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SBAR Nursing Communication Foley Follies (Video Explanation).

What is SBAR? SBAR nursing communication is one popular method of transferring patient care information between physicians and other healthcare professionals. Frequently taught to nurses, SBAR stands for Situation, Background, Assessment, Recommendation. SBAR nursing techniques are easy to learn and easy to implement. This communication method is highly respected by doctors, nurses and patients as a way to verify that vital information is being shared between hospital team members. Hour after hour, day after day, month after month, year after year, SBAR has proven itself to be the preferred communication method of choice. SBAR communication techniques help foster a culture of safety in a very dangerous hospital environment. Nurses love it because they use the process to fill vast amounts of free time during their shift. Hospitalists and other physicians love it because it interrupts their busy workflow to divert their complete and undivided attention toward 13 minute patient care presentations. Patients love it because they... Just. Don't. Know. Any. Better.

In an effort to make an already unbelievably awesome nursing documentation and handoff tool even better, I am recommending all hospitals implement my modified SBAR approach immediately. It's called SBARTS and it's fantastic. That's right folks, since SBAR is amazing, SBARTS promises to turn daily communication between nurses and doctors into one giant Happy Hospital. SBARTS stands for:

Situation

Identify the person to whom you are speaking.
Identify yourself, occupation and where you are calling from.
Identify the patient by name, date of birth, age, sex, reason for admission.
Identify what is going on with the patient.

Background

Give the patient's presenting complaint.
Give the patient's relevant past medical history.
Brief summary of background.

Assessment

Vital signs.
List if any vital signs that are outside of parameters; what is your clinical impression.
Severity of patient, additional concern.

Recommendation

Explanation of what you require, how urgent and when action needs to be taken.
Make suggestions of what action is to be taken.
Clarify what action you expect to be taken.

A number right before 11 and right after 9.
As in, the patient has 12/10 pain.

Seconds

1/60 of a minute. In other words. A very short period of time.
As in, this will just take ten seconds.

From here on out, I implore all hospitals to please consider using Happy's modified 10 second SBARTS nursing communication process. Otherwise, you may, as a patient, doctor or nurse, find yourself in the middle of a raging case of SBAR nursing follies. Er, I mean Foleys! Please enjoy this Happy Hospitalist original GoAnimate movie about the unappreciated and unintended consequences and dangers of aggressive SBAR. Happy's SBART could have fixed this. If only I had gotten to them sooner, all this nonsense could have all been avoided. In this video, by the book new nurse graduate SBAR nursing techniques failed to pick up on surrounding patient and doctor distress signals with devastating consequences. And by devastating, I mean bad patient satisfaction scores, also known as: The Only Thing That Matters These Days.

Here is a scene by scene transcript of the video:

Patient: Help me! Help me! I can't Pee! I need a Foley now! Nurse! Nurse! Please help me!
Nurse: NOBODY makes it through my shift without peeing!
Nurse: Must. Call. Doctor. Stat!
Doctor: I think I hear my phone ringing.
Doctor: What could they possibly want at 2:00 in the morning?
Doctor: This is Dr. Just Say What You Need Now.
Nurse: Thank you doctor Just Say What You Need Now. Is this Dr. Just Say What You Need Now?
Doctor: *standing*
Doctor: *golfing*
Nurse: Hello? Is this Dr Just Say What You Need Now? Please answer. I cannot move forward with my SBAR script without a response.
Patient: Please hurry! The pain is unbearable!
Doctor: Just Say What You Need Now.
Nurse: Great then. This is nurse Page It. I'm calling from the low pain threshold floor. I have Mr. SBAR Tragedy. He has 22 grandkids and he likes gladiator movies. Do you remember?
Patient: Nurse! Nurse! It's hurting bad! Hurry! Hurry! I need a catheter now!
Doctor: *weeping*
Nurse: Doctor? Just Say What You Need Now? Are you listening to me? Hello? Hello?
Doctor: *baffled*
Nurse: I'm calling about Mr SBAR Tragedy. You remember him? He's the white haired man with the large belly in room 12. He also had that skin cancer removed from his ear in 1958.
Doctor: *losing it*
Nurse: He also had bunion surgery 14 years ago and he uses a walker. CBS is his favorite television station. Does not any of this help you remember him?
Doctor: *put a fork in him*
Nurse: He's the one with the problems peeing. Does none of this ring a bell doctor? Doctor? Doctor? Are you still there?
Doctor: *he's done*
Nurse: I am worried, doctor. Very worried. Mr SBAR Tragedy is having severe pain and I need a Foley catheter stat!
Doctor: Why! Didn't! You! Just! Ask! Stick a foley in it. We're done here!
Patient: What! Friggin! Took! So! Long!
Administrator: I got a complaint in the mail today from Mr SBAR tragedy. The ONLY explanation I can come up with is a failure to AIDET. His. Ass.

If urine for some more good humor, check out these Happy Hospitalist original crude medical ecards:

"If I don't make it to your room before you pee all over the floor, it's because I was filling out a form to have the cleaning lady clean the pee off your floor."

If I don't make it to your room before you pee all over the floor, it's because I was filling out a form to have the cleaning lady clean the pee off your floor nurse ecard humor photo.

"Communication is vital in hospital care. And by vital, I mean vital signs. Vital signs are to doctors like lunch breaks are to nurses. Really important."

