President’s Report With another festive season behind us it’s hard to believe another year has passed and all of us will soon be looking forward to the 4th edition of ICD-10-AM training in the earlier part of 2004.
For the past year I had the opportunity of working at the Sheikh Khalifa Medical Center (SKMC) in Abu Dhabi, one of the United Arab Emirates. That year gave me the opportunity to get a clear picture of how people live, work and socialise in that part of the world. The people (over 150 different nationalities) were fascinating and very friendly. Laws were very different and had to be taken very seriously. You can read more in my article. Garry our Editor, did a great job putting together our last Codelink and as we know it is not an easy job especially if no one sends material for placing in our newsletter. He is always on the lookout for material so if you find something that you think may be of interest to your fellow Clinical Coders please be sure to contact him, or send it to your state representative for them to forward on to Garry.
The Coding Auditors’ Network (CAN) formed by the NCCH’s Data Quality sub-committee (with representation by CCSA), is an auditor’s course scheduled to commence in early 2004 through La Trobe University. This course will be conducted through distance education giving advantages to yet another professional pathway for experienced coders to follow. Tentatively planning has been undertaken for the next AGM and Strategic Planning Day to be held in early April. Any members who are interested in contributing items of interest to the CCSA are urged to send them to their local board member so they can be tabled. Joan Knights CCSA President Inside this issue:
ü President's report
ü A United Arab Emirate Experience 2
ü Introduction to Anaesthesia
ü Avian Influenza A H5N1 strain Sheikh Khalifa Medical Center, Abu Dhabi A United Arab Emirate (UAE) Experience
I am delighted to be taking you on a journey to Abu Dhabi, United Arab Emirates (UAE) where I have spent my last year. Many important
historical events are scarcely recorded, being held only in the memories of the locals. The stories, myths and legends passed down to sons and
daughters from senior members of their families are woven together, forming a tapestry of their past. It is very easy to get caught up in the fascination of the life in the UAE; visiting museums and hearing of the people’s trials and tribulations and joys and triumphs. I would like to focus however, on health and clinical coding in the UAE. Although many of my experiences are first hand, I will still take you through the many problems faced in implementing new health information systems, in particular the area of clinical coding. To understand how much has been achieved in such a short time and in such an unforgiving land, we need to return to a time before modern UAE where meagre resources, soaring temperatures and incredible hardship were a daily occurrence to the people of the region. That is until oil came along…. History of health in the region Before the unification of the seven Emirates in 1971 the only form of healthcare was herbal remedy, often delivered by unqualified healers. Travelling to one of these healers often involved long camel journeys in extreme heat through harsh terrain; many did not survive the journey. Those who survived the trip were then subjected to herbal remedies and ointments passed on from forefathers to sons as part of the culture and family traditions. Some travelled to other Gulf countries in search of better medical treatment, some as far as India. Under these circumstances it was not surprising that epidemics broke out (cholera, small pox, leprosy and other infectious diseases), causing infant and maternal mortality rates to soar. These people who endured such hardship and lack of proper healthcare, now enjoy the latest medical treatment available to them. When the UAE was formed there were seven hospitals with 70 beds and 12 Medical Centres to service the entire population of 180,000. Wise management of the new wealth that came to the region after the discovery of oil, brought a government focus on increasing their health care facilities in a bid to improve and deliver better quality health care to the population. Summary A member of the United Nations the UAE became a member of the World Health Organization, accepting its Constitution in order to address the issue of quality health in the region. A plan was devised by the UAE Ministry of Health to implement comprehensive quality assurance programs to meet all challenges faced by the health sector. Their new health policy aims at providing better quality healthcare throughout the healthcare network of primary, secondary, and specialty programs including rehabilitation programs. By 1998 the United Arab Health Care System had improved greatly with 54 hospitals offering advanced health care, of which 32 came directly under the government control. This has enabled the UAE citizens to benefit from the one of the best health care services in the world, most free of charge. Life expectancy has increased dramatically to 76 years for females, 74 years for males. Infant mortality has also fallen to 9.44 per 1000 among newborns, and 19 per 1,000 