 2 sat 94% or baseline" Requiring supplemental oxygen Or Oxygenation, One: O 2 sat 94% (0.94) or baseline O 2 sat 93% (0.93) and < baseline requiring supplemental oxygen (Note: the O 2 sat value will vary by condition) Exceptions to this are identified under Criteria-specific Changes., promotes consistency, and clarifies the intent of the criteria At the ACUTE level of care, changed: Resolved and initiating enteral nutrition 48h Resolved and initiating PO or tube feeding 2d At the ACUTE level of care, changed: Strict intake and output monitoring Intake and output monitoring At all levels of care in the General Transplant, GI Surgery, and General Surgical subsets, changed: Pain management Pain assessment, One: Patient denies pain Pain controlled Uncontrolled pain requiring change in medication, dose, or frequency (includes PO) and clarifies the intent of the criteria and clarifies the intent of the criteria Pain management has been removed from all other conditions with the exception of the following conditions in the General Medical subset: Abdominal pain Brain abscess at the CRITICAL level of care Encephalitis at the CRITICAL level of care Page 4 of 204

5 Revision Rationale Potential Care At the ACUTE level of care beginning on Episode Day 2, changed: Neurological assessment at least 4x/24h Neurological assessment at least 3x/24h and promotes consistency At the ACUTE level of care, under Partial Responder, where appropriate added or modified existing criteria. The criteria now appears as: Post Critical care 24h At all levels of care, changed: IV fluid IV fluid, One: 50 ml/kg/24h ( 10 kg) 40 ml/kg/24h (> kg) 30 ml/kg/24h (> kg) 75 ml/h (> 60 kg) At the ACUTE level of care, changed: Functional impairment 24h, One: Physical therapy and home discharge expected Discharge planning for post acute facility And: Physical therapy and home discharge expected 24h, One: Unable to ambulate or transfer safely Unable to crutch walk And: Rehabilitation therapy initiation 24h, Two: ADL or self care Bed mobility, transfers, or ambulation training Swallowing retraining, speech language training, or cognitive retraining And: Progressive activity and home discharge expected 24h, One: (38) Unable to ambulate or transfer safely Unable to crutch walk Functional impairment (new) and rehabilitation initiation 24h, One: PT evaluation and training OT evaluation and training Speech language evaluation and training Cognitive evaluation and retraining Swallowing evaluation and retraining and clarifies the intent of the criteria,, and clarifies the intent of the criteria Page 5 of 204

6 Revision Rationale Potential Care At the ACUTE level of care, changed: C. difficile colitis, actual or suspected 4d, All: Inadequate oral intake Strict intake and output monitoring IV fluid replacement based on losses Anti infective (includes PO) C. difficile colitis, actual or suspected 4d, All: Inadequate oral intake IV fluid replacement based on losses Anti infective (includes PO),, and clarifies the intent of the criteria At the ACUTE level of care, when Temperature is captured under Responder criteria, added the following under Partial Responder: T > 99.4 F (37.4 C) PO, new onset, One: Imaging study 24h Culture pending 2d Drug induced fever suspected and precipitating drug discontinued 3d At the ACUTE level of care, changed: Postural systolic BP drop > 20 and clarifies the intent of the criteria Postural hypotension, Both: Sustained drop in blood pressure within 3 mins of sitting or standing Blood pressure, One: Systolic BP drop > 20 mmhg Diastolic BP drop > 10 mmhg Acute kidney injury criteria added where appropriate and replace criteria for renal insufficiency or failure at the ACUTE and CRITICAL levels of care. Criteria appears as: ACUTE Acute kidney injury, Both: Urine output, One: 1 ml/kg/h < 180 ml/m 2 /24h Creatinine 1.5x baseline or ULN GFR > 25% (0.25) decrease from baseline Dialysis initiated Intervention, One: Volume expander 2d Diuretic 2x/24h, 3d Medication adjustment or discontinuation 3d, One: Diuretic (includes PO) Nephrotoxic agent (includes PO) Dialysis (initial), One: 6d since initiation, One: Hemodialysis Reflects current medical terminology and based on medical literature review Page 6 of 204

7 Revision Rationale Potential Care Peritoneal dialysis Anticipated to continue and discharge planning 24h, One: Peritoneal dialysis and teaching for home management Hemodialysis and arrangements for OP dialysis Evaluation for post acute care Dialysis discontinued and renal function monitoring 2d since discontinuation CRITICAL Acute kidney injury, Both: Potassium, One: > 6.0 meq/l (6.0 mmol/l) with ECG changes > 7.0 meq/l (7.0 mmol/l) Sodium < 120 meq/l (120 mmol/l) and volume overload Sodium > 158 meq/l (158 mmol/l) Hemodynamic instability Intervention, One: IV fluid resuscitation 2d Diuretic, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Dialysis, One: Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation Continuous renal replacement therapy Dialysis criteria at the INTERMEDIATE level of care have been deleted. Examples follow: Acute renal failure and dialysis initiation, One: Hemodialysis Peritoneal Dialysis initiation, One: Hemodialysis Peritoneal Dialysis (initial course), Both: Difficulty tolerating, One: Nausea or vomiting Dizziness Muscle spasms Hemodialysis or peritoneal Aligns with current medical guidelines Page 7 of 204

