This document provides information on the analysis of T-beams, including:
1) It defines T-beams and L-beams as beams with flanges projecting from one or both sides of the web, forming a T or inverted L shape.
2) It explains the concept of a T-beam as a combination of a rectangular beam and slab portion, and provides the formula to calculate the overall depth.
3) It shows the stress-strain diagram for a T-beam and defines terms like neutral axis, compression and tension forces, and lever arms.
4) It describes how to determine the position of the neutral axis based on the relative magnitudes of compression and tension forces.
Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist used for sedation, analgesia, and to reduce sympathetic nervous system activity. It has various clinical applications including premedication, intensive care unit sedation, procedural sedation, and as an adjuvant to local anesthetics to prolong their effects. Adverse effects include hypotension, bradycardia, and hypertension. Dexmedetomidine has benefits over other sedatives as it does not cause respiratory depression. It is useful for procedures requiring patient immobility like surgery, MRI, and attenuating responses to intubation and extubation.
This document provides an overview of the Theory of Structures course taught by Prof. Omkar Parishwad. The course covers topics like forces, center of gravity, moment of inertia, supports and loads, shear force and bending moment. It will be taught over approximately three weeks per topic. Assessment will include assignments, class tests, maintaining a journal, and exams. The goal is for students to understand structural concepts and their application to structures through history.
Mohr's circle is a graphical representation of the transformation of stresses on planes at a point in a material. It relates normal and shear stresses on inclined planes to the principal stresses. The circle is centered at the average stress and has a radius equal to the difference between the maximum and minimum principal stresses. Mohr's circle allows determination of stresses on any inclined plane from knowledge of the principal stresses and provides insight into failure conditions of materials.
Anesthesia for thoracic surgery (2) (4).pptxssuserb91f2d
1. Anesthesia for thoracic surgery requires establishing adequate lung separation, maintaining gas exchange, and ensuring circulatory stability during one-lung anesthesia.
2. This is typically achieved through use of a double-lumen endotracheal tube or bronchial blocker to isolate the lungs, along with positive pressure ventilation, intravenous induction and maintenance of anesthesia, and thoracic epidural analgesia.
3. Challenges include ventilation/perfusion mismatching when the dependent lung is compressed but still highly perfused during surgery in the lateral decubitus position.
Premedication aims to provide sedation, anxiolysis, analgesia and reduce postoperative nausea and vomiting. Several factors must be considered when choosing a premedication including patient characteristics, surgery details, and medical history. Common premedication drugs include benzodiazepines, opioids, antihistamines, and anticholinergics which are chosen based on their onset time to take effect before surgery. Special considerations are needed for pediatric patients, such as using intranasal or oral midazolam instead of intravenous routes due to easier administration.
This document provides an overview of preanesthesia evaluation. The key purposes are to obtain relevant medical history, assess perioperative risks, order appropriate tests, and formulate an anesthetic plan. Important components of the medical history include past and current medical problems, medications, allergies, and lifestyle factors. A physical exam focuses on vital signs, airway assessment, and systemic examination. For patients with cardiovascular or pulmonary diseases, specific evaluations and tests are recommended to optimize management and identify high-risk patients. The preanesthesia evaluation aims to detect underlying conditions, evaluate perioperative risks, and develop a customized anesthetic plan tailored to each patient's needs.
This document provides information on the analysis of T-beams, including:
1) It defines T-beams and L-beams as beams with flanges projecting from one or both sides of the web, forming a T or inverted L shape.
2) It explains the concept of a T-beam as a combination of a rectangular beam and slab portion, and provides the formula to calculate the overall depth.
3) It shows the stress-strain diagram for a T-beam and defines terms like neutral axis, compression and tension forces, and lever arms.
4) It describes how to determine the position of the neutral axis based on the relative magnitudes of compression and tension forces.
Dexmedetomidine is a selective alpha-2 adrenergic receptor agonist used for sedation, analgesia, and to reduce sympathetic nervous system activity. It has various clinical applications including premedication, intensive care unit sedation, procedural sedation, and as an adjuvant to local anesthetics to prolong their effects. Adverse effects include hypotension, bradycardia, and hypertension. Dexmedetomidine has benefits over other sedatives as it does not cause respiratory depression. It is useful for procedures requiring patient immobility like surgery, MRI, and attenuating responses to intubation and extubation.
This document provides an overview of the Theory of Structures course taught by Prof. Omkar Parishwad. The course covers topics like forces, center of gravity, moment of inertia, supports and loads, shear force and bending moment. It will be taught over approximately three weeks per topic. Assessment will include assignments, class tests, maintaining a journal, and exams. The goal is for students to understand structural concepts and their application to structures through history.
Mohr's circle is a graphical representation of the transformation of stresses on planes at a point in a material. It relates normal and shear stresses on inclined planes to the principal stresses. The circle is centered at the average stress and has a radius equal to the difference between the maximum and minimum principal stresses. Mohr's circle allows determination of stresses on any inclined plane from knowledge of the principal stresses and provides insight into failure conditions of materials.
Anesthesia for thoracic surgery (2) (4).pptxssuserb91f2d
1. Anesthesia for thoracic surgery requires establishing adequate lung separation, maintaining gas exchange, and ensuring circulatory stability during one-lung anesthesia.
2. This is typically achieved through use of a double-lumen endotracheal tube or bronchial blocker to isolate the lungs, along with positive pressure ventilation, intravenous induction and maintenance of anesthesia, and thoracic epidural analgesia.
3. Challenges include ventilation/perfusion mismatching when the dependent lung is compressed but still highly perfused during surgery in the lateral decubitus position.
Premedication aims to provide sedation, anxiolysis, analgesia and reduce postoperative nausea and vomiting. Several factors must be considered when choosing a premedication including patient characteristics, surgery details, and medical history. Common premedication drugs include benzodiazepines, opioids, antihistamines, and anticholinergics which are chosen based on their onset time to take effect before surgery. Special considerations are needed for pediatric patients, such as using intranasal or oral midazolam instead of intravenous routes due to easier administration.
This document provides an overview of preanesthesia evaluation. The key purposes are to obtain relevant medical history, assess perioperative risks, order appropriate tests, and formulate an anesthetic plan. Important components of the medical history include past and current medical problems, medications, allergies, and lifestyle factors. A physical exam focuses on vital signs, airway assessment, and systemic examination. For patients with cardiovascular or pulmonary diseases, specific evaluations and tests are recommended to optimize management and identify high-risk patients. The preanesthesia evaluation aims to detect underlying conditions, evaluate perioperative risks, and develop a customized anesthetic plan tailored to each patient's needs.
The document summarizes 90 critical care clinical trials covering important topics in intensive care. It focuses on the randomization method, excluded populations, and conclusions of each trial. The summaries are brief and not meant to replace reading the full text, but to provide a quick overview of the currently available evidence in critical care medicine.
This document provides an overview of engineering geology and rock mechanics. It discusses fundamentals such as lithology, rock structures, weathering, and rock mass classification systems. It also presents a case study on the 1928 failure of the St. Francis Dam in California, which was caused by unsuitable geological conditions including weakness along the San Francisquitto fault that were not properly considered in the dam's design and construction. The case study demonstrates the importance of engineering geological considerations for civil works.
RMR, or Rock Mass Rating, is a method used to design support plans for underground mine workings based on characteristics of the rock mass. It involves assigning ratings for 5 parameters - layer thickness, structural features, weatherability, rock strength, and groundwater - to determine an overall RMR value. This value is then used to classify the roof rock, estimate expected rock loads, determine the required support resistance and number of roof bolts, and calculate support load density and theoretical strata convergence. The document provides examples of how RMR is applied to these design aspects at a depth of 300m for a mine in India.