"Try giving me a verbal order again and I will SBAR your ass into submission."

"We really do tell nurses to page us out of your room when you think you have a right to more than five minutes of our time."

This post is for entertainment purposes only and likely contains humor only understood by those in a healthcare profession. Read at your own risk. If you are offended, learn my SBARTS method instead, then come back and I guarantee you'll laugh your ass off.

Clearing Up Confusion About Health Reform’s Out-of-Pocket Protections

Recent media coverage may have sown confusion about health reform’s requirement that health insurance plans cap how much consumers can pay out-of-pocket each year for medical care. The bottom line: for many plans, the protections will take effect as scheduled in 2014. Some plans will be able to wait an extra year to fully comply.

The health reform law requires that, starting next year, private insurance plans limit how much in cost-sharing charges — deductibles, copayments, and coinsurance — that people enrolled in a plan must pay each year for covered benefits provided by the plan’s network of health care providers. (This includes plans offered in the individual market or through employers. The requirement doesn’t apply to “grandfathered” plans.) In 2014, this “maximum out-of-pocket limit” will be $6,350 for an individual and $12,700 for a family.

Back in February, the Obama Administration provided an additional year to fully comply with this requirement but only for certain plans offered by employers.

Here are some clarifications about the February policy:

Health insurance plans in the individual market: In 2014, the maximum out-of-pocket limit will apply, as scheduled, to the individual (non-group) health insurance market. Millions of people are expected to gain coverage in this market in 2014, as health reform’s new improvements and federal subsidies significantly increase access to affordable coverage.

Employer-sponsored health insurance plans: The maximum out-of-pocket limit will also continue to generally apply to non-grandfathered plans offered by employers, including small group, large group, and self-insured plans. Employer plans that have a single insurer or administrator have to fully comply with the limit next year.

Employer plans that have “separately administered” benefits: The Administration provided the exception in February for these plans, in which an employer has one insurer or administrator for its primary package of health benefits and a different insurer or administrator for discrete benefits, such as prescription drugs. Because employers and insurers have claimed it will be difficult to coordinate an overall maximum out-of-pocket limit across separately administered benefits, they sought and received the ability to avoid full compliance for one year.

Even those employer plans with “separately administered” benefits that qualify for the delay still must apply some out-of-pocket limits in 2014. As the February guidance explained, these plans must ensure that their primary package of health benefits has an out-of-pocket limit of no more than $6,350 for individuals and $12,700 for families. A separately administered benefit, such as prescription drugs, that already has an existing limit on out-of-pocket costs must comply with the limits of $6,350 for individuals and $12,700 for families in 2014.

An employer plan wouldn’t have to add a cap to a separate benefit if the separate benefit currently lacks one. But this exception shouldn’t be misunderstood as broadly waiving the important out-of-pocket protection that health reform will bring in 2014.

Sarah Lueck
Center on Budget and Policy Priorities

(This was originally posted here on the Off the Charts Blog)

Billing Critical Care and Discharge On Same Calendar Date?

Can I bill a critical care code and a discharge code on the same day? That's a question a lot of folks finding The Happy Hospitalist are asking themselves. I am a hospitalist with over ten years of clinical experience and years of research in evaluation and management (E/M) medicine. I have a very short answer and one that should lay to rest any question about what code the physician should choose when they provide critical care on the date of discharge. On page 3 of 9 in CMS document MM6740, we are told

In all cases, physicians will bill the available code that most appropriately describes the level of the services provided.

That means, if you provide critical care you should bill for critical care, regardless of whether that service was provided on the day of admission or the day of discharge. Yes, I believe the physician can and should bill for critical care even if they discharged the patient on the same date as the critical care service was provided. But can they also bill a discharge code? I do not believe they can. Even though CMS tells us we should bill the available code that most appropriately describes the level of services provided, I believe their rules disallow both codes on the same calendar date. As such, physicians would be better off billing for their critical care services and not the discharge codes in these situations. My exhaustive research on this issue failed to disway my opinion on this matter. If there are any experts with further insight into this common scenario, I welcome your input to expand and accurately identify any misunderstandings. With that said, I think it's important to understand a few key points. Here are a few scenarios to consider.

CRITICAL CARE WITH ADMISSION AND DISCHARGE SAME DATE

There are two possible scenarios to consider when providing admission and discharge on the same calendar date with critical care: Critical care is provided on admission or critical care is not provided on admission.

SCENARIO 1: The initial admission work does not rise to critical care criteria but then critical care is subsequently provided and discharge is then made after that on the same calendar date. In this situation I would bill for the appropriate admit E/M charge and any related critical care charges and not bill the admit and discharge same day codes. Remember, CMS has told us to "bill the available code that most appropriately describes the level of services provided". That is our mandate.

