2. Jennifer C. Yanak, RN, MSN, MBA Brian J. Winkleman, MD Surgical Complications in the General Surgery, Bariatric Surgery, and Endoscopy Population

3. Goals Increase participants’ understanding of expected vs. unexpected surgical events Discuss the importance of linking conditions to a surgical procedure and seeking physician clarification when needed Recognize the difference in “time frame terminology” Review the impact of documentation on physician profile

4. What Is a Surgical Complication? Occurrences and conditions which arise that are not fundamental to the procedure Deviation from expected operative course Cause-and-effect relationship No defined time limit

5. Defining Proper Terminology Use proper “time frame” terminology – What does “postoperative” mean? Adverb: Time relationship Adjective: Causative relationship Or... eliminate the word “postoperative” altogether to eliminate any confusion Query in terms of “expected,” “unexpected,” or “due to surgery” The term “status post” can also be misinterpreted as a complication

6. Impact on Physician Profiles Better documentation can = worse profile – Complications can be “dings” against a physician’s profile – May lead to physician under documentation – Important to ensure a condition is a “true complication”

7. Surgical Complications EVERY surgeon has complications How to deal with complications: – Basic sciences from medical school – Internship/residency/ fellowship training – Morbidity and mortality conference – Experience from previous complications – Surgical mentor

8. How to Eliminate Surgical Complications Achievable by following the “3 P’s”: – “Perfect” the surgeon?? – “Promote” into academia – “Push” into retirement

9. How Can We Help: Clarify & Query Clarify the relationship of the patient condition to the surgical procedure – Did the condition exist prior to surgery? Was the condition present on arrival? Does the patient have a history of the condition? A thorough physician preoperative assessment is CRUCIAL, and it must be well DOCUMENTED!!!

10. How Can We Help: Clarify & Query Clarify the relationship of the patient condition to the surgical procedure (cont.) – Did the condition arise after the procedure? Is the condition a result of the underlying disease, not the surgery? Is the condition a true complication that occurred during or as a result of the surgery?

11. Variability Know that physician responses, coding, and practice guidelines will vary – Nurse to nurse – Coder to coder – Surgeon to surgeon – Hospital to hospital You can only control the way your CDI team practices at your institution

12. Acute Blood Loss Anemia Was it present on arrival or before surgery? Dilutional True (lab) anemia Was the anemia treated/monitored? Was the anemia due to a disease process or the surgery? Transfusions do not necessarily mean a complication – Blood can be given as a prophylactic measure

13. Acute Blood Loss Anemia: Coding & Documentation Postoperative anemia 285.9 Acute blood loss anemia 285.1 (cc) – Coding Clinic, first quarter 2007, p. 19 Hemorrhage complicating a procedure 998.1 – Coding Clinic, third quarter 2003, p. 13 Often based on the physician’s clinical judgment, not necessarily labs and transfusions – Coding Clinic, third quarter 2004, p. 4

14. Ileus Transient non-mechanical bowel obstruction resulting from aperistalsis of the GI tract Expected after major abdominal surgery – Exploratory laparotomy for obstruction: 3 to 7 days – Open colon resection: 3 to 5 days – Laparoscopic colon resection: 2 to 4 days Up to 15% of patients may develop prolonged ileus

15. Ileus How to minimize postoperative ileus: – Laparoscopic techniques Smaller incision sizes Reduced analgesic requirement – Nasogastric tubes? – Thoracic epidurals – Limit narcotic usage – Ketorolac (Toradol) NSAID

16. Ileus: Coding and Documentation Was it present on arrival or present prior to surgery? Was it treated? Paralytic ileus 560.1 (cc) Intestinal obstruction due to a procedure 997.4 In order to know if the ileus was expected or a complication, the physician would need to be queried

17. Surgical Site Infections Incidence: 2.6% of hospitalized patients 500,000 surgical site infections annually in the U.S. Increase healthcare costs, length of hospital stay, morbidity and mortality

18. Surgical Site Infections Patient factors: – Age – Obesity – Diabetes mellitus – Malnutrition – Depressed immune system – Presence of infection at remote body site – Colonization

19. Surgical Wounds Is the wound infected or non-healing? Wounds intentionally left open should NOT be coded as complications No time limit for wound infection to occur Does the patient have risk factors that delay wound healing?