8 Revision Rationale Potential Care Extended the higher levels of care to the last episode day (e.g., non-responder criteria moved to the last episode day). Revised or added the following standard interventions on continued stay, in addition to what was already included at the INTERMEDIATE and CRITICAL levels of care within the subset: INTERMEDIATE IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Vasoactive or inotrope Administration, One: Continuous and monitoring q3 4h Bolus q3 4h and monitoring Titration q3 4h and monitoring Titration > q4h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q3 4h Weaning 2d (the time limit is added to Episode Day 3 and beyond) Oxygen 35 39% ( ) CRITICAL IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope (22) Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning 2d (the time limit is added to Episode Day 3 and beyond) Oxygen 40% (0.40) Page 8 of 204

9 Revision Rationale Potential Care At the INTERMEDIATE level of care, changed: Volume expander and systolic BP, One: < 65 (age 12 mos) < 70 (age > 1 3 yrs) < 80 (age > 3 < 18 yrs) Hypovolemia, Both: Systolic BP, One: mmhg (age 12 mos) mmhg (age > 1 < 5 yrs) mmhg (age > 5 < 18 yrs) Volume expander 2d Aligns with current medical guidelines At the CRITICAL level of care, changed: BP systolic, One: < 50 (age 12 mos) < 70 (age > 1 < 18 yrs) Systolic BP, One: < 70 mmhg (age 12 mos) < 80 mmhg (age >1 < 5 yrs) < 90 mmhg (age 5 < 18 yrs) Aligns with current medical guidelines Criteria-Specific Changes Subset Episode day Level of Care - Anemia/Bleeding Episode Day 1 OBSERVATION Anterior epistaxis, Bleeding and hemophilia or von Willebrand s disease, Anemia/Bleeding Episode Day 1 ACUTE Upper GI (nonvariceal) bleeding, Lower GI bleeding, Posterior epistaxis, Vaginal bleeding, Deleted oxygen criteria : Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) (or baseline) And: Oxygen not required or humidified oxygen to maintain O 2 sat 94% (0.94) (or baseline) Deleted oxygen criteria : Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) (or baseline) And: Oxygen not required or humidified oxygen to maintain O 2 sat 94% (0.94) (or baseline) Oximetry Page 9 of 204

10 Anemia/Bleeding Episode Day 1 ACUTE Lower GI bleeding, Upper GI bleeding, Under Melena, One:, added: Disorientation Agitation Increasing irritability Increasing lethargy Depicts findings associated with bleeding Anemia/Bleeding Episode Day 1 ACUTE Posterior epistaxis, Vaginal bleeding, Hemophilia, Under Finding, One:, added: Disorientation Agitation Increasing irritability Increasing lethargy Depicts findings associated with bleeding Anemia/Bleeding Episode Day 1 ACUTE Hemophilia, Finding, Uncontrolled by OP treatment Bleeding, uncontrolled by OP treatment and clarifies the intent of the criteria Anemia/Bleeding Episode Day 1 CRITICAL Hemodynamic instability, Bleeding, Blood product transfusion, One: IV fluid resuscitation Vasoactive or inotrope, One: Continuous and monitoring q1 2h Titration q1 2h and monitoring Titration > q2h and monitoring 24h Intervention, One: Blood product transfusion IV fluid resuscitation IV medication administration, One: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Page 10 of 204

11 Anemia/Bleeding Episode Day 1 CRITICAL Hemodynamic instability, Bleeding,, Ruptured varices, Anemia/Bleeding Episode Day 1 CRITICAL Hemodynamic instability, Bleeding,, Massive hemoptysis, Anemia/Bleeding Episode Day 1 CRITICAL Hemodynamic instability, Bleeding,, Endotracheal intubation and mechanical ventilation for airway protection Oxygen 40% (0.40) Deleted: Endotracheal intubation and mechanical ventilation for airway protection Upper GI (non variceal), One: Endoscopy Arteriography with embolization Upper GI (non variceal), One: Endoscopy Transcatheter arteriography with embolization and clarifies the intent of the criteria Anemia/Bleeding Episode Day 1 CRITICAL Hemodynamic instability, Bleeding,, Lower GI, One: Nuclear scan Colonoscopy Arteriography with embolization Intussusception and non operative reduction Lower GI, One: Nuclear scan Colonoscopy Transcatheter arteriography with embolization Intussusception and non operative reduction and clarifies the intent of the criteria Anemia/Bleeding Episode Day 2 & 3 ACUTE Upper GI (nonvariceal) bleeding, Partial responder, Continued bleeding, Hct and Hb monitoring at least 3x/24h, Endoscopy or arteriography with embolization Endoscopy or transcatheter arteriography with embolization and clarifies the intent of the criteria Page 11 of 204

12 Anemia/Bleeding Episode Day 2 & 3 Anemia/Bleeding Episode Day 2 & 3 ACUTE Lower GI bleeding, Partial responder, Continued bleeding, Hct and Hb monitoring at least 3x/24h, ACUTE Anemia, Colonoscopy, nuclear medicine scan, or arteriography with embolization Colonoscopy Nuclear medicine scan Transcatheter arteriography with embolization Hct and Hb monitoring at least daily, One: Iron deficiency, Both: Iron supplement (includes PO) Diagnostic work up pending Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) and blood product transfusion Iron deficiency, All: Iron supplement (includes PO) Diagnostic work up pending Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) Blood product transfusion and clarifies the intent of the criteria and clarifies the intent of the criteria Page 12 of 204