CMS has previously told us that critical care and an E/M code can be billed on the same calendar date if the critical care was provided after the E/M service was provided. Unfortunately, they do not specifically agree or disagree that an E/M code can be billed after a critical care code. I believe, however, that this failure to provide guidance is a round-about way of saying post critical care E/M charges are not allowed on the same calendar date. If they were allowed, I do not know why would they specifically give guidance to allowing pre critical care E/M codes but not post critical care E/M services? I have written about this previously at the link provided just above.
In my opinion, that means discharge services, which are bundled into 99234-99236 codes cannot be billed in conjunction with critical care codes because the discharge services would presumable occur after the critical care service. We are left with a scenario where a patient is admitted and discharged on the same calendar date where a physician provides critical care, but cannot bill for the discharge services. I would bill an admit E/M code (probably initial inpatient admission codes (99221-99223) or initial hospital observation codes (99218-99220) if the documentation supports those codes) and then bill for critical care 99291. Attach a -25 modifier to the first E/M code. If more than 74 minutes of critical care was provided, bill for 99292 as well. I would not bill for discharge services because no code exists to capture that service. Billing for the admit and discharge same day codes would not allow the practitioner to capture their critical care service and CMS has told us to "bill the available code that most appropriately describes the level of service provided. The bundled admit and discharge codes 99234-99236 would not be appropriate in this situation. In this scenario, the work you do discharging the patient is free, but the RVU value of the critical care is still higher using an admit E/M code and critical care code than using the bundled admit and discharge code alone.
Remember, do not bill for critical care time on the discharge work (unless you are transferring the patient to another institution) as the patient would not presumably be critically ill during your discharge decision. In a previous discussion about billing critical care for family meetings in the ICU the following statement was discussed:

Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. In my opinion, billing for discharge work after critical care would have to fall into the "include pre and post service work" category because no other codes apply.

It is my opinion, if a physician is transferring a critically ill patient to another institution, discharge work should be considered part of the critical care time as the provider will be writing orders, making medication decisions, communicating their patient's condition with other healthcare providers and providing a safe transition to a higher level of care, as long as that work is provided in the immediate vicinity of the patient or the patient's unit.

SCENARIO 2: The initial admission work does rise to critical care criteria and discharge is subsequently made on the same calendar date. In this situation I would bill all appropriate critical care charges (99291 and or 99292) and not bill the admit and discharge same day codes. Remember, CMS has told us to "bill the available code that most appropriately describes the level of services provided". That is our mandate. Billing admit and discharge codes in this scenario would not allow the physician to capture critical care resources and would not be appropriate.

As I reviewed above, do not include your discharge work in your critical care time, unless that discharge work involves continued critical care decision making during a transfer to a another institution. Providers would have a hard time justifying to an auditor that routine discharge time was of a critical nature.

In either scenario, a single critical care code provides a higher relative value unit (RVU) compensation than any of the same day admit and discharge codes 99234-99236. Thus, whether the provider bills only critical care or an E/M code in addition to critical care code(s) they have the ability (and the right) to collect a higher payment for work that most appropriately describe the level of service provided. Under neither scenario do I believe the inpatient discharge codes 99238 or 99239 or observation discharge code 99217 be used or considered.

Some readers may be wondering how a patient could be critical and then be discharged on the same calendar date. As hospitalists, we see many patients who present with critical illness, or become critical but because of excellent care or rapid reversal of the critical situation, are able to be discharge on the same calendar date. Some of this has to do with when the clock starts running. Remember, Medicare and most insurances use the midnight-to-midnight calendar date rule when determining same day admit and discharges. If a patient came in at 12:01 am, they have until 11:59 pm that same day to be discharged as a same day admit and discharge. 23 hours and 59 minutes is a long time for some critical conditions to improve.

For example, patients with seizures who need airway support on a ventilator are critically ill on admission. Drug overdose patients with respiratory demise may respond rapidly to reversal agents. Patients with hyperglycemia or hypoglycemia may present with critical illness in the form of DKA, seizures, unresponsiveness, encephalopathy or other critical illness, but may respond rapidly to treatment. Just because a patient is treated appropriately and aggressively and shows rapid improvement does not mean their critical illness should be discounted. If a provider provides critical care, they should bill for critical care, regardless of how quickly they respond to treatment.

CRITICAL CARE WITH ADMISSION AND DISCHARGE DIFFERENT DATE

How should critical care be billed when the admission and discharge occur on different dates and the critical care is provided on the date of discharge. Regardless of whether the patient is inpatient or observation status if critical care is provided on the date of discharge, bill for the critical care service but do not bill for the discharge code. Any work provided on discharge after the critical care charge should not be billed as critical care time, unless, the discharge services involved transfer to another institution. I detailed this reasoning above. Remember, only bill for critical care time when the patient is critically ill. An auditor will ask for your money back if you're billing for a discharge summary on a stable patient going to a nursing home. The discharge work you provide on stable patients will be included in your critical care code(s). From an RVU perspective, critical care 99291 pays more than double the greater than 30 minute discharge code 99239. These scenarios can and do happen that result in critical care that requires immediate stabilization at the bedside that can allow for discharge later in the day. Providers have a right and an obligation to bill the available code that most appropriately describes the level of the services provided.

WHY NOT BILL 99291 AND 99238 OR 99291 AND 99239 ON DATE OF DISCHARGE?

I spent a great deal of time researching why discharge codes could not be billed as separate and identifiable services after critical care was provided on any given calendar date. I was surprised to find very little on this common scenario. Some scattered resources suggested billing the discharge after the critical care and using the -25 modifier. Some resources suggested there was no explicit exclusion by CMS that said both services could not be billed and paid on the same date. CMS says, "in all cases, physicians will bill the available code that most appropriately describes the level of the services provided."

