Harbor:InterQual Macros

Interqual Override Notes

Adult Alphabetical Topics

Atrial Fibrillation / Flutter

  • Admission Criteria – check ANY that apply
    • [ ] Symptomatic atrial fibrillation with uncontrolled ventricular response
    • [ ] Continuous antiarrhythmic infusion required
    • [ ] Digoxin loading required
    • [ ] Permanent pacemaker placement planned
  • High risk for hemodynamic instability requiring inpatient cardiac monitoring.

Diagnosis: Cellulitis

  • Admission Criteria – check ANY that apply
    • [ ] Immunocompromised patient
    • [ ] Infection involving prosthesis or implanted device
    • [ ] Orbital cellulitis
    • [ ] Failure of outpatient antibiotic therapy
  • High risk for progression to deep infection or sepsis requiring inpatient IV antibiotics.

Diagnosis: COPD Exacerbation

  • Admission Criteria – check ANY that apply
    • [ ] Oxygen saturation ≤89%
    • [ ] PaO2 ≤55 mmHg
    • [ ] PaCO2 >45 mmHg with respiratory acidosis
    • [ ] Increased work of breathing or cyanosis
    • [ ] Dyspnea despite ≥2 bronchodilator treatments
    • [ ] Noninvasive ventilation required
    • [ ] Mechanical ventilation required
  • High risk for hypercapnic respiratory failure requiring inpatient respiratory support.

Diagnosis: Deep Vein Thrombosis

  • Admission Criteria – check ANY that apply
    • [ ] Acute DVT confirmed on imaging
    • [ ] Risk of limb compromise
    • [ ] Hospital-acquired thrombosis
    • [ ] Continuous unfractionated heparin infusion required
    • [ ] IVC filter placement planned
  • High risk for pulmonary embolism requiring inpatient anticoagulation management.

Diagnosis: Diabetic Ketoacidosis

  • Admission Criteria – check ANY that apply
    • [ ] Blood glucose >250 mg/dL
    • [ ] Positive ketones
    • [ ] Anion gap >12
    • [ ] pH <7.25
    • [ ] Bicarbonate <15
    • [ ] Continuous insulin infusion required
  • High risk for metabolic instability requiring inpatient insulin therapy and monitoring.

Diagnosis: Gastrointestinal Bleeding

  • Admission Criteria – check ANY that apply
    • [ ] Hemoglobin <7 g/dL
    • [ ] Exertional dyspnea
    • [ ] Orthostatic hypotension
    • [ ] Syncope or presyncope
    • [ ] Altered mental status
    • [ ] INR ≥2
    • [ ] ≥1 L IV fluid resuscitation required prior to admission decision
    • [ ] Blood transfusion required
  • High risk for hemodynamic instability and recurrent bleeding requiring inpatient monitoring and intervention.

Diagnosis: Heart Failure

  • Admission Criteria – check ANY that apply
    • [ ] New onset heart failure symptoms
    • [ ] Pulmonary edema or pleural effusion on imaging
    • [ ] BNP above normal
    • [ ] Oxygen saturation <89% after ED treatment
    • [ ] Persistent dyspnea despite diuretic therapy
  • High risk for respiratory failure requiring inpatient diuresis and monitoring.

Diagnosis: Hypertensive Emergency

  • Admission Criteria – check ANY that apply
    • [ ] Severe hypertension with encephalopathy
    • [ ] Renal injury
    • [ ] Heart failure
    • [ ] Retinal hemorrhage or papilledema
    • [ ] Aortic dissection or aneurysm
  • High risk for stroke, myocardial infarction, or organ damage.

Diagnosis: Nephrolithiasis (Obstructing)

  • Admission Criteria – check ANY that apply
    • [ ] Imaging confirmed urinary obstruction
    • [ ] Creatinine >1.8
    • [ ] Urinary catheterization required
    • [ ] Urologic decompression planned
  • High risk for obstructive uropathy and urosepsis.

Diagnosis: Pneumonia

  • Admission Criteria – check ANY that apply
    • [ ] Oxygen saturation <89%
    • [ ] PaO2 <56 mmHg
    • [ ] PaCO2 ≥45 mmHg with respiratory compromise
    • [ ] Multilobar pneumonia
    • [ ] Pneumonia Severity Index ≥91
    • [ ] CURB-65 ≥3
    • [ ] Lung abscess, necrotizing pneumonia, or empyema
  • High risk for respiratory failure or sepsis.

Diagnosis: Pulmonary Embolism

  • Admission Criteria – check ANY that apply
    • [ ] Pulmonary embolism confirmed on imaging
    • [ ] Hypoxia ≤90% requiring supplemental oxygen
    • [ ] Right ventricular dysfunction
    • [ ] Abnormal cardiac biomarkers
    • [ ] Continuous anticoagulation infusion required
    • [ ] Thrombolytic therapy planned
  • High risk for hemodynamic collapse.

Diagnosis: Pyelonephritis / Complicated UTI

  • Admission Criteria – check ANY that apply
    • [ ] Urinary symptoms with abnormal urinalysis
    • [ ] Urine cultures pending after abnormal urinalysis
    • [ ] SIRS criteria present
    • [ ] Positive blood cultures
    • [ ] Pregnancy ≥24 weeks
    • [ ] Urinary obstruction or indwelling stent
    • [ ] IV antibiotics required
    • [ ] IV fluid resuscitation required
  • High risk for bacteremia and progression to sepsis.

