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atrial fibrillation

Fitbit Provides Useful Diagnostic Data in the ED

Posted on Mon, May 23, 2016
Fitbit Provides Useful Diagnostic Data in the ED

By Alfred Sacchetti, MD, FACEP

So you are working in the ED and the medics bring in a patient with uncontrolled a-fib. In the field, the patient had an irregularly irregular narrow complex tachycardia with a rate between 160 and 190. The rate was controlled with a bolus of IV Diltiazem and the patient was transported to your ED.

In the ED the patient notes he feels nothing abnormal about his heart and denies any sensations of palpitations or a racing heart and has no recollection of when his irregular heart beat began. The ECG in the emergency department demonstrates atrial fibrillation, the initial bolus of diltiazem has worn off and the patient's heart rate is again trending over 150, with stable blood pressure and respirations. Given this history, the patient is not a candidate for cardioversion since there is no way to confirm that the onset time of his arrhythmia was less than 48 hours, so he is relegated to rate control, anti-coagulation and admission.

That would normally be the end of a routine admission, but this is an EmCare Emergency Department and nothing we do is routine! As it turns out, the admitting nurse practitioner Carol McDougall, MSN, APN-C, noticed the patient was wearing an activity tracker (Fitbit™) which monitored the patient's heart rate. She and the emergency physician, Monika Smith, DO, then used the patient's iPhone™ to trace his heart rate over the last day. They found that the patient's atrial fibrillation began just three hours prior. Having confirmed that the onset of the arrhythmia was less than 48 hours, they proceeded to electrically cardiovert the patient back to normal sinus rhythm and discharge him to home directly from the ED with no anticoagulants. This is the first time an activity tracker has been used to aid in the medical management of a patient, and the case was so unique that it was reported in the Annals of Emergency Medicine.

As it turns out, activity trackers can provide emergency clinicians with quite a bit of useful information. Patients with self-limited complaints such as dizziness, near syncope and palpitations, can be very frustrating to manage when their symptoms resolve prior to ED arrival. However, if a patient's activity tracker can be interrogated, it has the potential to dramatically change that patient's care. A heart rate in the 30s associated with a near syncope event is managed much differently than the same complaint with a heart rate of 160. A totally normal heart rate may eliminate a cardiac etiology to a patient's symptoms entirely and point the clinician in a totally different direction for their work up.

In addition to heart rate, the number of steps recorded in the activity tracker can provide useful information to a clinician. A patient with a CHF complaint might also demonstrate a progressive decrease in his steps taken over the period of time he developed dyspnea, alerting the physicians and advanced practice providers of the course of the patient’s failure. Armed with this type of information, the patient’s primary care provider might be able to anticipate problems by monitoring the patient’s daily step activity. Finally, the amount of time an elderly patient was lying on the ground after a fall may be revealed by examining her activity tracker and determining the time when her steps stopped abruptly.
 
The ultimate utility of activity trackers to provide information to emergency personnel is yet to be determined and is most likely limited only by the ingenuity of the clinicians caring for the patient.

Al Sacchetti

Alfred Sacchetti, M.D., FACEP, is EmCare’s Chief of Emergency Services for Our Lady of Lourdes Medical Center in Camden, N.J. Dr. Sacchetti also acts as a Medical Research Director for EmCare’s North Division. He received his medical education and training at the Medical College of Pennsylvania. Dr. Sacchetti is the recipient of the 2013 Genesis Cup, EmCare’s recognition for innovation in healthcare, and leads the emergency medicine “hot topics” session at EmCare’s annual leadership conference.
 

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Documentation Tip of the Week: Atrial Fibrillation and Atrial Flutter for ICD-10

Posted on Wed, Aug 12, 2015
Documentation Tip of the Week: Atrial Fibrillation and Atrial Flutter for ICD-10

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

Atrial Fibrillation Definitions:

  • Paroxysmal A. Fib: Terminates within 7 days
  • Persistent A. Fib: Sustained > 7 days and is subject to rhythm control (e.g. metoprolol, flecanide, amiodarone) to maintain NSR
    • This is a Comorbid Condition (CC) and demonstrates Severity of Illness (SOI)
  • Permanent (chronic) A. Fib: NSR cannot be sustained and physician/patient cease further attempts to maintain NSR
  • History of Atrial Fibrillation: A. Fib in the past but now NSR and taking no medication to maintain NSR
ICD-10 Code Description CC or MCC

ICD-10 Codes for A Fib

 

I48.0 Paroxysmal atrial fibrillation --
I48.1 Persistent atrial fibrillation CC
I48.2 Chronic atrial fibrillation --
I48.91 Unspecified atrial fibrillation --
I18.3 Typical Atrial Flutter CC
I48.4 Atypical Atrial Flutter CC
I48.92 Unspecified Atrial Flutter CC



Timothy Brundage
Timothy Brundage, MD, is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his medical degree at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips or ask him about specific documentation issues by emailing him at DrBrundage@gmail.com.

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Documentation Tip of the Week: Atrial Fibrillation

Posted on Thu, Jun 05, 2014

Good documentation is important for new physicians astips well as veteran caregivers. While documentation-tips-graphic.pngdocumenting can seem like a very straightforward skill, there are often “best practices” that can be utilized. As a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, FL I write a “weekly documentation tip” email to help physicians improve their clinical documentation. I also share these documentation strategies with the residents I teach. In this 6-part series, each Thursday, I’ll be sharing my most recent documentation tips.
by: Timothy N. Brundage, M.D., CCDs


Atrial Fibrillation Definitions

  • Paroxysmal A. Fib: terminates within 7 days
  • Persistent A. Fib: sustained > 7 days and is subject to rhythm control (e.g. metoprolol, flecanide, amiodarone) to maintain NSR
    • This is a Comorbid Condition (CC) and demonstrates Severity of Illness (SOI)
  • Permanent (chronic) A. Fib: NSR cannot be sustained and physician/patient cease further attempts to maintain NSR
  • History of Atrial Fibrillation: A. Fib in the past but now NSR and taking no medication to maintain NSR
atrial-fib.png brundage-(1).pngTimothy N. Brundage, M.D., CCDs is a Certified Clinical Documentation Specialist and Diplomate of the American Board of Internal Medicine.










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