Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Stab wounds
Treatment: Inpatient admission
The acute inpatient admission was not medically necessary. 

The patient is a male.  He was seen at the hospital in the early morning after being stabbed multiple times in the back. The adolescent also suffered a laceration to the foot during the assault. 

The patient arrived as a Level I activation. On arrival, the patient's vital signs were: pulse rate 102 beats per minute (bpm) (minimally elevated), respiratory rate 26 (elevated), and blood pressure 115/77 (normal). Physical examination showed multiple stab wounds to the lower back and a large laceration of the right anterior foot with exposed tendon. Chest x-ray (CXR) was negative. Computed tomography (CT) of the head / brain was negative. CT scan of the chest, abdomen, and pelvis showed penetrating wounds of the back and a small left retroperitoneal hematoma. There was no evidence of a bowel or kidney injury. Lactate level was elevated at 11.9 (normal < 2.2). The Trauma Service determined none of the wounds required operative care. The wounds, including the foot, were sutured in the emergency room (ER). The patient received prophylactic antibiotics. 

The patient was admitted to acute inpatient level of care on the ward in the early morning hours for serial hemoglobin levels and physical examination. Follow-up hemoglobin after initial drop remained stable. Lactate level down trended (3.6 at 04:26 and normal by 10:00 that morning). 

The next day, the patient was awake and alert. He was tolerating regular diet. He was feeling well. He had mild pain on the top of the right foot where there had been repair of a laceration. He had no abdominal tenderness. The wounds were well approximated. The patient had stable hemoglobin. The patient was cleared to ambulate with crutches. The patient was discharged home. Discharge order was entered at 14:42. 

The patient underwent evaluation in the ER which demonstrated no bony injuries, no chest injury, no head injury, and no solid organ injury. CT scan showed penetrating wounds of the back and a small left retroperitoneal hematoma. Lacerations were repaired in the ER. Lactate level was elevated on arrival but returned to normal within eight hours. The patient was admitted for serial hemoglobin levels to insure there was no ongoing bleeding. Hemoglobin level remained stable for three draws in the mid-eleven range. Serial hemoglobin levels and exams did not require acute inpatient level of care. The care rendered was amenable to a lower level of care e.g. observation. The care the patient would have received at a lower level of care, e.g. observation, would have been identical to that which he in fact received. 

The patient could have been treated at a lower level of care without compromise of patient safety. He was hemodynamically stable. He underwent multiple imaging studies which did not demonstrate a penetrating intraabdominal or solid organ injury. The only finding of significance was a retroperitoneal hematoma of unstated size. The stab wounds and foot laceration were repaired in the ER. 

The patient remained hemodynamically stable, was cleared for crutch walking by physical therapy (PT) (due to foot laceration repair), and was discharged home.

The anticipated length of stay should have been less than one past-midnight stay from the time the decision to admit was made. As of the afternoon the next day, the patient had stable hemoglobin, stable vital signs, was on regular diet, and ambulatory. Acute inpatient level of care is not the appropriate level of care for this diagnosis or this patient's care. It is in excess of the level of care which is necessary to provide safe treatment.  If a dropping hemoglobin had occurred or other findings suggestive of a more severe injury, the patient can be switched to acute inpatient level of care. This was unnecessary for this patient.