The document discusses the importance of preoperative evaluation in ensuring patient safety and optimal outcomes. A thorough evaluation includes obtaining medical history, conducting a physical exam, and ordering appropriate tests. Key areas of focus include assessing cardiovascular, pulmonary, coagulation, and gastrointestinal status. Airway evaluation helps predict potential difficulties. The goals are to identify and address any issues that could impact anesthesia or surgery, provide informed consent, and reduce risk through optimization when possible.
The document discusses numerical modelling of surface subsidence associated with block cave mining. It presents the research objectives, which include developing a new methodology using finite-discrete element modelling (FEM/DEM) to analyze subsidence. The modelling methodology incorporates rock mass properties derived from classification systems. Conceptual studies examine factors controlling subsidence development such as joint orientation. The results could improve understanding of subsidence mechanisms and enhance prediction capabilities.
Class notes of Geotechnical Engineering course I used to teach at UET Lahore. Feel free to download the slide show.
Anyone looking to modify these files and use them for their own teaching purposes can contact me directly to get hold of editable version.
This PowerPoint is one small part of the Geology Topics unit from www.sciencepowerpoint.com. This unit consists of a five part 6000+ slide PowerPoint roadmap, 14 page bundled homework package, modified homework, detailed answer keys, 12 pages of unit notes for students who may require assistance, follow along worksheets, and many review games. The homework and lesson notes chronologically follow the PowerPoint slideshow. The answer keys and unit notes are great for support professionals. The activities and discussion questions in the slideshow are meaningful. The PowerPoint includes built-in instructions, visuals, and review questions. Also included are critical class notes (color coded red), project ideas, video links, and review games. This unit also includes four PowerPoint review games (110+ slides each with Answers), 38+ video links, lab handouts, activity sheets, rubrics, materials list, templates, guides, 6 PowerPoint review Game, and much more. Also included is a 190 slide first day of school PowerPoint presentation.
Areas of Focus within The Geology Topics Unit: -Plate Tectonics, Evidence for Plate Tectonics, Pangea, Energy Waves, Layers of the Earth, Heat Transfer, Types of Crust, Plate Boundaries, Hot Spots, Volcanoes, Positives and Negatives of Volcanoes, Types of Volcanoes, Parts of a Volcano, Magma, Types of Lava, Viscosity, Earthquakes, Faults, Folds, Seismograph, Richter Scale, Seismograph, Tsunami's, Rocks, Minerals, Crystals, Uses of Minerals, Types of Crystals, Physical Properties of Minerals, Rock Cycle, Common Igneous Rocks, Common Sedimentary Rocks, Common Metamorphic Rocks.
This unit aligns with the Next Generation Science Standards and with Common Core Standards for ELA and Literacy for Science and Technical Subjects. See preview for more information
If you have any questions please feel free to contact me. Thanks again and best wishes. Sincerely, Ryan Murphy M.Ed www.sciencepowerpoint@gmail.com
Black sand is sand that is black in color, there are a number of different dark sand grains that can form black sand, it concentrates often contain additional valuables, other than precious metals: rare earth elements, thorium, titanium, tungsten, zirconium and others are often fractionated during igneous processes into a common mineral-suite that becomes black sands after weathering and erosion, several gemstones such as garnet, topaz, ruby, sapphire, and diamond are found in placers and in the course of placer mining, and sands of these gems are found in black sands and concentrates. black sand is found in Egypt with economical quantities, it is located in the Mediterranean sea coast from Al Arish in north Sinai to Rashid in Al Buhayrah, the main concentration of black sand is in Kafrelshiekh. Black sand is considered as source of many ores used in building and construction such as Iron and steel industry, that is beside wide application in concrete and painting industries. In this work, Chemical, physical and mechanical characteristics of black sands compounds in Egypt are mentioned, the composition and locations of black sand will be discussed, the main common applications of black sands in building and construction industries will be mentioned, the application of black sands in insulation materials industries will be discussed the disadvantages and precautions of using black sands in some applications in buildings will be evaluated. The work end with group of results and recommendations to improve the economic of black sand applications in new fields related to construction and building material industries such as Titanium industries and composite materials.
This document summarizes key concepts from a chapter about metamorphism from the textbook Essentials of Geology. Metamorphism occurs when rocks undergo changes to their texture, mineralogy, and chemistry due to changes in temperature, pressure, and reaction with fluids. There are several processes involved, and metamorphic rocks exhibit distinctive properties based on the conditions they form under. Different metamorphic environments and intensities can produce different rock types. Index minerals are used to determine metamorphic grade.
This document discusses various methods of airway management and oxygenation during cardiopulmonary resuscitation (CPR). It covers topics such as bag-mask ventilation, advanced airways like endotracheal tubes and supraglottic airways, and passive oxygen delivery devices. The key points are that maintaining oxygenation through ventilation is important during CPR, but excessive ventilation can be harmful by interrupting chest compressions or increasing intrathoracic pressure. Placement of advanced airways should not unnecessarily delay CPR and defibrillation. There is no clear evidence about optimal ventilation strategies or devices during cardiac arrest.
The document summarizes the geological setting and engineering challenges for constructing a suspension bridge where the bedrock is granite located beneath 300m of glacial till and 200m of unconsolidated silt and mud, with the ends anchored in highly fractured shale that dips toward the water. Some of the challenges discussed include water ingress through fractures in the shale increasing weathering, slope failures due to clay expansion in the shale, and rapid scouring of the shale. The document outlines solutions such as anchoring directly into bedrock instead of shale, using concrete slabs with rock bolts over fractured shale areas, and locating anchor placements in zones with minor shale fractures. Bridge maintenance procedures are also briefly discussed.
A borehole is a narrow shaft bored in the ground, either vertically or horizontally. A borehole may be constructed for many different purposes, including the extraction of water, other liquids (such as petroleum) or gases (such as natural gas), as part of a geotechnical investigation, environmental site assessment, mineral exploration, temperature measurement, as a pilot hole for installing piers or underground utilities, for geothermal installations, or for underground storage of unwanted substances, e.g. in carbon capture and storage.
The document provides an introduction to seismic design, including:
1) It discusses plate tectonics and how earthquakes occur at plate boundaries.
2) It describes different effects of earthquakes like ground shaking, liquefaction, landslides, and tsunamis.
3) It explains seismic design categories which depend on location, soil type, occupancy, and expected ground shaking. The design category determines the required design procedures.
Rcc design and detailing based on revised seismic codesWij Sangeeta
The document summarizes important provisions of revised seismic codes affecting reinforced concrete (RCC) design and detailing, including:
- Revisions to building configuration definitions, load combinations, and stiffness modifiers.
- Prohibitions on certain structural systems without adequate experimentation/analysis.
- Revisions to design eccentricity, foundation isolation, column/beam sizing and reinforcement, and ductility provisions.
- Updates to standards IS:13920 regarding concrete grade, beam-column joints, lap splices, transverse reinforcement, and special confining reinforcement.
- Queries raised regarding compliance of existing/under construction buildings and clarification needed for irregular geometries.
Anesthesia Consideration in Pediatric and ObstetricsRifhan Kamaruddin
Pediatric patients have important physiological differences compared to adults that impact anesthesia care. Their respiratory systems have higher minute ventilation, oxygen consumption, and risk of airway closure. Blood volume is higher in neonates compared to older children and adults. The liver and kidneys are immature, increasing risk of hypoglycemia and difficulty excreting drugs. Thermoregulation is less developed, requiring measures to prevent hypothermia. Pre-operative assessment includes medical history, physical exam, and investigations to evaluate risk. Post-operative care focuses on preventing nausea, vomiting and adequately managing pain.