13 Anemia/Bleeding Episode Day 2 & 3 ACUTE Added: Hemoptysis, One: Responder, discharge expected today if clinically stable last 24h, Both: T 99.4 F (37.4 C) PO Hct and Hb within acceptable limits Partial responder, not clinically stable for discharge and requires continued stay, One: Bleeding controlled, Both: Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) Hct or Hb decreased last 24h Intervention, Both: Hct and Hb monitoring at least 3x/24h IV fluid or blood product transfusion Post Critical care 24h T > 99.4 F (37.4 C) PO, new onset, One: Imaging study 24h Culture pending 2d Drug induced fever suspected and precipitating drug discontinued 3d Anemia/Bleeding Episode Day 2 CRITICAL Hemodynamic instability, Non-responder criteria added to Episode Day 3: Hemoptysis, One: Responder, discharge expected today if clinically stable last 24h, Both: T 99.4 F (37.4 C) PO Hct and Hb within acceptable limits Non responder, not clinically stable for discharge and exceeds episode days at the Acute level of care for this condition, One: Use Extended Stay subset Refer for secondary review Added: Systolic BP, One: < 70 mmhg (age 12 mos) < 80 mmhg (age >1 < 5 yrs) < 90 mmhg (age 5 < 18 yrs) and clarifies the intent of criteria Page 13 of 204

14 Anemia/Bleeding Episode Day 2 CRITICAL Hemodynamic instability, Treatment, One: Blood product transfusion Vasoactive or inotrope, One: Continuous and monitoring q1 2h Titration q1 2h and monitoring Titration > q2h and monitoring 24h Volume expander Intervention, One: Blood product transfusion IV fluid resuscitation IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Anemia/Bleeding Episode Day 3 ACUTE Variceal bleed, Partial responder, Added Bleeding controlled for 48h : Bleeding controlled for 48h, Both: Medium or large varices Red wale marks found on endoscopy Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) Hct or Hb decreased last 24h Intervention, All: IV fluid or blood product transfusion Hct and Hb monitoring at least 3x/24h Octreotide or somatostatin Anti infective prophylaxis for bacterial infection (includes PO) and clarifies the intent of the criteria Page 14 of 204

15 Anemia/Bleeding Episode Day 3 CRITICAL Hemodynamic instability, One: Blood product transfusion Vasoactive or inotrope, One: Continuous and monitoring q1 2h Titration q1 2h and monitoring Titration > q2h and monitoring 24h Volume expander Hemodynamic instability, One: Blood product transfusion IV fluid resuscitation IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Anemia/Bleeding Episode Day 4 CRITICAL Added: Variceal bleeding controlled and hemodynamically stable 2d, Both: Anti infective prophylaxis for bacterial infection (includes PO) Octreotide or somatostatin Page 15 of 204

16 Anemia/Bleeding Episode Day 4 & 5 CRITICAL Added: Hemodynamic instability 2d, One: Blood product transfusion IV fluid resuscitation IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h,, and clarifies the intent of the criteria Antepartum / Postpartum Episode Day 1 OBSERVATION Not in active labor, Deleted: Abdominal pain or trauma, Both: Fetal monitoring Uterine monitoring for contractions Headache, unresponsive to IM or IV analgesic, One: NPO and IV fluid 100 ml/h Analgesic 2 doses Neurological assessment q4h T > 99.4 F (37.4 C) PO, Both: Cultures pending Anti infective Criteria for these conditions is now located in the General Medical or General Trauma subsets Antepartum / Postpartum Episode Day 1 OBSERVATION Not in active labor, Nausea and vomiting of pregnancy or suspected hyperemesis gravidarum, Persistent vomiting unresponsive to outpatient IV hydration Treatment, One: IV fluid Antiemetic Persistent vomiting unresponsive to outpatient IV hydration Intervention, One: Antiemetic IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg,, and clarifies the intent of the criteria Page 16 of 204

17 Antepartum / Postpartum Antepartum / Postpartum Antepartum / Postpartum Antepartum / Postpartum Episode Day 1 Episode Day 1 Episode Day 1 Episode Day 1 & 2 OBSERVATION Not in active labor, Rule out HELLP, pregnancy induced hypertension or preeclampsia, OBSERVATION Not in active labor, Spinal headache, postpartum, OBSERVATION Not in active labor, Vaginal bleeding 1 pad/h without fetal compromise, ACUTE Pre term premature rupture of membranes (PPROM), Deleted: Lab value monitoring (CBC, LFTs, platelets) at least 2x/24h Deleted: Antiemetic 3x/24h or serotonin antagonist q24h Deleted: Coagulation studies Gestation, One: 24 < 34 weeks and corticosteroid, administered or contraindicated (13, G19) 34 weeks Gestation, One: 24 < 32 weeks and corticosteroid, administered or contraindicated 32 weeks Based on medical literature review Page 17 of 204

18 Antepartum / Postpartum Episode Day 1 ACUTE Vaginal bleeding, > 1 pad/h in 2 nd or 3 rd trimester PT 1.5x ULN or INR PTT 1.5x ULN Platelets < 60,000/cu.mm (60x10 9 /L) Treatment, All: Transvaginal or transabdominal ultrasound NPO Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) (or baseline) IV fluid or blood product transfusion Hb and Hct monitoring at least 3x/24h TO: > 1 pad/h in 2 nd or 3 rd trimester Platelets < 60,000/cu.mm (60x10 9 /L) PT 1.5x ULN or INR 2.0 PTT 1.5x ULN Intervention, All: Hct and Hb monitoring at least 3x/24h IV fluid or blood product transfusion Transvaginal or transabdominal ultrasound and clarifies the intent of the criteria Antepartum / Postpartum Episode Day 1, 2, 3 & 4 ACUTE Gestational DM and 30 weeks gestation, Gestational DM and 30 weeks gestation, Both: Gestational DM, Both: Based on medical literature review Antepartum / Postpartum Episode Day 1, 2 ACUTE HELLP syndrome (hemolysis, elevated liver function tests, thrombocytopenia), Monitoring, Deleted: Lab value monitoring at least q12h Page 18 of 204

