Appeal type: Medical necessity
Decision: Upheld

Diagnosis: Respiratory distress; vomiting
Treatment: Inpatient admission 

The inpatient admission was not medically necessary.

The patient is a young female child with unremarkable medical history. She was referred to the ED late evening with two-day history of cold symptoms, same-day history of vomiting multiple times, and same day history of respiratory distress. She had been seen in the clinic earlier and was noted to have tachypnea and wheezing. She was treated with two doses of albuterol prior to referral to the ED. 

The patient's vital signs included temperature 36.8, heart rate 157, respiratory rate 44, and 96% saturation in room air. Examination was significant for respiratory distress with tachypnea, mild nasal flaring, and retraction, expiratory wheezing with good air exchange, moist mucous membranes, tachycardia, and non-focal neurologic exam. She was placed into ED Observation Status for first-time wheezing. Chest x-ray and viral respiratory panel were ordered. She was treated with DuoNeb, Decadron by mouth, and Zofran by mouth. She was re-evaluated after half-hour and continued to have mild persistent wheezing at the left lower lung field with shallow breathing while sleeping. Two more DuoNeb treatments were ordered. Chest x-ray was negative. She was re-evaluated after about two hours, with complete resolution of wheezing, but had developed fever to 38.0 treated with ibuprofen. She was re-evaluated after an hour, and was noted to have tachypnea with occasional cough. Oxygen saturation was 90-92% in room air. Viral panel was positive for human rhinovirus/enterovirus. She was re-evaluated a final time before admission, revealing tachypnea, slight wheezing in the right lung fields, with oxygen saturation 89-91% in room air. 

The patient was given an albuterol neb prior to admission to the pediatric floor. In total, she received three DuoNebs and albuterol every two hours. Admission diagnosis included viral upper respiratory illness with reactive airway disease. Admission orders included albuterol every two hours, supplemental oxygen to maintain saturation greater than 90%, continuous pulse oximetry, Zofran as needed, and regular pediatric diet for age. She was able to tolerate spacing of the albuterol to every four hours and was able to wean from supplemental oxygen to room air by midday and was deemed stable for discharge the following morning. 

This young previously healthy female child presented to the clinic with respiratory distress and cold symptoms. She was treated with albuterol, but remained symptomatic, so was referred to the ED. She was placed under observation in the ED for first time wheezing, receiving multiple doses of bronchodilator, systemic corticosteroids, and ibuprofen for fever. Diagnostic testing revealed infection with rhinovirus/enterovirus. Because she continued to be symptomatic with tachypnea and mild hypoxia, she was admitted for further management. She continued treatment with bronchodilators and briefly required supplemental oxygen, but was able to wean over the course of the morning. She tolerated a regular diet throughout her stay. 

Based on the documentation, it is unclear why the patient remained in the hospital the next day. Regardless, she was overall hemodynamically stable, with transient oxygen requirement, no persistent fevers, no significant respiratory distress and impending respiratory failure. She did not require acute inpatient admission, and could have been safely managed at a lower level of care such as observation.