Sedimentary rocks are formed by the lithification of sediments and include clastic sedimentary rocks such as sandstone and shale that are formed from fragments of pre-existing rocks transported by water, wind or ice. They also include chemical sedimentary rocks such as limestone that are formed via precipitation from solution. Sedimentary structures within these rocks provide clues about the depositional environment, and sedimentary rocks are classified based on their mineral composition, grain size, sorting and rounding. Common sedimentary rocks used in construction include sandstone, limestone and shale.
Airway management in obstetrics patientHASSAN RASHID
OBSTETRICAL PATIENTS POSE A CHALLENGE TO THE ANAESTHESIA PROVIDER. APART FROM VARIOUS PHYSIOLOGICAL CHANGES, AIRWAY CHANGES ALSO ARE OF IMPORTANT CONSIDERATION
Mechanical Ventilation Cheat Book for Internal Medicine ResidentsThe Medical Post
This short cheat book talks about basic concepts and physiology of artificial ventilation and also elaborates on point guided approach in maneuvering different modes of mechanical ventilation. Consider this as a basic overview and is intended for all internal medicine residents.
This document provides an overview of ARDS (acute respiratory distress syndrome) including its history, definition, pathophysiology, assessment, and treatment strategies. ARDS is characterized by acute hypoxemia, stiff lungs, and diffuse pulmonary infiltrates caused by inflammatory lung injury from direct or indirect insults. Key evidence-based treatment strategies discussed include lung protective ventilation with low tidal volumes, higher PEEP levels, targeting driving pressure, prone positioning, and rescue therapies like recruitment maneuvers which can improve oxygenation but their benefits are uncertain. The PROSEVA trial showed a significant reduction in 28-day mortality for prone positioning in severe ARDS patients.
The document summarizes 90 critical care clinical trials covering important topics in intensive care. It focuses on the randomization method, excluded populations, and conclusions of each trial. The summaries are brief and not meant to replace reading the full text, but to provide a quick overview of the currently available evidence in critical care medicine.
This document provides an overview of engineering geology and rock mechanics. It discusses fundamentals such as lithology, rock structures, weathering, and rock mass classification systems. It also presents a case study on the 1928 failure of the St. Francis Dam in California, which was caused by unsuitable geological conditions including weakness along the San Francisquitto fault that were not properly considered in the dam's design and construction. The case study demonstrates the importance of engineering geological considerations for civil works.
RMR, or Rock Mass Rating, is a method used to design support plans for underground mine workings based on characteristics of the rock mass. It involves assigning ratings for 5 parameters - layer thickness, structural features, weatherability, rock strength, and groundwater - to determine an overall RMR value. This value is then used to classify the roof rock, estimate expected rock loads, determine the required support resistance and number of roof bolts, and calculate support load density and theoretical strata convergence. The document provides examples of how RMR is applied to these design aspects at a depth of 300m for a mine in India.
The document discusses the importance of preoperative evaluation in ensuring patient safety and optimal outcomes. A thorough evaluation includes obtaining medical history, conducting a physical exam, and ordering appropriate tests. Key areas of focus include assessing cardiovascular, pulmonary, coagulation, and gastrointestinal status. Airway evaluation helps predict potential difficulties. The goals are to identify and address any issues that could impact anesthesia or surgery, provide informed consent, and reduce risk through optimization when possible.
The document discusses numerical modelling of surface subsidence associated with block cave mining. It presents the research objectives, which include developing a new methodology using finite-discrete element modelling (FEM/DEM) to analyze subsidence. The modelling methodology incorporates rock mass properties derived from classification systems. Conceptual studies examine factors controlling subsidence development such as joint orientation. The results could improve understanding of subsidence mechanisms and enhance prediction capabilities.
Class notes of Geotechnical Engineering course I used to teach at UET Lahore. Feel free to download the slide show.
Anyone looking to modify these files and use them for their own teaching purposes can contact me directly to get hold of editable version.
This PowerPoint is one small part of the Geology Topics unit from www.sciencepowerpoint.com. This unit consists of a five part 6000+ slide PowerPoint roadmap, 14 page bundled homework package, modified homework, detailed answer keys, 12 pages of unit notes for students who may require assistance, follow along worksheets, and many review games. The homework and lesson notes chronologically follow the PowerPoint slideshow. The answer keys and unit notes are great for support professionals. The activities and discussion questions in the slideshow are meaningful. The PowerPoint includes built-in instructions, visuals, and review questions. Also included are critical class notes (color coded red), project ideas, video links, and review games. This unit also includes four PowerPoint review games (110+ slides each with Answers), 38+ video links, lab handouts, activity sheets, rubrics, materials list, templates, guides, 6 PowerPoint review Game, and much more. Also included is a 190 slide first day of school PowerPoint presentation.
Areas of Focus within The Geology Topics Unit: -Plate Tectonics, Evidence for Plate Tectonics, Pangea, Energy Waves, Layers of the Earth, Heat Transfer, Types of Crust, Plate Boundaries, Hot Spots, Volcanoes, Positives and Negatives of Volcanoes, Types of Volcanoes, Parts of a Volcano, Magma, Types of Lava, Viscosity, Earthquakes, Faults, Folds, Seismograph, Richter Scale, Seismograph, Tsunami's, Rocks, Minerals, Crystals, Uses of Minerals, Types of Crystals, Physical Properties of Minerals, Rock Cycle, Common Igneous Rocks, Common Sedimentary Rocks, Common Metamorphic Rocks.
This unit aligns with the Next Generation Science Standards and with Common Core Standards for ELA and Literacy for Science and Technical Subjects. See preview for more information
If you have any questions please feel free to contact me. Thanks again and best wishes. Sincerely, Ryan Murphy M.Ed www.sciencepowerpoint@gmail.com
Black sand is sand that is black in color, there are a number of different dark sand grains that can form black sand, it concentrates often contain additional valuables, other than precious metals: rare earth elements, thorium, titanium, tungsten, zirconium and others are often fractionated during igneous processes into a common mineral-suite that becomes black sands after weathering and erosion, several gemstones such as garnet, topaz, ruby, sapphire, and diamond are found in placers and in the course of placer mining, and sands of these gems are found in black sands and concentrates. black sand is found in Egypt with economical quantities, it is located in the Mediterranean sea coast from Al Arish in north Sinai to Rashid in Al Buhayrah, the main concentration of black sand is in Kafrelshiekh. Black sand is considered as source of many ores used in building and construction such as Iron and steel industry, that is beside wide application in concrete and painting industries. In this work, Chemical, physical and mechanical characteristics of black sands compounds in Egypt are mentioned, the composition and locations of black sand will be discussed, the main common applications of black sands in building and construction industries will be mentioned, the application of black sands in insulation materials industries will be discussed the disadvantages and precautions of using black sands in some applications in buildings will be evaluated. The work end with group of results and recommendations to improve the economic of black sand applications in new fields related to construction and building material industries such as Titanium industries and composite materials.
This document summarizes key concepts from a chapter about metamorphism from the textbook Essentials of Geology. Metamorphism occurs when rocks undergo changes to their texture, mineralogy, and chemistry due to changes in temperature, pressure, and reaction with fluids. There are several processes involved, and metamorphic rocks exhibit distinctive properties based on the conditions they form under. Different metamorphic environments and intensities can produce different rock types. Index minerals are used to determine metamorphic grade.
This document discusses various methods of airway management and oxygenation during cardiopulmonary resuscitation (CPR). It covers topics such as bag-mask ventilation, advanced airways like endotracheal tubes and supraglottic airways, and passive oxygen delivery devices. The key points are that maintaining oxygenation through ventilation is important during CPR, but excessive ventilation can be harmful by interrupting chest compressions or increasing intrathoracic pressure. Placement of advanced airways should not unnecessarily delay CPR and defibrillation. There is no clear evidence about optimal ventilation strategies or devices during cardiac arrest.
