Guest post: The case for CDI work during the COVID-19 pandemic

by Julie Salomon, BSN, RN

The healthcare landscape has changed drastically over the last few months. How should a CDI specialist carry on while physicians are on the battlefield fighting an invisible, unpredictable viral opponent, the SARS-CoV-2 coronavirus (COVID-19)? For a CDI specialist, this question and others are top of mind. Should CDI programs slow down? How can a CDI team avoid burdening the physician further? What questions must be asked or avoided to limit disruption?

Accurate documentation has never been more important than in this time of COVID-19. CDI specialist are the keepers of the patient’s clinical story. Their collaborative partnership with physicians and coders ensures that patient data is complete. In a world without CDI specialists, significant diagnoses can be absent from the record or lacking in specificity, or COVID-19 may not be captured at all.

The impact of missing documentation will surface in rapidly declining severity of illness (SOI) and expected risk of mortality (ROM) scores in hospital populations. The data used for assessing COVID-19 patients for future reimbursement and SOI/ROM will be skewed, reflecting less complexity. Additionally, national benchmarking and research data will be inaccurate without the rigor of clarification provided by clinical documentation integrity teams.

The CDI specialist’s role has also changed. Gone are the days of straightforward case reviews. In the past, a CDI specialist had clear expectations of what needed further investigation, based on a patient’s presenting body system diagnoses. Although the CDI specialist continues to be the frontline investigator, searching for the connections in the words recorded or missing in the documentation, the difference now is that there are so many unknowns. What are the clues that may be critically important now or the key to unlocking COVID-19 connections later? COVID-19 touches every organ system, making the job of the CDI specialist quite complicated. In many cases, patients present without any evident connection to COVID-19 and only later the diagnosis becomes clear or suspect.  

The respiratory component of COVID-19 is the earliest presentation with initial symptoms of fever, dry cough, dyspnea, and ground glass opacities on chest X-ray. The most alarming initial development is patients who begin to recover, then take a turn for the worse and develop acute respiratory distress syndrome (ARDS), cytokine storm, and potential death. This is the expected patient presentation with an obvious link to COVID-19.

In this case, the focus is on fully capturing the comorbid diagnoses and organ system involvement. While it may sound like an easy task, physicians in hospitals at the epicenter of the pandemic are facing unprecedented patient volumes. CDI specialist must adapt by triaging documentation clarifications, limiting queries to the most critical situations.

Recent published studies and physician accounts illustrate the rapid evolution in understanding of the virus. After careful study, seemingly unrelated cases are found to be the coronavirus attacking organ systems in unexpected ways. Every patient seen must be treated as suspect.

For example, a 30-year-old healthy male presenting with a large vessel stroke, may be asymptomatic for COVID-19 but later test positive. Or a 12-year-old healthy girl with a stomachache who goes into cardiac arrest and requires a life flight, later is found to be COVID-19 positive. Patient presentation can cloud the present on admission (POA) status of COVID-19 raising the question of what should be considered POA versus hospital acquired COVID-19 with potential risk. Going back to CDI basics is critical in establishing what is present on admission versus what is discovered after careful study.

Along with the importance of POA and careful study, the links and relationships of all diagnoses must be crystal clear. Comorbidities such as cardiovascular disease, cancer, kidney disease, chronic lung disease, obesity, and hypertension become key predictors and definers of mortality risk. In addition, as the coronavirus directly targets organs and ignites the immune response, organ systems spiral out of control resulting in pulmonary embolism, sepsis, stroke, cardiac arrest, clotting and acute kidney failure. The loss of acuity, specificity or diagnoses impacts the accuracy of individual patient stories and taints future data as well.  

How can the CDI specialist triage accordingly? Leveraging technology can lighten the load by helping the CDI specialist focus on value cases. Utilizing prioritization and auto populating worklists specific to COVID-19 allows targeting of both the confirmed coronavirus cases and suspected cases as well.

The list of symptoms has grown to include headache, abdominal pain, thrombosis, diarrhea, nausea, and vomiting, all of which can be utilized to uncover suspected unconfirmed patients. Prioritization can illuminate high-value patterns in case presentation so the most important clarifications can be acted on prior to discharge. 

So, can the data wait? Should the CDI specialist step back from the physician? Or should the CDI specialist be the partner the physician needs now to assist with recording the true story of this battle? In the absence of accurate documentation, data is lost, resulting in mistaken hypotheses. It will take some time to learn all the twists and turns of COVID-19’s sinister patterns. A rich data set will provide the knowledge and clinical connections needed and provide experts with meaningful insights to win the next battle and ultimately the war.

Editor’s note: Salomon is chief product owner, 3M 360 Encompass, for 3M Health Information Systems. All opinions are those of the author and do not necessarily reflect those of ACDIS, HCPro, or any of its subsidiaries. To read ACDIS’ coverage of the COVID-19 pandemic, click here.