Meeting Interqual usually requires two separate sets of criteria:
- Severity of Illness (SI): documentation of the ED diagnosis or diagnoses (not chief complaint). It is not enough to document the patient has shortness of breath; you must try to describe how sick the patient is. For instance, for a CHF exacerbation, you should indicate if the patient has a new oxygen requirement or is hypoxic/hypoxemic; any indications of end-organ damage (like AKI), requiring positive pressure, X-ray or lab findings that are deranged, or with concomitant medical comorbidities making them worse. Physical exam findings are also useful here: edema, JVD, rhonchi, rebound tenderness, etc. It is okay to list a few different diagnoses in an attempt to get one to stick.
The other trick is to use numbers. Instead of saying “AKI” or “acidosis,” write what the creatinine is, or what the bicarb is.
- Intensity of Service (IS): This actually includes two pieces.
- Treatment: did you appropriately try and treat the patient in the ER, and they didn’t get better enough? This is where most of the ridiculous pieces for Interqual come in. For a given diagnosis, you should document treatments given in the ER (the famous two rounds of IV diuretics), or why you didn’t administer a treatment. For instance, a heart failure diagnosis requires explanation of why you did not administer a beta-blocker or ACE inhibitor: “did not administer ACE inhibitors as they are contraindicated in acute heart failure.”
- Inpatient Need: the key question to answer here is, “what attention or treatments are necessary that can only be administered as a full inpatient as opposed to observation status, at home or in an office?” For the CHF exacerbation, you can say things like “oxygen supplementation,” “frequent electrolyte checks,” “IV diuresis,” If they have vital sign abnormalities or need a monitor, you can add “telemetry” or “continuous hemodynamic monitoring.” IV antibiotics or fluids should be included here. Frequent reassessments (for example, q2h neuro checks) is also a helpful piece.
Separating these things out in your MDM or a reassessment note makes it easier for UR to find the information. A sample dot phrase is below:
Severity of Illness: (diagnosis, exam findings, lab results, imaging)
Note: _
Intensity of Service: (inpatient need)
Note:_
BY CHIEF COMPLAINT:
The below chief complaints are among the most common admitting diagnoses. The information contained in each represent the criteria to meet interqual for observation and inpatient level of care. Higher levels of care like stepdown or ICU usually have fewer issues meeting interqual.
ACS/NSTEMI
Observation Status
- SI: ALL of the below:
- “ACS suspected”
- No active chest pain, or pain controlled with medication
- Hemodynamically stable (i.e SBP>90)
- Normal or unchanged EKG with a negative first troponin
- IS: ALL of the below:
- Requires hemodynamic monitoring
- Need for serial troponins
- s/p administration of antiplatelet (and/or P2Y12 inhibitor)
Inpatient Status (targeted for tele)
- SI:
- For NSTEMI, document positive troponin and chest pain status
- For UA: suspicion for unstable angina and ALL:
- Angina at rest OR worsening with Canadian CV Society Class III or IV severity
- EKG changes with new or worsened ischemia, or paced
- IS:
- Same for NSTEMI and UA
- ALL of:
- BB, ASA, antiplatelet, and ACE/ARB administered or contraindicated
- Continuous cardiac monitoring
Putting It Together
SI: ACS suspected with chest pain managed with medication, new ischemic changes on EKG, worsening anginal chest pain with Class III severity, negative first troponin
IS: Continuous cardiac monitoring, serial troponins. Administered 325mg aspirin in the ER; beta-blocker, antiplatelet agents (such as clopidogrel or ticagrelor), ACE inhibitors, and ARBs contraindicated in the current clinical scenario
Acute Kidney Injury (AKI)
Observation Status
- SI: Creatinine Rise: one or more of
- ≥50% in 7 days
- ≥0.3mg/dL in 2 days
- ≥1.5x upper limit normal, unknown baseline
- ≥1.5x baseline AND above normal
- IS: Diuretic adjustment or discontinuation, OR
- >2x doses of diuretics in 24h given, OR
- IV fluids required at a rate ≥75ml/hr, OR
- Adjustment/discontinuation of nephrotoxic agent
Inpatient Status
- SI: requires either hx of intrinsic kidney disease OR hospital acquired
- Intrinsic disease/vasculitis, AND ALL OF:
- Creatinine rise:
- If baseline is KNOWN, Cr must double, OR
- If unknown, ≥2x upper normal
- GFR decrease more than 50% from baseline
- UOP <0.5 mL/kg/hr (can document no voids in ER)
- Creatinine rise:
- Intrinsic disease/vasculitis, AND ALL OF:
Putting It Together
SI: Creatinine increase >50% from baseline OR is >2x upper limit of normal
IS: Diuretic dosage needs to be initiated, discontinued, or adjusted, OR patient requires continuous IV fluids.
Diarrhea
- SI: 7 loose stools in >24 hours, signs/symptoms of dehydration, PO intolerance to oral resuscitation, vital sign abnormalities
- IS: IV fluids, monitoring, frequent electrolyte checks and repletion
CHF Exacerbation
- SI: PE – Clinically overloaded (edema, JVP, lungs). Labs – hypoxia/hypoxemia requiring O2, positive pressure, elevated end-organ markers, troponin. XR findings
- IS: Interventions – IV diuretics x2 PLUS ACEi/BB, O2/NIPPV, electrolyte repletion. Inpatient: IV diuresis, hemodynamic monitoring, frequent electrolyte checks and repletion.
*Note: simply documenting “2 doses of IV diuretics given” no longer works.
Hypertensive Urgency/Emergency
- SI: SBP>180 with evidence of end-organ damage (AKI, troponin elevation, hypertensive encephalopathy or symptomatic)
- IS: Antihypertensive agent given in ER without good control obtained
Pericardial Effusion (?)
- SI: Concern for active tamponade physiology, administration of NSAIDs or ASA in the ED,
- IS:
Pneumonia
- SI: 2 or more lobes must be involved (multifocal PNA). Hypoxia does not work by itself (even if the patient requires supplemental O2). NIPPV or HFNC also helpful. HAP or VAP.
- IS: Interventions – antibiotics in the ER/treat for sepsis, IVF or diuresis, O2 supplementation. Inpatient: continued IV abx with likely prolonged course, weaning of O2, hemodynamic monitoring
Pain Control
- SI: Cancer history, on chronic PO opiates at home
- IS: 3+ rounds of parenteral pain medication
Sepsis from Urinary Source
- SI: results of UA, WBC>12, HR>90, Creatinine>2, mental status change. Hx culture-proven resistant infection also helpful.
- IS: IV fluids, IV antibiotics, hemodynamic monitoring
TIA
- SI: known prior stroke, history of carotid stenosis, or crescendo TIAs is required.
- IS: Interventions: vascular imaging to rule out acute stroke, medical workup ruled out other causes. Administer (explain contraindications for) antiplatelet and anticoagulation medications (i.e. aspirin, plavix, heparin). Inpatient: echo, qXhr neuro checks (high risk of stroke), hemodynamic monitoring. Saying “MRI in AM” doesn’t help, nor does “stroke workup.”