"Due To" Methylene Blue: A CDS Goes Down the Rabbit Hole

Working as a CDS in the cardiovascular department, Cheryl Fenwick Evans saw a diagnosis she wasn't familiar with. Determined to know more, she dug a little deeper and was surprised by what she found. 

The role of CDS can be extremely rewarding. For me, it’s because I get to be part of the clinical world without the responsibility of caring for patients. This might sound harsh, but the truth is that I cared too much. I don’t miss the worry and heavy burden that plagued me as a hospital-based nurse, and I am grateful that I can apply my nursing experience as an effective CDS. This article is about how CDSs can truly contribute to clinical care, clinician education and the capture of accurate health information at the bedside.

My CDS journey started in November 2020, with Nicole Jenkins, a critical care nurse highly regarded by our ICU consultants. As an ICU nurse myself, I had cared for cardiac patients, but I didn’t know about vasoplegia. Our CDI programme was a pilot, based solely in the cardiovascular directorate. As I reviewed patients following their cardiac surgery, I started to recognize vasoplegia as a complication of the surgery. However, it was often coded as I73.9 for “peripheral vascular disease, unspecified”. My analytical brain kicked in, and off down the rabbit hole I went. Surely I am not the only CDS who goes down rabbit holes!

Vasoplegia is characterized as a “high-output shock state with poor (low) systemic vascular resistance (SVR)” and documented as either vasoplegia or vasoplegic shock (VS). Unsurprisingly, it’s most commonly associated with sepsis, and secondly following cardiac surgery, typically, in association with bypass, although it’s also known to occur in off-pump cardiac procedures.

Vasoplegia following cardiovascular surgery accounts for less than 5% of all circulatory shock. Despite this, between 5% and 50% of patients undergoing cardiac surgery may experience ‘vasoplegic syndrome’ with high morbidity and mortality rates in those patients (1-3). I’m sure I see longer admissions and a cascade of additional complications.

Armed with this information, we worked with our Coding Quality Lead and Critical Care Leads to create a local rule. The process was smooth because my colleague, Nicole (CDS), was already known to the unit’s clinical director. The following criteria were established to denote when vasoplegia was clinically significant.

  •  Administration of Methylene Blue.
  •  Use of Vasopressin infusion.
  •  Use of Noradrenaline at a dosage greater than 0.15mcg/kg/min.

When clinical notes stated, ‘vasoplegia … due to cardiopulmonary bypass (CPB),’ and it met the criteria above, coders could apply I97.89 for “other intraoperative and postprocedural disorders of circulatory system, not elsewhere classified” with an external cause code of Y83.8 for “other surgical procedures”. In doing so we had contributed to the accurate collection of health data, but the real win was the clinician education that resulted.

The principles of CDI, including the documentation of vasoplegia, now appear in the unit’s orientation handbook for both medical and nursing staff. Education around vasoplegia was also added to the quarterly clinician’s orientation. Cardiothoracic JMOs reported improved clinical notes relating to vasoplegia, and an improved understanding of its management and contribution to longer admissions. Our time with the unit was very successful for these reasons, and as the quality of documentation improved, we concentrated our efforts in the busier ward areas.

The role of the Clinical Documentation Specialist can offer opportunity to challenge the status quo, but it takes collaboration for change to occur. Whilst we should be mindful of scope creep, there are opportunities for the CDS to grow and learn new skills, demonstrating that a the CDS role can extend beyond record reviews and queries!



1) https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-2743-

2) https://pubmed.ncbi.nlm.nih.gov/32019600/

3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328055/


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