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Developing Respiratory Failure Clinical Criteria at Rady Children’s Hospital

Matthew R. DeVlieger

University of San Diego

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Abstract

This project seeks to elucidate the need for an overarching definition of respiratory failure in the

pediatric population, specifically at Rady Children’s Hospital. A lack of specific clinical criteria

for identifying the condition is seen industry-wide and many hospitals therefore form their own

definitions for reimbursement and accounting purposes. Diagnosing respiratory failure is a

significant factor in determining reimbursement rates for children’s hospitals, so therefore

ensuring compliance to a general definition should be of paramount importance to maximize

funds coming into the hospital for interventions administered during treatment. This paper will

go through the process of developing criteria for respiratory failure and show the need for a

standard for every patient to adhere to. The process of data abstraction will be documented to

determine the number of pediatric patients who were indicated as having or possibly having

respiratory failure based on the situational data but were not recorded as such. The aggregate

data will then be analyzed and presented to a team of physicians at Rady Children’s Hospital to

facilitate change management to develop these standards in all subsequent medical encounters.

Introduction

Respiratory failure is a significant issue within the pediatric population, and cases are

seen more frequently during the flu season (December through March). It is imperative to treat

signs of respiratory distress early in the process, and early detection is crucial before the

condition progresses further. Also, when treatment is administered, proper documentation is

required in order to receive the full credit the hospital is due, which includes proper

reimbursement for treatments given. To see how the hospital is doing with proper documentation

for respiratory failure, audits are sometimes required in patient’s charts to see the situation and

compare it to others which were coded as meeting criteria for respiratory failure. This project
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will do such an audit. Rady Children’s Hospital will validate the oxygen flow rates given to each

individual during treatment, what delivery device was used, record their hospital account record

in order to find them easier in the future, and find whether respiratory failure was coded in the

documentation.

Problem/Current situation

The problem for Rady Children’s Hospital is insufficient reimbursement for pediatric

respiratory failure cases. Treatment is administered for severe cases but the documentation does

not record the severity of the condition, thus minimizing funds coming into the hospital for

services rendered.

Literature Review

The current situation in healthcare clinical documentation and medical coding circles is

that there is no standard definition for diagnosing respiratory failure. Hospitals therefore need to

form their own definition on how they will gauge and document the condition. Respiratory

failure is rather common in pediatric medicine. It can develop from disorders affecting the lungs,

chest wall, control of breathing, or respiratory muscle strength. Many authorities in the field

believe that if a pediatric patient is treated with modalities such as high-flow nasal cannula,

positive pressure, or significant concentrations of supplemental oxygen, they should be

diagnosed and treated with respiratory failure to prevent progression to respiratory arrest (Bica et

al, 2016).

Another issue that occurs in the industry is that physicians often are reticent to diagnose

respiratory failure even when providing respiratory support because the condition they believe

necessitates care from a pulmonologist. If they treat them themselves questions might be raised

as to why they did not refer the patient on to a specialist. Also, clinicians often simply go by the
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“I know it when I see it” rule, and solely base respiratory failure on past experience and multiple

outside variables. This becomes an issue for inexperienced clinicians and unusual cases, thus

emphasizing the requirement to form overarching parameters as a standard for respiratory failure

diagnosis and documentation. Obviously there will always be exceptions to the rule, but

clinicians would be serviced greatly to reference these clinical criteria as an aid to prevention of

further complications in the pediatric population.

Goals and Activities

The goal of this project is to develop clinical parameters and criteria for accurately

diagnosing pediatric respiratory failure at Rady Children’s Hospital. The contributors will seek

to understand why some patients were not documented as having respiratory failure when

indicators were present by going through the medical record of each patient in the study. They

will audit the flowsheets within the Epic medical record to validate the highest oxygen rate that

was administered to the patient as recorded by the nurse or respiratory therapist. Then the

participants in the project will count the number of pediatric patients who had more than 5 liters

per minute administered (which is an arbitrary threshold criterium for indicating the condition)

and were not recorded as having respiratory failure. More information will then be sought as to

why the clinicians did not consider these patients to meet conditions to document them as having

the condition. Then the data will be considered in order to expand and include the variables into

a hospital-wide definition for documenting respiratory failure.

Deliverables

The deliverable for this project will be a presentation of data to executive board members

and physicians in order to seek understanding on how to best define the clinical criteria for

respiratory failure. The data will be collected from the Epic patient charts and given to these
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individuals in order for them to see where improvements can be made. Properly documenting

respiratory failure is important for both clinical research reporting accuracy as well as

maximizing reimbursement for the hospital for services rendered.

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References

Bica, V., Bridgeman, K., Buyrn, M., Campbell, J. D., Catalano, D. E., Faust, L., …Yung, A. J.

(2016, Oct.). Pediatric respiratory failure: The need for specific definitions. Association

of Clinical Documentation Improvement Specialists. Retrieved from www.acdis.org