Why would they allow E/M charge before a critical care code but not a discharge code after? CMS specifically states they allow an E/M code before a critical care code. I would presume because they don't specifically address billing an E/M code after a critical care code on the same calendar date, that they do not allow payment for that scenario. I wish they would provide better clarity in their manuals.

Perhaps it has to do with the AMA definition of the discharge codes. The CPT® manual states that discharge codes 99238 and 99239 are to be used by physicians to report all services provided to a patient on the date of discharge. CMS and the AMA do not always agree on their definitions, but I believe if physicians billed the discharge code, then the critical care service would be bundled into the discharge code and the critical care service would be denied. The critical care codes pay much more than the discharge codes. Getting paid for critical care and providing uncompensated discharge work is a better business decision. Alternatively, the physician can always submit a 99291 in combination with a 99238 or 99239 or 99217 using a -25 modifier and see what happens. The worst that can happen is that it can get denied. For a scenario that happens with relative frequency, I'm surprised of so few resources available on the internet for review.

I provide a detailed database of free E/M and CPT® lectures for physicians and other non-physician practitioners. I am a hospitalist with over ten years of clinical experience. My hospitalist resource center also has important information for all clinicians to review.

LINK TO E/M REFERENCE CARD POST

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Violence Against Nurses: Examples From The Front Line In America.

I asked my thousands of Facebook readers one simple question: What's the worst thing a patient has ever said or done to you over the years. Most of the responses involved violence against nurses in the form of verbal, physical and mental abuse. Some states have laws declaring assault on healthcare workers as a felony. Without further delay, here are dozens of real life experiences from nurses and other healthcare providers on the front lines of American medicine