19 Antepartum / Postpartum Episode Day 1 ACUTE Preeclampsia, Treatment, One: IV fluid, One: 125 ml/h 100 ml/h and renal failure Diuretic 2x/24h Antihypertensive Magnesium sulfate Intervention, One: Antihypertensive Diuretic 2x/24h IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg Magnesium sulfate,, and clarifies the intent of the criteria Antepartum / Postpartum Episode Day 1 ACUTE Postpartum complication (requiring readmission), Preeclampsia, Treatment, One: Antihypertensive Magnesium sulfate IV fluid, One: 125 ml/h 100 ml/h and renal failure Diuretic 2x/24h Intervention, One: Antihypertensive Diuretic 2x/24h IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg Magnesium sulfate,, and clarifies the intent of the criteria Page 19 of 204

20 Antepartum / Postpartum Episode Day 1 ACUTE Postpartum complication (requiring readmission), Blood product transfusion, One: Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) Postural systolic BP drop > 20 Bleeding, actual or suspected, Both: Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) Platelets < 60,000/cu.mm (60x10 9 /L) or > 1,000,000/cu.mm (1000x10 9 /L) Heart rate /min, sustained Hct and Hb decreased last 24h Postural hypotension, Both: Sustained drop in blood pressure within 3 mins of sitting or standing Blood pressure, One: Systolic BP drop > 20 mmhg Diastolic BP drop > 10 mmhg PT 1.5x ULN or INR 2.0 PTT 1.5x ULN Intervention, One: Blood product transfusion Return to OR last 24h Requiring Hct and Hb monitoring at least 3x/24h, 2d and clarifies the intent of the criteria Antepartum / Postpartum Episode Day 1, 2, 3, 4, 5, 6 & 7 ACUTE Medical Comorbid Condition, Deleted Medical Comorbid Condition section Criteria for these conditions is now located in the General Medical, Diabetes Mellitus, Carbon Monoxide Poisoning, or Pyelonephritis subsets Page 20 of 204

21 Antepartum / Postpartum Episode Day 1 INTERMEDIATE Added: INTERMEDIATE, One: IV medication administration, Both: Medication, One: Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Vasoactive or inotrope Administration, One: Continuous and monitoring q3 4h Bolus q3 4h and monitoring Titration q3 4h and monitoring Titration > q4h and monitoring 24h Oxygen 35 39% ( ) Antepartum / Postpartum Episode Day 1, 2, 3 & 4 CRITICAL Hemodynamic instability, Hemodynamic instability, Both: Systolic BP < 90 or decrease from baseline Heart rate > 120/min, sustained Treatment, One: IV fluid resuscitation Blood product transfusion Vasoactive or inotrope, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Hemolytic uremic syndrome and Hb and Hct monitoring at least q4h, One: Plasmapheresis FFP Immunosuppressant Dialysis (initial) and 7d since initiation, One: Hemodialysis Peritoneal Hemodynamic instability, Both: Systolic BP < 90 mmhg or decrease from baseline Heart rate > 120/min, sustained Intervention, One: IV fluid resuscitation Blood product transfusion Dialysis, One: Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation Continuous renal replacement therapy and clarifies the intent of the criteria. Vasoactive or inotrope criteria are now covered under IV medication administration criteria. Page 21 of 204

22 Antepartum / Postpartum Episode Day 1, 2, 3, 4, 5, 6, & 7 CRITICAL Added: IV medication administration, Both: Medication, One: Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Antepartum / Postpartum Episode Day 1, 2, 3, & 4 CRITICAL Deleted: Antihypertensive administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Seizures or postictal state (eclampsia) and anticonvulsant administration, One: Continuous and monitoring q1 2h Bolus q1 2 and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h and promotes consistency. Antihypertensive and anticonvulsant criteria are now covered under IV medication administration criteria. Page 22 of 204

23 Antepartum / Postpartum Episode Day 2 & 3 OBSERVATION Criteria have been restructured to create Responder criteria for each condition. All conditions become nonresponders on Episode Day 2 with the exception of: Nausea and vomiting of pregnancy or suspected hyperemesis gravidarum, One: Responder, discharge expected today if clinically stable last 12h, Both: Vomiting controlled Tolerating PO Partial responder, not clinically stable for discharge and requires continued stay, One: Inadequate oral intake, One: Advancing diet as tolerated IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg Spinal headache, One: Responder, discharge expected today if clinically stable last 12h, One: Headache and pain controlled Partial Responder, not clinically stable for discharge and requires continued stay, One: Epidural blood patch 24h IV caffeine and fluid These conditions become Non-responders on Episode Day 3: Nausea and vomiting of pregnancy or suspected hyperemesis gravidarum, One: Responder, discharge expected today if clinically stable last 12h, Both: Tolerating PO Vomiting controlled Non responder, not clinically stable for discharge and exceeds episode days at the Observation level of care for this condition, One: Use appropriate subset (Episode Day 1) based on clinical findings Refer for secondary review Spinal headace, One: Responder, discharge expected today if clinically stable last 12h, One: Headache and pain controlled Non responder, not clinically stable for discharge and exceeds episode days at the Observation level of care for this condition, One: Use appropriate subset (Episode Day 1) based on clinical findings Refer for secondary review Page 23 of 204

