Respiratory System/ Asthma
Inpatient Hospital

The patient is a young female with a past medical history of asthma who presented to the ED with a 1 day history of wet cough and runny nose associated with subjective fever. Her mother noticed belly breathing the night prior and she gave nebulized Albuterol x 1 and Motrin x 1 but on the day of presentation she noticed difficulty breathing so she decided to come to the ER. She also reported the child was not eating at baseline but was tolerating oral intake with 5-6 wet diapers. In the ER she presented with temp 100.9, heart rate (HR) 184, respiratory rate (RR) 39 and oxygen (O2) sat 100% on room air. Her RR went up to 55, the patient was noted on exam to have bilateral (B/L) expiratory wheezing, tachypnea and pan retractions. She was given Combi nebs x 3, Solu-Medrol, Magnesium Sulfate, normal saline (NS) bolus and albuterol neb Q2hr. After 3 Combi nebs she continued with wheezing and retractions. Her RR was 40/min. She had normal chest x-ray (CXR) in the ER. She was negative for both respiratory syncytial virus (RSV) and the Flu. After 4.5 hours in the ER she was reevaluated and continued to have tachypnea with wheezing and belly breathing. The decision was made at that point to admit to the floor.

She was admitted for reactive airway disease (RAD) for further management and to monitor respiratory status. She was started on Albuterol Q2hrs as well as systemic steroids. The morning after admission, the patient was assessed and found to have RR 40 and good air entry at 2hr post Albuterol treatment. She did have end expiratory wheezes at bases. The patient was gradually weaned to Albuterol q4 hrs, which she tolerated. Prior to discharge she was in no respiratory distress, afebrile, and tolerating oral feedings adequately. At issue is the medical necessity of the inpatient stay.

The health plan's determination is overturned. The literature recommends admission and close monitoring for patients with persistent respiratory distress in the face of an asthma exacerbation after proper ER management has been implemented. This patient was symptomatic enough to require IV magnesium as systemic steroids and bronchodilators were not sufficient to control her symptoms. These patients are more likely to experience deterioration and need for higher acuity of care once admitted. She still had wheezing and retractions at the time of admission and required nebulizer treatments every two hours. Such frequent treatments which would also require increased monitoring would not be appropriate for a lower level of care. Even though the length of her stay did not span 2 midnights, the intensity of services provided and the condition of the patient when the decision to admit was made necessitated inpatient level of care.