My personal favorite is a very intoxicated woman brought to the ICU in four point restraints. It seems she was a really mean drunk, had made some people pretty angry and she had been beaten with a baseball bat. Her face was so swollen, she could barely get one eye open. She had continued to be belligerent and uncooperative to the ER staff, and finally they had had enough and brought her to ICU without even treating any of her injuries. When they wheeled her into the room with those leather restraints on, she opened her one eye a slit, sized me up, and said, "Don't even f&@*#n look at me-I'll hurt you real bad!" By morning, as she was sobering up, she kept wanting to look at herself in a mirror and she kept saying, "Why would anyone want to hurt me like this? I'm a nice person!"
Oh the memories! Yep, I've been through all the usual hitting, kicking, cursing, violence, spitting, groping, innuendos, tube ripping out, food throwing, refereeing, and other awesomeness in nursing with patients. Also when I worked for a pharmacy the police naturally had to be called a few times because of patients making threats. The police even drove me home once after a patient's doctor refused his Vicodin fill. I lived not even one block away.
I'm a social worker, and the families are the mean ones to me. They lie, manipulate and threaten, call names, etc, all because there mommies can't get a skilled nursing bed at their favorite facility!
I like it when people scream "You motherf***kers, I said I can't breathe!" If you can scream, you can breathe. Respiratory 101.
ER nursing is a full contact sport... Without the padding!
It's one thing to encounter these things with a confused patient. If all hospitals would become a united front and advocate the protection of staff by enforcing policies to have these patients arrested for assault and/or battery, it would decrease the abuse health care workers endure nationwide. Of course, this would alter "patient satisfaction scores."
Had a "paraplegic" patient get all cranky that she wasn't getting the narcs she wanted, she kept saying she was going to go ama. I finally lost it and told her to get up and go.
I had a hep C patient (who knew it) spit blood at me during a trauma. He was completely mentally intact. When I told him you can't do that, his response.... You people are worthless. I promptly netted his face with a spit trap.
I got pulled to psych one night and a patient's CPAP mask kept slipping off and beeping so I would go in to fix it. The 4th or 5th time he finally said this doesn't fit I'm gonna make a new one out of your tit skin. As flattering as that was, I told him I didn't think that would make a big enough mask.
From a patient perspective, it's hard not to call names when there is a finger in your butt and nobody bought you dinner first.
This certainly isn't this worst but pretty funny. We had a patient tell another nurse there are three things wrong with this hospital the first is your breathe.
Had a pissed off patient rip off her colostomy bag & throw it at me because the doctor would not order anymore narcotics.
"Lesbian, c*nt, b*tch whore, you infect people with your HIV blood from fucking n*gers." Very creative. Somehow people forget that once we have you sedated with 10/2/50 we choose the catheter sizes to obtain blood/urine samples! Yes and people pooping the bed who are A&Ox3 and telling you to clean them up, and then walking out of the ER once discharged. Really?!
Where should I begin, bit while trying to insert IV, spit in the face, clawed on my face and one of my personal favorite statements, a patient wwith "severe migraine" yelling and screaming at everyone, took the time to call me "white trailer park trash" and the nursing assistant standing next to me "my black sidekick." The more we laughed, the more irate he became and we we're only 2 hrs into our 12 hrs. Doc went into his room told him tests were neg and because his "severe migraine" appeared to have subsided, discharged him home with ibuprofen. This nut case was so furious, he waited in the parking lot for me and "my sidekick" to go home. Had to call Sheriff, the moron went home then came back with a different car. This time he received a personal ride home-in back of patrol car!
For 32 years I've been an RN in a Trauma ICU in a Level 1 Trauma hospital. There is nothing that shocks me anymore. I've been hit, kicked, spit at, had full urinals thrown at me, it goes on and on. Thank goodness for four point restraints, Ativan and propofol.
In my short experience of being an RN in the ER, I've been called every name in the book at least twice spit at, swung at, kicked at, pinched & groped. And once, an intoxicated patient decided he'd had enough fun and pulled out his IV and flung blood from the tubing at me. Good times... good times. I've developed a pretty thick skin as well as some pretty awesome defensive ninja moves!
The Nebraska Medical Center has signs all over the place that it is a felony to assault a health care worker in the performance of their job, and violators will be prosecuted to the fullest extent if the law. Haven't had to test it yet, but I'm glad to know I work for an organization that puts my health and safety over patient satisfaction scores!
Spitting. If it hits me, welcome to the vent so I can help you control your secretions!
I was very pregnant and a patient removed an entire pack of cookies from atop my med cart. (It was a nursing home, and the kitchen had sent up snack for the whole unit). In my attempt to get it away from her she said "If you want that baby you're carrying to live, you better back the F*$% up". Since then I have moved to the hospital, and have been called every name in the book, get physically assaulted just about every shift. It never ends. That's neuro for ya though!
I find some women family members can be real nasty and say antagonizing remarks. I chalk it up to they couldn't make it through nursing school and are jealous.
A patient (A&Ox3) crapped in the bed and told me I'd better clean it up before there was a complaint.
Patient tried to stab me with a hunting knife because I refused to write an RX for oxy!
I am a phlebotomist and a patient informed me that the hospital served sh*t for food. He then lifted the lid off his dinner tray and there was a perfectly formed turd lying on his plate. I just stated to the patient, "Well I guess they do".
There are several things I remember. One in particular stands out. Years ago, I went into a woman's room to give her a synthroid which she took everyday of her life. She wanted me to fluff her pillow, get a drink of water, etc. before taking her medicine. Management had told us to really be nice to her as she was complaining about the service. This was in the '80's. Anyway, I did everything she wanted and forgot to give the pill and left it on her bedside table. The next shift, another nurse found it and reported it. The patient said to the head nurse: "She supposed to make sure I take my medicine." To this day, I watch 99.9% of my patients take their medicine no matter how long it takes. She totally ruined my ability to trust my patients to do what they know to do or say they will do. I don't hesitate to tell my patients why I watch them if they ask me.
I had a female patient request a bedpan and then once she had a bowel movement proceeded to throw it at us!
I've been kicked, punched, bitten, peed on, puked on and spat on. I've had just about every bodily fluid on my clothes (other than breast milk) at one point or another. I've been insulted, cussed at and listened to racial, sexist and cruel things said about other nurses. I've refereed fights between family members and even families and patients. Daily, I have to stop and laugh to myself at the fact that I went to college for this. But I honestly, even with all that, love what I do.
I had a dementia/Alzheimer's patient slap me across the face. Ouch! And he had been smiling few minutes before.
Before I became an RN I was an STNA working in long term care. A little 99 year old lady leaned over and bit my upper arm while I was transferring her from the bed to wheelchair. She held on to it for dear life. It didn't break the skin but I had a huge raised black bruise and I'm the one who had to get a piss test. I didn't bite her!
I was told in the middle of my night shift by a man who could transfer himself to the bedside commode with no problems, "You need to change my diaper." I discovered the man had put a brief on when he went to bed. I said, "You seemed to be doing fine earlier." He said, "It's your job." I was so pissed off, after that I made no eye contact with him and no effort to speak Spanish either. Also the classic still smoking COPDer who is screaming at the top of her lungs "I can't breathe!!! I can't breathe!!!!" And the meth head who screams at me "F*#k you!!!" Whereupon I scream just as loud back, "I wouldn't give you the satisfaction!!!"
Had a patient aim her ass at an aide and attempted to projectile shit on her. She was HIV + and oriented.
One called me a b***h-a** n*****. One reported me to the state for I don't even know what after she became enraged I wouldn't disclose what religion I believe in!
We had one gentlemen threaten to come back and shoot all of us for discharging his girlfriend without notifying him (he wasn't POA). You want to laugh it off but these days you have to take it seriously.
As a 27+ year Critical Care Paramedic, I've been punched, slapped, kicked, bitten, pinched, spit on, pissed on, shit on, ducked any one of a 1000 things thrown at me, shot at (TacMedic as well), screamed at, yelled at, cussed out VERY colorfully, wrestled with, had my heritage questioned, my parents marital status questioned, my sexual orientation questioned (How DARE they assume I'm straight? Offends me every time!) threatened with everything from death to sticking one of several things into any orifice they fancied...pretty much everything most of us in healthcare have gone through. EMS is not for sissies, lol! I am passionate and LOVE what I do, all the same. The good saves and great patients...the courage I see every shift...the chance to REALLY make a difference...that is GOLDEN.
We were having our usual Saturday Night Smackdown in the Trauma ICU and my admit was a meth user who was coming down and not happy about it. While moving him from stretcher to bed we had to release the leather restraints. He got one leg loose and kicked me and broke my nose! One of the trauma surgeons who was a black belt jumped on him and applied some type of move that got him under control really quick. I later thought that might have been a really useful skill that we should learn in nursing school! Thank you to the plastics guy who made my nose pretty again.
I had a patient stand on top of the exam table and refuse to come down unless I gave him a script for Vicodin. I told him I'd call the police if he didn't get down and left him in there. He finally got down and left.
I can't believe the stuff we endure. It amazing that we keep coming back for more. We should be able to press charges against patients for assault and battery.
I had a four year old call me a bitch right before I was going to give him shots and working in public health only gets crazier every day with people feeling entitled and expecting VIP treatment.
I had a lady stab me in the hand with a pen I had just given her to write my name down because she wanted to complain about me because I was the triage nurse that night and she didn't feel I was sending her kid back fast enough.
Threatened me with a bomb!
When I was working in a nursing home as a CNA an Alzheimer's resident bit my boob while I was leaning over tying her gown.
They neglect to warn you of the abuse that will be heaped on you when you go to nursing school. I met a former nurse who'd been punched in the face by a patient so hard that she required multiple reconstructive surgeries. People act like animals.
9 years of inpatient and community based mental health before getting my RN has calloused me against nearly every form of verbal, psychological and physical violence. Luckily, I have never been sexually assaulted. Glad to be away from that now.
Kicked in the abdomen when pregnant with second child!
Have been punched, slapped, kicked, shit on (on purpose).
Something along the lines of "I'm going to f**cking kill you".
I've been punched, kicked and bitten. The latter was considered an exposure so I had to go through the whole protocol. The interrogation by employee health was a worse experience than dealing with the patient.
A 48 yr old capable of walking. The bed rail was let down and the patient curtain opened and shown where the bathroom was straight across the hall. One of my MDs called STAT another nurse (thankfully I was on lunch break) the patient's family member had gotten bed pan from cabinet and she was squatting in floor with gown fully open in back for every Joe Blow to walk by and see....yes., gotta love ER = Everyone's Retarded.
Oh, but one guy with a brain tumor who was also having an adverse reaction to Ativan said things that I wouldn't repeat in the privacy of my own home. He was sweet as could be the next day.
I am an ER pharm and it gets bad in there too. My hair is short so our stroke patients have said crazy stuff. One said "I would never take your ugly f$$$ing ass out to eat with that haircut"as he finished cursing the nephrologist on her way out the door. Lots of prisoners come thru as well so it can get colorful language wise. I actually got it worse in retail.
Had a patient cornering me and shoving an IV pole in my face because I refused to apologize for "9-11"... spat on, punched, kicked, shit balls thrown at by HIV patient with dubious CD4 count... oh joy...
I was blocked up against a wall and beaten in the chest by a patient with meningitis until help came to get them off me. I went to employee health I wanted to go home but we were already short so I stayed in work the whole night.

