Proprietary Notice and Disclaimers Cholecystitis COPD Diabetes Mellitus Diabetic Ketoacidosis Deep Vein Thrombosis admit the patient is being made. For Electrolyte or Mineral Imbalance

Copyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland.

InterQual® Level of Care: Acute Adult Criteria

2018 Clinical Revisions

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Review and Incorporation of Recent Medical Literature Change Healthcare is committed to keeping the InterQual product suite current and accurate. Criteria are continually reviewed and updated, with new editions of every product released annually. Change Healthcares’ staff of physicians, nurses, and other licensed healthcare professionals, and its extensive array of primary care and specialty consultants, participate in ongoing criteria revision as new medical information emerges. Each annual release of the criteria reflects a thorough review of new medical literature, society guidelines, and current practice standards and incorporates consultant and user feedback.

Customer Hub The Customer Hub (https://customerhub.changehealthcare.com) provides interactive support, answers to commonly asked questions, and links to other resources. For a user ID and password, contact your Customer Hub site administrator or [email protected]

Potential Care Management Impact This Clinical Revisions document outlines the updates McKesson Health Solutions has made to the criteria to reflect the latest changes in the clinical evidence. Whether content has been added or updated, a level of care changed or a new condition added that did not exist before; certain criteria changes may affect your organization’s care management approach. Listed below, McKesson Health Solutions has designated the major criteria updates that may impact your organization with a () symbol.

Revisions The following section includes information regarding:

Organization and features New subset Subset name changes Revisions to criteria Revisions to medical codes



New subsets Acute Kidney Injury (AKI) Bone Marrow Transplant/Stem Cell Transplant (BMT/SCT) Dehydration or Gastroenteritis Hematology/Oncology: Acute Leukemia or Lymphoma Hematology/Oncology: Brain Malignancy or Metastasis Hematology/Oncology: Chemotherapy Hematology/Oncology: Hemolytic Uremic Syndrome Hematology/Oncology: Malignant Disease Hematology/Oncology: Tumor Lysis Syndrome Infection: General Infection: Sepsis Rhabdomyolysis or Crush Syndrome Withdrawal Syndrome

Global Changes

Revision Revision Type Rationale Potential Care Management Impact ()

Initial Review content was added to the following subsets:

Acetaminophen Overdose Carbon Monoxide Poisoning Cystic Fibrosis Rhabdomyolysis or Crush

Syndrome Withdrawal Syndrome

Usability Initial review criteria are intended to be used as real-time decision support in the emergency department for when Observation or inpatient hospital level services are warranted. They help the reviewer determine whether a patient is appropriate for Observation or inpatient admission at the point of care. For more information about applying Initial Review criteria, please see the Review Process.




Responder and Non-responder days have been adjusted based on length of stay data. Responder criteria often appear starting on Episode Day 2 and are designated as “Early responder” until the 25th percentile of the average length of stay for a condition. This change appears in the following subsets: Asthma Carbon Monoxide Poisoning Hypertensive Disorders of

Pregnancy Labor and Delivery Postpartum Complications after

Discharge Withdrawal Syndrome

Literature This change is in alignment with length of stay data.

The Non-Responder day has been updated in the following subsets to align with length of stay data (the 75th percentile). In these subsets Observation has been limited to 24 hours:

Subset 2017 2018

Acetaminophen Overdose

4 5

ACS 6 5

Acute Kidney Injury 3 8

Literature This change is in alignment with length of stay data.




Asthma 7 6

Carbon Monoxide Poisoning

4 5

Cystic Fibrosis 14 14

Dehydration or Gastroenteritis

3 4

Diabetes Mellitus 7 6

Diabetic Ketoacidosis

7 6

General Surgery 11 3-21

Heart Failure 9 8

Hypertensive Disorders of Pregnancy

3-x 6

Hyperosmolar Hyperglycemic State

7 6

Hypoglycemia 8 7

Infection: General 3 7

Infection: GI/GU/GYN

2-9 11

Infection: Sepsis 3 9

Labor and Delivery 2-x 6




Postpartum Complication after Discharge

2-x 6

Syncope 6 5

Rhabdomyolysis or Crush Syndrome

3 8

Withdrawal Syndrome

3 7

Abbreviations have been spelled out throughout the criteria.

Usability These changes were made to clarify the intent of the criteria.

Criteria has been restructured to align with InterQual Auto Review®.

Usability These changes were made to support automatic reviews of the electronic medical record and allow for consistent application of the criteria at any time in the review process.




At the INTERMEDIATE level of care, changed:

From: IV medication administration, Both:

Medication, One: Antiarrhythmic Anticonvulsant Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Vasoactive or inotrope

Administration, One: Continuous and monitoring q3-4h Bolus q3-4h and monitoring Titration q3-4h and monitoring

To:

Antiarrhythmic: Antiarrhythmic, One: IV antiarrhythmic and hemodynamically

stable Antiarrhythmic conversion from IV to PO,

One: No proarrhythmic risk 24h Proarrhythmic risk and continuous cardiac

monitoring (excludes Holter) 3d

Anticonvulsant: Anticonvulsant, One: Seizure, Both:

Seizure activity resolved Anticonvulsant, continuous

Usability These criteria were changed based on the best available evidence and are supported by InterQual® consultants. The usage of these criteria are tailored to the specific subset and level of care. Medications are included as appropriate for the condition.

At the CRITICAL level of care, changed:

From: IV medication administration, Both:

Medication, One: Antiarrhythmic Anticonvulsant

Usability These criteria were changed based on the best available evidence and are supported by InterQual® consultants. The usage of these criterion are tailored to the specific subset and level of care. Medications




Antihypertensive Beta blocker Calcium channel blocker Diuretic Insulin Neuromuscular blocker Vasoactive or inotrope

Administration, One: Continuous and monitoring q1-2h Bolus q1-2h and monitoring Titration q1-2h and monitoring

To:

Antiarrhythmic: Antiarrhythmic, One: Arrhythmia, One:

Urgent electrical cardioversion performed within last 24h

Defibrillation performed within last 24h Temporary pacemaker insertion

performed within last 2d Antiarrhythmic, All: IV antiarrhythmic Arrhythmia, One:

Recurrent arrhythmia (G1)

Refractory arrhythmia (G1)

Symptomatic, One: Chest pain Heart failure, Both: Heart failure Finding, One:

Arterial Po2 < 56 mmHg (7.4 kPa)

O2 sat < 89% (0.89) and < baseline

Hemodynamic instability, One: Heart rate > 120/min,

sustained (G50)

Systolic blood pressure, One: < 90 mmHg without chronic

hypertension < 110 mmHg with chronic

hypertension > 30 mmHg decrease from

baseline

Labile

Mean arterial pressure (MAP) < 65 mmHg

are included as appropriate for the condition.




Anticonvulsant: Anticonvulsant, Both: Seizure, One:

Recurrent seizure

Refractory seizure

IV anticonvulsant

Antihypertensive: Antihypertensive, One: Acute hypertension, All:

Blood pressure, One: Systolic > 160 mmHg Diastolic > 100 mmHg

Antihypertensive, One:

IV alpha blocker IV beta blocker IV calcium channel blocker IV centrally acting antihypertensive IV diuretic IV vasodilator

Requiring invasive hemodynamic monitoring

Diuretic: Diuretic, One: Heart failure, All:

Heart failure Finding, One: Arterial Po2 < 56 mmHg (7.4 kPa) O2 sat < 89% (0.89) and < baseline

Intervention, One: Diuretic, continuous Diuretic, every 1-2h

Vasoactive or inotrope: Vasoactive or inotrope, All: Medication, One:

Vasopressor Vasodilator Inotrope (excludes low or fixed dose for

end stage heart failure) Continuous IV medication Requiring invasive hemodynamic

monitoring




At the INTERMEDIATE level of care, changed:

From: Mechanical ventilation or NIPPV, One:

Respiratory interventions q3-4h

Weaning 2d

To:

Mechanical Ventilation, Day 2-X: Mechanical ventilation, Both: Mechanical ventilation Intervention, One:

Continued intervention required, Both: At least every 3-4h Respiratory intervention, One:

Chest physiotherapy (CPT) Metered dose inhaler (MDI)

treatment Nebulizer treatment Suctioning Ventilator setting change

Weaning 2d, Both:

Weaning 2d Intervention, One:

Reduction in ventilator support Reduction in FiO2 Increased length of spontaneous

breathing trials Increased number of spontaneous

breathing trials

Noninvasive Positive Pressure Ventilation (NIPPV), Day 1: Noninvasive positive pressure ventilation

(NIPPV), Both:

Noninvasive positive pressure ventilation (NIPPV)

Finding, One: O2 sat, One:

< 89% (0.89) and < baseline

Room air assessment not clinically appropriate

Arterial PO2 40-55 mmHg (5.3-7.3 kPa) and pH 7.50-7.55

Usability These criteria were changed based on the best available evidence and are supported by InterQual® consultants. The usage of these criteria are tailored to the specific subset and level of care.




Arterial Pco2 55-59 mmHg (7.3-7.9 kPa) and pH 7.25-7.30

Venous Pco2 55-59 mmHg (7.3-7.9 kPa) and pH 7.25-7.30

Noninvasive Positive Pressure Ventilation (NIPPV), Day 2-X: Noninvasive positive pressure ventilation

(NIPPV), Both:


Intervention, One: Continued intervention required, Both:

At least every 3-4h Respiratory intervention, One: Chest physiotherapy (CPT) Metered dose inhaler (MDI)

treatment Nebulizer treatment Noninvasive positive pressure

ventilation (NIPPV) setting change Suctioning

Weaning 2d, Both: Weaning 2d Intervention, One: Reduction in ventilator support Reduction in FiO2

Increased length of spontaneous breathing trials


From: Mechanical ventilation or NIPPV, One:


Weaning 2d

To:

Mechanical Ventilation, Day 1: Mechanical ventilation

Mechanical Ventilation, Day 2-X: Mechanical ventilation, Both: Mechanical ventilation

Usability These criteria were replaced based on the best available evidence and are supported by InterQual® consultants. The usage of these criteria are tailored to the specific subset and level of care.




Intervention, One: Continued intervention required, Both: At least every 3-4h Respiratory intervention, One:

Chest physiotherapy (CPT) Metered dose inhaler (MDI)

treatment Nebulizer treatment Suctioning Ventilator setting change

Weaning 2d, Both:

Weaning 2d Intervention, One:

Reduction in ventilator support Reduction in FiO2 Increased length of spontaneous

breathing trials Increased number of spontaneous

breathing trials

Noninvasive Positive Pressure Ventilation (NIPPV), Day 1: Noninvasive positive pressure ventilation

(NIPPV), Both:


Finding, One: O2 sat, One:

< 89% (0.89) and < baseline

Room air assessment not clinically appropriate (65)

Arterial PO2 40-55 mmHg (5.3-7.3 kPa) and pH 7.50-7.55



Noninvasive Positive Pressure Ventilation (NIPPV), Day 2-X: Noninvasive positive pressure ventilation

(NIPPV), Both:


Intervention, One: Continued intervention required, Both:

At least every 3-4h




Respiratory intervention, One: Chest physiotherapy (CPT) Metered dose inhaler (MDI)

treatment Nebulizer treatment Noninvasive positive pressure

ventilation (NIPPV) setting change Suctioning

Weaning 2d, Both: Weaning 2d Intervention, One: Reduction in ventilator support Reduction in FiO2

Increased length of spontaneous breathing trials

Increased number of spontaneous breathing trials

Mental Status updated to include Glasgow Coma Scale (GCS)

Usability This change was made to clarify the intent of the criteria.

At ALL levels of care, changed:

From: Chest tube, Removed and no reaccumulation by

CXR

To: Chest tube removed and no

reaccumulation of air or fluid by chest x-ray (CXR)



From: Acute kidney injury, Both:

Finding, One: Potassium > 6.0 mEq/L (6.0 mmol/L), One: AV dissociation Loss of P wave Multifocal PVCs Neuromuscular deficit

Ventricular fibrillation

Ventricular tachycardia

Usability These criteria were replaced based on the best available evidence and are supported by InterQual consultants. The usage of these criteria are tailored to the specific subset and level of care.




