Guest post: COVID-19 primer for CDI, part 2

By Alba Kuqi, MD, CICA, CCS, CDIP, CCDS, CRCR, CSMC for ACDIS CDI Blog

As of late April 2020 (roughly five months since the outbreak of the pandemic), there have been nearly a million confirmed COVID-19 cases and more than 55,000 deaths, resulting in a fatality rate of approximately 5.6%. Current studies, however, suggest that the actual fatality rate is likely to be lower around 0.7% because of a high rate of presumably undiagnosed and mild COVID-19 cases. According to the Centers for Disease Control and Prevention (CDC), asymptomatic carriers may account for as many as 25% of all cases.

Based on our current data, the majority of COVID-19 patients (more than 80% of the patients) have a mild infection, and some people don’t develop any symptoms at all. For others, they can develop mild symptoms like fever, cough, and shortness of breath. Other symptoms include fatigue and loss of smell and taste.

Serious problems include pneumonia and if there is severe lung damage, that can cause acute respiratory distress syndrome (ARDS), which occurs when the lung inflammation is so severe that fluid builds up around and within the lungs. COVID-19 can also cause septic shock, which happens when the blood pressure falls dramatically, and the blood organs are starved for oxygen. ARDS and shock are the main cause of death for the people with the infection. Finally, it is worth noting that even people with fewer comorbid conditions who are young and healthy can develop pulmonary fibrosis, which is a chronic condition that can severely impair their quality of life.

The gold standard for diagnosing COVID-19 is a reverse transcription polymerase chain reaction (RT-PCR) test, which detects very small amounts of viral RNA. In the early days of the pandemic in China, RT-PCR was only 30%-70% sensitive, while chest CT was performed and reported much more sensitive results.

More recent data from the University of Washington, however, suggest that second generation COVID-19 testing is faring much better with 95% or more sensitivity. Despite its usefulness in the early days of the epidemic in China, chest CT findings are no longer part of the diagnostic criteria for COVID-19. There are still issues with access to RT-PCR and related wait times in the United States and elsewhere.

Newer rapid testing for COVID-19 can get the results within minutes. One of these tests is isothermal amplification, which also checks for viral RNA. The other is rapid serological testing, which checks for antibodies created by the immune system to fight the virus. Since it is checking for antibodies made by the body, it can detect previous infections even after the virus is gone.

Over the past few weeks, several major United States radiology societies have come out with statements making it clear that CT should be used sparingly in COVID, and only when it will impact care management. In some cases, however, a patient may have imaging tests done for other reasons and the scans may reveal findings potentially suggestive of COVID-19. In these instances, provider should be familiar with COVID-19 imagining features.

The key findings on chest-CT include ground-glass opacities, consolidations, and crazy paving patterns. Individuals presenting to hospitals with these CT findings may need isolation and should get thorough confirmatory testing and appropriate treatment. A recent article in The Lancet says that “the definite diagnosis of COVID-19 mostly relies on positive RT-PCR on respiratory samples, although discriminant features have been reported on thoracic CT scan.”

CDI review focus

Capturing COVID-19 patients’ chronic conditions will give us a better clinical picture and will affect reimbursement as well. CDI professionals need to review the entire medical record, make sure to understand the actual spectrum of illness, and capture the highest severity of illness (SOI), and risk of mortality (ROM).

For example, patients with a longer length of stay usually exhibit some degree of malnourishment. Multiple factors are contributing to this; for example, patients wait on the test results, and some nursing facilities won’t accept patients back if they test positive for COVID-19. Each patient should be approached uniquely, and anytime we see discrepancies or missing information in the record, clarification may be needed.

Collecting complete and accurate data is essential to understand who is infected, who is hospitalized, who expired, and what can be done to better prepare ourselves for a future pandemic outbreak. The epidemiological risk factors for developing COVID-19 or having a bad outcome are:

• Advanced age
• Coronary artery disease
• Hypertension
• Diabetes

Remember while reviewing records and sending queries, however, that providers and first responders are under an immense amount of stress right now and their priority is necessarily taking care of their patients. CDI professionals need to be aware of their busy schedules and priorities and make sure not to place unnecessary queries during this time.