Make sure to check out the hundreds of original Happy Hospitalist nurse ecards on Pinterest.

"I get kicked, beaten, stabbed spit on and cursed at. And I always respond with kindness, except that one guy who made fun of my haircut. I kicked his ass real good."

To view this ecard product selection, turn off the “content filter” function on the left hand side of the Zazzle store linked above.

Alternatively, nurse violence against doctors appears to be on the rise. Perhaps all that violence against nurses is having devastating consequences...

Be careful doctors, there are some crazy nurses out there with a short fuse. Don't stop the nurse's Ativan. I mean the patient's Ativan. I mean the nurse's Ativan... Nurse: Happy, Mr. Smith is driving me nuts. If you stop his Ativan, so help me God I'm going to kill you.

Faith Leaders Leading the Way on ACA Outreach

CBHC's Faith Caucus is taking a lead role in our efforts to promote enrollment in Illinois' new Health Insurance Marketplace, and a crucial partner in spreading the positive word on health care reform. We are so pleased that the role of our faith leaders in outreach around the Affordable Care Act was important enough to have an AP story!

Faith leaders emerge as key to health law outreach

CHICAGO — Religion and the nation's new health law haven't exactly been viewed as friendly partners in the public eye, with most of the attention focused on religious employers' objections to covering the cost of birth control.

But under the radar, leaders in some Illinois faith communities are spreading the word about the Affordable Care Act to make sure their uninsured members know about new benefits available starting in 2014 and about the approaching enrollment start date.

Read more here: http://www.bnd.com/2013/08/09/2736052/faith-leaders-emerge-as-key-to.html#storylink=cpy

For the full story, please visit http://www.bnd.com/2013/08/09/2736052/faith-leaders-emerge-as-key-to.html.

Thanks to Rev. Carole Hoke, Rev. Dr. Shirley Fleming, and Aida Giachello of the CBHC Faith Caucus, and to Carla Johnson (@CarlaKJohnson) of the AP for the story.

Billing For Family Meetings as Critical Care in the ICU Explained.

Can a physician bill family meetings as critical care in the ICU? This is a situation that happens with daily frequency in ICU medicine. Hospitalists and intensivists are always meeting with family and other surrogate caregivers for critically ill patients. Can this resource time spent in family meetings be billed for and paid for based on current evaluation and management (E/M) rules? That's a question I was recently asked. Here is the reader's question in detail:

Hello, I have known about your website for a while, but I haven't really investigated it much until recently. I'm a young hospitalist who finished residency several years ago. This past April, I went to this inpatient coding session at an ACP meeting. Their physician did an excellent job and that has been really helpful to me and I have since been spreading it to my group. I am a hospital-employed physician and unfortunately, we have a bare-bones coding department. Thus, I have run into a few situations where my coding person hasn't been able to answer my questions fully. I was hoping to run a situation by you to see how you personally might handle the coding or maybe you know of an easy resource that I can look at to answer the question.