The document summarizes the geological setting and engineering challenges for constructing a suspension bridge where the bedrock is granite located beneath 300m of glacial till and 200m of unconsolidated silt and mud, with the ends anchored in highly fractured shale that dips toward the water. Some of the challenges discussed include water ingress through fractures in the shale increasing weathering, slope failures due to clay expansion in the shale, and rapid scouring of the shale. The document outlines solutions such as anchoring directly into bedrock instead of shale, using concrete slabs with rock bolts over fractured shale areas, and locating anchor placements in zones with minor shale fractures. Bridge maintenance procedures are also briefly discussed.
A borehole is a narrow shaft bored in the ground, either vertically or horizontally. A borehole may be constructed for many different purposes, including the extraction of water, other liquids (such as petroleum) or gases (such as natural gas), as part of a geotechnical investigation, environmental site assessment, mineral exploration, temperature measurement, as a pilot hole for installing piers or underground utilities, for geothermal installations, or for underground storage of unwanted substances, e.g. in carbon capture and storage.
The document provides an introduction to seismic design, including:
1) It discusses plate tectonics and how earthquakes occur at plate boundaries.
2) It describes different effects of earthquakes like ground shaking, liquefaction, landslides, and tsunamis.
3) It explains seismic design categories which depend on location, soil type, occupancy, and expected ground shaking. The design category determines the required design procedures.
Rcc design and detailing based on revised seismic codesWij Sangeeta
The document summarizes important provisions of revised seismic codes affecting reinforced concrete (RCC) design and detailing, including:
- Revisions to building configuration definitions, load combinations, and stiffness modifiers.
- Prohibitions on certain structural systems without adequate experimentation/analysis.
- Revisions to design eccentricity, foundation isolation, column/beam sizing and reinforcement, and ductility provisions.
- Updates to standards IS:13920 regarding concrete grade, beam-column joints, lap splices, transverse reinforcement, and special confining reinforcement.
- Queries raised regarding compliance of existing/under construction buildings and clarification needed for irregular geometries.
Anesthesia Consideration in Pediatric and ObstetricsRifhan Kamaruddin
Pediatric patients have important physiological differences compared to adults that impact anesthesia care. Their respiratory systems have higher minute ventilation, oxygen consumption, and risk of airway closure. Blood volume is higher in neonates compared to older children and adults. The liver and kidneys are immature, increasing risk of hypoglycemia and difficulty excreting drugs. Thermoregulation is less developed, requiring measures to prevent hypothermia. Pre-operative assessment includes medical history, physical exam, and investigations to evaluate risk. Post-operative care focuses on preventing nausea, vomiting and adequately managing pain.
Sedimentary rocks are formed by the lithification of sediments and include clastic sedimentary rocks such as sandstone and shale that are formed from fragments of pre-existing rocks transported by water, wind or ice. They also include chemical sedimentary rocks such as limestone that are formed via precipitation from solution. Sedimentary structures within these rocks provide clues about the depositional environment, and sedimentary rocks are classified based on their mineral composition, grain size, sorting and rounding. Common sedimentary rocks used in construction include sandstone, limestone and shale.
Airway management in obstetrics patientHASSAN RASHID
OBSTETRICAL PATIENTS POSE A CHALLENGE TO THE ANAESTHESIA PROVIDER. APART FROM VARIOUS PHYSIOLOGICAL CHANGES, AIRWAY CHANGES ALSO ARE OF IMPORTANT CONSIDERATION
Mechanical Ventilation Cheat Book for Internal Medicine ResidentsThe Medical Post
This short cheat book talks about basic concepts and physiology of artificial ventilation and also elaborates on point guided approach in maneuvering different modes of mechanical ventilation. Consider this as a basic overview and is intended for all internal medicine residents.
This document provides an overview of ARDS (acute respiratory distress syndrome) including its history, definition, pathophysiology, assessment, and treatment strategies. ARDS is characterized by acute hypoxemia, stiff lungs, and diffuse pulmonary infiltrates caused by inflammatory lung injury from direct or indirect insults. Key evidence-based treatment strategies discussed include lung protective ventilation with low tidal volumes, higher PEEP levels, targeting driving pressure, prone positioning, and rescue therapies like recruitment maneuvers which can improve oxygenation but their benefits are uncertain. The PROSEVA trial showed a significant reduction in 28-day mortality for prone positioning in severe ARDS patients.
Predictors of weaning from mechanical ventilator outcomeMuhammad Asim Rana
This is a very useful presentation for respiratory therapists and ICU and Emergency physicians. Intended to teach how to assess you patient's readiness for weaning from mechanical ventilator and successful separation from machine.
1) Non-invasive positive pressure ventilation (NIPPV) delivers positive airway pressure without an invasive interface like an endotracheal tube.
2) NIPPV can benefit patients with respiratory failure from COPD, cardiogenic pulmonary edema, obesity hypoventilation syndrome, and other conditions by reducing work of breathing and improving oxygenation.
3) Bi-level positive airway pressure (BPAP) and continuous positive airway pressure (CPAP) are common NIPPV modes. BPAP delivers different pressures during inspiration and expiration while CPAP maintains a constant pressure.
Non-invasive ventilation (NIV) provides ventilation without an artificial airway. It can be negative pressure or positive pressure. Positive pressure NIV uses an interface like a mask to deliver ventilation. NIV is used for conditions like asthma, pneumonia, heart failure, and weaning from ventilation. It reduces the need for intubation and has benefits like lower mortality, shorter hospital stays, and reduced complications compared to invasive ventilation. Proper patient selection, interfaces, settings, and monitoring are needed to effectively use NIV.
This document discusses rapid sequence intubation (RSI) for airway management in the pre-hospital setting. It outlines the philosophy of RSI, including that it should only be used if absolutely necessary due to risks. The document provides guidance on RSI techniques, medications, equipment, and verification of proper endotracheal tube placement. Several studies are referenced that show risks of RSI including increased mortality rates, hypoxia, and worse outcomes for head injured patients compared to bag-valve-mask ventilation alone. Proper training and only using RSI for prolonged transports are emphasized.
This document provides an overview of acute respiratory distress syndrome (ARDS), including:
1) The updated Berlin definition of ARDS which requires a minimum PEEP of 5 cm H2O and specifies diagnostic criteria based on oxygenation levels.
2) The pathophysiology of ARDS involves an initial exudative phase followed by a proliferative phase and sometimes a fibrotic phase.
3) Management focuses on supportive ventilation with low tidal volumes and identification and treatment of precipitating factors, with corticosteroids and prone positioning helping in some cases. Refractory hypoxemia may be addressed through approaches like HFOV, IRV, APRV, inhaled nitric oxide, or ECMO.
This document provides guidance on coding respiratory failure. It defines the types of respiratory failure coded in ICD-10 category J96 based on whether it is acute, chronic, or unspecified and whether there is accompanying hypercapnia or hypoxia. It also outlines the official guidelines for coding acute respiratory failure as the principal or secondary diagnosis depending on the circumstances of admission. Two case examples are provided to demonstrate how to determine if respiratory failure should be coded as hypercapnic or hypoxic based on the documented clinical findings.
Presented by Dr.Nial Ferguson at Pulmonary Medicine Update Course held at Cairo, Egypt. Pulmonary Medicine Update Course is the leading Pulmonary Critical Care event in Egypt. Organized by Scribe www.scribeofegypt.com
Sleep apnea is a common disorder where breathing pauses or becomes shallow during sleep. These pauses can last from a few seconds to minutes and occur 30 or more times per hour. The main causes of sleep apnea are blockages in the throat muscles that keep the airway open, such as relaxed throat muscles, enlarged tongue or tonsils, or weight issues that narrow the airway. Left untreated, sleep apnea can lead to high blood pressure, heart failure, stroke, and other health issues. It is categorized into obstructive, central, and complex types.