Widening QRS Sodium, One: < 120 mEq/L (120 mmol/L) and

volume overload > 160 mEq/L (160 mmol/L)

Hemodynamic instability, One: Heart rate > 120/min, sustained Systolic BP, One:

< 90 mmHg without chronic hypertension

< 110 mmHg with chronic hypertension

> 30 mmHg decrease from baseline

Labile

Mean arterial pressure < 65 mmHg Intervention, One:

IV fluid resuscitation 2d

Diuretic, One:

Continuous and monitoring q1-2h Bolus q1-2h and monitoring Titration q1-2h and monitoring Titration > q2h and monitoring 24h

Dialysis, One: Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation Continuous renal replacement therapy

To: Acute kidney injury (AKI), Both:

Finding, One: Potassium > 6.0 mEq/L (6.0 mmol/L), One: Atrioventricular (AV) dissociation Loss of P wave Multifocal premature ventricular

contractions (PVCs) Neuromuscular deficit Ventricular fibrillation


Widening QRS Sodium, One:

< 120 mEq/L (120 mmol/L) and volume overload

> 160 mEq/L (160 mmol/L) Intervention, One: IV fluid resuscitation 2d

Diuretic, continuous Dialysis, One:

Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation

Continuous renal replacement therapy (CRRT)




At the ACUTE level of care, changed:

From: C. difficile colitis resolving, Both: Diarrhea improving Hydration maintained

To: C. difficile colitis, Both:

Decrease in frequency and severity of diarrhea

Tolerating PO




Subset: Acetaminophen Overdose

Episode Day Level of Care/Criteria Point Revision Revision

Type Rationale

Potential Care Management Impact ()

Episode Day 1

OBSERVATION Added:

Toxic acetaminophen (APAP) ingestion, suspected, All: Toxic acetaminophen (APAP) ingestion,

suspected Acetaminophen (APAP) level <

150 g/mL (992.1 mol/L) Finding, One:

Unknown time of acetaminophen (APAP) ingestion

Unknown quantity of acetaminophen (APAP) ingestion

Acetaminophen (APAP) level monitoring every 4h

Assessment at least every 4hAcetaminophen (APAP) overdose,

suspected, All Acetaminophen (APAP) overdose,

suspected Finding, One:

Acetaminophen level 150-300 g/m(992.1-1984.2 m)

Chronic acetaminophen ingestion, One: Acetaminophen (APAP) level

> 10 g/mL (66.1 mol/L) Aspartate aminotransferase (AST)

> 50 U/L (0.84 kat/L) (4)

Alanine aminotransferase (ALT) > 50 U/L (0.84 kat/L)

N-Acetylcysteine (NAC) 21 hour protocol (IV only)

Literature These criteria

were added to more accurately reflect the criteria required to meet the Observation level of care.




Type Rationale


Episode Day 1 ACUTE Added:

Finding, One: Acute acetaminophen (APAP)

ingestion > 10 g Acetaminophen (APAP)

level 150-300 g/mL (992.1-1984.2 mol/L) (3)

Chronic acetaminophen (APAP) ingestion, One: Acetaminophen (APAP) level

> 10 g/mL (66.1 mol/L) Aspartate aminotransferase (AST)

> 50 U/L (0.84 kat/L)


N-Acetylcysteine (NAC) 72 hour protocol (PO or nasogastric only)

Literature These criteria

were added to more accurately reflect the criteria required to meet the Acute level of care.

Episode Day 1 INTERMEDIATE Removed:

Finding, One: Acute acetaminophen ingestion > 10

gAPAP level 150-300 g/mL (992.1-1984.2 mol/L)

No evidence of hepatotoxicity Chronic ingestion, One:

APAP level > 10 g/mL (66.1 mol/L)

AST or ALT > 50 U/L (0.84 kat/L) Intervention, One: N-Acetylcysteine (NAC) protocol

(includes PO or NG)

Consensus These criteria were deleted because patients who met these criteria can be safely cared for in the Acute level of care. InterQual® consultants support this decision.




Type Rationale


Episode Day 1 CRITICAL Changed:

Finding, One: AST > 1000 U/L (16.7 kat/L)

APAP level > 300 g/mL (1984.2 mol/L)

Hepatic encephalopathy

Intervention, One: N-Acetylcysteine (NAC) protocol

(includes PO or NG)

To: Acetaminophen (APAP) overdose All:

Acetaminophen (APAP) overdose Finding, One:

Acetaminophen (APAP) level > 300 g/mL (1984.2 mol/L)

Aspartate aminotransferase (AST) > 1000 U/L (16.7 kat/L)


Hepatic encephalopathy One:

Stage IV, One: Coma Obtundation Stupor

Intervention, One: N-Acetylcysteine (NAC) 72 hour

protocol (PO or nasogastric only)

N-Acetylcysteine (NAC) 21 hour protocol (IV only)

Literature

These criteria were added based upon the current available evidence and are supported by InterQual® consultants.

Episode Day 2 ACUTE Added:

N-Acetylcysteine (NAC) protocol (PO or nasogastric only) 3d

Post Critical care 24h

Literature





Type Rationale



Acetaminophen overdose, One:

N-Acetylcysteine (NAC) protocol (includes PO or NG)


Episode Day 2, 3, & 4

CRITICAL

- Acetaminophen (APAP) overdose,

- Finding,

Added: Alanine aminotransferase (ALT) >

1000 U/L (16.7 kat/L)

Literature


Episode Day 2 CRITICAL Added:

Cerebral edema, One: Increased intracranial pressure (ICP)

monitoring (includes OR placement) Corticosteroid Hyperosmolar therapy, One:

Mannitol Hypertonic saline 3%

(0.03) solution

Literature





Type Rationale



Acetaminophen overdose, Both:

Finding, One: APAP level 10 g/mL

(66.1 mol/L) LFT improving and > baseline Coagulation abnormal and

> baseline N-Acetylcysteine (NAC) protocol

(includes PO or NG)


Episode Day 4 ACUTE

- Responder,

Added: N-Acetylcysteine (NAC) protocol

completed (PO or nasogastric only

Usability

This criteria point was added to more accurately reflect the criteria required to meet the Acute level of care.




Type Rationale


Episode Day 4 ACUTE

Responder,

- Complication or comorbidity,

Removed: Coagulation studies within

acceptable limits


Episode Day 4 ACUTE

Partial responder,

Added: N-Acetylcysteine (NAC) protocol (PO

or nasogastric only) 3d

Post Critical care 24h

Literature




Subset: Acute Coronary Syndrome (ACS)

Episode Day Level of Care/Criteria Point


Episode Day 1

GLOBAL Extensive restructuring has occurred in Episode Day 1 in the Acute Coronary Syndrome (ACS) subset.

Usability These criteria were restructured to streamline the review process. This is supported by InterQual® consultants.

Episode Day 1

OBSERVATION

ACS suspected,

Changed: Pain resolving Systolic BP > 90 mmHg or baseline ECG normal, unchanged, or non-diagnostic

To: Acute Coronary Syndrome (ACS) suspected, All:

Pain, One: Pain free

Pain controlled with medication

Systolic BP > 90 mmHg or baseline Electrocardiogram (ECG), Both:

Electrocardiogram (ECG) Finding, One: Normal Unchanged Left bundle-branch block (LBBB), One:

Old left bundle-branch block (LBBB) Age undetermined left bundle-branch

block (LBBB) Non-diagnostic

Literature These criteria were restructured based on the current available evidence and are supported by InterQual® consultants.





Episode Day 1

INTERMEDIATE

NSTE-ACS,

Changed: NSTEMI, Both:

Positive cardiac biomarkers

Pain controlled and ischemic symptoms resolved

Unstable angina and controlled chest, arm, jaw, shoulder pain, or anginal equivalent, Both:

To: Non-ST-elevation myocardial infarction (NSTEMI),

Both: Finding, Both:


Pain, One: Pain free


Anticoagulant contraindicated Unstable angina (UA), All:

Unstable angina (UA) Pain, One:

Pain free


Usability These criteria were restructured based on the current available evidence and are supported by InterQual® consultants.





Episode Day 1

CRITICAL Changed:

STEMI confirmed by ECG NSTE-ACS, One:

NSTEMI, Both: Positive cardiac biomarkers

Symptom, One: Persistent chest, arm, jaw, shoulder pain Evidence of silent ischemia

Anginal equivalent Unstable angina and persistent chest, arm,

jaw, shoulder pain, or anginal equivalent Both:

ACS suspected and LBBB (new or age undetermined) on ECG

To: Acute coronary syndrome (ACS) suspected, All: Acute coronary syndrome (ACS) suspected Left bundle-branch block (LBBB) (new) on

electrocardiogram (ECG) Non-ST-elevation myocardial infarction (NSTEMI),

Both: Finding, All:


No ST elevation on electrocardiogram (ECG) Symptom, One: Persistent chest pain Persistent arm pain Persistent jaw pain Persistent shoulder pain Evidence of silent ischemia

Anginal equivalent ST-elevation myocardial infarction (STEMI), Both: Finding, Both:

Positive cardiac biomarkers (G7)

Confirmed by electrocardiogram (ECG) Unstable angina (UA), All:

Unstable angina (UA) Persistent pain

Usability These criteria were restructured based on the current available evidence and are supported by InterQual® consultants.



Subset: Acute Kidney Injury (AKI)

Episode Day

Level of Care/Criteria Point


All Episode Days

GLOBAL This subset is a breakout subset from General Medical. Criteria from the General Medical: Genitourinary section was used to create this subset.


Episode Day 1

OBSERVATION

Genitourinary,

-Acute kidney injury,

-Finding,

-Creatinine,

Changed: Increased by 50% (0.50) within last 7d Increased by 0.3 mg/dL

(26.5 mol/L) within last 2d 1.5-1.9x baseline and > ULN 1.5-1.9x ULN

To: Creatinine increased by 50% 0.50) within last 7d

Creatinine increased by 0.3 mg/dL (26.5 mol/L) within last 2d Creatinine 1.5-1.9x upper

limit of normal (ULN) and unknown baseline

Known baseline, Both:

Creatinine 1.5-1.9x baseline

Creatinine > upper limit of normal (ULN)

Usability These changes were made to clarify the intent of the criteria and are supported by InterQual® consultants.



Episode Day



Episode Day 1

ACUTE

Genitourinary,


-Finding,

-Creatinine,

Changed: 2x baseline and > ULN

2x ULN

To: Known baseline, Both: (G5)

Creatinine 2x baseline

Creatinine > upper limit of normal (ULN)

2x upper limit of normal (ULN) and unknown baseline

Usability These changes were made to clarify the intent of the criteria and are supported by InterQual® consultants.

Episode Day 1

CRITICAL Genitourinary,


-Finding,

Removed: Hemodynamic instability, One: Heart rate > 120/min,

sustained

Systolic BP, One: < 90 mmHg without

chronic hypertension < 110 mmHg with

chronic hypertension > 30 mmHg decrease

from baseline

Labile

Mean arterial pressure < 65 mmHg

Usability These criteria were changed to streamline the review process. This is supported by InterQual® consultants.



Episode Day



Episode Day 1

CRITICAL Genitourinary,

-Acute kidney injury, -Finding, -Intervention,

Changed: Diuretic, One: (31, 32)

Continuous and monitoring q1-2h

Bolus q1-2h and monitoring Titration q1-2h and

monitoring

To: Calcium chloride Calcium gluconate Glucose 50% (0.50) with insulin

Literature These criteria were changed based on current available evidence and are supported by InterQual® consultants.



Subset: Arrhythmia

Episode Day Level of Care/Criteria Point Revision Revision Type Rationale


Initial Review INTERMEDIATE Added: Suspected drug

toxicity requiring continuous cardiac monitoring (excludes Holter), One: Bradycardia <

60/min and symptomatic

Documented pause 3 sec

2nd degree heart block (Mobitz II)

Usability This criteria were added to be consistent with Episode Day 1.



Subset: Asthma

Episode Day

Level of Care/Criteria Point Revision Revision Type Rationale


Initial Review

OBSERVATION Changed: Asthma, Both: 1-3h after treatment with, One: Short-acting beta-agonist 3 doses ( 2 doses in pregnancy)

Outpatient treatment (includes PO) 2d

Wheezing unresolved, One: O2 sat 91-95%

(0.91-0.95) PEF or FEV1 40-69%

(0.40-0.69)

Heart rate 100-120/min, sustained

Dyspnea, One: Difficulty taking PO Prefers sitting

Talks in phrases Pulsus paradoxus 10-25

mmHg

To: Asthma, Both: Finding, One:

Failed outpatient treatment (includes PO) 2d (2)

1-3h of ED intervention with, One: Short-acting

beta-agonist plus ipratropium 3 doses

Short-acting beta-agonist plus ipratropium 2 doses in pregnancy

Symptom, Both: Wheezing unresolved Finding, One: O2 sat < 96% (0.96)

Length of Stay Criteria for majority patients were moved to Observation based on the average LOS for Asthma. InterQual® consultants agree that most asthma patients improve rapidly with treatment. In addition, included ipratropium to align with the current guidelines.