24 Antepartum / Postpartum Episode Day 2 ACUTE Hyperemesis gravidarum, Antiemetic, One: 3x/24h Serotonin antagonist Antiemetic, One: 3x/24h Serotonin antagonist daily and promotes consistency Antepartum / Postpartum Episode Day 2 ACUTE Placenta abruptio, Severe hemorrhage, uterine spasm or fetal distress, All: IV fluid or blood product transfusion Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) (or baseline) Continuous fetal monitoring Uterine monitoring for contractions Severe hemorrhage, uterine spasm or fetal distress, All: Continuous fetal monitoring IV fluid or blood product transfusion Uterine monitoring Antepartum / Postpartum Episode Day 2 ACUTE Placenta previa, Uterine and fetal monitoring 4x/24h Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) (or baseline) IV fluid or blood product transfusion Fetal monitoring IV fluid or blood product transfusion Uterine monitoring Antepartum / Postpartum Episode Day 2 ACUTE Fetal compromise, Monitoring, Deleted: Ultrasound assessment Page 24 of 204

25 Antepartum / Postpartum Episode Day 2 ACUTE Preeclampsia, Antihypertensive Magnesium sulfate IV fluid, One: 125 ml/h 100 ml/h and renal failure Diuretic 2x/24h AST or ALT elevated Biophysical profile within normal limits Hyperreflexia Proteinuria > 1+ Systolic BP > 140 mmhg or diastolic BP > 90 mmhg Uric acid > 6 mg/dl ( mol/l) Intervention, One: Antihypertensive Diuretic 2x/24h IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg Magnesium sulfate and clarifies the intent of the criteria Page 25 of 204

26 Antepartum / Postpartum Episode Day 2 & 3 ACUTE Added: Vaginal bleeding, One: Responder, discharge expected today if clinically stable last 12h, Both: T 99.4 F (37.4 C) PO Bleeding controlled or resolved Partial responder, not clinically stable for discharge and requires continued stay, One: Vaginal bleeding, All: Continued bleeding Hct and Hb monitoring IV fluid or blood product transfusion Non-responder criteria added on Episode Day 3: Vaginal bleeding, One: Responder, discharge expected today if clinically stable last 12h, Both: T 99.4 F (37.4 C) PO Bleeding controlled or resolved Non responder, not clinically stable for discharge and exceeds episode days at the Acute level of care for this condition, One: Use Extended Stay subset Refer for secondary review Antepartum / Postpartum Episode Day 2, 3, 4, & 5 ACUTE Postpartum complication (requiring readmission) Criteria have been restructured to create Responder criteria for each condition. Criteria now appears as: Bleeding, One: Responder, discharge expected today if clinically stable last 12h, Both: T 99.4 F (37.4 C) PO 24h Hct and Hb within acceptable limits Partial responder, not clinically stable for discharge and requires continued stay, One: Bleeding, actual or suspected, Both: Hct < 25% (0.25) or Hb < 8.3 g/dl (83 g/l) Platelets < 60,000/cu.mm (60x10 9 /L) or > 1,000,000/cu.mm (1000x10 9 /L) Heart rate /min, sustained Hct and Hb decreased last 24h Postural hypotension, Both: Sustained drop in blood pressure within 3 mins of sitting or standing Blood pressure, One: Systolic BP drop > 20 mmhg Diastolic BP drop > 10 mmhg PT 1.5x ULN or INR 2.0 PTT 1.5x ULN, promotes consistency, and Page 26 of 204

27 Antepartum / Postpartum (cont d) Episode Day 2, 3, 4, & 5 (cont d) ACUTE Postpartum complication (requiring readmission) (cont d) Intervention, One: Blood product transfusion Return to OR last 24h Requiring Hct and Hb monitoring at least 3x/24h, 2d Infection, actual or suspected, One: Responder, discharge expected today if clinically stable last 12h, One: T 99.4 F (37.4 C) PO Partial responder, not clinically stable for discharge and requires continued stay, One: Post Critical care 24h T > 99.4 F (37.4 C) PO, One: Known source and anti infective Imaging study 24h Culture pending 2d Drug induced fever suspected and precipitating drug discontinued 3d Preeclampsia, One: Responder, discharge expected today if clinically stable last 12h, All: T 99.4 F (37.4 C) PO 24h AST or ALT within acceptable limits BP < 140/90 mmhg x2 readings q6h Proteinuria 1+ Hyperreflexia resolved Uric acid 6 mg/dl ( mol/l) Partial responder, not clinically stable for discharge and requires continued stay, One: Preeclampsia, Both: AST or ALT elevated Hyperreflexia Proteinuria > 1+ Systolic BP > 140 mmhg or diastolic BP > 90 mmhg Uric acid > 6 mg/dl ( mol/l) Intervention, One: Antihypertensive Diuretic 2x/24h IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg Magnesium sulfate Wound dehiscence and repair, One: Responder, discharge expected today if clinically stable last 12h, All: T 99.4 F (37.4 C) PO Adequate healing Wound regimen established Partial responder, not clinically stable for discharge and requires continued stay, One: Wound dehiscence and repair 2d The Non-responder day for bleeding, infection, and Page 27 of 204

