2022 COPD for Hospital Based – Post Test

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Question 1 of 10

1. Question
1. The Two Midnight Rule
- a. Requires all patients be in-house for two midnights before inpatient status is ordered
- b. Follows the Medical Inpatient Only listing which is updated each year
- c. States that documentation for inpatient far exceeds that for observation status
- d. States that active management of a clinical condition should be expected to transcend two midnights to be considered inpatient
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Question 2 of 10

2. Question
2. You expected a COPD exacerbation patient to stay more than two midnights based on presentation and prior history and so you ordered for inpatient care. The patient responded more quickly than expected and on the evening rounds of day two, asked to go home. Clinically, you agree with his request. Because the patient did not pass two midnights, you should
- a. Change the admit order to Observation AFTER you discharge the patient
- b. Change the admit order to Observation BEFORE you discharge the patient
- c. Leave the Inpatient order in place, but document that the clinical condition responded more rapidly than expected
- d. Keep the patient until after midnight so secure the “two midnight” criteria for inpatient admission
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Question 3 of 10

3. Question
3. On day two of a hospital stay where the patient was admitted as inpatient for COPD exacerbation, what would help secure this as inpatient on day two?
- a. Occasional PACs on overnight monitor
- b. Noting an increased work of breathing on ambulation to the toilet (no accessory muscle use and RR 13) and RA saturation 96%
- c. Continued shortness of breath (sat 95% off supplemental O2) at rest. RR12.
- d. Shortness of breath on ambulation with O2 saturation 85% in a patient not on home O2 previously
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Question 4 of 10

4. Question
4. Which of the following COPD scenarios would most likely merit INPATIENT hospitalization from initial presentation?
- a. COPD patient with T99, cough and congestion. Frequent COPD admissions where patient commonly is discharged to home on the second hospital day
- b. COPD exacerbation with RR 15, cough w/ thick increased phlegm, sat 96% on RA. Patient has baseline dementia and his mentation remains altered, but not much different than baseline
- c. COPD on 2 liters of home O2, presents with sat 81% and bumped to 4 liters. CXR with LLL pneumonia. On 4 liters in ED now with saturation is 91% at rest and slight accessory muscle use
- d. COPD patient who still smokes AMA, has 3d of wheezing and has used MDI 2x/day for 3d without relief. RA saturation on presentation is 95%
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Question 5 of 10

5. Question
5. A 82 year old with COPD presents with a 2 day history of cough, congestion, low grade fever and sputum increase with discoloration. On admit from ED there is a RA saturation of 92% (baseline is 95%). His labs are stable with K+ 4.2, Hgb 9.9 (baseline 10.2), and a Cr of 1.4 (baseline 0.9). CXR shows increased lung markings and a slight effusion. You order inpatient, but the Physician Advisor has requested on the morning of day two that you reconsideration for placement in Observation. What are some clinical indicators on day TWO that would confirm a need for continued care beyond two midnights and therefore merit an inpatient admission? Choose ALL that are correct:
- a. The saturation drops to 86% and the 2 liters of oxygen is titrated to 4 liters with a sat of 93%
- b. The renal numbers increase on day two from 1.4 to 1.7 and you document a concern that the renal status may worsen. You increase IVF and order a recheck of a Chem7 in the AM
- c. When removing the oxygen (2 liters), the saturation drops to 85% on ambulation to the bathroom, requiring a re-institution of oxygen therapy to maintain baseline saturations
- d. The Hgb drops to 9.4 from 9.9. All other conditions are improving. Vitals are stable.
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Question 6 of 10

6. Question
6. Hemodynamic instability (orthostatic VS, altered mentation) is found in a patient with COPD on presentation to the ED. This patient is appropriate for inpatient admission IF the patient on day two continues to exhibit instability after treatment and appears to need care that exceeds two midnights. That care is noted in the progress notes to show “active management”.
- a. True
- b. False
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Question 7 of 10

7. Question
7. Regarding patients with COPD exacerbation, which is true?
- a. CMS expects the majority of patients to be admitted as inpatient from the ED
- b. Of those admitted, the length of stay ranges about 1 day more for SRHS patients than the national geometric length of stay.
- c. O2 sats < 95% merit admission to inpatient on presentation
- d. If the patient is not better on day 2, an inpatient admission is approved with just the provider’s order because of the length of stay
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Question 8 of 10

8. Question
8. Which of the following is true of respiratory failure? Choose the BEST answer.
- a. Documentation should include physical signs/symptoms of respiratory distress, clinical data such as ABG, pulse oximetry or capnography readings, and treatment
- b. Linkage to etiology is best practice, when possible (i.e., “due to LLL PNA”)
- c. Respiratory failure should be indicated if present on admission (POA status) and updated with documentation to show the current status (improved, resolved, etc.) even on the discharge summary
- d. All are true statements
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Question 9 of 10

9. Question
9. A 77 year old male with a 60 pack-year smoking history and non-supplemental oxygen requiring COPD presents with SOB x 3d duration. Though not indicative of securing an inpatient status determination on admission, the following information would help in making that clinical decision:

(choose all that are correct)
- a. Making reference to the last admission 2 months ago with a similar presentation that ended up with a prolonged hospital stay and a 2d mechanical ventilation complication
- b. Noting the O2 sat of 95% on RA in the PCP office and the sat of 85% on RA here
- c. Commenting on the labored breathing, accessory muscle use, and the “fatigued” look at presentation
- d. Noting the CXR finding of RLL with a layering pleural effusion
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Question 10 of 10

10. Question
10. Which of the following are appropriate documentation notations for the COPD inpatient?
- a. AECOPD with asthma without hypoxemia
- b. Chronic obstructive asthma exacerbation with hypoxia
- c. COPD exacerbation, improved, followed by pulmonology
- d. All of the above are appropriate
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2022 COPD for Hospital Based – Post Test

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