Episode Day



Peak expiratory flow (PEF) 26-69% (0.26-0.69)

Forced expiratory volume at one second (FEV1) 26-69% (0.26-0.69)

Heart rate > 100/min, sustained

Dyspnea, One: Agitation

Difficulty taking PO Hunched over position Prefers sitting

Talks in phrases Talks in words Unable to take PO

Pulsus paradoxus > 10 mmHg

Use of accessory muscles, One: Diaphragmatic

breathing Intercostal retractions Nasal flaring Suprasternal

retractions

Initial Review

ACUTE Changed: Asthma, Both: 1-3h after treatment with, One: Short-acting beta-agonist 3 doses ( 2 doses in pregnancy)


Wheezing unresolved, One: O2 sat 90% (0.90) PEF or FEV1 26-39%

(0.26-0.39)

Finding, Both: Respiratory status, One: PEF or FEV1 40-69%

(0.40-0.69) (4, 5)

O2 sat 91-95% (0.91-0.95)

Finding or risk factor, One:

Length of Stay Criteria for the majority of patients were moved to Observation based on the average LOS for Asthma. InterQual consultants agree that most asthma patients improve rapidly with treatment and only those with high risk factors or those at high risk of



Episode Day



Diabetes mellitus and blood sugar > 300 mg/dL (16.7 mmol/L)

Difficulty perceiving airflow obstruction or severity

History of, One: Sudden, severe

exacerbation Intubation Critical care

admission Pneumonia confirmed

by imaging, One:

T > 99.4°F (37.4°C) PO

WBC 13,000/cu.mm (13x109/L)

WBC 4,000/cu.mm (4x109/L)

Bands > 10% (0.10)

ANC < 500/cu.mm (500x106/L)

Severe and persistent mental illness or substance use disorder, Both:

Patient unreliable and unable to adhere to outpatient instructions or treatment (12)

Caregiver unavailable or unable to manage care


Hunched over position Talks in words Unable to take PO


Pulsus paradoxus 26-40 mmHg

Use of accessory muscles, One:

respiratory failure require admission. In addition, Included ipratropium to align with the current guidlelines.



Episode Day



Diaphragmatic breathing

Intercostal retractions Nasal flaring Suprasternal

retractions

To: Asthma, Both: 1-3h of ED intervention

with, One: Short-acting beta-agonist

plus ipratropium 3 doses


Wheezing unresolved, One: Finding, Both: Respiratory status, One: Forced expiratory

volume at one second (FEV1) 26-69% (0.26-0.69) (5, 6)

Peak expiratory flow (PEF) 26-69% (0.26-0.69) (5, 6)

O2 sat < 96% (0.96) Finding or risk factor, One: Diabetes mellitus and

blood sugar > 300 mg/dL (16.7 mmol/L)

Difficulty perceiving airflow obstruction or severity


exacerbation IntubationCritical

care admission Pneumonia confirmed

by imaging, One:

T > 99.4°F (37.4°C) PO

WBC 13,000/cu.mm (13x109/L)

WBC



Episode Day



4,000/cu.mm (4x109/L)

Bands > 10% (0.10)

ANC < 500/cu.mm (500x106/L)

Initial Review

CRITICAL Removed: Mechanical ventilation or

NIPPV

Usability This deletion deletion was made to align with global changes made to clarify the intent of the criteria.

Episode Day 1

OBSERVATION Changed: Asthma, Both: 1-3h after treatment with, One: Short-acting beta-agonist 3 doses ( 2 doses in pregnancy)


Wheezing unresolved, One: O2 sat 91-95%

(0.91-0.95) PEF or FEV1 40-69%

(0.40-0.69)

Heart rate 100-120/min, sustained

Dyspnea, One: Difficulty taking PO Prefers sitting

Talks in phrases Pulsus paradoxus 10-25

mmHg

Intervention, All:

Short-acting beta-agonist 2 doses

Corticosteroid (includes PO) Oxygenation, One:

O2 sat 96% (0.96) or baseline (G12)

O2 sat 95% (0.95) and < baseline requiring

Length of Stay Criteria for majority patients were moved to Observation based on the average LOS for Asthma. InterQual® consultants agree that most asthma patients improve rapidly with treatment. Included ipratropium to align with the current guidlelines.



Episode Day



supplemental oxygen

Oximetry or arterial blood gas

To: Asthma, Both: Finding, One:

Failed outpatient treatment (includes PO) 2d (2)

1-3h of ED intervention with, One: Short-acting

beta-agonist plus ipratropium 3 doses


Symptom, Both: Wheezing unresolved Finding, One: O2 sat < 96% (0.96) Peak expiratory flow

(PEF) 26-69% (0.26-0.69)

Forced expiratory volume at one second (FEV1) 26-69% (0.26-0.69)



Difficulty taking PO Hunched over position Prefers sitting


Pulsus paradoxus > 10 mmHg



retractions Intervention, All:



Episode Day



Corticosteroid (includes PO) Oximetry or arterial blood

gas (15, 17)

Short-acting beta-agonist 2 doses

Episode Day 1

ACUTE Changed: Asthma, Both: 1-3h after treatment with, One: Short-acting beta-agonist 3 doses ( 2 doses in pregnancy) (2)

Outpatient treatment (includes PO) 2d (3)

Wheezing unresolved, One: O2 sat 90% (0.90) PEF or FEV1 26-39%

(0.26-0.39) (4, 5)

Finding, Both: Respiratory status, One: PEF or FEV1 40-69%

(0.40-0.69) (4, 5)

O2 sat 91-95% (0.91-0.95)

Finding or risk factor, One: Diabetes mellitus and

blood sugar > 300 mg/dL (16.7 mmol/L)

Difficulty perceiving airflow obstruction or severity (8)



admission Pneumonia confirmed

by imaging, One: (9, 10)

T > 99.4°F (37.4°C) PO (G110)

WBC 13,000/cu.mm (13x109/L)

WBC

Length of Stay Criteria for the majority of patients were moved to Observation based on the average LOS for Asthma. InterQual consultants agree that most asthma patients improve rapidly with treatment and only those with high risk factors or those at high risk of respiratory failure require admission. Included ipratropium to align with the current guidlelines.



Episode Day



4,000/cu.mm (4x109/L)

Bands > 10% (0.10)

ANC < 500/cu.mm (500x106/L) (G1)

Severe and persistent mental illness or substance use disorder, Both: (11)

Patient unreliable and unable to adhere to outpatient instructions or treatment (12)


Dyspnea, One: Agitation (13)

Hunched over position Talks in words Unable to take PO

Heart rate > 120/min, sustained (G106)

Pulsus paradoxus 26-40 mmHg (7)



retractions Intervention, All: (17)

Short-acting beta-agonist 6x/24h (2)

Corticosteroid (includes PO) Oxygenation, One:

O2 sat 91% (0.91) or baseline (G12)

O2 sat 90% (0.90) and < baseline requiring supplemental oxygen (G12, G86)

Oximetry or arterial blood gas (16)



Episode Day



To: Asthma, One: Failed Observation

treatment, Both: Wheezing unresolved Finding, One: Dyspnea, One:

Agitation (7)

Difficulty taking PO Hunched over position Prefers sitting (8)


O2 sat < 96% (0.96) Peak expiratory flow

(PEF) 26-69% (0.26-0.69) (5)

Forced expiratory volume at one second (FEV1) 26-69% (0.26-0.69) (6)

Continued asthma symptoms after, Both: 1-3h of ED intervention

with, One: Short-acting

beta-agonist plus ipratropium 3 doses (3, 4)

Short-acting beta-agonist plus ipratropium 2 doses in pregnancy (3)

Wheezing unresolved, All: Finding, Both:

Respiratory status, One: Forced expiratory

volume at one second (FEV1) 26-69% (0.26-0.69) (5, 6)

Peak expiratory flow (PEF) 26-69% (0.26-0.69) (5, 6)

O2 sat < 96% (0.96)

Finding or risk factor, One:



Episode Day



Diabetes mellitus and blood sugar > 300 mg/dL (16.7 mmol/L)

Difficulty perceiving airflow obstruction or severity (10)



admission Pneumonia

confirmed by imaging, One: (11, 12)

T > 99.4°F (37.4°C) PO (G21)

WBC 13,000/cu.mm (13x109/L)

WBC 4,000/cu.mm (4x109/L)

Bands > 10% (0.10)

ANC < 500/cu.mm (500x106/L) (G1)

Intervention, All: (16)

Corticosteroid (includes PO) Oximetry or arterial blood

gas (15, 17)

Short-acting beta-agonist 6x/24h (3, 18)

Episode Day 2

ACUTE Changed: Responder, discharge

expected today if clinically stable last 12h, All:

To: Early responder, discharge

expected today if clinically stable last 12h, All:

Usability Based on the current LOS norms episode day 2 is now an early responder day.



Episode Day



Episode Day 2, 3, 4, & 5

ACUTE

-Partial responder

Changed: Wheezing unresolved,

Both: Finding, One: PEF or FEV1 40-69%

(0.40-0.69) (4, 5)

O2 sat 90% (0.90) Heart rate

100-120/min, sustained (G106)

Dyspnea, One: Difficulty taking PO Prefers sitting (6)

Talks in phrases Pulsus paradoxus

10-25 mmHg (7)

To: Continued asthma, All:

Wheezing unresolved Finding, One: Dyspnea, One:

Agitation (7)

Difficulty taking PO Hunched over position Prefers sitting (8)



O2 sat < 96% (0.96) Peak expiratory flow

(PEF) < 70% (0.70) (5)

Forced expiratory volume at one second (FEV1) < 70% (0.70) (6)

Usability InterQual consultants agree that this change aligns with more realistic severity for continued care of the asthma patient.



Subset: Carbon Monoxide Poisoning


Revision Revision Type Rationale


Episode Day 1 INTERMEDIATE

- Finding,

Changed:

Carboxyhemoglobin 30% (0.30) without mental status change

To:

Carboxyhemoglobin 30% (0.30)

Usability This change was made to clarify the intent of the criteria for Auto Review.

Episode Day 1 CRITICAL Changed: Finding, One: Carboxyhemoglobin 30% (0.30)

with mental status change (G70)

Carboxyhemoglobin 40% (0.40) Intervention, One: Hyperbaric oxygen

Mechanical ventilation or NIPPV, One:

Respiratory interventions q1-2h (G99)

Weaning 2d Oxygen 100% (1.00)

To: Carbon monoxide poisoning, Both: Finding, One: Carboxyhemoglobin 40% Neurological impairment, Both: Carboxyhemoglobin

at 30% (0.30) Mental status change Intervention, One: Hyperbaric oxygen therapy (HBOT) Oxygen 100% (1.00) Mechanical ventilation Noninvasive positive pressure ventilation (NIPPV)

Usability This criteria point was changed to more accurately reflect the criteria required to meet the Critical level of care.






Episode Day 2 ACUTE

- Responder,

Added: Temperature 99.4°F (37.4°C)

PO

O2 sat 92% (0.92) or within acceptable limits

Carboxyhemoglobin < 10% (0.10) or within acceptable limits

Neurological stability

Complication or comorbidity, One: No complication or active

comorbidity relevant to this episode of care

Complication or comorbidity and clinically stable for discharge, One

Functional impairment, One:

Discharge to home, One:

Patient or caregiver able to safely manage impairment

Home care services arranged Discharge to inpatient facility

for rehabilitative services

Literature These criteria were added based upon the current available evidence and are supported by InterQual® consultants.