28 Antepartum / Postpartum (cont d) Antepartum / Postpartum Episode Day 2, 3, 4, & 5 (cont d) Episode Day 2, 3, 4, 5, 6, & 7 ACUTE Postpartum complication (requiring readmission) (cont d) INTERMEDIATE preeclampsia is Episode Day 5. The Non-responder day for wound dehiscence and repair is Episode Day 3. Added: INTERMEDIATE, One: IV medication administration, Both: Medication, One: Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Vasoactive or inotrope Administration, One: Continuous and monitoring q3 4h Bolus q3 4h and monitoring Titration q3 4h and monitoring Titration > q4h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q3 4h Weaning (weaning is associated with an end point of 2d beginning on Episode Day 3) Oxygen 35 39% ( ) Antepartum / Postpartum Episode Day 3 & 4 ACUTE Hyperemesis gravidarum, Partial responder, Inadequate oral intake, One: IV fluid, enteral or parenteral nutrition Antiemetic, One: 3x/24h Serotonin antagonist Inadequate oral intake, All: Advancing diet as tolerated Antiemetic, One: 3x/24h Serotonin antagonist daily IV fluid and clarifies the intent of the criteria Page 28 of 204

29 Antepartum / Postpartum Episode Day 3 ACUTE Pre term premature rupture of membranes (PPROM), < 34 wks gestation, Both: Anti infective (includes PO), One: T > 99.4 F (37.4 C) PO GBS (+) or status unknown Not indicated Uterine and fetal monitoring 4x/24h 34 wks gestation and delivery not anticipated, Both: Anti infective (includes PO), One: T > 99.4 F (37.4 C) PO GBS (+) or status unknown Not indicated Uterine and fetal monitoring 4x/24h Anti infective (includes PO), One: GBS (+) or status unknown Not indicated T > 99.4 F (37.4 C) PO Fetal monitoring Uterine monitoring Antepartum / Postpartum Episode Day 3, 4, 5 & 6 ACUTE Placenta previa, Partial responder, IV fluid or blood product transfusion, One: Postural systolic BP drop > 20 Hct and Hb decreased last 24h Elevated PT or PTT Uterine and fetal monitoring 4x/24h (2) Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) (or baseline) IV fluid or blood product transfusion, One: Elevated PT or PTT Hct and Hb decreased last 24h Postural hypotension, Both: Sustained drop in blood pressure within 3 mins of sitting or standing Blood pressure, One: Systolic BP drop > 20 mmhg Diastolic BP drop > 10 mmhg Based on medical literature depicting findings associated with postural hypotension Page 29 of 204

30 Antepartum / Postpartum Episode Day 3, 4, 5 & 6 ACUTE Preeclampsia, Partial responder, Treatment, One: Antihypertensive Magnesium sulfate IV fluid Intervention, One: Antihypertensive Diuretic 2x/24h IV fluid, One: 75 ml/h, One: Weight < 60 kg Renal insufficiency Hx HF 100 ml/h and weight 60 kg Magnesium sulfate and promotes consistency Antepartum / Postpartum Episode Day 3 ACUTE Pre term labor, < 34 wks gestation, Both: Fetal monitoring Uterine monitoring < 34 wks gestation, All: Corticosteroid, administered or contraindicated Fetal monitoring Uterine monitoring and promotes consistency Antepartum / Postpartum Episode Day 3, 4 & 5 ACUTE Labor or delivery, Partial responder, Rule out HELLP or preeclampsia, One: Lab value monitoring (CBC, LFTs, and platelets) at least 3x/24h Antihypertensive Magnesium sulfate Preeclampsia suspected, Both: Elevated BP Proteinuria Worsening edema Intervention, One: Antihypertensive Diuretic 2x/24h Lab value monitoring 24h Magnesium sulfate,, and clarifies the intent of the criteria Page 30 of 204

31 Antepartum / Postpartum Episode Day 3, 4 & 5 ACUTE Labor or delivery, Partial responder, Spinal headache 2d, One: IV caffeine and fluid Epidural blood patch 24h Antiemetic 3x/24h or serotonin antagonist q24h Spinal headache 2d, One: Epidural blood patch 24h IV caffeine and fluid,, and clarifies the intent of the criteria Antepartum / Postpartum Episode Day 3, 4, & 5 ACUTE Labor or delivery, Partial responder, T > 99.4 F (37.4 C) PO, One: Known source and anti infective New fever requiring evaluation T > 99.4 F (37.4 C) PO and new onset, One: Imaging study 24h Culture pending 2d Drug induced fever suspected and precipitating drug discontinued 3d,, and clarifies the intent of the criteria Antepartum / Postpartum Episode Day 5, 6, & 7 ACUTE Pre term premature rupture of membranes (PPROM), Partial responder, Treatment, Uterine and fetal monitoring 4x/24h Fetal monitoring Uterine monitoring Antepartum / Postpartum Episode Day 5 & 6 ACUTE Placenta abruptio, Partial responder, Finding, Added: Postural hypotension, Both: Sustained drop in blood pressure within 3 mins of sitting or standing Blood pressure, One: Systolic BP drop > 20 mmhg Diastolic BP drop > 10 mmhg Based on medical literature depicting findings associated with postural hypotension Page 31 of 204

