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UASI Monthly CDI Scenario Discussion – Functional Quadriplegia

H&P: 97yo female presented to the ER from her nursing home after developing a fever.  Patient complains of a productive cough for 2 days.  Patient is bedbound at the nursing home and dependent on the staff for all ADLs.  Impression:  Suspect pneumonia, will obtain sputum culture and start antibiotics.

PMH: Dementia, severe arthritis with contractures, paroxysmal a-fib

Nursing notes: Patient requires assistance for all ADLs.  Patient is bedbound and turned every 2hrs per skin protocol.

Home medications:  metoprolol, Coumadin, Celebrex

Vitals: T100.2, HR 82, RR 18, BP 124/86, SpO2: 96% on RA, BMI 18.2

PE:  A&Ox2-at baseline for the patient, lung sounds coarse in the left base, frail, bilateral hands and RLE contracted

Labs: WBC: 11.0, H&H: 13.5 & 36, BUN 24, Creat 0.92, Sputum culture: positive for Pseudomona aeruginosa.

CXR: LLL infiltrates

Hospital medications: Ceftriaxone IV and continue home medications

Discharge Summary:  Patient is a frail and underweight elderly female that was admitted with Pseudomonas pneumonia with no sepsis present. Treated with IV antibiotics.  Repeat CXR improved.  Plan to change to po antibiotics and return to the nursing home today.

Question:   Are there query opportunities based on the scenario stated above?

Discussion: Patient is bedbound and dependent on staff for all ADLs  without a history of a spinal cord injury or brain injury.

Diagnostic criteria for Functional Quadriplegia:

  • Complete inability to move extremities due to an underlying disease process.
    • Flexion contracturesBedbound
    • Inability to turn
    • Dependent on staff for ADLs- “total care”
  • No history of spinal cord injury or any damage done to the spinal cord or any damage to the brain.

Treatment for:

  • Provide patient’s daily care and hygiene, including feeding.
  • Care is provided to prevent or manage any associated complications such as skin breakdown, aspiration, infection and malnutrition

UASI Recommends:

Query for Functional Quadriplegia

Documentation without clarification:

Principal Diagnosis: Pneumonia due to Pseudomonas (J15.1)

Secondary Diagnosis: BMI 19.9 or less, adult (Z68.1), Underweight (R63.6),  PAF (I48.0), dementia (F03.90)

Working DRG: 178 Respiratory infections and inflammations w/CC

RW: 1.087       GMLOS: 3.6     SOI/ROM: 2/2

Documentation with clarification:

Principal Diagnosis: Pneumonia due to Pseudomonas

Secondary Diagnosis: Functional Quadriplegia (R53.2), BMI 19.9 or less, adult, Underweight, PAF, dementia

Working DRG: 177 Respiratory infections and inflammations w/MCC

RW: 1.7799     GMLOS: 5.2    SOI/ROM: 2/2

CDI Educational Tips:

  • Functional Quadriplegia Definition: “Complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord.  The patient with functional quadriplegia requires assistance with all activity of daily living” ‘Functional Quadriplegia: A code for a real Condition’ by Erica Remer, MD, CCDS, icd10monitor.

  • Consider this diagnosis for patients with severe, end-stage dementia or an advanced progressive neurogenerative disorder such as MS, ALS, Cerebral Palsy or Huntington’s disease.  The nursing admission functional assessment should provide clinical validation demonstrating the patient’s inability to move extremities, requiring total assist with activities of daily living.  These patients often present with contractures and muscular atrophy. ~ACDIS tip: Functional quadriplegia, November 12, 2020-CDI strategies-Volume 14, Issue 51.

  • These patients demonstrate high resource consumption, as they are unable to perform the most basic of functions without assistance.

  • Review the nursing notes and/or PT/OT notes on patients from nursing homes or with any of the high-risk diagnoses listed above to see if they need total assistance with ADLs.

  • Questions to ask while reviewing cases:
    • This patient requires total assistance for ADLs, do they have a spinal cord injury or brain injury?  If the answer is “no” consider placing a query for Functional Quadriplegia.If a patient has MS or advanced ALS do they require someone to provide ADLs? If the answer is “yes” consider placing a query for Functional Quadriplegia.If a patient is elderly, frail, has contractures or severe dementia do they require someone to provide ADLs? If the answer is “yes” consider placing a query for Functional Quadriplegia.
    • Is there a Braden score documented?  What is the mobility rating?  If the scores are 1-completely immobile or 2-very limited and Activity (1-bedridden) this documentation can be used as clinical indicators to support a query.

This is a short synopsis of a possible patient record and is not intended to be all inclusive.  This is for educational purposes only and not intended to replace your institutional guidelines.