Episode Day 2, 4

ACUTE

- Partial Responder,

Added: Functional impairment (new) and

rehabilitation initiation 24h, One:

Physical therapy (PT) evaluation and training

Occupational therapy (OT) evaluation and training

Speech-language evaluation and training

Cognitive evaluation and retraining

Swallowing evaluation and retraining

Post Critical care 24h Temperature > 99.4°F (37.4°C)

PO and new onset, One:

Imaging study 24h Culture pending 2d Drug-induced fever suspected

and precipitating drug discontinued 3d








- Responder,

Added: Temperature 99.4°F (37.4°C)

PO

O2 sat 92% (0.92) or within acceptable limits

Carboxyhemoglobin < 10% (0.10) or within acceptable limits

Neurological stability


Episode Day 2 INTERMEDIATE Removed: Carboxyhemoglobin 10% (0.10) and

> baseline, One:

Hyperbaric oxygen

Oxygen 100% (1.00)

Usability This criteria point was removed to more accurately reflect the criteria required to meet the Intermediate level of care.



Subset: COPD



Initial Review

Episode Day 1

OBSERVATION ACUTE INTERMEDIATE

Changed: Dyspnea unresolved

following short-acting beta-agonist 3 doses, One:

To: Dyspnea unresolved Short-acting beta-agonist

3 doses, One: Administered in the ED Administered in medical

practitioner's office


Initial Review

Episode Day 1, 2, 3-6

ACUTE Removed: Central cyanosis, new onset or worsening

Usability These criteria were removed from Acute Level of Care based upon the current available evidence and are supported by InterQual® consultants.





Initial Review INTERMEDIATE Added: Dyspnea unresolved Short-acting beta-agonist 3

doses, One: (4) Administered in the ED Administered in medical

practitioner's office Finding, One: Arterial Po2 40-55 mmHg

(5.3-7.3 kPa) and pH 7.50-7.55 (5)

Arterial Pco2 55-59 mmHg (7.3-7.9 kPa) and pH 7.25-7.30 (5)

Central cyanosis, new onset (G13)

Central cyanosis, worsening (G13)

O2 sat, One: < 89% (0.89) and <

baseline (G6) Room air assessment

not clinically appropriate (26)

Venous Pco2 55-59 mmHg (7.3-7.9 kPa) and pH 7.25-7.30 (5)

Intervention, One: Oxygen 40% (0.40)


Literature These criteria were added based on the best available evidence and are supported by InterQual® consultants.






Dyspnea unresolved following short-acting beta-agonist 3,

Changed: O2 sat, One:

< 89% (0.89) and < baseline (G12)

Room air assessment not clinically appropriate (36)

Arterial Po2 40-55 mmHg (5.3-7.3 kPa*) and pH 7.50-7.55 (4)

Arterial or venous Pco2 55-59 mmHg (7.3-7.9 kPa) and pH 7.25-7.30 (4)

To: Finding, One: Arterial Po2 40-55 mmHg

(5.3-7.3 kPa) and pH 7.50-7.55


Central cyanosis, new onset

Central cyanosis, worsening

O2 sat, One: < 89% (0.89) and <

baseline Room air assessment

not clinically appropriate


Consensus This change was made to clarify the intent of the criteria and supported by InterQual® consultants.





Episode Day 2, 3, 4, 5, & 6

ACUTE Early/Responder, Complication or comorbidity, Complication or comorbidity and clinically stable for discharge, New onset infection,

Added: WBC > 4,000/cu.mm (4 x109/L)


Episode Day 2, 3, 4, 5, & 6

ACUTE Partial Responder, New onset infection, actual or suspected,

Added: WBC < 4,000/cu.mm (4 x109/L)


Episode Day 2, 3-6

CRITICAL Added: Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS)

Evidence These criteria were added based on the best available evidence and are supported by InterQual® consultants.



Subset: Cystic Fibrosis



Episode Day 1 ACUTE

-Pulmonary exacerbation,

-Finding,

Changed: Failed outpatient treatment

To:

Failed outpatient treatment, All:

Anti-infective (new) Nebulizer treatment, One: Nebulizer treatment,

increased frequency Nebulizer treatment,

increased dose No evidence of clinical

improvement

Literature This criteria point was changed to more accurately reflect the criteria required to meet the Acute level of care.

Episode Day 1 ACUTE

-Pulmonary exacerbation,

-Finding,

-Pulmonary function,

Changed: FEV1 decreased by 10%

(0.10) from baseline and performed within last 14 days

To:

FEV1 performed within last 3 months

Literature







-Respiratory insufficiency,

-Finding,

Changed: Arterial Po2 < 56 mmHg (7.4

kPa) Arterial Pco2 > 50 mmHg

(6.7 kPa) and pH < 7.35 without mental status change

Venous Pco2 > 55 mmHg (7.3 kPa) and pH < 7.35 without mental status change

To: Arterial Po2 40-54 mmHg

(5.3-7.2 kPa) Arterial Pco2 50-59 mmHg

(6.7-7.9 kPa) and pH < 7.35 without mental status change

Venous Pco2 50-59 mmHg (6.7-7.9 kPa) and pH < 7.35 without mental status change

Literature This criteria point was changed to more accurately reflect the clinical complexity required for care at the Intermediate level of care.


-Respiratory insufficiency,

-Intervention,

Changed: Anti-infective Respiratory interventions

q3-4h, One:

NIPPV

Oxygen 40% (0.40)

To: Anti-infective Oxygen, One: Respiratory intervention,

Both:

Intervention, One: High flow nasal

cannula (HFNC) (10)

Oxygen 40% (0.40)

Respiratory interventions every 3-4h

Noninvasive positive pressure

ventilation(NIPPV)

Literature






Episode Day 1 CRITICAL

Changed: Massive hemoptysis and hemodynamic

instability, Both:

To: Hemoptysis, All:

Hemoptysis > 240ml/24h

Literature


Episode Day 2-5, & 6-13

CRITICAL

Changed: Massive hemoptysis, One: Lung resection required (use

General Surgical subset)

Hemodynamic instability, One:

Blood product transfusion Bronchial artery embolization

performed within last 24h

Post bronchial artery embolization monitoring 24h

To: Hemoptysis > 240ml/24h, One:

Lung resection required (use General Surgical subset)

Blood product transfusion Bronchial artery embolization

performed within last 24h

Post bronchial artery embolization monitoring 24h

Literature







Removed: Respiratory failure, actual or

impending, Both: Finding, One:

Arterial Pco2 > 50 mmHg (6.7 kPa) and pH < 7.25

Increasing muscle fatigue

Mental status change

Mechanical ventilation or NIPPV, One:


Weaning 2d

Usability These criteria were removed to streamline the review process.

Episode Day 1, 2-5, & 6-13

INTERMEDIATE

Added: Oxygen, One:

High flow nasal cannula (HFNC) and respiratory monitoring every 3-4h

Oxygen 40% (0.40)

Consensus


Episode Day 1, 2-5, & 6-13

CRITICAL

Added: Oxygen, Both: High flow nasal cannula

(HFNC)

Respiratory monitoring every 1-2h

Consensus






Episode Day 2-5, & 6-13

CRITICAL

Added: Extracorporeal membrane

oxygenation (ECMO) or extracorporeal life support (ECLS)

Consensus This criteria point was changed to more accurately reflect the clinical complexity required for care at the Critical level of care and are supported by InterQual® consultants.



Subset: Dehydration or Gastroenteritis

Episode Day

Level of Care/Criteria Point Revision Revision

Type Rationale Potential Care Management Impact ()

All Episode Days

GLOBAL The specific conditions of dehydration and gastroenteritis have been removed from General Medical and are now combined into a new subset titled Dehyration or Gastroenteritis.


Episode Day 1

OBSERVATION Gastrointestinal,

Changed: Dehydration, Both:

To: Dehydration or gastroenteritis, One:




Episode Day



Episode Day 1

ACUTE Dehydration or gastroenteritis,

Changed: Finding, Two:

BUN > 45 mg/dL (16.1 mmol/L) or creatinine > 3.0 mg/dL (265.2 mol/L) and > baseline (G12)

Heart rate, sustained > 100/min (G106) Inadequate oral intake (G62) Mental status change (excludes coma,

stupor, obtundation) (G70) Orthostatic hypotension, Both: Sustained drop in blood pressure

within 3 min of sitting or standing (G106)

Blood pressure, One: Systolic BP drop 20 mmHg Diastolic BP drop 10 mmHg

Sodium > 150 mEq/L (150 mmol/L) Urine specific gravity > 1.030 Vomiting, persistent and unresponsive

to 2 doses antiemetic (5)

Intervention, One:

To: Failed Observation Intervention, One:

Literature

Consensus-based

This criteria point was added based on the current available length of stay evidence and is supported by InterQual® consultants.



Subset: Diabetic Ketoacidosis (DKA)



All Episode Days

GLOBAL ACUTE CRITICAL

Added: Beta-hydroxybuterate

Literature This lab value was added to the criteria point for ketones because the presence of beta-hydroxybuterate is indicative of ketosis based on the best available evidence and is supported by InterQual® consultants.


ACUTE Removed: Hyponatremia, Both: Sodium 120-129 mEq/L

(120-129 mmol/L) Intervention, One: Diuretic and oral sodium

supplement Fluid restriction Medication administration, One: Demeclocycline (includes

PO) Diuretic 2x/24h Tolvaptan (includes PO)

Consensus-based

InterQual® consultants agree that this is not a common co-morbid condition associated with diabetic ketoacidosis.





Episode Day 4 & 5

ACUTE

-Partial responder, not clinically stable for discharge and requires continued stay,

Removed: Finding, One: Ketonemia Ketonuria

Consensus-based

InterQual® consultants agree that diabetic ketoacidosis should be resolved within the first 72 hours of admission.



Subset: Extended Stay



All Episode Days GLOBAL

ACUTE

INTERMEDIATE

CRITICAL

Bone Marrow Transplant (BMT) and Stem Cell Transplant (SCT) criteria have been removed from the Extended Stay subset. Criteria for these conditions can be found in the Bone Marrow Transplant/Stem Cell Transplant (BMT/SCT) subset.



Subset: General Medical




All Episode Days GLOBAL

The following conditions have been removed from the General Medical subset and separated into their own condition-specific subsets. Redirection links have been provided.

Acute Kidney Injury (AKI)

Bone Marrow Transplant/Stem Cell Transplant (BMT/SCT)

Dehydration or Gastroenteritis

Hematology/Oncology: Acute Leukemia or Lymphoma

Hematology/Oncology: Brain Malignancy or Metastasis

Hematology/Oncology: Chemotherapy

Hematology/Oncology: Hemolytic Uremic Syndrome

Hematology/Oncology: Malignant Disease

Hematology/Oncology: Tumor Lysis Syndrome

Infection: General

Usability This change was made to streamline the review process.






Infection: Sepsis


Withdrawal Syndrome

Episode Day 2 OBSERVATION

The Observation level of care has been removed from Episode Day 3 for all conditions. Episode Day 2 is now the Non-responder day.

Length of stay

This change was made to align with the current length of stay data.

Episode Day 3-X ACUTE

INTERMEDIATE CRITICAL

This year condition specific length of stay endpoints were added to align with current length of stay data for the following conditions. The length of stay number represents days since onset of condition.

Condition LOS

Pericardial effusion 7d

Pericarditis 6d

Peripheral artery occlusion

7d

Hyphema 6d

Intraocular pressure ≥ 25 mmHg

5d

Ascites 7d

Bowel obstruction 7d

Length of stay

This change was made to align with the most current length of stay data.






Hepatic encephalopathy

7d

Ileus 7d

Jaundice or bilirubin > 2.5 mg/dL

6d

Pancreatitis, chronic 6d

Obstruction of bladder

6d

Obstruction of renal pelvis

4d

Obstruction of ureter

5d

Obstruction of urethra

7d

Nephrotic syndrome 7d

Hyperviscosity syndrome

6d

Thrombocytopenia 7d

Pulmonary infiltrate (non-infectious)

6d

Upper airway mass 7d

Hepatorenal syndrome and creatinine > 1.5 mg/dL

8d






Ventriculostomy 6d

Graft versus host disease

7d

Post lung transplant and suspected rejection

8d

Pulmonary arterial hypertension

7d

Disseminated intravascular coagulation

7d



Subset: General Surgery



N/A GLOBAL Extensive restructuring has occurred in the General Surgical subset. The days now appear as Pre-op day, Operative Day, and Post-op Day 1, 2, and 3-21. At the Acute level of care, all three responder types (Responder, Partial responder, and Non-responder) appear on Episode Day 3-21. The solid organ transplant criteria has also been incorporated into this subset.

Post-op Day 1

ACUTE Total hip or knee replacement note

Changed:

Moderate or long stay surgery

To:

Short stay surgery

Consensus This note was changed based upon current available evidence and are supported by InterQual® consultants.