for infants compared to the international rate of 89 per 1,000. However, when many of these health care centres were built there were many inconsistencies for the need and provision of the medical record, some had adequate storage but some had next to none and the quality of service provided varied greatly from one facility to another. M edical record departments have recently increased their focus, playing a major role in hospital management, quality improved patient care and strategic planning. It is evident that the medical record departments face huge challenges to upgrade the storage systems in all facilities and recruit sufficiently qualified and trained medical records staff. This is paramount to improving the level of service to patients and health care providers and to bringing the service in line with other countries by recording mortality and morbidity statistics through coding in healthcare facilities. Research was undertaken to find out just how many hospitals in the emirate of Abu Dhabi were actually coding. It was found that the General Health Authority (GHA) and 5 of the major tertiary hospitals, were coding, but all are using different editions of the World Health Organization’s International Classification of Diseases. The example of this is the GHA is using International Classification of Diseases-Tenth Revision (ICD-10) basic. One hospital, previously managed by a Canadian health group, is using the Canadian version of the International Classification of Diseases- Ninth Revision-Clinical Modification (ICD-9-CM). Another hospital has been coding inpatient discharges using the American ICD-9-CM coding system, while another specialising in obstetrics and gynaecology has no Health Information Management, processes for chart management are not in place and coding is not done at all. One Ladies College, where many Health Information Management students attend, use ICD-10-AM, Australian Modification, 3rd edition in their coding module further exacerbating the problem. All these problems are mainly due to the inability to make a decision as to which classification the country is to use. The capacity to measure health and determine epidemiological change requires the collection of all inpatient data. The medical record is a very useful tool for the collection of data pertaining to all factors of health. We will use the Canadian managed Sheikh Khalifa hospital as an example. The Sheikh Khalifa Medical Centre, currently using the Canadian modification of ICD-9-CM; is regarded as being the best hospital for reporting statistics to the government and is often used as a benchmark by the other major hospitals in the region. There is no interface to the hospital management system so data is collected by transferring demographic data from the hospital management system (Meditech) to Access. Coders go through the record and input the allocated code(s) to the modified stand-alone Access database along with the ward movement, clinician visits and length of stay. When the coding has been completed at the closure of the month, the Data Analyst then takes the data from Access to Excel where it is ‘tidied up’ and analysed. The results are then forwarded on to the relevant administrative departments. Clinical Coders’ Society of Australia
Many clinical coders and data analysts in the UAE are from countries such as Canada, USA and Australia: which use different coding
classifications. Many remain resident for many years and lose touch with updated information, consequently being then unable to update systems.
To increase numbers of local HIM s and clinical coders, and also to introduce national ladies into the workforce, the Government, through the Emirate Higher Colleges has created training programs for Health Information Management (HIM) and Medical Administrative
Technologies (MAT). These have made an enormous contribution which in time will hopefully reduce the cost of bringing in foreign workers to do tasks that nationals are capable of doing. Culture The UAE Constitution on women, adopted on the establishment of the State(s) records: The family is the basis of society; which shall be responsible for protecting childhood and motherhood. Laws shall be formulated in all fields to observe this protection and care, in a way which safeguards the dignity of women, preserves their identity and secures for them the conditions appropriate for a prosperous life and suitable work which is accordance with the nature and capabilities as mothers and wives and as workers. (4) This does have a few obstacles in that in keeping with traditional norms of the region, the strong emphasis on the role of a woman to be a mother remains. That is, the culture dictates that the national female is expected to produce multiple children and cannot be expected to stay in the workforce for long periods of time. However since the rising level of female literacy, this is changing and now the ladies of the Emirates have virtually no occupation closed to them. However, traditions and social attitudes can still hold them back. For example many UAE men are strongly opposed to ladies working at all, while others will approve of female family members working in areas where they do not ever come into contact with men. So