The Real-World Boards: Question #5
An administrator lusting for compliance needs your help
These are the Real-World Boards. As in the real world, there is often no “right” answer, and you are only competing against yourself. Upgrade to the Lifelong Learner level for full access to all the questions and unlimited CME credits with an included Learner+ account.
A hospital administrator announces that all care must henceforth be “guideline-compliant,” believing this will inoculate the system from all liability, increase reimbursement, and produce high “quality” scores. She asks for your help; you say, “no way.”
She then offers you 50% protected time and an additional $100,000 per year as an administrative bonus. “Is that legal?” you ask. She chuckles. “No one checks that stuff anymore,” she replies.
She emails you records of a recent patient with community-acquired pneumonia and asks if the care was “guideline-compliant.” You decide to use the 2019 IDSA/ATS joint guideline and subsequent ATS updates as a rubric. You also browse the PulmCCM website, where you note that it is not affiliated with ATS or IDSA.
The 58-year-old male patient was cared for on the medical unit. His SpO2 was 96% on 3 liters of oxygen (Pao2 72 on FiO2 ~0.32, P/F ratio 225), breathing 22 times per minute, with otherwise normal vital signs and white count. BUN was 22 mg/dL with a normal creatinine. Platelets were 95K. Chest film showed a left lower lobe infiltrate. He was delirious on presentation, but this resolved by hospital day 1. He never required intermediate-level or ICU care.
“Can we upcode this as a severe community-acquired pneumonia?” the administrator asks, her eyes glittering like diamonds.
All patients with CAP who require mechanical ventilation or vasopressors are considered to have severe disease.
IDSA/ATS’s guideline also provides a menu of “minor criteria,” any 3 of which together classify a patient as having severe CAP. The criteria include:
BUN ≥ 20 mg/dL (a component of the CURB-65 score)
PaO2:FiO2 ratio ≤ 250
Platelets <100K
Disorientation or confusion
Hypotension requiring aggressive fluid resuscitation
Hypothermia ≤ 36 degrees Celsius
Multilobar infiltrates
White blood cell count <4K
Three or more minor criteria had a pooled sensitivity of 56% and specificity of 91% for predicting ICU admission, according to a 2011 systematic review.
With delirium, elevated BUN, thrombocytopenia, and a P:F ratio of 225, this patient appears to have four minor criteria.
The administrator confides that the hospitalist who cared for the patient is “terrible”. You note in the chart the name of the attending, a widely respected internist. “He keeps his patients in the hospital forever,” she explains. “And he ignores CDI queries.”
She suggests referring him to the peer review committee. “On what basis?” you ask. She seems surprised that someone would ask that, but then points out that he misclassified the patient as having nonsevere community-acquired pneumonia, rather than severe CAP. You acknowledge that, strictly according to the guideline text, this is true.
You note the patient was treated with ceftriaxone 2 g daily and clarithromycin 500 mg twice daily.