Thank you for viewing the Chest Pain MI Registry August case scenario regarding sequence number 12342, episode event, and how it relates to metric 45, in-hospital risk-standardized rate of bleeding. A 78-year-old female patient presented to the emergency department five days prior to this admission for a fall that resulted in two fractured ribs. The patient was stable and was discharged home. On the current admission, she presented via EMS with complaints of shortness of breath and chest pain to the emergency department. Care was provided per the standard protocol. The initial ECG was read and signed by the cardiologist at 4.38 p.m., and it was deemed negative for STEMI. Initial hemoglobin result was 10.9 grams per deciliter at 5.20 p.m. Proponent results were positive for myocardial infarction with a value above the 99th percentile. Subsequent testing included a chest X-ray, which revealed a large hemothorax requiring a chest tube insertion. The chest tube was inserted by a CT surgeon at 5.55 p.m. The next morning, the hemoglobin was obtained with a value of 6.8 grams per deciliter. Our question is how is sequence 1, 2, 3, 4, 2 episode events coded? Number 1, bleeding at access site. Number 2, bleeding gastrointestinal. Number 3, bleeding genitourinary. Number 4, bleeding other. Number 5, bleeding retroperitoneal. Number 6, bleeding surgical or intervention required for bleeding event. Number 7, both numbers 4 and 6, or number 8, both 1 and 6. Please take a few moments to review the scenario, the question, and the possible answers. Any bleeding event indicates if the patient experienced a confirmed bleeding event observed and documented in the medical record that was associated with any of the following. A hemoglobin drop of greater than or equal to 3 grams per deciliter, or a transfusion of whole blood or packed red blood cells, or a procedural intervention or surgery at the bleeding site to reverse, stop, or correct the bleeding, such as surgical closures, exploration of the arteriotomy site, balloon angioplasty to seal an arterial tear, or endoscopy with cautery of a GI bleed. The answer is number 7, both 4 and 6. Bleeding surgical procedure or intervention required for bleeding event and bleeding other are both coded as yes. Sequence 12343, episode, event, date, and time of bleeding other is coded with the date and time the diagnosis of helomothorax was made. And sequence 12343, episode, event, date, and time of bleeding surgical procedure or intervention required for bleeding event is coded with the time the chest tube was inserted. Sequence number 12342, episode, events, indicate the event that occurred during the hospitalization with a target value of any occurrence between arrival at this facility and discharge. The diagnosis of hemothorax occurred after arrival. Let us review a bit further in metric 45, in-hospital risk standardized rate of bleeding STEMI, pre-admit, and end-STEMI patients, which evaluates the hospital's risk standardized rate of bleeding for STEMI, pre-admit, and end-STEMI patients. Bleeding is a count of eligible patients who experienced a bleed determined by the risk model. The count of eligible patients who experienced a bleed is determined by the risk model as follows. Please note any one of the following meets the criteria. Absolute hemoglobin drop of greater than or equal to 4 grams per deciliter. Stroke, retroperitoneal bleed, a baseline hemoglobin of greater than 9 grams per deciliter and an RBC transfusion. A baseline hemoglobin of less than 9 grams per deciliter and an RBC transfusion and a bleeding event. Note, bleeding in CABG patients is included as a bleed only if it occurred prior to surgery. And major bleeding is a frequent complication for patients with acute MI and is associated with significant morbidity and mortality. This case is coded with events of bleed other and bleeding surgical procedure or intervention required. The patient is included in the numerator of metric 45 in-hospital risk standardized rate of bleeding because the definition of bleeding is met with an absolute hemoglobin drop of greater than or equal to 4 grams per deciliter. The coding of bleed other and bleeding surgical procedure or intervention required in episode events has no impact on metric 45. The risk standardized bleeding ratio of each published quarter can be found in the detailed line view of the dashboard. Risk standardized bleeding ratio is found in the detailed report as displayed. If the ratio is less than 1, then the facility had fewer bleeding events than the model predicted. If the ratio is equal to 1, then the facility had the same number of bleeding events as the model predicted. If the ratio is greater than 1, then the facility had more bleeding events than the model predicted. Strategies such as ultrasound-guided access to mitigate risk should be developed and tested to lower costs and improve outcomes in an era of alternative payment models. Thank you for viewing the Chest Panami Registries August 2022 case scenario.

chest pain

bleeding complications

fractured ribs

shortness of breath

coding sequence