Book excerpt: Documentation concerns related to pediatric respiratory failure

Even if the treating physician does not immediately document “acute respiratory failure” in the pediatric patient’s record, looking for specific wording and indicators can help support a CDI query to bring that diagnosis in—provided it is appropriate for that patient during that encounter. There are a number of common respiratory failure risk factors to watch for in pediatric patients:

• Young age
• Premature birth
• Immunodeficiency
• Chronic pulmonary, cardia, or neuromuscular diseases
• Anatomic abnormalities
• Cough, rhinorrhea, or other symptoms of an upper respiratory infection
• Lack of immunizations

In addition to heightened risk, historical health factors could also lead to respiratory distress or failure. For instance, is there documentation of a fever or sepsis? Does the patient have a respiratory syncytial virus infection? Has the patient recently gone under general anesthesia or been exposed to sedatives, which could suggest hypoventilation? If the patient is experiencing neuromuscular weakness or paralysis, there may also be an underlying condition which could link to respiratory failure.

Other clues may be found through in physical examination documentation. The physician may document dyspnea (audible labored breathing, shortness of breath, or irregular breathing patterns), tachypnea, bradypnea, cyanosis (a blue or gray cast to the skin), or pallor. Each of these may be an indication of respiratory distress or failure. There are, however, some common physical signs of this condition. They are:

• Altered level of consciousness
• Nasal flaring
• Retraction—suprasternal, intercostal, supraclavicular, abdominal breathing
• Head bobbing

The physician may also document using words such as drooling, tripod positioning, air-hungry, anxious-appearing, or sudden onset of refusing feedings or difficulty feeding. Documentation of any of these terms can serve as support for a query.

CDI professionals may also run into the problem that physicians shy away from using the word failure in a number of scenarios. In the example mentioned above, many physicians hesitate to diagnose respiratory failure without intubation. Many physicians see high flow nasal cannula (HFNC), BiPAP, and CPAP as preventing respiratory failure altogether and therefore they will not document that diagnosis. A helpful exercise may be to consider what would happen if HFNC, BiPAP, or CPAP was discontinued for a patient? In many cases, the patient would need to be ventilated due to respiratory failure.

Another issue can arise from the hesitancy to document the condition without pulmonary causes. If these hesitancies persist after CDI querying, then education is in order. Acute respiratory failure can be caused by conditions such as status epilepticus leading to encephalopathy and decreased respiratory drive, a traumatic head injury or anoxic brain injury that stops respiratory drive, or septic shock. Consider bringing case studies to the educational table and talk through the scenarios with the physicians.

Editor’s note: This article is an excerpt from the book Pediatric CDI: Building Blocks for Success.