while the ladies participating in education far exceeds the males, their role in the workforce is very weak and the traditions holding them back remain very strong. Teaching the UAE ladies is very different to teaching Australian students although some are happy to learn, some are literally placed in class when their only wish is to be a manager only. Much of this is brought about by social status in the society; this makes some females reluctant to enter a specialized area such as coding. They consider coding is below their station, even when it is an integral part of the Health Information Management program and that they require the coding skills to understand the whole picture of quality management. The UAE student obtains education free of charge. On completion they are then given monetary rewards some as high as 20.000 Dirhams (10,000 AUD). The objective of this is to encourage national students to complete the courses and therefore to reduce input of foreign workers. The UAE like many countries is committed to the implementation of quality healthcare management and continuous quality improvement of performance, which involves work, service, information, processes, objectives of departmental staff from cleaners to managers (5) consequently making it very interesting and challenging for a country that achieved so much in so little time. Future of Coding Coding in the UAE is slowly coming together but at a very slow pace. Until the decision is made on where to go from here, statistical information on coded data is in fact only being passed to the government by one hospital. However to enable benchmarking, each of the hospitals in the UAE must report their data to one central area. This agency can then provide statistics to each of these hospitals so they can have access to benchmarking reports and resource utilisation data. To achieve this it is imperative that each hospital employ coders of their own so information can be entered into each hospitals system in an accurate and timely manner. This is best achieved via the development, implementation and maintenance of national standards to ensure quality, consistency, timeliness and accuracy of the coded data. By providing continuous coder education, raising the professional profile of clinical classification and encouraging HIM students to choose coding when graduating from the Higher Colleges is essential for the UAE to develop the capacity to produce high quality data and thereby to provide accurate statistics on the morbidity and mortality of the population. Practical training sessions within the hospital setting would be essential education to help these females realise how important coding is to the quality of the healthcare facilities in their country.
President Clinical Coders’ Society of Australia (CCSA) and CCSA representative for Western Australia.
2. Tegloan, L. 1998 Quality in Healthcare Health Information Management Journal 28 (2) 103
3. Photo Undertaking an ICD-10 Coding Workshop at SKMC April 2003
4. United Arab Emirates Yearbook 1998 Trident Press (UK) Ltd. London pp 150, 161, 166, 172
Key principles of Quality Management for Health Information and their Departments, Health Information Journal 28 (4) 189
Clinical Coders’ Society of Australia Introduction to Anaesthesia 1. Drugs commonly used for Sedation. Benzodiazepines (sedative, anxiolytic- to calm nerves, or to treat muscle spasm):
Midazolam – used orally and intravenously (has the advantage of being amnesic [reducing memory]). Diazepam (Valium) – used orally, per rectum (PR) and intravenously (IV). Temazepam – used orally.
Promethazine (Phenergan) – oral.
Chloral hydrate – used orally. Pentobarbitone – used IV & PR (used overseas).
Opioids: (analgesic [pain reliever] to supplement sedation for painful procedures):
Fentanyl. Morphine. Pethidine (usually IV).
Ketamine IV – used low dose for analgesia and higher doses for anaesthesia/sedation.
Intravenous Induction Agents:
Propofol(used low dose for sedation) given by anaesthetists.
2. Drugs Used for General Anaesthesia. Intravenous induction agents (given as a bolus). Di-isopropylphenol:
Propofol -this can also be used in continuous infusion form for maintenance of anaesthesia.
Barbiturates: NMDA Antagonists: Analgesics. Opioids (IV):
Fentanyl Morphine Remifentanil Alfentanil Sufentanyl
Nitrous oxide [N2O] (inhaled): (see below) Clinical Coders’ Society of Australia Inhalational Agents. Induction:
Sevoflurane – which has short onset and offset, is non- irritant to airways and is relatively expensive so
not used for maintenance during long procedures.
Halothane – is an older alternative with longer onset and offset.
Isoflurane – which has medium onset and offset. Halothane and Enflurane – old er alternatives. Desflurane – newer and soon to be released in Australia.
Inhalational agents are always administered with oxygen. Normal air consists of 21% oxygen and, during anaesthesia, oxygen is usually administered as a fractional proportion between 30% and 100%. Oxygen is either combined with air or nitrous oxide [N2O] administered during both induction and maintenance. N2O is usually administered at ~66% and, at that concentration, is a good analgesic and is used to supplement the inhalational anaesthetic agent.