32 Antepartum / Postpartum Episode Day 5, 6 & 7 CRITICAL The Critical level of care has been extended to the last episode day and includes the standard interventions as outlined in the global revisions with the additions noted here: DIC and blood product transfusion HELLP Syndrome, Both: Platelets < 50,000/cu.mm (50x10 9 /L) PT 1.5x ULN or INR 2.0 PTT 1.5x ULN Blood product transfusion Hemodynamic instability, Both: Systolic BP < 90 mmhg or decrease from baseline Heart rate > 120/min, sustained Intervention, One: IV fluid resuscitation Blood product transfusion Dialysis, One: Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation Continuous renal replacement therapy Asthma Episode Day 1 OBSERVATION and ACUTE 1h after receiving ED treatment, 1h after receiving ED treatment, One: 1h after receiving treatment, One:,, and clarifies the intent of the criteria Asthma Episode Day 1 CRITICAL Impending respiratory failure, Treatment, All: Short acting beta agonist (includes MDI with spacer) q1 2h or continuous Corticosteroid Oxygenation, One: Mechanical ventilation or NIPPV Heliox Oxygen to maintain O 2 sat 91% (0.91) (or baseline) Corticosteroid, One: Short acting beta agonist (includes MDI with spacer) q1 2h or continuous Mechanical ventilation or NIPPV Heliox and promotes consistency Page 32 of 204

33 Asthma Episode Day 2, 3, 4 & 5 ACUTE Partial responder, Pneumonia confirmed by imaging, Both: O 2 sat 90% (0.90) T > 99.4 F (37.4 C) PO Treatment, Both: Oxygen not required or oxygen to maintain O 2 sat 91% (0.91) (or baseline) Anti infective (includes PO) or respiratory interventions q4h Pneumonia confirmed by imaging, One: Anti infective (includes PO) Respiratory interventions q4h,, and clarifies the intent of the criteria Asthma Episode Day 2, 3, 4 & 5 Asthma Episode Day 2 & 3 ACUTE Partial responder, INTERMEDIATE Added: New onset infection, actual or suspected, Both: T > 99.4 F (37.4 C) PO WBC > 13,000/cu.mm (13x109/L) Bands > 10% (0.10) Intervention, One: Imaging study 24h Culture pending 2d Drug induced fever suspected and precipitating drug discontinued 3d INTERMEDIATE, Both: Oxygen 35 39% ( ) Respiratory interventions at least q3h INTERMEDIATE, One: IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Vasoactive or inotrope Administration, One: Continuous and monitoring q3 4h Bolus q3 4h and monitoring Titration q3 4h and monitoring Titration > q4h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q3 4h Weaning (weaning is associated with an end point of 2d on Episode Day 3) Oxygen 35 39% ( ),, and clarifies the intent of the criteria Page 33 of 204

34 Asthma Episode Day 2 & 3 CRITICAL Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning Short acting beta agonist (includes MDI with spacer) q1 2h or continuous Corticosteroid, One: Short acting beta agonist (includes MDI with spacer) q1 2h or continuous Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning ( 2d beginning Episode Day 3) Heliox Oxygen 40% (0.40) and promotes consistency Asthma Episode Day 3, 4 & 5 ACUTE Partial responder, Added: Inadequate oral intake and IV fluid, One: 50 ml/kg/24h ( 10 kg) 40 ml/kg/24h (> kg) 30 ml/kg/24h (> kg) 75 ml/h (> 60 kg) Asthma Episode Day 4 & 5 CRITICAL The Critical level of care has been extended to the last episode day and includes the standard interventions as outlined in the global revisions with the additions and exceptions noted here. Corticosteroid, One: Short acting beta agonist (includes MDI with spacer) q1 2h or continuous Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning 2d Heliox Oxygen 40% (0.40),, and promotes consistency Asthma Episode Day 5 ACUTE Partial responder, Added: Persistent asthma, Both: O 2 sat 90% (0.90) PEF or FEV % ( ) Intervention, All: Short acting beta agonist (includes MDI with spacer) 6x/24h Corticosteroid (includes PO) Oxygenation, One: O 2 sat 91% (0.91) or baseline O 2 sat 90% (0.90) and < baseline requiring supplemental oxygen Oximetry Page 34 of 204

35 Bronchiolitis Episode Day 1 CRITICAL Mechanical ventilation or NIPPV Mechanical ventilation or NIPPV Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning and promotes consistency Bronchiolitis Episode Day 3 & 4 ACUTE Partial responder, Treatment, No change in oxygen requirement last 48h home oxygen therapy arranged 24h No change in oxygen requirement last 2d and and clarifies the intent of the criteria Bronchiolitis Discharge Screens HOME and HOME CARE Bronchiolitis discharge planning, Education on the importance of, Added: Vaccination for RSV in high risk infants Croup Episode Day 1 OBSERVATION Persistent stridor (excludes stridor at rest) after, One: ER treatment 1 3h OP corticosteroid (includes PO) 2d Second OP visit (same episode) Persistent stridor (excludes stridor at rest) after, One: (1) Outpatient treatment 1 3h OP corticosteroid (includes PO) 2d Second OP visit (same episode) Aligns with current medical guidelines Croup Episode Day 1 CRITICAL Treatment, Croup Episode Day 3 ACUTE Partial responder, Mechanical ventilation or NIPPV and respiratory interventions q1 2h Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning Added: Persistent stridor Both: Oxygenation, One: O 2 sat 94% (0.94) or baseline O 2 sat 93% (0.93) and < baseline requiring supplemental oxygen Racemic epinephrine nebulizer q4h and promotes consistency Page 35 of 204