Susan P Pilbeam presented on patient-ventilator asynchrony and how monitoring the diaphragm's electrical activity (Edi) can help identify and reduce asynchrony. Asynchrony is common, occurring in 25-53% of patients, and can lead to longer ventilation times and muscle atrophy. Edi monitoring provides insights not available from ventilator waveforms alone and can guide modes like NAVA that use Edi to synchronize breathing. Case studies showed rapid resolution of respiratory issues when switching to NAVA-guided ventilation.
This document provides an overview of weaning from mechanical ventilation. It discusses preliminary concerns like ventilatory support strategies, physical rehabilitation, and sedation practices. Readiness criteria for weaning and the spontaneous breathing trial are also covered. Some highlights include problems like rapid breathing, cardiac dysfunction, and respiratory muscle weakness. Extubation concerns such as airway protection, laryngeal edema, and post-extubation stridor are also summarized. The document emphasizes being vigilant in recognizing readiness for weaning trials and their success or failure.
This document discusses ARDS (acute respiratory distress syndrome), including its history, definitions, pathophysiology, and evidence-based treatment strategies. ARDS is characterized by diffuse pulmonary inflammation and reduced lung compliance. Traditional ventilator strategies have been shown to cause ventilator-induced lung injury, so current recommendations focus on lung-protective ventilation with low tidal volumes and high PEEP. Additional rescue therapies for refractory hypoxemia include recruitment maneuvers, proning, and ECMO. Proper diagnosis requires consideration of alternative conditions and use of diagnostic tools like echocardiogram, bronchoscopy, and chest CT scan.
This document discusses various aspects of mechanical ventilation and weaning patients off ventilators. It addresses the problems associated with prolonged intubation versus premature extubation. It emphasizes the nurse's responsibility to monitor patients' readiness for weaning and to gradually decrease mechanical support. The document also discusses definitions of weaning success and ensuring patients are weaned at the appropriate time.
This document summarizes evidence on the use of noninvasive ventilation (NIV) in acute respiratory failure. It finds that NIV is an effective first-line treatment for moderate-to-severe exacerbations of chronic obstructive pulmonary disease (COPD) and acute cardiogenic pulmonary edema, reducing the need for invasive mechanical ventilation and improving outcomes. It also discusses how NIV is used in other clinical settings such as postoperative care, pneumonia, asthma, and palliative care. The document concludes that appropriate patient selection and technique are important for the successful use of NIV.
Recent Advances in NIV
1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases.
2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options.
3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema.
4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher
1) Acute respiratory distress syndrome (ARDS) is a life-threatening lung condition caused by injury to the lungs. It can result from direct lung injury, such as pneumonia, or indirect injury, like sepsis.
2) ARDS progresses through exudative and proliferative phases characterized by fluid accumulation and scarring in the lungs. This impairs gas exchange and causes respiratory failure.
3) Mechanical ventilation is used to treat respiratory failure but can further damage the lungs if not done carefully. The ARDSNet trial showed using low tidal volumes of 6 ml/kg improved survival compared to larger volumes.
This presentation reviews the benefits of allowing preserved spontaneous breathing in acute respiratory failure. Partial ventilatory support modes like pressure support, airway pressure release ventilation (APRV), proportional assist ventilation (PAV) and neurally adjusted ventilatory assist (NAVA) allow spontaneous breathing while providing ventilatory support. A systematic review found that these modes are associated with improved hemodynamics, gas exchange and reduced medication use compared to controlled mechanical ventilation. However, the review included a variety of study designs and only two small randomized controlled trials, so definitive conclusions cannot be drawn regarding outcomes. While observational studies suggest clinical benefits, more high-quality research is still needed.
1. The document discusses mechanical ventilation, including its history, principles, objectives, modes, settings, complications, and clinical applications.
2. Key points include the various modes of mechanical ventilation like volume controlled, pressure controlled and pressure support. It also outlines objectives, settings, and safety principles of mechanical ventilation.
3. Complications discussed are ventilator-induced lung injury, ventilator-associated pneumonia, and physiological and artificial airway complications. Clinical applications include indications, contraindications and criteria for use of non-invasive positive pressure ventilation.
The document discusses techniques for researching and incorporating evidence into appeal letters to overturn claim denials. It recommends following leads from denial letters to relevant regulations, guidelines and literature. Specific resources highlighted include CMS manuals, LCDs, CPT/ICD guidelines, peer-reviewed studies and position statements. Attendees will learn how to build an evidence-based argument and guide reviewers to an favorable decision.
The key issues with Chest Pain one-day stays are that Medicare considers them medically unnecessary unless the documentation clearly supports that inpatient level of care was required for more than 24 hours. The main factors considered are severity of symptoms, need for monitoring or treatment exceeding 24 hours, and appropriateness of care setting. Successful appeals for one-day stays need to provide clear evidence that the inpatient admission met medical necessity criteria.
The document discusses proper documentation of wound care including describing wound origin, treatment including different types of debridement, and ensuring documentation supports the use of specific procedure codes like excisional debridement. It emphasizes capturing details about wound location, size, stage for pressure ulcers, and relationship to underlying conditions to support accurate coding. Providers are encouraged to clarify terms and relationships in response to queries to ensure wounds and treatments are coded appropriately.
This document provides information about an upcoming webinar on documenting and coding septicemia and sepsis. The webinar will have three panels on documenting sepsis, coding and audits for sepsis, and appealing denials for sepsis cases. It also includes detailed clinical information on defining and diagnosing sepsis, systemic inflammatory response syndrome, organ dysfunction, and coding guidelines for infectious versus non-infectious causes of sepsis.
The document discusses an upcoming presentation on auditing respiratory neoplasm cases for RAC denials and focuses on understanding the RAC's concerns regarding these cases, incorporating clinical guidelines to aid in auditing practices, and reviewing key documentation elements and common issues seen in respiratory neoplasm cases to facilitate successful appeals.
The document discusses how to successfully appeal denials of inpatient claims related to heart failure and shock by understanding that it is a frequently targeted diagnosis, providing documentation to support the coding and medical necessity of the inpatient stay, and citing clinical practice guidelines and evidence-based sources to justify treatment decisions. It also notes that specifying the type of heart failure such as systolic versus diastolic can result in higher reimbursement levels.
Effective Appeals from the ALJ Perspective Handout, 9-29-2010
Judge Irwin Schroeder (Administrative Law Judge) provides insight on how to file an effective provider appeal.
1. Top MS-DRG’s at Risk
MS-
Documentation, Coding Audit, and Appeal Workshops
Sponsored by Intersect Healthcare, Inc.
Part Three:
Respiratory Failure with Ventilator
Support >96 hours
(MS-DRG 207)
Next Session:
Wednesday, July 7
W d d J l
1:00PM EST
Chest Pain (1 day stay):
A Clinical Documentation, Coding Audit &
Appeal Workshop (MS-DRG 313)
Top MS-DRG’s at Risk
MS-
Documentation, Coding Audit, and Appeal Workshops
Sponsored by Intersect Healthcare, Inc.
Part Three:
Respiratory Failure with Ventilator
Support >96 hours
(MS-DRG 207)
Your Panel:
Tracey Goessel, MD
Clinical Overview of MS-DRG 207
Charmira Johnson, CCS, BS, LPN, CCDS
The RAC and MS-DRG 207
Denise Wilson, RN, RRT, MS
Appealing a MS-DRG 207 Denial
1
2. MS DRG 207:
Respiratory Failure with
Ventilator Support >96 hours
V til t S t h
Tracey Goessel, M.D.