3. Differentiating between sedation and general anaesthesia.
Sedation can be divided into two categories - conscious or deep/unconscious sedation. When receiving conscious sedation, the patient is able to maintain verbal communication during the procedure. Deep sedation equates to unconscious sedation or general anaesthesia i.e. the patient is sleepy enough to be unable to speak. General anaesthesia is a drug induced state of hypnosis or unconsciousness where the patient is also amnesic (doesn’t remember), and analgesed (has adequate pain relieving medication so he/she doesn’t respond to pain). The patient may be paralysed with muscle relaxants, and may have a breathing tube, in the form of an endotracheal tube or laryngeal mask. 4. The process of anaesthesia from pre -operative visit to recovery.
The patient is first seen for ‘pre-operative assessment’ by the anaesthetist in the emergency department, on the ward/day or pre surgical admission units or in the pre-operative waiting areas. The anaesthetist proceeds to take a history with regards to past surgical history, past medical history, allergies and medications, the current problem and then examines the patient as required. Investigations will then be checked or ordered, and the results reviewed, as needed. A discussion is then held with the patient/parents with regard to pre- medication required such as panadol, benzodiazepines or the administration of local anaesthetic creams. The type of anaesthetic the patient will receive is then discussed i.e. sedation vs. general and/or regional anaesthesia. Additional factors that are discussed include the requirement for nerve blocks, epidural catheter insertion, side effects of drugs administered or general anaesthetic, post- operative pain control, the risks of the anaesthesia and nerve blocks. The need for transfusion or other interventions, such as intra-arterial blood pressure monitoring or central line insertion and their risks, may also be mentioned, when relevant, at this time. A consent document is currently required for surgery and the consent for anaesthesia is implied within this document. The patient and the operating surgeon, or his delegate, sign this. In South Australia, a separate anaesthetic consent is also obtained. The patient is then transferred to the pre-operative waiting area. Here, he/she and his/her support person or family are met by the anaesthetic nurse/technician and anaesthetists, and then moved to induction area. This area may be a separate room adjacent to the theatre
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or they may be wheeled directly into the theatre itself. Sometimes, a support person e.g. parent of the child or husband/partner of the patient for caesarean section, may be invited to accompany the patient into the induction area. Anaesthesia is ‘induced’ with either intravenous line insertion (a needle or ‘IV’ is put in) and a bolus of sedation agent and/or intravenous induction agent is given. The alternative is an inhalational technique where the patient breathes oxygen +/- nitrous oxide and the inhalational induction agent. The patient ‘goes to sleep’ either on a trolley or the operating theatre table. Monitoring is attached, usually prior to the patient being anaesthetised, including pulse oximetry, a non-invasive blood pressure cuff +/- ECG monitoring. A further anaesthetic option used, either as the sole method of anaesthesia or in conjunction with general anaesthesia, is where regional techniques are used - such as arm blocks or spinal or epidural anaesthesia. An IV will be placed first, some sedation may be given and then a needle is inserted in the appropriate region e.g. lumbar or thoracic region of the back (with the patient sitting upright or lying on their side) and local anaesthetic +/-opioids are administered via this needle or catheter. The region of the body where surgery is to be performed is numbed e.g. the lower half of the body for caesarean section, prostate surgery or hip/leg surgery and the sensation of pain and touch is blocked. The nerves to the muscles are also numbed and so it is difficult or impossible to move the limbs while under the effect of the regionally administered local anaesthetic. Once anaesthetised, the patient is then transferred from the trolley onto the operating table, if required, invasive monitoring is then inserted, such as central venous line or intra-arterial blood pressure monitoring. An indwelling urinary catheter (IDC) may also be inserted to empty the bladder and permit measurement of urine output. An IDC is usually inserted routinely if the surgery is long duration or in the pelvic region. The patient is then positioned on the table and appropriately padded. The patient is then prepared (‘prepped’) with antiseptic solution wash (Betadine, aqueous or alcohol Chlorhexidine) and draped, and surgery proceeds. The anaesthetist monitors the patient continually throughout the procedure and