ABSTRACT
OBJECTIVE: In a prospective study we analysed the quality of ICD-coding in clinical everyday life of a department for internal medicine. METHODS: A skilled intern--the so-called DRG assistant--was temporarily released from clinical work. Over nine weeks he had to control all diagnoses contemporaneously that were ICD-coded by his colleagues on admission and discharge of their patients. The DRG-assistant had to ask for missing or correct implausible diagnoses, or inappropriate ICD-coding and with it also train his colleagues in appropriate coding. The effects of the DRG-assistant's correction of coding, on DRG-consistent grouping and on the potential financial loss or benefit generated by his work were recorded. After stoppage of this control in a subsequent phase of the study the effect of the absence of the DRG-assistant, the absence of reminders and coding control and the changes of the clinic's revenue were determined. RESULTS: Corrections of ICD-coding by the DRG-assistant alone caused a remarkable increase in case-mix-index (CMI). CMI's mean value increased from 1.76 to 1.84 and the clinic's revenue increased by 180 Euro per patient (a total of about 80,000 Euro in nine weeks). After the end of the control, the case-mix-index dropped within three weeks down to 1.14, corresponding with a potential loss of 1200 Euro per patient (assuming that patients' morbidity was the same over the time of the study). Coding corrections could not improve CMI in this situation. CONCLUSION: Contemporaneous control of ICD-coding by physicians seems to be essential in DRG based accounting.
Subject(s)
Current Procedural Terminology , Diagnosis-Related Groups/standards , Costs and Cost Analysis , Diagnosis-Related Groups/economics , Diagnostic Errors/economics , Forms and Records Control , Humans , Medical Records/standards , Physicians , Prospective Studies , Time FactorsABSTRACT
OBJECTIVE: Long-term extracorporeal lung assist is limited by a significant mechanical blood trauma resulting in bleeding and hemolysis. To reduce the drawbacks of extracorporeal lung assist a new technique has been developed, by which the driving force for the extracorporeal circuit derives from the patients arterio-venous pressure gradient (pumpless extracorporeal lung assist). The aim of this clinical study was to test the feasibilty and effectiveness of pumpless extracorporeal lung assist in patients with acute respiratory distress syndrome. METHODS: Twenty patients (41+/-16 years) with acute respiratory distress syndrome of various causes and failing respirator therapy were enrolled. The minimum hemodynamic requirements included a cardiac output (CO) >6 l/min and mean arterial pressure (MAP) >70 mmHg. Pumpless extracorporeal lung assist was established using a short circuit arterio-venous shunt including a special designed low-resistance membrane oxygenator which was placed between the patients legs. RESULTS: At the time of inclusion FiO(2) in all patients was 1.0 (paO(2) 45.9+/-7 mmHg, paCO(2) 58.9+/-17 mmHg). After 24 h of pumpless extracorporeal lung assist FiO(2) was reduced to 0.8+/-0.1. A significant improvement in oxygenation (paO(2) 84.1+/-21 mmHg, P<0.05) and CO(2) removal (paCO(2) 32.7+/-5 mmHg, P<0.05) was notable. The mean extracorporeal flow was 2.6+/-0.6 l/min, which represented approximately 25% of the patients mean CO (10.8+/-2 l/min). The median assist time was 12+/-8 (1-32) days. Fifteen out of twenty patients were weaned off pumpless extracorporeal lung assist. Five out of twenty patients died while on the system (four sepsis, one ventricular fibrillation). Three out of twenty patients died after successful weaning on day 8, 30, and 50, respectively. Twelve out of twenty patients were discharged in a healthy state (overall survival 60%). Technical problems included thrombosis of the venous cannula (n=5), thrombus formation within the membrane oxygenator (n=2), membrane oxygenator plasma leakage (n=2), and membrane oxygenator contamination with Candida albicans. No bleeding complication was observed. CONCLUSION: Pumpless extracorporeal lung assist is feasible and effective in a selected group of patients with acute respiratory distress syndrome but preserved hemodynamic function. By eliminating the pump and reducing the tubing length blood trauma can be minimized. Being very simple the system entails fewer risks of technical complications and also facilitates nursing care.
