by Amber Sterling, RN, BSN, CCDS
Getting CDI specialists involved at the point of entry in the emergency department (ED) provides numerous benefits to downstream documentation and coding accuracy:
- The entire CDI effort for each case becomes more effective.
- Electronic health record (EHR) documentation begins with an accurate report—important when ED documentation captures the severity of the patient at presentation, which often differs from the documentation of the admitting physician, who sees the patient after he or she has been stabilized.
- Cohesive documentation helps to improve CC/MCC capture rates, and solidifies medical necessity for admission.
Consider these five tactical guidelines to help spur ED CDI efforts.
1. Start Early: The best starting point is early evaluation of patient admission status. Knowing which trajectory the patient encounter will take informs your CDI workflow. Admission status can go one of two ways:
Inpatient admission: For cases where the inpatient admission appears medically justified based on clinical findings and screening criteria, the CDI specialist’s role is simple. The goal is to confirm ED documentation accuracy, since emergency documentation often differs from admitting documentation, which is done after the patient has been stabilized. Incorporating ED documentation in the codeable record will help capture diagnoses and present a clearer picture of the patient’s condition.
Maybe, possible admission: In this case, additional steps should be taken. More documentation is needed in the ED record to support inpatient status. The CDI specialist should work closely with the ED case manager and ED physician to discuss specifically what documentation is required to meet inpatient medical necessity.
Involve the CDI specialist right away, and engage the emergency services physician to clarify exactly what is required to support the admission determination.
2. Use technology to trigger action: The most successful CDI programs take advantage of technology. CDI in the ED is no exception. Use technology alerts, such as a “bed request” or “transfer from ED to inpatient status” as a trigger point for the CDI specialists to review the case prior to patient transfer.
CDI specialist can achieve great success, speaking with attending physicians between the ED and the nursing unit. Signs and symptoms that warranted a visit to the ED often stabilize after several hours of emergency treatment, therapies, and tests. CDI specialists bridge the gap between clinical findings in the ED and patient condition hours later in the nursing unit. If attending physicians aren’t available, rely on your organization’s hospitalists to meet with you, case management, and the patient prior to nursing transfer.
Start in locations that already have a hospitalist program in place who see patients in the ED prior to admission. This gives the CDI specialist the best opportunity to work with both the attending and the ED physician to capture necessary information in the record.
3. Collaborate with case management: From a screening practice standpoint, patients typically must meet a combination of criteria to justify medical necessity for inpatient admission. This gap represents a proactive query opportunity for CDI to make sure all diagnoses are addressed, DRGs are assigned appropriately, and principal diagnoses are identified correctly.
Cross-training in medical necessity screening criteria is essential for CDI specialists assigned to the ED. CDI specialists should also develop a strong collaboration with case management. Knowing case management’s role in the care process prepares CDI to fully understand the workflows, timelines, and criteria that drive clinical documentation. When you better understand decision points, and how your work affects what follows, it is easier to determine what and when to query.
4. Define Your Reporting Structure
The reporting structure is key to how communications are handled within the ED. Roles, responsibilities and communication channels should be clearly defined at the director level. Collaboration should be purposeful and direct to achieve the full benefits of CDI in the ED.
5. Be Prepared for Push-back
Based on my experience launching a program for emergency services, physicians may resist—at first. But once the downstream benefits are realized, your efforts become best practice. A concerted effort to educate the ED physicians on the “why” of a CDI program is needed in the ED, and should be made to help the physicians understand the crucial link their documentation makes in a more accurate and thorough record. As with other CDI efforts, ED physicians are more cooperative once they are aware of how their documentation impacts the quality of care for the patient.
CDI programs in emergency settings carry a unique set of challenges for everyone involved, including CDI specialists, case managers and physicians. These five strategies will position CDI specialists to help streamline documentation workflow in the ED and on the nursing unit.
Editor’s note: Amber Sterling, RN, BSN, CCDS is the director of CDI services at TrustHCS. Sterling has experience in the cardiac ICU, PACU, general ICU, case management, and utilization review. Most recently, she worked as the director of CDI for a five-hospital network, where she developed a CDI quality audit program, trained physician advisors in reconciling cases, creating a retrospective DRG denial review process, and developed and implemented a physician engagement program. Contact her at amber.sterling@TrustHCS.com.