administers antibiotic prophylaxis and intra- venous fluids, when required. Temperature monitoring and warming of the patient or cooling are performed as required. Blood loss is monitored and blood product transfusion administered also as required. Blood sugar can also be monitored. The anaesthetist will also administer anti- nausea and vomiting medication and deep venous thrombosis prophylaxis in the form of medication or stockings, which may have be applied or given prior to surgery. The anaesthetist will keep the patient ‘asleep’ or sedated with either inhalation agent and/or intravenous agent and give analgesic medication as required. Intraoperative monitoring of the patient and the response of their vital signs during surgery guides the anaesthetist to adjust these medications. The anaesthetist will anticipate the end of surgery and will start weaning back the medications, extubating (if an airway tube was placed) the patient at the end of surgery and usually suctioning the airway. The patient is then transferred to the trolley and wheeled out on this to recovery. In recovery, the patient has ongoing intensive monitoring, with one on one nursing care. Issues such as pain control, vomiting and intra-venous fluid requirements are addressed by this nurse, in conjunction with the orders from the anaesthetist and surgeon involved. Appropriate investigations are ordered and performed as required, such as follow-up haemoglobin assessment, or x-ray, particularly in the case where a chest tube has been placed. Once the patient has been monitored for a period of ½ to 1 hour (or longer depending on the type of surgery), and consciousness has been regained, they will then be transferred to the ward or day stay unit. Ward staff collect the patient and wheel them to the next care area with the help of an attendant. Nursing care is continued on the ward with routine observation and monitoring – specifics include vital signs, sedation scores, pain scores and nausea and vomiting scores – with ongoing intravenous fluid and drug administration, as required. Some patients require epidural infusions, intra- venous morphine infusions, patient controlled analgesic devices, or intra-venous morphine boluses for pain relief. Later, over hours or
Clinical Coders’ Society of Australia
days, they progress to oral analgesics such as panadol, nonsteroidal antiinflammatory drugs (e.g. Ibuprofen), codeine or oxycodone. This is ordered in the drug chart by the anaesthetist intra-operatively. The patient who requires epidural or continuous intravenous opioid infusions is usually followed by a pain service postoperatively. This service is usually staffed by anaesthetists and a specialised nurse consultant, or, in private hospitals, the anaesthetist who anaesthetised the patient will be on call for and review the patie nt’s analgesic therapy. The patient who requires epidural or continuous intravenous opioid infusions is usually followed by a pain service postoperatively. This service is usually staffed by anaesthetists and a specialised nurse consultant, or, in private hospitals, the anaesthetist who anaesthetised the patient will be on call for and review the patient’s analgesic therapy.
5. Common Anaesthetic Abbreviations
American Society of Anaesthesiologists Classification
Fractional inspired oxygen concentration
Intermittent positive pressure ventilation
Mallampati one –1 to 4 grades, a score for mouth opening
Clinical Coders’ Society of Australia Avian Influenza (H5N1 strain)
On 14 January 2004, the World Health Organization (WHO) announced an alert regarding an outbreak of avian influenza in Asia. Avian influenza A (H5N1) strain infections have been detected in the poultry populations in a number of Asian countries. There are only a small numbers of laboratory confirmed cases of H5N1 infection in humans, all appearing to have been infected through contact with diseased birds.
Not thought to be capable of passing from person to person, there are fears that it might acquire that ability if its DNA mingled with that of a human flu virus, a well-known feature of viruses.
Spates of bird flu are viewed with alarm because they are a possible source of the next human pandemic; in view of the high mortality of human influenza associated with this strain, the prospect of a worldwide pandemic has health authorities closely monitoring all aspects of the outbreaks.
Avian Influenza Health Links
The 1918 flu pandemic, was it an avian flu virus? Opinion differs:
The latest updates on Influenza A (H5N1) strain;
6. Common Anaesthetic Drug Abbreviations
MEDICINE ADMINISTRATION FORM To Be Completed By Parent/Guardian Student Name:_________________________________________________________________________________ Race: ____________ Height: ____________ Weight: ___________ Sex:__________ Date of Birth:________________________ Social Security #______________________________ Parent:______________________________________ Street Address:_______