I need to know what to do in the following situation: I see a ventilated patient. I manage his vasopressors. I manage his vent. I assess his critical care needs. It’s all maximal life support and life threatening. I do this at 8AM in the morning. I bill for 60 minutes of critical care. That is the clear part.

What is unclear is later in the day when the family comes in and they request an update. I spend 45 minutes with the family and we discuss his case. We discuss findings, diagnostics, treatment options, etc. The entire time is spent counseling on these topics. How do I bill this subsequent visit? Is it billable? Some of my partners said they bill it critical care (99292), but I’m finding conflicting results on this. I found one source that said to bill critical care for this you have to state the following:
Patient cannot participate
Need guidance regarding further care
Need to discuss code status
Explain prognosis
Review other options regarding other care
Review other options regarding other care OR stopping care (end of life discussion)
Should I bill a 99292 (extra critical care time)? Can you bill a subsequent visit code (99233) based on the counseling since it’s not critical care. I don't think a prolonged service code can be used if I don't have a subsequent visit code already billed. Thanks so much for your help. If this is too much, I understand. Thanks for your site!

Thanks for your question reader. Your question has actually been answered by the Centers for Medicare & Medicaid (CMS) directly. Look for section 30.6.12 titled Critical Care Visits and Neonatal Intensive Care (Codes 99291 - 9 9292) (page 65), under Section E titled Critical Care Services and Physician Time (starting on page 68) where they discuss family counseling/discussions in Section E starting on page 69. They give you the answer in this Chapter 12 of the Medicare Claims Processing Manual on pages 69 and 70. Here is what they say:

Family Counseling/Discussions:

Critical care CPT codes 99291 and 99292 include pre and post service work. Routine daily updates or reports to family members and or surrogates are considered part of this service. However, time involved with family members or other surrogate decision makers, whether to obtain a history or to discuss treatment options (as described in CPT), may be counted toward critical care time when these specific criteria are met:

The patient is unable or incompetent to participate in giving a history and/or making treatment decisions, and
The discussion is necessary for determining treatment decisions.

For family discussions, the physician should document the following

The patient is unable or incompetent to participate in giving history and/or making treatment decisions.
The necessity to have the discussion (e.g., "no other source was available to obtain a history" or "because the patient was deteriorating so rapidly I needed to immediately discuss treatment options with the family"),
Medically necessary treatment decisions for which the discussion was needed, and
A summary in the medical record that supports the medical necessity of the discussion.

All other family discussions, no matter how lengthy, may not be additionally counted towards critical care. Telephone calls to family members and or surrogate decision-makers may be counted towards critical care time, but only if they meet the same criteria as described in the aforementioned paragraph.

So the answer to your question is yes. Talking with family in a family conference can be billed as critical care if the criteria detailed above are followed. If your family conference time meets the criteria detailed above and your additional time spent passes beyond the 74 minute threshold for critical care code 99291, then bill for a 99292 for each additional 30 minutes of time spent beyond 74 minutes of initial calendar date 99291 critical care time. What if one physician provides the time for 99291 and another physician provides the family visit that qualifies for an add-on code 99292? Is that allowed? In this same resource detailed above in Section E (page 68) Medicare says, " Physicians of the same specialty within the same group practice bill and are paid as though they were a single physician (§30.6.5)." In the past, Medicare computers could not handle having different physicians provide a 99291 and a 99292. They should, because they say they should. Perhaps they have finally fixed their algorithms to follow their own policy.You can find much more about CPT coding by obtaining your own copy of the AMA's 2013 CPT manual available at the graphic above and to the right.

In answering your additional questions, you cannot bill a subsequent care code after a critical care code on any given calendar date, but you can bill critical care after and E/M code. I have previously discussed this and have detailed when it is appropriate to bill an E/M charge and a critical care code on the same date at the provided link. In addition, you cannot bill a prolonged care add-on code with critical care. I have previously discussed add-on codes 99356 and 99357 in the hospital setting. Only certain E/M codes are allowed to be companion codes with these prolonged care codes . Critical care codes are not included as acceptable companion codes. I hope this helps.

The Happy Hospitalist has a wealth of other coding information for all your clinical needs. You can find all my CPT and E/M coding lectures here. I also have an assortment of clinical relevant information in my hospitalist resources section as well and a bedside E/M bedside pocket reference card detailed below.

LINK TO HOSPITALIST E/M POCKET REFERENCE CARD POST

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Primary Care Doctors Need Connections to ACA Information and to Navigators, Counselors

As the effort to promote the Health Insurance Marketplace and enroll consumers gears up, and clinics and community organizations hire, train and deploy the various “assisters” who will help patients and families get coverage, we shouldn’t ignore one of the most important touchpoints between the health care system and consumers – patient/physician interaction. Patients trust their doctors and may look to them for guidance about the Affordable Care Act (ACA). Unfortunately, many doctors haven’t been well educated about the ACA or what’s going to happen once the Marketplace is live.