20. Surgical Wounds: Coding & Documentation Healing slowly/non-healing 998.83 – Clarify if delayed wound healing is due to the surgery or due to another disease process/risk factor Dehiscence 998.31 and 998.32 – Used for operative or surgical wounds Disruption of a traumatic injury wound 998.33 – Used for a previously closed traumatic wound Coding Clinic, fourth quarter 2008, pp. 149–152

21. Malnutrition Includes undernutrition and overnutrition Major impact on wound healing and immune system Appearance, weight loss, disease process Look for BMI, albumin, total protein, prealbumin, diet type, dietary supplementation No definition available from CMS – Set practice criteria with your CDI team and include RD for guidance

22. Malnutrition Well-nourished or mildly malnourished patients usually require no additional nutritional support if an oral diet is expected within 4 to 7 days There is some evidence that patients with preexisting nutritional deficits may benefit from 7 to 10 days of preoperative enteral or parenteral supplementation Patients at increased risk for postoperative complications: – Esophagectomy with albumin level < 3.75 g/dL – Gastrectomy or pancreatectomy with albumin level < 3.25 g/dL – Colectomy with albumin < 2.5 g/dL

23. Malnutrition: Coding & Documentation 263.* (mild, moderate, unspecified - cc) 261 severe malnutrition (mcc) 579.3 malnutrition following GI surgery (cc) – Coding Clinic, fourth quarter 2003, pp. 104– 105

24. Atelectasis/Respiratory Insufficiency/ Respiratory Failure Make sure respiratory issue is more than just anesthesia reversal Is the intubation for safety concerns and not for actual respiratory failure? Most common respiratory issues after surgery are atelectasis and pneumonia

25. Atelectasis/Respiratory Insufficiency/ Respiratory Failure: Coding & Documentation When in doubt, always clarify Atelectasis 518.0 (cc) – More than just an incidental finding – Coding Clinic, fourth quarter 1990, p. 25 Acute respiratory failure (518.81 - mcc) Respiratory insufficiency following trauma and surgery (518.5 - mcc) – Coding Clinic, third quarter 1988, pp. 8–9 Look for Bipap/CPAP, not just intubation

26. Case Studies General surgery – Appendectomy – Cholecystectomy Bariatric surgery – Gastric bypass Endoscopy – Colonoscopy

27. Case #1 67-year-old male presents to the ER with a 3- day history of fevers, nausea, vomiting, and right lower quadrant pain – Temp 101, HR 110, Resp 22, BP 145/95 – WBC 15.5 – Appendix CT scan demonstrates dilated appendix, peri-appendiceal fat stranding, and fluid collection in the right lower quadrant

28. Case #1 Patient taken to the OR for laparoscopic appendectomy – Perforated appendicitis, base of the appendix is retrocecal and “stuck” – Converted to open appendectomy – Abdomen washed out with antibiotic solution – Patient discharged home on POD #2

29. Case #1 Patient returns to the ER on POD #7 with fevers, chills, and worsening right lower quadrant pain – WBC 17.2 – CT abdomen/pelvis demonstrates an abscess in the right lower quadrant – CT guided drain – PICC line for IV antibiotics – Discharged home with home health care on POD #12

30. Case #2 42-year-old obese Caucasian female presents to the ER with sharp right upper quadrant abdominal pain, nausea, and vomiting – Temp 100.5, HR 100, RR 18, BP 135/80 – WBC 13.5, Hgb 12.5, LFTs mildly elevated – Right upper quadrant ultrasound demonstrates cholelithiasis, gallbladder wall thickening, and peri-cholecystic fluid

31. Gallbladder Anatomy

32. Case #2 Converted to open cholecystectomy secondary to bleeding from the gallbladder fossa – EBL 350 cc While in the recovery room: – Patient pale, HR 130, BP 90/60 – Hgb 6.2 Patient taken back to OR for exploration – Bleeding from the cystic artery

33. Case #3 55-year-old female with morbid obesity (BMI 65), hypertension, hyperlipidemia, non-insulin- dependent diabetes mellitus, sleep apnea on CPAP – Undergoes laparoscopic Roux-en-Y gastric bypass with a 150 cm limb – Intraoperative esophagogastroduodenoscopy demonstrates a patent, hemostatic anastomosis with no evidence of leak

34. Laparoscopic Gastric Bypass

37. Case #3 Later that evening: Temp 101.5, HR 120s, Resp 32, UOP 15 mL/hr WBC 20.5, Hgb 12.5 Fluid bolus - no response CT PE study negative UGI demonstrates a leak at the gastrojejunostomy Subsequent DVT/PE, renal and respiratory failure

38. Case #4 72-year-old female on Coumadin for atrial fibrillation admitted for anemia and hematochezia – Coumadin reversed – Bowel preparation – Colonoscopy under IV sedation Poor bowel preparation Patient restless Findings: Hemorrhoids, sigmoid diverticulosis, no active bleeding

39. Case #4 1 hour after colonoscopy, the patient reports abdominal pain and distention – 2 mg of morphine ordered for “gas” pains – Abdominal pain worsens – Acute abdominal series demonstrates pneumoperitonem – Patient taken to the OR for emergent sigmoid colectomy

40. Endoscopy Risks – Anesthesia – Bleeding 1 in 1000 cases – Perforation 1 in 1700 cases 1 in 700 cases with polypectomy