36 Epilepsy Episode Day 1 OBSERVATION Known or suspected seizure disorder, Sub therapeutic anticonvulsant drug level Seizures 2 within 24h and change from baseline Change in seizure duration New onset seizure Seizure, One: Known seizure disorder, Both: Anticonvulsant, One: Drug level not measurable and patient non adherent with drug regimen Sub therapeutic drug level 2 seizures within 24h and a change from baseline Change or progression in seizure type Increase in seizure duration New onset seizure Added criteria for those patients on medications that a drug level is not measurable Epilepsy Episode Day 1 OBSERVATION Respiratory compromise with seizure, Changed : Treatment, All: Neurological assessment at least q4h Seizure precautions Oxygen not required or oxygen to maintain O 2 sat 94% (0.94) or baseline Intervention, All: Neurological assessment at least q4h O 2 sat 93% (0.93) and < baseline requiring supplemental oxygen Seizure precautions and clarifies the intent of the criteria Epilepsy Episode Day 1 ACUTE Known seizure disorder, Epilepsy Episode Day 1 ACUTE New onset seizure and 2 within 24h, Therapeutic anticonvulsant drug level, One: Seizures 2 within 24h and change from baseline Change in seizure duration or type Anticonvulsant, Both: Anticonvulsant, One: Therapeutic drug level Drug level not measurable and patient adherent with drug regimen 2 seizures within 24h and a change from baseline Change or progression in seizure type Increase in seizure duration Anticonvulsant Anticonvulsant (includes PO) and clarifies the intent of the criteria and clarifies the intent of the criteria Page 36 of 204

37 Epilepsy Episode Day 1 CRITICAL Neurological assessment t least q1-2h, Neurological assessment at least q1 2h, One: Mechanical ventilation or NIPPV and respiratory interventions q1 2h Anticonvulsant, One: Continuous and monitoring q1 2h Bolus q1-2h and monitoring Intervention, One: IV medication administration, Both: Medication, One: Anticonvulsant Vasoactive Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning Neurological assessment q1 2h Epilepsy Episode Day 2, 3, & 4 INTERMEDIATE The INTERMEDIATE level of care has been extended to the last episode day and includes the standard interventions as outlined in the global revisions with the addition noted here: Neurological assessment q3 4h Page 37 of 204

38 Epilepsy Episode Day 2 CRITICAL CRITICAL, All: Neurological assessment q1 2h Seizure precautions Intervention, One: Anticonvulsant, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Mechanical ventilation, One: Respiratory interventions q1 2h Weaning CRITICAL, One: IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning Neurological assessment q1 2h Epilepsy Episode Day 3 & 4 ACUTE Partial responder, Evaluation inconclusive or non diagnostic, All: Neurological assessment at least 4x/24h Seizure precautions Continuous or video EEG Seizure evaluation inconclusive or non diagnostic, All: Anticonvulsant (includes PO) Continuous or video EEG Neurological assessment at least 3x/24h Seizure precautions and clarifies the intent of the criteria Page 38 of 204

39 Epilepsy Episode Day 3 & 4 ACUTE Partial responder, Aspiration pneumonitis confirmed by imaging, Both: O 2 sat 93% (0.93) T > 99.4 F (37.4 C) PO Treatment, One: Oxygen to maintain O 2 sat 94% (0.94) or baseline Respiratory interventions q4h Pneumonia confirmed by imaging, Both: T > 99.4 F (37.4 C) PO O 2 sat 93% (0.93) Intervention, One: Requiring supplemental oxygen Anti infective (includes PO) or respiratory interventions at least q4h and clarifies the intent of the criteria Epilepsy Episode Day 3 & 4 ACUTE Partial responder Added: Blood sugar 350 mg/dl (19.4 mmol/l) requiring insulin adjustment 24h, One: IV 2x/24h SC 4x/24h Epilepsy Episode Day 3 & 4 CRITICAL The CRITICAL level of care has been extended to the last episode day. Criteria now appears as: IV medication administration, Both: Medication, One: Analgesic or sedative Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope (8) Administration, One: Continuous and monitoring q1 2h Bolus q1 2h and monitoring Titration q1 2h and monitoring Titration > q2h and monitoring 24h Mechanical ventilation or NIPPV, One: Respiratory interventions q1 2h Weaning 2d Neurological assessment q1 2h Failure to Thrive Episode Day 1 ACUTE Deleted the age limit of less than 5 years from all criteria and clarifies the intent of the criteria Page 39 of 204

40 Failure to Thrive Episode Day 6 CRITICAL The CRITICAL level of care has been extended to the last episode day and includes the standard interventions as outlined in the global revisions with the addition noted here: Refeeding syndrome resolved and nutrition restarted 24h, All: Nutrition management and refeeding syndrome prophylaxis, One: Tube feeding Parenteral nutrition Diet as tolerated Laboratory monitoring Continuous cardiac (excludes Holter) and respiratory monitoring Neurological assessment Intake and output monitoring Daily weight Gastroenteritis Episode Day 1 OBSERVATION Treatment, Gastroenteritis Episode Day 1 ACUTE Treatment, Encourage PO intake Advancing diet as tolerated Encourage PO intake Advancing diet as tolerated and clarifies the intent of the criteria and clarifies the intent of the criteria Page 40 of 204