CEO
FairCode Associates
What is “Respiratory Failure”?
Inability of the lungs to p
y g perform their basic
task of gas exchange: the transfer of
oxygen from inhaled air into the blood and
the transfer of carbon dioxide from the
blood into exhaled air.
We tend to think of it as being a state
where the patient’s oxygen is too low; but
it can be also a state where the CO2 is too
high.
2010 Intersect Healthcare, Inc. FairCode 4
2
3. What are the Causes of
Respiratory Failure?
Alveolar Hypoventilation
– Drug overdose/respiratory suppressants
– Chest wall trauma
– Neurologic disorders (stroke, MS), Neuromuscular disorders
(myasthenia gravis), Muscular disorders (muscular dystrophy)
Capillary wall/alveolar damage
– Near drowning
– Pesticide exposure
– Smoke inhalation/fire
Inadequate alveolar wall surface – COPD!
Loss of elasticity in the lungs
– Pulmonary fibrosis
– Sarcoidosis
– ~ 100 others
Loss of pulmonary vascular bed
– Massive pulmonary embolism
2010 Intersect Healthcare, Inc. FairCode 5
How Do We Diagnose Respiratory Failure
– From a Clinical and Coding Standpoint?
In patients without underlying disease,
the general rule of thumb is p
g pO2 < 60
and/or the pCO2 > 50.
COPD patients often have baseline pO2s
that are low and pCO2s that are elevated.
Look at pH: is patient acidotic, or compensated?
Drop of 10-15 points in p
p p pO2 from baseline is
suggestive.
Patient does not need to be on
ventilator for respiratory failure to be
the diagnosis!
2010 Intersect Healthcare, Inc. FairCode 6
3
4. What are the Challenges in Physician
Documentation of Respiratory Failure?
The use of the term “respiratory insufficiency” as a
synonym.
The failure to document baseline blood gases in
COPD patients
The hesitancy to document respiratory failure if the
patient is not on a ventilator.
2010 Intersect Healthcare, Inc. FairCode 7
When is ventilatory support considered
Non-invasive mechanical ventilation?
BiPAP S/T-D ventilatory support system: augments
patient’s ability to breath on their own – while it is
continuous,
continuous it does not qualify as “continuous
continuous
manual ventilation” because it is not given via
ET/NT or trach tube
CPAP - continuous positive airway pressure not
through ET/NT or trach tube
NIPPV - noninvasive positive pressure ventilation
i i iti til ti
NPPV - nonpositive pressure ventilation
PEEP - not given via ET/NT or trach tube
2010 Intersect Healthcare, Inc. FairCode 8
4
5. When is ventilatory support considered
Non-invasive mechanical ventilation?
BiPAP S/T-D ventilatory support system: augments
patient’s ability to breath on their own – while it is
continuous,
continuous it does not qualify as “continuous
continuous
manual ventilation” because it is not given via
ET/NT or trach tube
CPAP - continuous positive airway pressure not
through ET/NT or trach tube
NIPPV - noninvasive positive pressure ventilation
i i iti til ti
NPPV - nonpositive pressure ventilation
PEEP - not given via ET/NT or trach tube
2010 Intersect Healthcare, Inc. FairCode 9
When is Ventilatory Support Considered
Invasive Mechanical Ventilation?
BiPAP though given via ET/NT or trach tube
CPAP given via ET/NT or trach tube (mostly!)
PEEP given via ET/NT or trach tube
IPPV - invasive positive p
p pressure ventilation
2010 Intersect Healthcare, Inc. FairCode 10
5
6. What are the Challenges in Physician
Documentation of a Patient
Already on a Ventilator?
Capturing when the post-operative period on a
ventilator counts as an “unexpected, extended
period of mechanical ventilation ”
ventilation.
Capturing the time of intubation.
Anesthesia records usually precise; ER records less so.
Incision of tracheotomy/cricothyroidostomy represents moment of
intubation in surgical airways.
Capturing the time of extubation
extubation.
Oral/nasotracheal intubation: ends when tube pulled.
Weaning periods count with trach patients.
Tube may remain indefinitely, so once pt weaned off mechanical
ventilation, that is when clock stops.
Respiratory therapy notes generally more helpful and specific than
MD notes
2010 Intersect Healthcare, Inc. FairCode 11
What are the Challenges in Determining When to
Make Respiratory Failure Principal Diagnosis?
Respiratory failure is not a symptom. It is a
diagnosis. As such, it may be coded as the principal
diagnosis,
diagnosis even when the cause is known
known.
For the most part, if respiratory failure is present at
admission, it trumps the underlying cause. You list
it first.
Chapter-specific coding guidelines may over-ride
this
thi rule:
l
– Obstetrics
– Poisoning
– HIV
– Newborns
2010 Intersect Healthcare, Inc. FairCode 12
6
7. Example:
A 24-year-old female throws a massive
pulmonary embolus, requires intubation,
and is on the ventilator for 5 days.
– If the embolus is a peri-partum pulmonary embolism,
then OB sequencing guidelines require you to list PE
first. This leads you to 781/782 Other Antepartum
Diagnoses with or without Medical Complications
– If the embolus is not obstetric in nature, then
respiratory failure may be sequenced first, leading to
MS DRG 207.
2010 Intersect Healthcare, Inc. FairCode 13
Accordingly:
Work to get the attending to specify the
cause of the respiratory failure. If he/she
documents that it is a cause outside of the
poisoning/HIV/newborn/obstetric arena,
you may code respiratory failure first.
2010 Intersect Healthcare, Inc. FairCode 14
7
8. When in Doubt…
Refer to Coding Clinics
Query, query, query!
2010 Intersect Healthcare, Inc. FairCode 15
Sample Queries
Respiratory Insufficiency
– The term “respiratory insufficiency” is not specific from a coding
standpoint. The patient presented with pneumonia, cyanosis and the
following blood gases: pH 7.29/pO2 57/pCO2 49/HCO3 15. Please define
the condition that was the underlying cause of the above documented
laboratory studies.
Unexpected, extended period of ventilation
– The patient underwent an anterior/posterior cervical fusion. Post-
operatively, you noted “extensive anterior edema” and maintained the
patient on a ventilator for 18 hours in the ICU. In your opinion, does this
represent a normal post-operative ventilatory duration, an extended post-
operative ventilatory duration, or are you unable to determine?
Underlying cause of respiratory failure
– This patient presented with respiratory failure requiring mechanical
ventilation. He was documented to have consumed an overdose of Tylenol,
requiring Mucomyst administration, as well as bi-lobar aspiration
pneumonia. Please define what, in your opinion, was the underlying cause
of the respiratory failure, if known.
Copyright 2009 5
16
2010 Intersect Healthcare, Inc. FairCode
8
9. The RAC
and
MS DRG
MS-DRG 207
C a
Charmira Orr BS, LPN, CCS, CPC, CCDS
aO S, , CCS, C C, CC S
Intersect Healthcare, Inc.
Learning Objectives
To U d
T Understand How to Use Past Findings
t dH t U P t Fi di
of the RAC Demonstration Area to Help
Tell Your Coding Validation Story
To Understand How to Break Down the
Guidelines to Abstract Data from the
Medical Record
To Understand How to Tell Your Coding
Validation Story
2010 Intersect Healthcare, Inc. 18
9
11. Respiratory System Diagnosis with Ventilator
Support >96 Hours (MS-DRG 207)
MDC4 GMLOS/RW AND
• GMLOS‐ • Non Operating
• Medical‐ Room
Any 12.8 Procedures
Principal • RW 5.1055 • ICD‐9 CM 96.72‐
Continuous
Diagnosis • Transfer invasive
in MDC 4
in MDC 4 DRG mechanical
mechanical
ventilation for
96 consecutive
hours or more
2010 Intersect Healthcare, Inc. 21
Understanding the Guidelines
The Uniform Hospital Discharge Data Set ( UHDDS)
defines the principal diagnosis as the condition
established after study and is the primary reason
responsible for the admission of the patient to the acute
care setting within the hospital. In accordance to coding
guidelines the reason and circumstances that led to the
inpatient admission must take precedence as the
primary diagnosis.
