When is it Critical Care?

Tuesday, August 21, 2018

Critical care includes such a broad range of presentations in emergency medicine and sometimes these variable presentations are difficult to ascertain when comprehensive level 5 99285 care becomes critical care 99291.

Many ED physicians work fervently treating emergent cases of pneumonia or UTI in combination with high fever, low blood pressure and tachycardia using fluids, pressers, and antibiotics, knowing they have a potentially critical patient, but at many times some fail to understand when it is acceptable to acknowledge critical care time should be documented in the record.

In an attempt to understand just what CMS defines as critical care let’s examine their own definition: Critical care is defined as the direct delivery by a physician(s) medical care for a critically ill or critically injured patient. A critical illness or injury acutely impairs one or more vital organ systems such that there is a high probability of imminent or life threatening deterioration in the patient's condition. Jul 25, 2014

“ The care must involve highly complex decision making that is necessary to assess, manipulate and support vital system functions to treat vital organ failure (shock, renal/hepatic/respiratory failure, etc.), and/or prevent further life-threatening deterioration of the patient's condition.” ACP Hospitalist March 2010

These definitions leave a wide range of patient presentations from acute stroke and STEMI to urinary tract sepsis and pneumonia. Take for example the presentation of a 40 yo male with STEMI, severe chest pain, SOB diaphoresis with slight hypotension and tachycardia. You immediately or cardiac w/u, ASA, fluids monitor and EKG reveal marked ST elevation in II, III, and AVF. You immediately call the cardiologist and send the patient to cath lab in 20 minutes. This patient to you is one of dozens you have treated over the years, and you feel that he was in no way critical at the time you cared for him. By the strictest of definitions you are correct, but CMS has concluded did you intervene in this patient’s care in a way you prevented further deterioration of his myocardial infarction by getting him to the cath lab in a prompt, efficient and safe manner. If you had done nothing and not intervened at all and let him lay there with chest pain he probably would have extended his MI or even died. Thru your emergent and competent intervention you saved further end organ injury.

This identical scenario can be applied to stroke intervention, GI bleeding, sepsis, head injuries, multiple trauma, airway compromise, breathing difficulties. To this day your patients approach you and thank you for “saving their life” when the facts show you did intervene in a timely manner and chose the correct path for the patient to follow even though you were not the actual interventionalist in the case.

In the sepsis case at the beginning of the article, there is trepidation on part of the physician to code critical care. Let’s point out that sepsis and septic shock have different meanings. Sepsis refers to the potential of end organ injury not matter what the source of the infection is, and if you did anything to prevent or reduce end organ injury even if it were not septic shock you are correct in applying critical care time. Also septic shock has more clear and defined general definitions as expressed in the following:

“Until recently, septic shock was considered to be composed of three components, including systemic arterial hypotension, tissue hypoperfusion associated with organ dysfunction, and hyperlactatemia (2). According to the new definition of this issue (3), septic shock can be diagnosed under two conditions. The first condition is persistent hypotension after fluid resuscitation and requiring vasopressors to maintain MAP >65 mmHg. The secondcondition is serum lactate level >2 mmol/L. Since heart rate, respiration rate, and other laboratory data are not included, the diagnosis and recognition of septic shock have become simplified. This very new definition implies that increased serum lactate level may represent tissue hypoperfusion associated with signs of organ dysfunction in critically ill patients. In addition, it is of note that the serum lactate cut off level was decreased from 4 to 2 mmol/L. Serum lactate level as a clinical tool was described approximately half a century ago by Broder and Weil (4). At that time, serum lactate level >4 mmol/L was associated with shock status. Since the serum lactate level was decreased to 2 mmol/L, serum lactate level is a more sensitive marker for septic shock.” J Thorac Dis 2016;8(7):1388-1390

In emergency medicine we all know when the patient is critically injured or sick by how much stress and anxiety provoking it can be pending on the experience and education of the physician. Hopefully using this understating of what the CMS definition of critical care really means will make it easier to understand that it’s not the obvious, but the potential of what would happen to the patient if you did nothing at all.