After learning that a colleague had to sit through a quality control hearing with hospital administrators and that the hospital was marked as “non-compliant” because a patient suffering a heart attack received thrombolytics at 32 minutes instead of within the 30 minute time frame required by Medicare, I did a little research on the Medicare documentation guidelines. I found a “Hospital OQR Specifications Manual” detailing the circumstances in which a hospital/physician will not be considered as being out of compliance when a delay in administering tPA occurs.
According to Medicare, there has to be a reason documented by the treating physician why thrombolytics were not given in a timely manner. That reason for delay may not include any “system” reason such as equipment malfunction, issues relating to staff (such as delay in receiving medications from pharmacy or delay in nurse administering the medications), or any administrative issues.
Documentation must clearly state that the thrombolytics were “held” or were “delayed” due to a non-system reason such as:
- Patient request for delay in treatment pending arrival of family members or pending consultation with personal physician
- Patient refusal of fibrinolytics
- Delay in treatment due to medical issues such as ruling out bleeding (such as controlling high or low blood pressure)
- Waiting for return of laboratory testing that may impact decision to give thrombolytics (such as elevated INR that may increase bleeding risk)
- Stabilizing patient condition (such as treating arrhythmias or starting IVs or intubating patient, etc.)
- Consulting with a specialist regarding patient’s condition or treatment (for example neurology or cardiology)
- Patient required CPR or advanced airway management within 30 minutes of arrival
Examples of possible documentation might include
- “Thrombolytics delayed until patient’s surgical history could be obtained from different hospital”
- “Thrombolytics held until consult with cardiologist regarding PTCA”
- “Thrombolytics held pending discussion with surgeon regarding patient’s recent surgical procedure and bleeding risk”
- “Thrombolytics held at patient’s request until family members arrive”
- “Thrombolytics delayed due to discussion of risks, benefits, and alternatives to treatment with patient. After this discussion, patient agrees to thrombolytic therapy”
- “Thrombolytics initially held as EKG did not meet criteria. On repeat EKG, patient found to meet criteria for thrombolytics”
- “Thrombolytics delayed while patient’s low blood pressure/respiratory status stabilized.”
I’m sure that you can come up with other acceptable documentation given the above guidelines.
If any of these events occurred and may have delayed administration of tPA, Retavase, or other thrombolytics, make sure that you document the events so that you can ensure that you meet all Medicare guidelines … which will make you and your administrators much happier.