- ICD- 9 codes Various respiratory Conditions
throughout the Index
AND
Mechanical Ventilation- Located under ICD-9 code 96.7
Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)
CPAP delivered through endotracheal tube or tracheostomy (invasive interface)
Endotracheal respiratory assistance, Invasive positive pressure ventilation [IPPV]
Mechanical ventilation through invasive interface That by tracheostomy
Weaning of an intubated (endotracheal tube) patient
Excludes: Noninvasive ventilation like face mask, nasal cannulas, nasal catheters
2010 Intersect Healthcare, Inc. 22
11
12. Mechanical Ventilation –ICD-9
96.7 Guidelines Cont’d
Endotracheal Intubation
To calculate the number of hours (duration) of continuous mechanical ventilation during a
hospitalization, begin the count from the start of the (endotracheal) intubation. The
duration ends with (endotracheal) extubation
extubation.
If a patient is intubated prior to admission, begin counting the duration from the time of
the admission. If a patient is transferred (discharged) while intubated, the duration would
end at the time of transfer (discharge).
For patients who begin on (endotracheal) intubation and subsequently have a
tracheostomy performed for mechanical ventilation, the duration begins with the
(endotracheal) intubation and ends when the mechanical ventilation is turned off (after
the weaning period).
Tracheostomy
To calculate the number of hours of continuous mechanical ventilation during a
hospitalization, begin counting the duration when mechanical ventilation is started. The
duration ends when the mechanical ventilator is turned off (after the weaning period).
If a patient has received a tracheostomy prior to admission and is on mechanical
ventilation at the time of admission, begin counting the duration from the time of
admission. If a patient is transferred (discharged) while still on mechanical ventilation via
tracheostomy, the duration would end at the time of the transfer (discharge).
Please Note Must code in addition If performed:
endotracheal tube insertion (96.04)
tracheostomy (31.1-31.29
2010 Intersect Healthcare, Inc. 23
Auditing to tell the Story
Examine
Query Review
Track
Documentation Abstract
Data
Identify Code
Compare
12
13. Process Steps to Auditing the
Medical Record
1. Examine - The medical record to ensure
that it is a complete record. Physician
p y
attestation statement and Discharge
Summary is on the record, as well as nurses
notes, treatment records and etc..
2. Review - Must review the Entire Medical
Record to accurately assign the principal and
secondary diagnosis
3. Abstract- Data from the Medical Record
a. Abstraction Worksheet
2010 Intersect Healthcare, Inc. 25
Abstraction Worksheet
1. Is there an inpatient admission order for the initial date of service? Yes/No
2. What are the documented reasons for admitting the patient to inpatient care?
3. On the attestation statement is there a change in the working diagnosis to the principal diagnosis? Yes/No
4. What is the principal diagnosis billed on the claim?
5. Is this the same principal diagnosis assigned to the medical record? Yes/No
6. Was the patient transferred from another acute care facility on mechanical ventilation? Yes/No
7. Length of stay: ____________________
8. What is the documented diagnosis for patient to be on mechanical ventilation?
9. Is there any laboratory values to support? ABG’s Yes/No
10. Discharge Status
Home or Self Care -01
Discharged/ Transferred to a Short Term General Hospital for Inpatient Care -02
Discharged/ Transferred to a SNF with Medicare Certification in Anticipation of killed Care - 03
Discharged/Transferred to an Intermediate Care Facility - 04
g / y
Discharged/Transferred to Another Type of Health Care Facility Not elsewhere in the Code List- 05
Discharged/ Transferred to Home Care- 06
AMA -07
Expired-20
11. Where there any test that revealed any Malignant conditions? Yes/No
2010 Intersect Healthcare, Inc. 26
13
14. Abstraction Worksheet Cont’d
12. Was treatment during stay directed at the Malignant conditions? Yes or No
13. Were there any complications noted during stay?
Yes or No
14. Date and time if applicable of endotracheal intubation or tracheostomy for ventilation:
________________________________________________________
Was this patient transferred to this institution on mechanical ventilation? Yes or No
Was patient discharged or transferred while intubated: _____________________
If applicable date and time patient was extubated:_________________________
Was ET or Tracheostomy performed in inpatient status? ____________________
Date and time mechanical ventilation was initiated? _______________________
Was patient weaned during time on the vent? If so hours___________________
Date and time mechanical ventilation ended:_____________________________
Was the patient completely weaned off the vent, and restarted within any time frame during the same
admission? Yes or No, If applicable list dates______________________
15. Is there any evidence in the medical record that the patient was only intubated for a procedure? Yes/No
16. Is there any evidence in the medical record that the ventilation is due to postoperative complications?
17. Was the patient diagnosed with any type of Respiratory Failure? Yes/No
If so; Date and time and list any applicable testing that led to diagnosis
__________________________________
18. Was the patient admitted with Respiratory failure or did it develop after admission? Yes/No
2010 Intersect Healthcare, Inc. 27
Process Steps to Auditing the
Medical Record
4. Code - Reviewer will code from data that they abstracted
5. Compare - Codes they assign to the codes that were
billed
6. Identify - Any areas in the medical record for areas of
uncertainty and discrepancies
7. Track Data Collected- Highlight areas, photocopy
areas in question to possibly highlight for physician
8. Query - The provider on any discrepancies found. Send
them the highlighted p
g g portions of the medical record so
that they can view. DO not lead .. Only identify what is in
the record and ask for clarification
a. Statement of Issue or Discrepancy
b. Date Initiated
c. Contact person and Info
d. Date Query Completed
2010 Intersect Healthcare, Inc. 28
14
15. The Story
Principal Diagnosis Documentation to support Secondary Diagnosis Procedures MS-DRG
2010 Intersect Healthcare, Inc. 29
Learning Objectives
Ensure there is documentation in the medical record to
support assigning a principal diagnosis within MDC 4
Ensure that there is a definitive diagnosis that affects or
will affect the respiratory system to initiate – INVASIVE
MECHANICAL VENTILATION (i.e. surgery, respiratory
failure, and etc.)
Be bl t t
B able to track the time that mechanical ventilation is
k th ti th t h i l til ti i
initiated to the time that it ends within the institution
Know the difference between Invasive and Non-Invasive
Ventilation
2010 Intersect Healthcare, Inc. 30
15
16. Coding Clinics
Intubation / Mechanical Ventilation
/Respiratory Failure
Absence of intubation and mechanical ventilation does not
preclude the use of a diagnosis of respiratory failure, 518.8x.
(See Coding Clinic, third quarter 1988, page 7.)
Respirator Dependence
Code 46.1, other dependence of machines, respirator, was
expanded 10/1/2004. Code46.11, dependence on respirator,
10/1/2004 Code46 11 respirator
status, is only used if there are no complications or
malfunctions of respirator and is always a secondary code.
Code 46.12, encounter for respirator dependence during power
failure, can only be a principal or first-listed code. (DRG 467)
(See Coding Clinic, fourth quarter 2004, pages 100 and 101.)
2010 Intersect Healthcare, Inc. 31
Coding Clinics
Sequencing of respiratory failure in association with
respiratory conditions.