Subset: General Transplant




N/A GLOBAL

The solid organ transplant criteria has been incorporated into the General Surgical Subset. The bone marrow and stem cell transplant criteria is now a new subset called Bone Marrow Transplant/Stem Cell Transplant (BMT/SCT).



Subset: General Trauma



Global

(All Episode Days)

OBSERVATION

ACUTE

INTERMEDIATE

CRITICAL

The following conditions have been removed from the General Trauma subset and separated into their own condition-specific subsets. Redirection links have been provided.


Electrolyte and Mineral Imbalance

Usability This change was made to streamline the review process.





Initial Review

Episode Day 1

ACUTE

-Musculoskeletal,

Changed: Fracture, subluxation, or dislocation,

One: Finding, One: Fracture, subluxation, or dislocation

of cervical, thoracic, or lumbar spine (excludes uncomplicated compression fractures)

Dislocation of a major joint prosthesis

To: Fracture, One:

Cervical spine (excludes uncomplicated compression fractures)

Thoracic spine (excludes uncomplicated compression fractures)

Lumbar spine (excludes uncomplicated compression fractures)

Subluxation, One:




Dislocation, One:





Usability These criteria were changed to streamline the review process.





Initial Review

CRITICAL

-Neurological,

Changed: Acute head injury requiring serial CT,

One: Finding, One: Epidural hematoma

Subdural hematoma Intraparenchymal contusion or

hematoma Subarachnoid hemorrhage

To: Hematoma, contusion, or

hemorrhage, One: Epidural hematoma

Subdural hematoma Intraparenchymal contusion Intraparenchymal hematoma Subarachnoid hemorrhage



-Neurological,

Changed: Acute head injury requiring serial CT,

Both: Finding, One: Epidural hematoma

Subdural hematoma Intraparenchymal contusion or

hematoma Subarachnoid hemorrhage Neurological assessment q1-2h, 2d

To: Hematoma, contusion, or hemorrhage,

Both: Finding, One: Epidural hematoma

Subdural hematoma Intraparenchymal contusion Intraparenchymal hematoma Subarachnoid hemorrhage

Intervention, Both: Follow up computed tomography

(CT)

Neurological assessment every 1-2h, 2d






Initial Review

Episode Day 1

CRITICAL

-Neurological,

-Finding,

Changed: Increased ICP

To: Intracranial pressure (ICP) 20 mmHg

Literature

These criteria were changed based upon the current available evidence and are supported by InterQual® consultants.

Initial Review

Episode Day 1

CRITICAL

-Neurological,

-Head trauma,

-Finding,

Changed: Seizures, One:

Abnormal CT or MRI Continuous or intractable

To: Seizure, One:

Recurrent seizure Refractory seizure

Literature







-General,

-Organ injury,

Changed: Spleen or liver injury, Both: (13)

Grade I (14)

Requiring Hct or Hb monitoring at least 4x/24h

To: Spleen injury, Both:

Spleen injury, Grade I

Finding, One: Hct monitoring at least 4x/24h Hb monitoring at least 4x/24h

Liver injury, Both:

Liver injury, Grade I

Finding, One: Hct monitoring at least 4x/24h Hb monitoring at least 4x/24h



-General,

-Organ injury,

Changed: Suspected with non-diagnostic exam,

Both: CT, MRI, or ultrasound, scheduled

or performed within 24h To:

Organ injury suspected with non-diagnostic exam

Imaging, One: Computed tomography (CT),

One: Performed within 24h Scheduled within 24h

Magnetic resonance imaging (MRI), One: Performed within 24h Scheduled within 24h

Ultrasound, One: Performed within 24h Scheduled within 24h







-Neurological,

-Finding,

Changed: Concussion with loss of consciousness Disorientation Increasing lethargy or irritability Increasing headache or unsteady gait Vomiting > 2x and 3d post head

injury

To: Concussion with loss of consciousness Disorientation Irritability Lethargy Headache Unsteady gait Head injury, Both: 3d post injury Vomiting > 2x



-Respiratory,

-Nonfatal drowning,

Changed: Requiring supplemental oxygen

To: Respiratory monitoring at least every

4h

Usability This criteria point was added to encompass the appropriate monitoring that can be safely provided at the Observation level of care.






-Respiratory,

-Smoke inhalation,

Changed: O2 sat 91% (0.91) and <

baseline (G12)

To: O2 sat 89-91% (0.89-0.91) and <

baseline

Usability These criteria were changed based upon the current available evidence and are supported by InterQual® consultants.





Episode Day 1 ACUTE

-General,

Changed: Spleen or liver injury, Both:

Finding, One:

Grade II Grade III

Intervention, One: Monitoring for progression of

symptoms, Both: NPO and IV fluid, One:

75 mL/h, One: Weight < 60 kg Age 65 Renal insufficiency

Heart failure, chronic 100 mL/h and weight 60 kg


Blood product transfusion To:

Liver injury, Both:

Finding, One:

Liver injury, Grade II Liver injury, Grade III

Intervention, One: Hb monitoring at least 4x/24h Hct monitoring at least 4x/24h Blood product transfusion

Spleen injury, Both:

Finding, One:

Spleen injury, Grade II Spleen injury, Grade III

Intervention, One: Hb monitoring at least 4x/24h Hct monitoring at least 4x/24h

Blood product transfusion






Episode Day 1 ACUTE

-Eye,

-Hyphemia,

Changed: Patient or caregiver unable to

adhere to treatment regimen To:

Outpatient management, One: Patient unable to adhere to

treatment regimen Caregiver unable to adhere to


Episode Day 1 ACUTE

-Musculoskeletal,

Changed: Fracture, subluxation, or dislocation,

Both: Finding, One: Fracture, subluxation, or dislocation

of cervical, thoracic, or lumbar spine (excludes uncomplicated compression fractures) (2)

Fracture of femur, hip, or pelvis and not a surgical candidate (31, 32)


To: Fracture, subluxation, or dislocation,

Both: Finding, One: Fracture, One:




Not a surgical candidate, Fracture of femur and not a

surgical candidate Fracture of hip and not a

surgical candidate Fracture of pelvis and not a

surgical candidate Subluxation, One:









Dislocation, One:





Episode Day 1 ACUTE

-Musculoskeletal,

-Fracture, subluxation or dislocation,

-Intervention,

Changed: Traction (includes OR placement) 4d, One: Application of Halo traction

(initial)

Continuous or cyclic regimen of skeletal or pelvic traction

Skeletal traction (Crutchfield tongs)

To: Traction, One:

Initial application of Halo traction (includes OR placement), 4d

Pelvic traction, One: Continuous, 4d Cyclic, 4d

Skeletal traction, One: Continuous, 4d Cyclic, 4d

Crutchfield cervical tongs (includes OR placement), 4d






Episode Day 1 ACUTE

-Skin,

-Burn,

-Finding,

Changed: Involving face, genitalia, hands,

feet, or joint To:

Affected site, One: Face Feet Genitalia Hands Joint


Episode Day 1 ACUTE

-Skin,

-Burn,

-Burn therapy,

Changed: O2 sat 91% (0.91) and < baseline requiring supplemental oxygen

To: O2 sat 89-91% (0.89-0.91) and < baseline requiring supplemental oxygen

Consensus based

This change was made to clarify the intent of the criteria and supported by InterQual® consultants.






-General,

-High risk trauma,

-Finding,

Changed: Ejection from vehicle, One: Partial Complete

Intrusion into vehicle (including roof), One: > 12 inches (30.4 cm)

occupant site > 18 inches (45.7 cm) other

site Motorcycle crash > 20 mph (32.2

kph) Pedestrian or bicyclist, One: Thrown Run over Impact > 20 mph (32.2 kph)

To: Partial ejection from vehicle Complete ejection from vehicle Intrusion into vehicle (including

roof) > 12 inches (30.4 cm) occupant site

Intrusion into vehicle (including roof) > 18 inches (45.7 cm) other site

Motorcycle crash > 20 mph (32.2 kph)

Pedestrian, One: Pedestrian thrown Pedestrian run over Impact > 20 mph (32.2 kph)

Bicyclist, One: Bicyclist thrown Bicyclist run over Impact > 20 mph (32.2 kph)







-Respiratory,

Added: Oxygen, One:

High flow nasal cannula (HFNC) and respiratory monitoring every 3-4h

Literature

These criteria were added based on the best available evidence and are supported by InterQual® consultants.






-General,

Removed: Acute kidney injury,

Finding, One: Potassium > 6.0 mEq/L (6.0

mmol/L), AV dissociation Loss of P wave Multifocal PVCs Neuromuscular deficit Ventricular fibrillation


Widening QRS Sodium, One:

< 120 mEq/L (120 mmol/L) and volume overload

> 160 mEq/L (160 mmol/L) Hemodynamic instability,


Systolic BP, One: < 90 mmHg without chronic



baseline

Labile

Mean arterial pressure < 65 mmHg

Intervention, One: IV fluid resuscitation

Diuretic, One:

Continuous and monitoring q1-2h Bolus q1-2h and monitoring Titration q1-2h and monitoring

Dialysis, One: Hemodialysis 7d since initiation Peritoneal dialysis 7d since

initiation Continuous renal replacement

therapy







-General,

Changed: Spleen or liver injury,

Grade IV or V, One:

Monitoring for progression of symptoms, Both: NPO and IV fluid, 75 mL/h,

Weight < 60 kg Age 65 Renal insufficiency

Heart failure, chronic 100 mL/h and weight 60 kg


Blood product transfusion Angioembolization

To:

Liver injury, One:

Liver injury, Both:

Grade, One:

Liver injury Grade IV

Liver injury Grade V

Intervention, One: Hct or Hb monitoring, One: Hb monitoring at least 4x/24h Hct monitoring at least 4x/24h


Spleen injury, One:

Spleen injury, Both:

Grade, One:

Spleen injury Grade IV

Spleen injury Grade V

Intervention, One: Hct or Hb monitoring, One: Hb monitoring at least 4x/24h Hct monitoring at least 4x/24h








- Cardiovascular or peripheral vascular,

Changed: Cardiac tamponade or pericardial

effusion, One: Pericardial drain Pericardiocentesis

To:

Cardiac tamponade, One: Pericardial drain Pericardiocentesis

Pericardial effusion, One: Pericardial drain Pericardiocentesis



- Cardiovascular or peripheral vascular,

Changed: Cardiac tamponade or pericardial

effusion, One: Insertion of pericardial drain

performed within last 24h Pericardiocentesis performed within

last 24h To:

Cardiac tamponade, One: Insertion of pericardial drain

performed within last 24h Pericardiocentesis performed within

last 24h Pericardial effusion, One:

Insertion of pericardial drain performed within last 24h

Pericardiocentesis performed within last 24h


Episode Day 2 ACUTE

-General,

Changed; Bleeding, Both: To: Bleeding, actual or suspected, Both






Episode Day 2, 3-X

ACUTE

-General,

-Spleen or liver injury,

-Intervention,

Removed: Monitoring for progression of

symptoms, Both: IV fluid or advancing diet as

tolerated


Episode Day 2 ACUTE

-Musculoskeletal

-Fracture, subluxation, or dislocation,

-Traction,

Changed: Skeletal traction (Crutchfield tongs)

To:

Crutchfield cervical tongs

Literature


Episode Day 3-X ACUTE

-Eye,

-Responder,

Removed: Ocular foreign body, Both:

Status post removal Intraocular pressure within

acceptable limits

Literature This criteria point was removed to align with length of stay data.


opyright 2018 Change Healthcare LLC and/or one of its subsidiaries. All Rights Reserved. Produced in Cork, Ireland.

Subset: Heart Failure




Initial Review

Episode Day 1

OBSERVATION

Changed: O2 sat 89-91% (0.89-0.91) and

< baseline after at least 2h treatment Dyspnea and not returned to baseline

after at least 2h treatment

To: O2 sat 89-91% (0.89-0.91) O2 sat < baseline after at least 2 doses

of diuretics

Dyspnea and not returned to baseline after at least 2 doses of diuretic

Usability This criteria point was added to more accurately reflect the criteria required to meet the Observation level of care.

Initial Review

Episode Day 1

ACUTE

- Finding,

Changed: Dyspnea and not returned to baseline

after at least 2h treatment, One:

To: Persistent dyspnea, Both:

Dyspnea and not returned to baseline after at least 2 doses of diuretic

Usability This criteria point was added to more accurately reflect the criteria required to meet the Acute level of care.

