Should we have known that we needed to query for hemorrhagic shock based on the data below?

cuculicacuculica
in CDI Talk Archive
We received a comment from one of our doctors stating that we missed an opportunity for query for hemorrhagic shock.

The patient came in with rectal bleed – as per patient - tarry stools – quiac positive for blood. In the ER initial BP 117/69, HB 11.3 After a minute, the patient’s BP dropped to 93/45 and a bolus of 1000 NS was given. Hb in ER was 11.3 and after 8 hours the Hb dropped to 8.1 (2 units of blood was given). IMP: GI bleed secondary to probably source of diverticular bleeding. EGD done the next day of admission – bleed from diverticuli. House MD stated severe acute blood loss anemia.
The MD was queried for the etiology of GIB and the severity of anemia.
The patient was sent home after 4 days.

Comments

  • digardskdigardsk
    edited May 2016
    I would have considered that query, and have queried in similar
    circumstances. I have found physician reticent to give it to us though!
    Wish we had your doctor...




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    >>> CDI Talk 10/19/2012 9:00 AM >>>
    We received a comment from one of our doctors stating that we missed an
    opportunity for query for hemorrhagic shock.

    The patient came in with rectal bleed – as per patient - tarry stools
    – quiac positive for blood. In the ER initial BP 117/69, HB 11.3 After
    a minute, the patient’s BP dropped to 93/45 and a bolus of 1000 NS was
    given. Hb in ER was 11.3 and after 8 hours the Hb dropped to 8.1 (2
    units of blood was given). IMP: GI bleed secondary to probably source of
    diverticular bleeding. EGD done the next day of admission – bleed from
    diverticuli. House MD stated severe acute blood loss anemia.
    The MD was queried for the etiology of GIB and the severity of anemia.

    The patient was sent home after 4 days.


  • mdomineseymdominesey
    edited May 2016
    From what I understand, shock is one of two things 1. Sustained hypotension (30 minutes) with possible organ damage, or 2. Hypotension resistant to pressors. Also, I do not believe pressors are absolutely necessary, and that big bolus of fluid is a HUGE intervention! I likely would have placed my shock query which includes several other less severe diagnoses for selection as well as other and unable to determine and not indicated



    Mark N. Dominesey, RN, BSN, MBA, CCDS, CDIP
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  • katysuegood@gmail.comkatysuegood@gmail.com
    Its always interesting to hear what other MD's criteria is for a given dx. My MD's probably would have laughed in my face if I asked about shock. I'm pretty sure I would have gotten a "who doesn't get a liter bolus in the ER?" if I tried to use that as an indicator and the BP given is marginal but not even really hypotensive depending on a person's usual BP.
    I'm not saying that a query wouldn’t be valid. But, I don’t think my Dr's are there yet.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

    -----Original Message-----
    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Friday, October 19, 2012 12:01 PM
    To: Kathryn Good
    Subject: [cdi_talk] Should we have known that we needed to query for hemorrhagic shock based on the data below?

    We received a comment from one of our doctors stating that we missed an opportunity for query for hemorrhagic shock.

    The patient came in with rectal bleed – as per patient - tarry stools – quiac positive for blood. In the ER initial BP 117/69, HB 11.3 After a minute, the patient’s BP dropped to 93/45 and a bolus of 1000 NS was given. Hb in ER was 11.3 and after 8 hours the Hb dropped to 8.1 (2 units of blood was given). IMP: GI bleed secondary to probably source of diverticular bleeding. EGD done the next day of admission – bleed from diverticuli. House MD stated severe acute blood loss anemia.
    The MD was queried for the etiology of GIB and the severity of anemia.
    The patient was sent home after 4 days.


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  • angelisa.romanelloangelisa.romanello
    edited May 2016
    Based on the CDI Handbook for 2012, which I use daily, I also would not have queried for hemorrhagic shock based on the clinical information provided below. There appears to be only a 3gm drop in hemoglobin and 2 units were transfused which is pretty standard here for a GIBleed. I would also like to see possibly an ICU admission, several units of IV fluids for a bolus and possibly pressors, however as Mark indicated, they are not entirely necessary.

    Lisa

    Lisa Romanello, RN,BSN,FNS,CCDS
    CDI Specialist
    CJW Medical Center
    Chippenham Campus
    804-228-6527


  • katysuegood@gmail.comkatysuegood@gmail.com
    edited May 2016
    As I was mulling this over in my head, I was just thinking the same. That if this was hemorrhagic shock, basically any patient admitted with a GI bleed would have Shock. It sounds like standard treatment to me.
    Also, when I think of indicators of shock, I also would want to know how emergent all this treatment was. Were we doing rapid blood transfusions? What was the mental status? What did the patient look like? Were they tachycardic? With shock, we should be seeing multi-system impact in my experience.
    Of course, this is all really hard to get sometimes from the documentation in the actual record.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


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