The national American Academy of Pediatrics recently conducted a survey of its members and found that improvement is needed in pediatrician awareness of the Affordable Care Act (ACA). The survey, conducted in late 2012, showed that nearly half of pediatricians are vaguely or not at all familiar with key components of the ACA. Specifically, they lacked knowledge of some components that could directly benefit their practices – such as the temporary increase in payment from Medicaid to Medicare levels, and coverage of Bright Futures services with no cost-sharing for children enrolled in new insurance plans.

Pediatricians also cited low confidence in their ability to respond to parents’ questions regarding the new law. Only 5% of pediatricians reported that they are very confident in their ability, while 33% reported that they are not at all confident, with the rest somewhat or moderately confident. Clinicians such as pediatricians are not yet being asked many questions by their patients and parents, so they have not been motivated to learn their own key points or prepare their office staff to provide information. In the AAP survey, 86% of pediatricians reported that they are seldom or never asked questions concerning the ACA. Most of their knowledge to date comes from what they see in the media, so they are very much aware of aspects such as the ban on pre-existing condition exclusions, the requirements to have health insurance by 2014 or pay a fine, and the provision allowing young adults to stay on parents’ health insurance up to age 26. But once the Marketplace is up and running, and public relations campaigns about enrollment are in full swing, and assisters are everywhere, what will they need to know so they can effectively advise their patients?

Locally, two major primary care provider associations did an assessment of members which confirmed an interest in more support and information. In May 2013, the Illinois Chapter of the American Academy of Pediatrics (ICAAP) and the Illinois Academy of Family Physicians (IAFP) conducted an informal survey asking pediatricians and family physicians to estimate need for Marketplace information among patients, patient’s parents and family members, and clinic staff. Responses were received from nearly 40 unique medical practice sites employing over 500 physicians. Only 3 responded that they would not be interested in any education or services related to the Marketplace. Nearly all (85%) want information on the Marketplace to post or handout to patients, and almost as many (75%) want a counselor or assister to speak to their practice staff.

While the number of medical practices that are independent, small business is dwindling, and most staff have insurance coverage via a hospital or health system, staff may still need information for friends and family members or to make new choices if products through the Marketplace are better for their families. Only about a quarter of physicians responding expected their health system to provide information on the Marketplace for patients and staff, and most (65%) said their health system was definitely not planning to employ navigators or counselors, which may be more available in the safety net clinics than in private systems. But the need for information – even in private practices – is there! Many physicians attested to seeing their patients lose insurance due to the economy, and pediatricians regularly note that while their patients are insured via All Kids or private insurance, many of their parents or primary caregivers are not. Children also age out of All Kids or their parents’ insurance and so many young adults will seek help in securing coverage.

For the ACA roll out to work, consumers need to get quality, consistent messages about the need to enroll and how to use the health care system, no matter where they are. Targeting efforts in low income communities and in clinics that currently serve the uninsured makes sense, but the ACA effects everyone, and all primary care offices should be able to connect a patient or family who needs coverage to someone who can help them.

Scott G. Allen, MS, Executive Director
Illinois Chapter, American Academy of Pediatrics

Special Report: Impact of ACA on Uninsured Asians in Illinois

The Affordable Care Act (ACA) will greatly improve the health of Americans by offering newly available coverage to the uninsured without pre-existing health condition exclusions, improving physical and mental health, and reducing the financial burden associated with healthcare. The Asian Health Coalition (AHC) and Health & Disability Advocates (HDA) jointly present this Special Issue Brief predicting that 75,000 currently uninsured Asians in Illinois will be eligible for coverage in 2014 through the Medicaid expansion signed into law last week (SB 26) and the health insurance marketplace (formerly known as the “Exchange”).

Working with datasets from the U.S. Census Bureau’s American Community Survey and Public Use Microdata Area (PUMA), key findings show:

Of the nearly 600,000 Asian Americans in Illinois, more than 80% live in just 4 counties comprising Cook, DuPage, Kane and Lake.
There is more than a 40% rate of limited English-proficiency in many Asian subgroups (Chinese, Korean, Laotian, Pakistani).
More than 92,000 Asian Americans in Illinois are presently without health insurance.
75,000 individuals (or more than 80% of the uninsured Asians) are expected to be eligible for coverage in 2014 with one-third of those obtaining coverage through the Medicaid expansion and the remaining two-thirds through the new health insurance marketplace.

Insurance Coverage by Asian Subgroup

“Health insurance makes a big difference in access to necessary medical care, financial security, and ultimately health outcomes for vulnerable populations,” said Stephanie Altman, Programs & Policy Director at HDA. "The uninsured receive less preventive care and recommended screenings than those with health insurance, and therefore may forego needed care or prescriptions due to cost,” she added.

“Open enrollment is just 60 days away and outreach and enrollment efforts targeted to communities of color are more important than ever if we are to maximize enrollment into new health coverage options”, said Edwin Chandrasekar, AHC’s Executive Director. “The Illinois Department of Public Health has awarded $27 million to community-based organizations through the In-Person Counselor Grant Program and this is a positive step in the right direction to tailoring outreach and education strategies to meet the diverse racial and ethnic Asian American subgroup needs.”

For more information about this brief, please contact the Asian Health Coalition at (312) 372-7070 or info@asianhealth.org.

Edwin Chandrasekar
Asian Health Coalition