Initial review

Episode Day 1

ACUTE

- Clinical risk factor,

Removed:

Cardiac troponin, positive

Literature This criteria point was removed to more accurately reflect the criteria required to meet the Acute level of care.






Initial Review

Episode Day 1

ACUTE

- Clinical risk factor,

Changed: Severe and persistent mental illness

or substance use disorder, Both:

Patient unreliable and unable to adhere to outpatient instructions or treatment


To: Mental illness, All:

Severe and persistent mental illness

Patient unreliable

Risk for non-adherence, One: Unable to adhere to outpatient

instructions

Unable to adhere to outpatient treatment

Caregiver, One: Unable to manage care Unavailable

Substance use disorder, All:

Severe and persistent substance use disorder

Patient unreliable

Risk for non-adherence, One: Unable to adhere to outpatient

instructions

Unable to adhere to outpatient treatment

Caregiver, One: Unable to manage care Unavailable

Usability These criteria were changed to streamline the Auto Review process.

Initial Review

Episode Day 1

CRITICAL Removed: IABP

Literature This criteria point was removed to more accurately reflect the criteria required to meet the Critical level of care.






Episode Day 2, 3, 4-7

CRITICAL Changed: Arrhythmia, Both: ECG finding, One:

Atrial fibrillation, atrial flutter, or supraventricular tachycardia and hemodynamic instability

Ventricular fibrillation Ventricular tachycardia Wide complex tachycardia

Intervention, One: Electrical or chemical cardioversion

Defibrillation

To: Arrhythmia, One: Urgent electrical cardioversion performed

within last 24h Defibrillation performed within last 24h Temporary pacemaker insertion

performed within last 2d Antiarrhythmic, All:

IV antiarrhythmic Arrhythmia, One: Recurrent arrhythmia

Refractory arrhythmia

Symptomatic, One: Chest pain Heart failure, Both:

Heart failure Finding, One: Arterial Po2 < 56 mmHg (7.4 kPa) O2 sat < 89% (0.89) and <

baseline Hemodynamic instability, One:





baseline

Labile








Episode Day 1 CRITICAL Changed: Arrhythmia, Both: ECG finding, One:

Atrial fibrillation, atrial flutter, or supraventricular tachycardia and hemodynamic instability

Ventricular fibrillation Ventricular tachycardia Wide complex tachycardia

Intervention, One: Electrical or chemical cardioversion

Defibrillation

To: Arrhythmia, One: Antiarrhythmic, All:

IV antiarrhythmic Arrhythmia, One: Recurrent arrhythmia

Refractory arrhythmia

Symptomatic, One: Chest pain Heart failure, Both:

Heart failure Finding, One: Arterial Po2 < 56 mmHg (7.4 kPa) O2 sat < 89% (0.89) and <

baseline Hemodynamic instability, One:





baseline

Labile





Subset: Hematology/Oncology: Acute Leukemia or Lymphoma


Revision Revision Type

Rationale Potential Care Management Impact ()

All Episode Days GLOBAL This subset is a breakout subset from General Medical. Criteria from the General Medical: Hematology or Oncology section was used to create this subset.


Episode Day 1 ACUTE

-Acute leukemia or lymphoma suspected,

-Finding,

-WBC,

Removed: ANC < 1,000/cu.mm (1000x106/L)

Consensus based

InterQual® consultants agree that patients undergoing chemotherapy would not have a low ANC.



Subset: Hematology/Oncology: Chemotherapy




All Episode Days

GLOBAL

This subset is a breakout subset from General Medical. Criteria from the General Medical: Hematology or Oncology was used to create this subset.


Episode Day 1 OBSERVATION Added: OBSERVATION, Both:

Vomiting and failed outpatient antiemetic

Intervention, One: Antiemetic, One:

3x/24h Dexamethasone

Serotonin antagonist at least daily

IV fluid, One:


Heart failure, chronic 100 mL/h and weight

60 kg

Consensus based

InterQual® consultants agree that patients with vomiting can be treated safely in the observation level of care.






Episode Day 1 ACUTE

-Chemotherapy,

-Adverse effect during or post chemotherapy administration,

-Gastrointestinal,

-Finding,

Changed:

Vomiting and failed outpatient antiemetic

To: Vomiting and failed Observation

level of care

Usability The criteria was changed to allow treatment at the Acute level of care for patients that have failed the Observation level of care.



Subset: Hematology/Oncology: Hemolytic Uremic Syndrome




All Episode Days

GLOBAL This subset is a breakout subset from General Medical. Criteria from the General Medical: Hematology or Oncology section was used to create this subset.


Episode Day 1

ACUTE

-Hemolytic uremic syndrome,

Changed: Hb or Hct monitoring at least 2x/24h, One: Apheresis

Dialysis (initial) and 7d since initiation, One:

Hemodialysis Peritoneal

FFP Immunosuppressant

To: Intervention, One:

Hct monitoring at least daily Hb monitoring at least daily

Treatment, One: Apheresis



Fresh frozen plasma (FFP)

Immunosuppressant

Consensus based

InterQual® consultants agree that the frequency of lab monitoring of at least once daily is appropriate.






Episode Day 1

INTERMEDIATE Added: Hyperkalemia, All:

Potassium > 6.0 mEq/L (6.0 mmol/L) Electrocardiogram (ECG) changes, One:

Peaked T waves Premature ventricular contractions

(PVCs) > 6/min Intervention, One:

Calcium chloride Calcium gluconate Glucose 50%(0.50) with insulin

Seizure, Both: Seizure activity resolved Anticonvulsant, continuous

Consensus based

These criteria were added for patients requiring interventions at the Intermediate level of care who are hemodynamically stable.

Episode Day 1

CRITICAL

-Hemolytic uremic syndrome,

-Intervention,

Added: Hemolytic uremic syndrome, Both:

Finding, One: Potassium > 6.0 mEq/L (6.0 mmol/L), One: Atrioventricular (AV) dissociation Loss of P wave Multifocal premature ventricular

contractions (PVCs) Neuromuscular deficit



Widening QRS Sodium, One: < 120 mEq/L (120 mmol/L) and

volume overload > 160 mEq/L (160 mmol/L)

Intervention, One: Calcium chloride Calcium gluconate IV fluid resuscitation 2d

Diuretic, continuous Dialysis, One: Continuous renal replacement

therapy (CRRT)

Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation

Glucose 50% (0.50) with insulin

Usability These criteria were added for patients requiring interventions at the Critical level of care.



Subset: Hematology/Oncology: Malignant Disease



All Episode Days



Episode Day 1 ACUTE

-Malignant disease,

Changed: Spinal cord

compression by imaging, One: Corticosteroid 2d Radiation 2d

To: Spinal cord

compression, One: Corticosteroid 2d

since initiation Radiation 2d since

initiation

Usability This criteria was changed to clarify the intent of the criteria.



Subset: Hematology/Oncology: Tumor Lysis Syndrome




All Episode Days



Episode Day 1 ACUTE

-Tumor lysis syndrome,

-Finding,

Changed: Laboratory monitoring at

least 4x/24h

To: Laboratory monitoring, One:

Low risk and laboratory monitoring at least daily

Consensus based

InterQual® consultants agree that the frequency of lab monitoring of at least once daily is appropriate for patients at low risk of developing tumor lysis syndrome.

Episode Day 1 ACUTE

-Tumor lysis syndrome,

Added: Hemodialysis ≤ 7d since

initiation

Consensus based

This criteria was added to accommodate patients with tumor lysis syndrome who require hemodialysis.






Episode Day 1 CRITICAL Added: Tumor lysis syndrome, Both:

Finding, One: Hyperkalemia, Both: Potassium > 6.0

mEq/L (6.0 mmol/L), Finding, One:

Atrioventricular (AV) dissociation

Loss of P wave Multifocal premature

ventricular contractions (PVCs)

Neuromuscular deficit



Widening QRS Sodium, One: < 120 mEq/L (120

mmol/L) and volume overload

> 160 mEq/L (160 mmol/L)

Intervention, One: Calcium chloride Calcium gluconate IV fluid resuscitation

2d

Dialysis, One: Continuous renal

replacement therapy (CRRT)

Hemodialysis 7d since initiation

Peritoneal dialysis 7d since initiation

Glucose 50% (0.50) with insulin

Usability This criteria was added to accommodate patients with tumor lysis syndrome who require treatment at the Critical level of care.



Subset: Hyperglycemia




Initial Review

Episode Day 1

ACUTE

-Diabetes mellitis and blood sugar > 500 mg/dL without ketonuria or ketonemia,

-Finding

Changed: Mental status change

(excludes coma, stupor, and obtundation)

To: Mental status change

(excludes coma, stupor, and obtundation) or Glasgow Coma Scale 9-14

Usability Clarifies the intent of the criteria. Glascow Coma Scale 9-14 is included in mental status change.

Episode Day 4 ACUTE


Removed: Blood sugar, All:

Finding, One: > 250 mg/dL

(13.9 mmol/L) < 70 mg/dL (3.9

mmol/L) Blood sugar monitoring at

least 4x/24h

Medication adjustment, One:

Insulin, One:

Continuous IV 2x/24h SC or IM injection

4x/24h Oral hypoglycemic

agent

Consensus-based

InterQual® consultants agree that diabetic ketoacidosis should be resolved within the first 72 hours of admission.



Subset: Hypertensive Disorders of Pregnancy




-Rule out preeclampsia,

-Laboratory evaluation,

-Urine protein analysis,

Changed: Urine protein analysis, One:

24h urine collection Protein:creatinine ratio Reagent-strip test

To: Urine protein analysis, One:

24h urine collection Random urine sample Reagent-strip test

Usability This criteria point was changed to clarify the intent of the criteria.

Episode Day 1 ACUTE

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) 2d

Changed: HELLP syndrome (hemolysis,

elevated liver enzymes, low platelets) 2d, All:

Platelet count 50,000-100,000/cu.mm (50-100x109/L)

To: Hemolysis, elevated liver

enzymes, low platelets (HELLP) syndrome 2d, All:

Aspartate aminotransferase (AST) or alanine aminotransferase (ALT) > 70 U/L (1.17 kat/L)


Finding, One: Fragmented or contracted red

cells on blood smear Total serum lactate

dehydrogenase (LDH) 600 IU/L (10.02 kat/L)

Total bilirubin > 1.20 mg/dL (20.52 mol/L)

Literature These criteria were changed based on the current available evidence to define the findings associated with hemolysis, elevated liver enzymes, low platelet syndrome. This change is supported by InterQual® consultants.





Episode Day 1 CRITICAL Added: Acute kidney injury (AKI), Both:


mmol/L), One: Atrioventricular (AV)

dissociation Loss of P wave Multifocal premature







> 160 mEq/L (160 mmol/L)

Intervention, One: IV fluid resuscitation 2d

Diuretic, continuous Dialysis, One: Hemodialysis 7d since

initiation Peritoneal dialysis 7d

since initiation

Consensus-based

These acute kidney injury (AKI) criteria were added to address the complications and management of acute kidney injury.

Episode Day 1, 2, 3, 4, & 5

CRITICAL Added: Continuous renal replacement

therapy (CRRT)

Consensus-based

The continuous renal replacement therapy (CCRT)criteria were added to address the management of acute kidney injury in the Critical level of care.





Episode Day 1, 2, 3, 4, & 5

CRITICAL Added: Heart failure, All: Heart failure Finding, One:

Arterial Po2 < 56 mmHg (7.4 kPa)

O2 sat < 89% (0.89) and < baseline

Intervention, One: Diuretic, continuous Diuretic, every 1-2h

Consensus-based

Heart failure criteria were added to address the management of this disorder in the Critical level of care.

Episode Day 1, 2, 3, 4, & 5

CRITICAL

Hemodynamic instability,

Changed: Hemodynamic instability, One:

Blood product transfusion IV fluid resuscitation 2d

To: Hemodynamic instability, Both: Finding, One:


Systolic blood pressure, One: < 90 mmHg without

chronic hypertension < 110 mmHg with chronic


baseline (G6)

Labile (23)


Intervention, One: Blood product transfusion IV fluid resuscitation 2d

Literature These criteria were changed based on the current available evidence to define the findings associated with hemodynamic instability. This change is supported by InterQual® consultants.






