Guest post: Remember patient care

By Howard Rodenberg, MD, MPH, CCDS

I may have mentioned in these pages that despite (or in spite of) my transition to full-time bureaucracy, I still do some ER shifts every month. I do so for a number of reasons. First, I’ve always had this theory...totally unsupported by fact, experience, or management gurus...that no matter how high you go or where you go in an organization, you ought to still be able to do the job you were doing when you first signed up.

According to the Rodenberg Rule of Management Ascendency, if the CEO of IBM started out as a copier repairman, at some level he or she should still be able to clear a paper jam. Nobody expects an engineer to become an accountant, or to be fluent in every advancement in your field; but if you can’t do the basic functions, you lose credibility with those you are trying to lead. As a result, I feel strongly that unless I continue to see patients, I won’t have the professional respect of those clinicians I’m trying to influence. I’ll have no leg to stand on in my role as a CDI physician advisor if I’m asked when was the last time I saw a patient and I have to think about it.

I’ve also been around the block enough to know that today’s security is tomorrow’s unemployment, as the job I have may disappear at any time with the next bit of technology or a new leader’s desire to show “fiscal discipline” or promote “culture change.” The only way to make sure you’re still employable is to have clinical currency. Finally, as a part-time hobby, ED physician pays pretty well.

I bring this up because we often get so tangled in ICD-10-CM and the rules governing documentation and coding assignment that we forget all we do is based on patient care. The only way to get back to basics, to see what the terminology actually means and how it applies is to work with patients themselves.

A few months ago I had patient that made me look at the documentation of acute myocardial infarction (AMI) in a totally different way, one that would not have occurred to me were I still not spending my weekends in the Convenience Store of American Health Care (24/7, turkey sandwiches and Sprite).

A young man, barely out of his teens, dropped in one morning complaining of chest pain. He had an hour of pain the night before, and an hour of pain that morning, but by the time he drifted into my neck of the woods his pain had vanished.

The nurse practitioner ordered an EKG, and we looked at it together. It looked odd…a minimal bit of ST elevation here and there, one little box high, but nothing consistent, no reciprocal changes, nothing that screamed out “TAKE ME TO THE CATH LAB!” Plus, he had no risk factors, looked great, and was pain-free. So you can imagine our surprise when the troponin came back elevated. Not just elevated into the indeterminate zone, but into the double digits, even without a decimal point.

The cardiologist was incensed, as they often are during nights, weekends, or in fact any time the earth rotates around the sun. "Clearly that’s a STEMI!” he fumed (not only do cardiologists incense, but they fume) and took the patient down to the cath lab. About that time his senior partner came to the ER to give us a lashing. But when he looked at the EKG, he paused and said, “Well, I don’t know what that is, either.”

We started to feel better. And the cardiologist himself was more subdued when he called back and said there was no coronary disease, and that the patient had Takotsubo cardiomyopathy, more commonly known as “broken heart syndrome.” (I’ll let you look that one up yourself. Learning by doing.)

I was reviewing the chart later in the day and noticed that the ED diagnosis entered by the nurse practitioner was a “NSTEMI.” I normally wouldn’t pay attention to this, but it entered into the CDI part of my brain that NSTEMI really wasn’t a diagnosis. I had just been working on an institutional definition of Type 2 MI, and in that effort had just became acquainted with the Third Universal Definition of Myocardial Infarction.

A joint project of multiple groups including the American College of Cardiology and the American Heart Association, the Third Universal Definition was developed to aid research and analysis by establishing specific criteria to facilitate research. (It’s hard to know what the study means if you don’t know who or why someone was included in it.) The criteria include not only a definition of myocardial infarction, but also a clinical classification of the underlying mechanisms of infarction. There are five different classifications. Type 1 is related to atherosclerotic plaque and thrombus in the coronary artery; Type 2 is due to an “ischemic imbalance” (supply/demand mismatch). Type 3 is seen in patients who have cardiac death prior to full evaluation, and types 4 and 5 are associated with percutaneous coronary intervention PCI and coronary artery bypass grafting CABG procedures.

So if you’ve ever wondered where the term “Type 2 MI” comes from, this is the mother lode. But you know what’s NOT a term used to define or classify myocardial infarction? NSTEMI, that’s what.

This led me to realize that STEMI isn’t a diagnosis, either. What we call a “STEMI” is really a triage tool, a finding on the EKG that suggests something’s going on that needs further investigation. In a broad sense, ST segment elevation is no more specific or sensitive than an elevated white blood cell count or yellow crime scene tape around the local bar. It tells you that something’s going on, but generally doesn’t tell you what.

It is true that ST segment elevation is one of the criteria that may characterize an MI; and if we’re using the Third Universal Criteria, we might say that ST-segment elevation is generally associated with a Type 1 MI. But the literature is actually pretty clear that there’s a 2-3% incidence of alternate causes for ST segment elevation in patients with normal coronary arteriography, including pericarditis, pancreatitis, cholecystitis, and subarachnoid hemorrhage. In addition, it’s important to recognize that MI is not defined by the presence of ST–segment elevation, but is confirmed with a combination of elevated troponins and wall motion abnormalities on echocardiography, symptoms of ischemia, angiographic proof of coronary thrombosis, or new fixed changes such as bundle branch block on the post-acute EKG.

This is not to minimize the need to recognize ST-segment elevation on an EKG. If 3% of the time the cause is not cardiac, 97% of the time it is, and that patient does need emergent investigation and likely intervention with cardiac angiography. It’s important to recognize ST-segment elevation as a significant red flag that should set off the fire alarms. But it’s not a diagnosis unto itself.

The Third Universal Definitions make this point clear. Nonetheless, those of us in ED medicine and prehospital care…and, I suspect, a lot of cardiologists and internists…still cling to the idea that STEMI and NSTEMI are discrete diagnoses. They are not, and either can result from coronary disease, supply/demand mismatch, or both. (You could even make the case that all MI’s, Types 1-5, are really just a supply/demand mismatch, in that the cardiac tissue is not supported by flow either from increased myocardial oxygen demands or decreased flow through the narrowed or blocked coronary vessel.)

As CDI professionals, we have the opportunity to educate clinician peers to see STEMI and NSTEMI as triage tools, and to use the Third Universal Definitions to reflect more specific and accurate diagnoses.

Now, excuse me…I have go to unjam the copier.

Editor’s note: Rodenberg is the adult physician advisor for CDI at Baptist Health in Jacksonville, Florida. Contact him at howard.rodenberg@bmcjax.com or follow his personal blog at writingwithscissors.blogspot.com. Advice given is general. Readers should consult professional counsel for specific legal, ethical, clinical, or coding questions. Opinions expressed are that of the author and do not represent HCPro or ACDIS.