The sequencing depends on the reason for admission. When
respiratory failure due to an underlying respiratory condition is the
reason for the admission, the respiratory failure is the principal
diagnosis. When the respiratory failure develops after admission, it is
a secondary diagnosis. When a patient is admitted due to respiratory
failure and pneumonia, the respiratory failure is sequenced first. These
conditions are not co-equal. The guideline regarding two or more
interrelated conditions meeting the definition of principal diagnosis
does not apply, since this has been specifically addressed in separate
Coding Clinic instructions.
g
(See Coding Clinic, first quarter 2005, pages 3-8, and Coding
Clinic, second quarter 2003, pages 21 and 22; Coding Clinic, second
quarter 2000, page 21; Coding Clinic, second quarter 1991, pages 3-5;
and Coding Clinic, November- December 1987, pages 5 and 6.)
2010 Intersect Healthcare, Inc. 32
16
18. Learning Objectives
• Understand how to create a successful
coding or medical necessity appeal for
Respiratory System Diagnoses by:
– Understanding the issue at hand
– Providing a ‘Road Map’ for the reviewer
– Presenting a Preponderance of Evidence
• (Best Practice, Regulatory and CMS Guidelines)
• Understand how to tailor appeals to
the Administrative Law Judge
2010 Intersect Healthcare, Inc. 35
Understanding the Issue at Hand
OIG Report on DRG 475 released December
1998
– (DRG 475 is now MS‐DRG 207, 208)
DRG 475 was top 5% of DRGs in terms of
relative weight
relative weight
– http://oig.hhs.gov/oei/reports/oei‐03‐98‐
00560.pdf
2010 Intersect Healthcare, Inc. 36
18
19. Understanding the Issue at Hand
In 1996, it was estimated that 7% of DRG 475
should have been coded to a lower weight DRG
should have been coded to a lower weight DRG
In 1996, Approximately $10,000 difference per
case, or $11.5 million
DRG 475 vs. DRG 127 Heart Failure and Shock
High Relative Weight and vulnerable to upcoding
2010 Intersect Healthcare, Inc. 37
Trending DRG Discharges
Department of Health and
Human Services, Office of
Inspector General,
Medicare Payments for
DRG 475
Respiratory System
Diagnosis with Ventilator
Support, December 1998
OEI‐03‐98‐00560
http://oig.hhs.gov/oei
/reports/oei-03-98-
00560.pdf
2010 Intersect Healthcare, Inc. 38
19
20. Planning for Appeals
Considerations for Deciding to Appeal
– Cost
– Time
– Resources
– Chance of Overturn
First Things First Planning
– Return on Investment
In addition to:
– Root Cause Analysis
– Education/Remediation Plan
2010 Intersect Healthcare, Inc. 39
Building the Foundation
Close examination of decision letter
– What are the instructions for appeal?
– What forms do I need?
– Where do I send my appeal?
– What was the issue?
Create Appeal Letter Templates
2010 Intersect Healthcare, Inc. 40
20
21. Building the Foundation
http://racb.cgi.com/Issues.aspx
2010 Intersect Healthcare, Inc. Copyright 2009 5
41
Creating the Structure
Paint the Picture
– Comorbidities and Complications (CC or MCC)
– Medical Complexity
Provide a Road Map
– Where is the Documentation?
Write to the ALJ
– Best chance of overturn
Provide a Preponderance of Evidence
2010 Intersect Healthcare, Inc. Copyright 2009 4
42
21
22. Creating the Structure
Use the Best Evidence
– CMS Internet Only Manuals (IOM)
– National Coverage Determinations; Local
Coverage Determinations
– ICD-9-CM Official Coding Guidelines
– Coding Clinics
First Things First Planning
– Code of Federal Regulations (CFR)
– Social Security Act
– Evidence Based Guidelines, Position Statements,
Expert Opinions from National Medical
Associations
2010 Intersect Healthcare, Inc. Copyright 2009 5
43
Providing a Road Map
2010 Intersect Healthcare, Inc. 44
22
23. Providing a Road Map
http://www.ama‐
assn.org/ama1/pub/upload
/mm/362/icd9cm_coding_g
/mm/362/icd9cm coding g
uidelines_08_09_full.pdf
2010 Intersect Healthcare, Inc. 45
Providing a Road Map
ICD-9-CM TABULAR LIST OF PROCEDURES (FY10)
96.7 Other continuous invasive mechanical ventilation
Includes: BiPAP delivered through endotracheal tube or tracheostomy (invasive interface)…
Excludes: non invasive bi level positive airway pressure [BiPAP] (93 90)
non-invasive bi-level (93.90)….
Note: Endotracheal Intubation
To calculate the number of hours (duration) of continuous mechanical ventilation during a
hospitalization, begin the count from the start of the (endotracheal) intubation. The
duration ends with (endotracheal) extubation.
Tracheostomy
To calculate the number of hours of continuous mechanical ventilation during a
hospitalization, begin counting the duration when mechanical ventilation is started. The
duration ends when the mechanical ventilator is turned off (after the weaning period).
96.70 Continuous invasive mechanical ventilation of unspecified duration
Invasive mechanical ventilation NOS
96.71 Continuous invasive mechanical ventilation for less than 96 consecutive hours
96.72 Continuous invasive mechanical ventilation for 96 consecutive hours or more
2010 Intersect Healthcare, Inc. 46
23
24. Providing a Road Map
2010 Intersect Healthcare, Inc. 47
Providing a Road Map
2010 Intersect Healthcare, Inc. 48
24
25. Preponderance of Evidence
• Indications for Mechanical Ventilation
– http://www.merck.com
– Indications: There are numerous indications for endotracheal
intubation and mechanical ventilation but, in general, mechanical
ventilation should be considered when there are clinical or
laboratory signs that the patient cannot maintain an airway or
adequate oxygenation or ventilation. Concerning findings include
respiratory rate > 30/min, inability to maintain arterial O2
saturation > 90% with fractional inspired O2 (Fio2) > 0.60, and
PaCO2 of > 50 mm Hg with pH < 7.25. The decision to initiate
mechanical ventilation should be based on clinical judgment that
considers the entire clinical situation and should not be delayed
until the patient is in extremis.
• Last full review/revision August 2007 by Brian K. Gehlbach, MD; Jesse Hall, MD
• Content last modified August 2007
2010 Intersect Healthcare, Inc. Copyright 2009 17
49
Preponderance of Evidence
Guidelines on the Management of
Community-Acquired Pneumonia in Adults
– Time to First Antibiotic Dose
• For patients admitted through the emergency department (ED), the first
antibiotic dose should be administered while still in the ED. (Moderate
recommendation; level III evidence)
– Switch from Intravenous to Oral Therapy
• Patients should be switched from intravenous to oral therapy when they are
hemodynamically stable and improving clinically, are able to ingest
medications, and have a normally functioning gastrointestinal tract. (Strong
recommendation; level II evidence)
– Duration of Antibiotic Therapy
• Patients with CAP should be treated for a minimum of 5 days (level I
evidence), should be afebrile for 48 to 72 h, and should have no more than
1 CAP
CAP-associated sign of clinical i
i d i f li i l instability (
bili (see T bl b l ) b f
Table below) before
discontinuation of therapy. (level II evidence) (Moderate
recommendation)
Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐acquired
pneumonia in adults.
Mandell LA, et.al; Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community‐
acquired pneumonia in adults. Clin Infect Dis 2007 Mar 1;44 Suppl 2:S27‐72. [335 references] PubMed
http://www.guidelines.gov
2010 Intersect Healthcare, Inc. Copyright 2009 17
50
25
26. Capping the Issue
Use guidelines in place at the time care was provided
Include an Attachments List
Include all Attachments
Electronic Copy
First Things First Planning
Use a Document Editor to Highlight the Medical
Record
Send all Communication via a Traceable Method
2010 Intersect Healthcare, Inc. 51
26