ACUTE Changed: Delivery, One: Use Labor and Delivery

subset Planned within 48h, Both:

< 34 wks gestation Corticosteroid administered

within last 48h

To: Delivery, One: Use Labor and Delivery

subset Planned within 48h, Both:

24 and 34 wks gestation

Corticosteroid administered within last 48h




Subset: Hypoglycemia



Initial Review

Episode Day 1

OBSERVATION

ACUTE

CRITICAL

-Hypoglycemia,

Changed: Blood sugar < 70 mg/dL

(3.9 mmol/L) upon presentation

To: Blood sugar < 70 mg/dL

(3.9 mmol/L) prior to initiation of treatment

Usability Clarifies the intent of the criteria.

Initial Review

Episode Day 1

ACUTE

Hypoglycemia,

Changed: Mental status change,

persistent (excludes coma, stupor, and obtundation)

To: Mental status change,

persistent or Glasgow Coma Scale (GCS) 9-14 after glucose treatment (excludes coma, stupor, and obtundation)


Initial Review

Episode Day 1

CRITICAL

Hypoglycemia,

-Finding,

Added: Glasgow Coma Scale

(GCS) 8






Episode Day 2 ACUTE


Removed: Acute kidney injury,

Both:

Finding, One: Urine output < 0.5

mL/kg/h Creatinine, One:

1.5x baseline and > ULN (G12)

1.5x ULN GFR > 25% (0.25)

decrease from baseline

Dialysis initiated Intervention, One: Volume expander

2d

Diuretic 2x/24h, 3d

Medication adjustment or discontinuation 3d, One:

Diuretic (includes PO)

Nephrotoxic agent (includes PO)



Dialysis discontinued and renal function monitoring 2d since discontinuation

Consensus- based

InterQual® consultants agree that acute kidney injury is not a common comorbid condition in patients with acute hypoglycemia.


-Hypoglycemia resolved,

Added: Blood sugar 70 mg/dL

(3.9 mmol/L)






Episode Day 2 CRITICAL Changed: Neurological assessment

q1-2h, 2d

To: Neurological impairment or

condition, Both:

Finding, One: Acute onset Deterioration

Neurological assessment every 1-2h, 2d


Episode Day 4 ACUTE


Removed: Blood sugar, All:

Finding, One: > 250 mg/dL

(13.9 mmol/L) < 70 mg/dL (3.9

mmol/L) Blood sugar monitoring

at least 4x/24h Medication adjustment, One:

Insulin, One:

Continuous IV 2x/24h SC or IM injection

4x/24h Oral hypoglycemic

agent

Consensus- based

InterQual® consultants agree hypoglycemia should be resolved within 72 hours.



Subset: Infection: General



All Episode Days GLOBAL This subset is a breakout subset from General Medical. Criteria from the following General Medical sections were combined: Infection: General, Infection: ENT, and Infection: Eye. Fever of Unknown Origin, systemic infection, and sepsis criteria are now located in the Infection: Sepsis subset. Abscess, cutaneous criteria have been moved to the subset, Infection: Skin. The conditions addressed in this subset are listed in alphabetical order under each applicable level of care. Changes made to the content of the criteria on Episode Day 1 are noted below.







-Infection,

-Other infection, actual or suspected,

Added: Mononucleosis, All:

Mononucleosis Finding, Both: Impaired swallowing Inadequate oral intake

IV fluid, One:


Heart failure, chronic 100 mL/h and weight 60

kg

Consensus-based

InterQual® consultants agree that mononucleosis may be treated at the Observation level of care.

Episode Day 1 ACUTE

-Infection, General,

-Other general infection, actual or suspected,

-Infection, actual or suspected,

Removed: Finding, One:

Failed outpatient anti-infective treatment (includes PO), One:

Continued deterioration despite 24h treatment

Unable to tolerate or absorb oral antiinfective

Unresponsive to 5 doses or 3d outpatient antiinfective

Consensus-based

These criteria were removed because most patients are anticipated to respond to treatment within less than 48 hours. Criteria to address the care of these patients can be found in the Observation level of care. This change is supported by InterQual® consultants.





Episode Day 1 ACUTE



-Infection, actual or suspected,

-Anti-infective,

-Finding,

-Central venous catheter,

Added: Outpatient blood culture

positive

Literature This criteria point was added to more accurately reflect the criteria required to meet the Acute level of care for those patients with a central venous infection.





Episode Day 1 ACUTE


-Finding,

Changed: Positive culture, smear,

antigen, or latex agglutination for bacteria, fungi, or protozoa, One: Biopsy, surgical (excludes

skin)

Blood Bone marrow Effluent smear

To: Laboratory result indicative of

infection, Both: Test, One: Positive culture for bacteria Positive smear for bacteria Positive antigen for bacteria Positive latex agglutination for

bacteria Positive culture for fungi Positive smear for fungi Positive antigen for fungi Positive latex agglutination for

fungi Positive culture for protozoa Positive smear for protozoa Positive antigen for protozoa Positive latex agglutination for

protozoa Source, One: Biopsy, surgical (excludes

skin)

Blood Bone marrow Effluent smear

Usability These criteria were restructured to streamline the review process.





Episode Day 1 ACUTE



-Dengue, actual or suspected,

Added: Failed Observation management,

Both: Finding, All:


Consensus-based

InterQual® consultants agree that patients with Dengue are appropriate at the Acute level of care after failed Observation treatment.





Episode Day 1 ACUTE



Changed: Tuberculosis, actual or suspected

and negative airflow isolation, One: Public health risk and

anti-infective (includes PO)

< 3 consecutive negative AFB sputum smears

Positive AFB sputum smear and anti-infective (includes PO)

To: Tuberculosis, All:

Tuberculosis, actual or suspected Anti-infective (includes PO) Negative airflow isolation Finding, One: Not safe for discharge, One: (25)

Public health risk (26)

Acid-fast bacillus (AFB) sputum smears, One:

< 3 consecutive negative acid-fast bacillus (AFB) sputum smears

Positive acid-fast bacillus (AFB) sputum smear, One: < 3 consecutive

negative acid-fast bacillus (AFB) sputum smears

Usability These criteria were changed to clarify the intent of the criteria.





Episode Day 1 ACUTE

-Infection, ENT,

-Mononucleosis,

Removed: Mononucleosis, Both:

Finding, Both: Impaired swallowing Inadequate oral intake

Intervention, All: Corticosteroid IV fluid, One:


Heart failure, chronic 100 mL/h and weight 60

kg Oximetry

Literature The intervention criteria points, corticosteroid and oximetry, were deleted based on current evidence. This change is supported by InterQual®

consultants.

Episode Day 1 ACUTE

-Infection, ENT,

-Mononucleosis,

Added: Mononucleosis, Both:

Mononucleosis Failed Observation management,

Both: Finding, Both:

Impaired swallowing Inadequate oral intake

Consensus-based

InterQual® consultants agree that patients with mononucleosis are appropriate at the Acute level of care after failed Observation treatment.


-Infection,

-Other infection diagnosis, actual or suspected,

Removed: Ebola virus disease and

hypovolemia, Both:

Systolic BP 90-99 mmHg Volume expander

Usability The Intermediate level of care criteria were changed to encompass all patients who require the Intermediate level of care in this subset.






-Infection,


Added: Other infection, actual or suspected, One: Hypovolemia, Both:

Systolic blood pressure 90-99 mmHg

Volume expander 2d

Usability The Intermediate level of care criteria were changed to encompass all patients who require the Intermediate level of care in this subset.


-Infection,


Added: Peritonsillar abscess, All:

Peritonsillar abscess, actual or suspected

Risk of airway compromise Finding, One: Confirmed by imaging Difficulty swallowing Drooling

Intervention, All: Anti-infective Oximetry Surgical evaluation, One:

Performed within 24h Scheduled within 24h

Retropharyngeal abscess, All:

Retropharyngeal abscess, actual or suspected

Risk of airway compromise Finding, One: Confirmed by imaging Difficulty swallowing Drooling

Intervention, All: Anti-infective Oximetry Surgical evaluation, One:

Performed within 24h Scheduled within 24h

Literature This criteria was added to allow for patients with specific infections to meet at the Critical level of care.



Subset: Infection: GI/GU/GYN



All Episode Days GLOBAL This subset was changed from having Episode Day 1 and Episode Days 2-11, to Episode Day 1, Episode Day 2, Episode Days 3-10, and Episode Day 11.

This was done so that the length of stay for the conditions within this subset could be differentiated.

This change resulted in the removal of Partial responder and Non-responder day criteria from Episode Days 2-11.

Episode Day 11 is the Non-responder day for all levels of care.






-Acute pyelonephritis,

Added: Finding, One:


Continued deterioration despite 24h treatment (includes PO)

Unable to tolerate oral anti-infective

Unresponsive to outpatient anti-infective (includes PO), One:

3d 5 doses

Consensus-based

InterQual® consultants agree that patients with acute pyelonephritis can receive appropriate treatment in the Observation level of care after failed outpatient treatment.


Added: C. difficile colitis, Both:

C. difficile colitis, actual or suspected



Noncompliant with outpatient anti-infective (includes PO)


Unresponsive outpatient anti-infective (includes PO), One:

3d

Consensus-based

InterQual® consultants agree that C. difficile colitis can receive appropriate treatment in the Observation level of care after failed outpatient treatment.






Added: Pelvic inflammatory disease,

Both: Pelvic inflammatory disease Finding, One:





3d 5 doses

Surgical emergency cannot be excluded (e.g., appendicitis)

Consensus-based

InterQual® consultants agree that patients with pelvic inflammatory disease can receive appropriate treatment in the Observation level of care after failed outpatient treatment.

Episode Day 1 ACUTE

-Acute pyelonephritis,

-Finding,

Added: Failed Observation

anti-infective treatment, Both:

Continued deterioration

24h treatment

Consensus-based

InterQual® consultants agree that patients with acute pyelonephritis may be treated at the Acute level of care after failed Observation treatment.





Episode Day 1 ACUTE

-C. difficile,

Removed: Failed OP anti-infective

treatment (includes PO), One:



Unresponsive to 3d or 5 doses OP anti-infective

Consensus-based


Episode Day 1 ACUTE

-C. difficile,

-Finding,




24h treatment (includes PO)

Consensus-based

InterQual® consultants agree that patients with C. difficile colitis are appropriate at the Acute level of care after failed Observation treatment.





Initial review

Episode Day 1

ACUTE

-Pelvic inflammatory disease,

-Finding,

Removed: Failed OP anti-infective



Unable to tolerate or absorb oral anti-infective

Unresponsive to 3d or 5 doses OP anti-infective

Consensus-based


Episode Day 1 ACUTE

-Pelvic inflammatory disease,

-Finding,




24h treatment

Consensus-based

InterQual® consultants agree that patients with pelvic inflammatory disease are appropriate at the Acute level of care after failed Observation treatment.



Subset: Infection: Skin



All Episode Days GLOBAL The condition, Abscess, cutaneous, was moved to this subset from the General Medical subset.


Episode Day 1

OBSERVATION Added: Abscess, cutaneous, Both:

Abscess, cutaneous Finding, One:

Temperature > 99.4°F (37.4°C) PO

WBC 13,000/cu.mm (13x109/L) Bands > 10% (0.10) Failed outpatient anti-infective



Non-compliant with outpatient anti-infective (includes PO)



3d 5 doses

Usability These criteria were added to provide for care which can be safely provided in the Observation level of care for a cutaneous abscess. This change is supported by InterQual® consultants.






Cellulitis,

Finding,

Added: Failed outpatient anti-infective





Unresponsive to outpatient anti-infective (includes PO), One: 3d

Consensus-based

These criteria were added because most patients are anticipated to respond to treatment within less than 48 hours. This change is supported by InterQual® consultants.






Added: Herpes zoster, All: Herpes zoster Failed outpatient anti-infective


Continued deterioration despite 24h treatment (includes PO) (Non-compliant with outpatient anti-infective (includes PO)



3d 5 doses

Intervention, Both: Anti-infective Skin assessment and care

Wound infection, All:

Wound infection Failed outpatient anti-infective






3d 5 doses

Intervention, Both: Anti-infective Wound assessment and care

Consensus-based

These criteria were added because most patients with these conditions are anticipated to respond to treatment within less than 48 hours. This change is supported by InterQual® consultants.





