RE: Parameters for Acute Blood Loss Anemia?

kmaritan

Went to conference put on by Gloryanne Bryant (Previous ACDIS advisory board member) about 5 years ago. For acute blood loss anemia it was discussed to use the parameter of 20% drop in hematocrit (20% drop in hgb would be fairly close also).

Some general rules I use for surgery cases and have had good success with are:
1) In query/clarification always start with a baseline, like pre op hct/hgb. If a procedure is further into the patient stay, I would use the hct/hgb earlier on the day of surgery as the baseline. The baseline is important because if a patient is anemic to start, hct around 30, had 500 cc estimated blood loss in OR and POD #2 the hct is 26, a query/clarification for ABLA is not indicated because the drop is only 13.3%.
2) To allow time for the patients to get back to homeostasis after any blood loss and infusion of all types products during surgery (main IV fluids, blood, blood products, volume expanders, etc):
a) For all open heart procedures, I do not write query/clarification until POD #3 (need the hct/hgb this POD #3 to be >20% drop from baseline)
b) For all other surgical procedures, I do not write query/clarification until POD #2 (need the hct/hgb this POD #2 to be >20% drop from baseline)
3) For low estimated surgical blood losses but >20% drop in hct/hgb remember to include in query/clarification the fact of i.e., fractured hip (bone bleeds - each crack in the pelvis can bleed 500 cc) and also use the first 24 hrs of hemovac or JP drain output to be considered with the blood loss.


Karen Maritano, R. N.
Clinical Documentation Specialist
Legacy Health
Portland, Oregon
503-413-7154





-----Original Message-----
From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
Sent: Wednesday, May 16, 2012 10:57 AM
To: Maritano, Karen M. :LPH Care Management
Subject: [cdi_talk] Parameters for Acute Bloos Anemia?

Do any of your programs have a parameter(ie: a 3-4 gram drop in Hbg)to use as a guide as to when to query for Acute Blood Loss Anemia in a patient who has undergone surgery?
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paflor2

For further thought: if a surgical patient dies, having "acute blood loss anemia" in the record CAN POSSIBLY trigger a PSI 04. PSI 04 is Death among Surgical Inpatients with Serious Treatable Complications. This isn't one of the most clear-cut PSIs out there and there are many exclusions to it. Sometimes, this code is justifiable, but sometimes it does seem a bit harsh to create a PSI for a physician and for your facility with this diagnosis alone.

dvitalone1

If physician writes drop in hgb or hgb dropped but doesn’t mention anemia code 790.01 can be used which is a CC

judithbates

Actually, doesn't the MD have to doc precipitous drop in HCT??? We have never embraced that documentation as a query opportunity and I'm really not sure why. Has anyone out there Q for 790.01???
The discussion of ABLA comes up on this site regularly and sometimes causes quite a bit of discussion. As I said if anyone has the HCPro pocket guide, there is great info regarding this topic and many others we encounter daily...

Judi Bates RN, BSN, CCDS
Our Lady of Lourdes Medical Center
CDI Specialist
856-757-3161
Beeper 66x2906

ssalinas

Precipitous is a non-essential modifier meaning precipitous does not
have to be stated. Seems crazy but that is how the alpha index lists
it.

Sharon

dvitalone1

Conference last year and in CDI Boot Camp we were instructed that if the physician documents drop in hgb or hgb drop you can code 790.01. The physician does not have to say the word precipitous. Please correct me if I am misunderstanding this information.

robert.hodges2

The tabular index of the ICD-9-CM manual says the same thing. The word "drop" does let you capture the code.

Robert

Robert S. Hodges, BSN, MSN, RN, CCDS
Clinical Documentation Improvement Specialist
Aleda E. Lutz VAMC
Mail Code 136
1500 Weiss Street
Saginaw MI 48602

cmorell

If we have an elective procedure and the patient has a significant drop (usually 2 g/dl) and receives at least 2 units PRBCs we have encouraged the physicians to document expected acute blood loss anemia.
Conversely, we don't query when we feel it is inherent to the procedure such as open heart or a valve unless we see a large volume of replacement after the initial post op period.

An interesting link http://depts.washington.edu/medcons/mch/transfusion.html
states:

Key points
1. Preoperative anemia is associated with increased postoperative mortality.
2. Optimum transfusion thresholds remain uncertain.
3. Transfusion is not purely a benign intervention—there is increasing concern for immunomodulatory effects.
4. Erythropoietin may be considered in patients who refuse transfusion, but there are significant risks associated with its use and uncertain benefit.

Charrington "Charlie" Morell

ddouthit

So this raises the question of drop in H/H is a symptom code and anemia is a diagnosis...what differentiates the two from a clinical perspective and does this lend to a query opportunity for just a drop in H/H?

robert.hodges2

If anemia is documented you can't capture the drop in H&H code. One of the rules.

Robert

dvitalone1

You need to look at the clinical picture of patient for anemia. If the clinical picture reflects true anemia but physician only documenting drop in Hgb with no mention of anemia then a query is warranted.
If the patient does not meet clinical picture of anemia & there is not documentation of anemia then you capture 790.01

Of course it goes without saying that the dx must meet the rules of reporting a secondary diagnosis.


DAWN M. VITALONE, RN
Clinical Documentation Improvement Specialist
Community Hospital
Munster, IN