Episode Day 1

ACUTE

Added: Abscess, cutaneous, All:

Abscess, cutaneous Finding, One:

Failed Observation drainage and anti-infective treatment, Both:


24h treatment anti-infective

Immunocompromised

Platelet count < 100,000/cu.mm (100x109/L)

Anti-infective

Consensus-based

These criteria were added because patients with a cutaneous abscess are anticipated to respond to treatment within less than 48 hours. This change is supported by InterQual® consultants.

Episode Day 1

ACUTE

Cellulitis,

Finding,

Removed: Failed OP anti-infective treatment

(includes PO), One:

Progression despite at least 2d OP anti-infective


Unresponsive to 5 doses or 3d OP anti-infective

Consensus-based

These criteria were removed because patients with cellulitis are anticipated to respond to treatment within less than 48 hours. This change is supported by InterQual® consultants.





Episode Day 1

ACUTE

Cellulitis,

Finding,

Added: Failed Observation treatment

including anti-infective, Both:



Consensus-based

These criteria were added for those patients who require inpatient care and have not responded to treatment in Observation.

This change is supported by InterQual® consultants.

Episode Day 1

ACUTE

Diabetic foot ulcer,

Finding,

Intervention,

Assessment of vascular supply,

Changed: Recently performed

To: Performed within the last 3

mos






Episode Day 1 ACUTE

Herpes zoster,

Finding,


(includes PO), One:

Continued deterioration despite 24h anti-infective treatment

Progression despite at least 2d OP anti-infective (includes PO)



Consensus-based

These criteria were removed because patients with herpes zoster are anticipated to respond to treatment within less than 48 hours. This change is supported by InterQual® consultants.

Episode Day 1 ACUTE

Herpes zoster,

Finding,

Added: Failed Observation anti-infective

treatment, Both:



Consensus-based






Episode Day 1 ACUTE

Wound infection,

Finding,


(includes PO), One:

Continued deterioration despite 24h anti-infective treatment



Consensus-based

These criteria were removed because patients with a wound infection are anticipated to respond to treatment within less than 48 hours. This change is supported by InterQual® consultants.

Episode Day 1 ACUTE

Wound infection,

Finding,

Added: Failed Observation anti-infective

treatment, Both:



Consensus-based







Responder,

Added: WBC < 13,000/cu.mm (13x109/L) Bands 10% (0.10) Absolute neutrophil count (ANC) 500/cu.mm (500x106/L)

Literature These criteria were added to increase to the specificity of the findings needed for discharge from the Observation level of care.


Responder,

Blood sugar,

Added: Infection resolving, One:

Abscess resolving and wound healing or manageable

Cellulitis resolving and decreased inflammation (e.g., pain, edema, warmth, or area of erythema)

Herpes infection and no new lesions

Wound care regimen established and adequate healing

Usability These criteria were added to correspond with the changes to the Observation criteria on Episode Day 1.

Episode Day 2 ACUTE

Episode Day 2 was restructured. Responder criteria were removed. The following criteria were added: Infection, One: Osteomyelitis (use

Infection-Musculoskeletal subset) Abscess, cutaneous

Cellulitis Diabetic foot ulcer Herpes zoster Wound infection

Anti-infective

Usability These criteria were added to correspond with the changes to the Acute criteria on Episode Day 1.



Subset: Labor and Delivery



Episode Day 1, 2, 3, 4, & 5

CRITICAL Added: Acute kidney injury (AKI),

Both:

Finding, One: Potassium > 6.0 mEq/L

(6.0 mmol/L), One: Atrioventricular (AV)

dissociation Loss of P wave Multifocal premature







> 160 mEq/L (160 mmol/L)



initiation Peritoneal dialysis 7d

since initiation

Consensus-based






Episode Day 1, 2, 3, 4, & 5

CRITICAL Added: Continuous renal replacement

therapy (CRRT)

Consensus-based






Episode Day 1, 2, 3, 4, & 5

CRITICAL

HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) 2d,

-Finding,

Changed: Platelet count <

50,000/cu.mm (50x109/L)

PT 1.5x ULN or INR 2.0 PTT 1.5x ULN

To: Lab values, All: Platelet count <

50,000/cu.mm (50x109/L)


Finding, One: Fragmented or

contracted red cells on blood smear

Total serum lactate dehydrogenase (LDH) 600 IU/L (10.02 kat/L)


Increased risk of bleeding, One: PT 1.5x upper limit of

normal (ULN) or INR 2.0

PTT 1.5x upper limit of normal (ULN)

Literature These criteria were changed based on the current available evidence to define the findings associated with hemolysis, elevated liver enzymes, low platelet syndrome. This change is supported by InterQual® consultants.





Episode Day 1, 2, 3, 4, & 5

CRITICAL Added: Oxygen, Both:

High flow nasal cannula (HFNC)

Respiratory monitoring every 1-2h

Consensus-based

The oxygen criteria were added to address the needs of patients requiring high levels of oxygen.

Episode Day 1, 2, 3, 4, & 5

CRITICAL

Hemodynamic instability,

Changed: Blood product transfusion IV fluid resuscitation 2d

To: Finding, One:


Systolic blood pressure, One: < 90 mmHg without

chronic hypertension < 110 mmHg with

chronic hypertension > 30 mmHg decrease

from baseline

Labile


Intervention, One: Antifibrinolytic





Subset: Postpartum Complications After Discharge



Episode Day 1 ACUTE -HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) (hemolysis, elevated liver enzymes, low platelets) 5d,

Changed: Platelet count

50,000-100,000/cu.mm (50-100x109/L)

To: Lab values, One:







Literature These criteria were changed based on current available evidence to define the findings associated with hemolysis, elevated liver enzymes, low platelet syndrome. This change is supported by InterQual® consultants.






Added: Acute kidney injury (AKI), Both:


mmol/L), One: Atrioventricular (AV)

dissociation Loss of P wave Multifocal premature ventricular

contractions (PVCs) Neuromuscular deficit



Widening QRS Sodium, One: < 120 mEq/L (120 mmol/L)

and volume overload > 160 mEq/L (160 mmol/L)



initiation Peritoneal dialysis 7d since

initiation

Consensus-based



Added: Continuous renal replacement therapy

(CRRT)

Consensus-based







-HELLP syndrome (hemolysis, elevated liver enzymes, low platelets) 2d,

-Finding,

Changed: Platelet count < 50,000/cu.mm

(50x109/L) PT 1.5x ULN or INR 2.0 PTT 1.5x ULN

To: Lab values, All: Platelet count < 50,000/cu.mm

(50x109/L) Aspartate aminotransferase

(AST) or alanine aminotransferase (ALT) > 70 U/L (1.17 kat/L)





Increased risk of bleeding, One: PT 1.5x upper limit of normal

(ULN) or INR 2.0 PTT 1.5x upper limit of

normal (ULN)






Episode Day 1, 2, 3, 4, & 5

CRITICAL Changed: Hemodynamic instability, One:


To: Hemodynamic instability, Both: Finding, One:





baseline

Labile


Intervention, One: Antifibrinolytic







Episode Day 3 & 4-5

ACUTE

-Partial responder,

-HELLP syndrome,

Changed: Finding, One: AST, ALT, or LDH elevated Platelet count

50,000-100,000/cu.mm (50-100x109/L)

To: Lab values, One:










Subset: Rhabdomyolysis or Crush Syndrome

Episode Day


Type Rationale


All Episode Days

GLOBAL The specific conditions of rhabdomyolysis and crush syndrome were removed from General Medical and General Trauma and have been combined into a new subset titled Rhabdomyolysis or Crush Syndrome.


Episode Day 1

OBSERVATION -General Trauma, -Musculoskeletal,

Changed: Crush injury, Both:

Finding, All: Compromised local circulation Involvement of muscle mass Myoglobinuria or hemoglobinuria absent Prolonged compression

To:

OBSERVATION, All: Rhabdomyolysis or crush syndrome Muscle edema or hematoma Myoglobinuria absent Prolonged compression lasting at least 1h Pulses decreased or absent

Literature These criteria were updated based on current available evidence and are supported by InterQual® consultants.



Episode Day


Type Rationale


Episode Day 1

ACUTE

-General Medical,

-Musculoskeletal,

Changed: Rhabdomyolysis, Both:

Finding, One: CPK > 1,000 U/L (17.0 kat/L) Hemoglobinuria Myoglobinuria

To: Rhabdomyolysis or crush syndrome Finding, One: Creatine phosphokinase (CPK) > 1,000 U/L (17.0 kat/L)

Myoglobinuria


Episode Day 1

CRITICAL

-General Trauma,

-Musculoskeletal,

Changed: Crush syndrome, Both:

Finding, One: BUN > 40 mg/dL (14.3 mmol/L) or creatinine

> 2.0 mg/dL (176.8 mol/L) Calcium < 8 mg/dL (2.00 mmol/L) Potassium > 6.0 mEq/L (6.0 mmol/L) with ECG

changes Urine output < 0.5 mL/kg/h


Dialysis, One: Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation Continuous renal replacement therapy

To: CRITICAL, All: Rhabdomyolysis or crush syndrome Finding, One: Blood urea nitrogen (BUN) > 40 mg/dL (14.3

mmol/L) Calcium < 8 mg/dL (2.00 mmol/L) Creatinine > 2.0 mg/dL (176.8 mol/L) Echocardiogram (ECG) changes, One:

Atrioventricular (AV) dissociation Loss of P wave Multifocal premature ventricular contractions

(PVCs) Neuromuscular deficit Ventricular fibrillation Ventricular tachycardia




Episode Day


Type Rationale


Widening QRS Potassium > 6.0 mEq/L (6.0 mmol/L) Urine output < 0.5 mL/kg/h

Intervention, One: Calcium chloride Calcium gluconate Dialysis, One:

Hemodialysis 7d since initiation Peritoneal dialysis 7d since initiation Continuous renal replacement therapy (CRRT)

Glucose 50%(0.50) with insulin

IV fluid resuscitation 2d



Subset: Syncope



All Episode Days GLOBAL Extensive restructuring of this subset was done to align with the length of stay data. The acute level of care was added to Episode Day 4 & 5.

Episode Day 1 ACUTE

INTERMEDIATE

-Intervention,

-Imaging,

Changed: Recently performed

To: Previously

performed (within the last 3 mos)

Literature This criteria point was changed based on the current available evidence and is supported by InterQual® consultants.


-Finding,

-Cardiac disease, structural or functional,

Changed: Previous myocardial

infarction

To: Myocardial infarction

within the last 6 mos

Literature This criteria point was added based on the current available evidence and is supported by InterQual® consultants.






-Finding,

-Abnormal ECG,

Changed: Pacemaker or ICD

replacement within last 24h, One: Lead fractured or

displaced Malfunction

To: Implantable device failure,

Both: Finding, One: Lead displaced Lead fractured Device malfunction

Intervention, One: Implantable

cardioverter defibrillator (ICD) replacement within 24h

Pacemaker replacement within 24h

Usability These criteria were changed to clarify the intent of the criteria.

Episode Day 1& 2 CRITICAL

-Finding,

-Aortic stenosis 1.0 cm2 by imaging,

Added: Intervention, One: Valve repair or

replacement (use General Surgery subset)


Episode Day 2, 3, & 4 ACUTE

-Partial responder,

Added: Post Critical care 24h

Usability This criteria point was added to allow for a patient to step down from a higher level of care.



Subset: Withdrawal Syndrome

Episode Day



Internal Comments

All Episode Days

GLOBAL This subset is a breakout subset from General Medical. Criteria from the General Medical: Withdrawal Syndrome section was used to create this subset.




Episode Day



Internal Comments

All Episode Days

ACUTE

-Intervention,

-Medication assisted withdrawal management (includes PO) ≤ 3d,

INTERMEDIATE

-Finding,

-Withdrawal syndrome,

CRITICAL

-Finding,

-Withdrawal syndrome,

Added: Medication assisted

withdrawal management (includes PO) 3d, One: Withdrawal medication

(includes PO) , One: Anticonvulsant Barbiturate

Benzodiazepine

Opiate antagonist

Opioid

Sympatholytic

Usability This change was made to clarify the medications used for withdrawal management.

All Episode Days

ACUTE

-Finding,

Changed: Thrombocytopenia To: Platelet count below

150,000/cu.mm (150x109/L)


Documents

Proprietary Notice and Disclaimers Cholecystitis COPD Diabetes Mellitus Diabetic Ketoacidosis Deep Vein Thrombosis admit the patient is being made. For Electrolyte or Mineral Imbalance