Diagnosis: Sepsis

  • Admission Criteria – check ANY that apply
    • [ ] Suspected infection with SIRS criteria
    • [ ] Elevated lactate
    • [ ] Hypotension
    • [ ] Altered mental status
    • [ ] Acute kidney injury
  • High risk for septic shock or organ failure requiring inpatient management.

Diagnosis: Septic Shock

  • Admission Criteria – check ANY that apply
    • [ ] Hypotension despite fluid resuscitation
    • [ ] Vasopressor infusion required
    • [ ] Elevated lactate
    • [ ] Organ dysfunction
  • High risk for cardiovascular collapse requiring ICU-level care.

Diagnosis: Sickle Cell Disease (Adult)

  • Admission Criteria – check ANY that apply
    • [ ] Acute pain crisis requiring ≥4 IV analgesic doses
    • [ ] Acute chest syndrome
    • [ ] Aplastic crisis requiring transfusion
    • [ ] Fever ≥38.5°C
  • High risk for respiratory complications or severe anemia.

Diagnosis: Stroke

  • Admission Criteria – check ANY that apply
    • [ ] Acute ischemic stroke
    • [ ] Intracranial hemorrhage
  • High risk for neurologic deterioration requiring inpatient monitoring.

Diagnosis: TIA

  • Admission Criteria – check ANY that apply
    • [ ] Transient neurologic deficit with crescendo events
    • [ ] Endocardial vegetation present
    • [ ] Prior stroke with recurrent TIA
  • High risk for progression to stroke.

Adult Conditions Typically Managed at Observation Level of Care

These diagnoses typically meet short-term hospital monitoring rather than inpatient admission based on standard utilization review criteria. If a patient with one of these diagnoses requires inpatient admission due to severity of illness, treatment intensity, or risk of clinical deterioration, ALSO include the additional Override – Inpatient Medical Necessity Statement macro below to document medical necessity for admission.

Diagnosis: Abdominal Pain

  • Observation Criteria – check ANY that apply
    • [ ] Undifferentiated abdominal pain requiring diagnostic evaluation
    • [ ] Stable vital signs
    • [ ] No evidence of surgical abdomen
  • Requires short-term monitoring and diagnostic evaluation to determine underlying cause.

Diagnosis: Chest Pain (Rule-Out ACS)

  • Observation Criteria – check ANY that apply
    • [ ] Chest pain without diagnostic ECG changes
    • [ ] Initial troponin negative
    • [ ] Hemodynamically stable
  • Requires serial cardiac testing and cardiac monitoring to evaluate for evolving acute coronary syndrome.

Diagnosis: Nausea and Vomiting / Dehydration

  • Observation Criteria – check ANY that apply
    • [ ] Nausea, vomiting, or diarrhea with dehydration
    • [ ] Electrolyte abnormalities
    • [ ] Inability to tolerate oral intake
  • Requires IV hydration and monitoring of electrolyte status and clinical response.

Diagnosis: Migraine

  • Observation Criteria – check ANY that apply
    • [ ] Severe migraine requiring parenteral therapy
    • [ ] No focal neurologic deficits
  • Requires symptom control and neurologic reassessment.

Diagnosis: Syncope

  • Observation Criteria – check ANY that apply
    • [ ] Transient loss of consciousness
    • [ ] Stable vital signs after evaluation
    • [ ] No evidence of stroke or serious arrhythmia
  • Requires diagnostic evaluation and cardiac monitoring to determine underlying cause.

Override – Inpatient Medical Necessity Statement

  • Admission Criteria – check ANY that apply
    • [ ] Physiologic instability
    • [ ] Failure of outpatient or ED treatment
    • [ ] Clinical deterioration despite therapy
    • [ ] High-risk comorbidities
    • [ ] IV medications or infusion therapy required
    • [ ] Escalation of respiratory support required
    • [ ] Blood transfusion or IV fluids required
    • [ ] Urgent procedure planned
    • [ ] Continuous cardiopulmonary monitoring required
  • The patient requires inpatient level care due to severity of illness, intensity of required services, and risk of clinical deterioration.

Pediatric Utilization Review (UR) Macros (Alphabetized)

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Diagnosis: Asthma

  • Admission Criteria – check ANY that apply
    • [ ] Impending respiratory failure
    • [ ] NIPPV required
    • [ ] Persistent wheezing despite therapy
    • [ ] Cyanosis
    • [ ] Altered mental status
    • [ ] Oxygen saturation <96%
    • [ ] Increased work of breathing
  • High risk for respiratory failure requiring inpatient bronchodilator therapy.

Diagnosis: Bronchiolitis

  • Admission Criteria – check ANY that apply
    • [ ] Oxygen saturation <90%
    • [ ] Apnea
    • [ ] Cyanosis
    • [ ] Nasal flaring or severe retractions
    • [ ] Tachypnea for age
    • [ ] Inadequate oral intake
  • High risk for respiratory deterioration requiring inpatient monitoring.

Diagnosis: Constipation

  • Admission Criteria – check ANY that apply
    • [ ] Failure of outpatient laxatives or enemas
    • [ ] No bowel movement for ≥7 days
    • [ ] Colonic irrigation or PEG therapy required
  • High risk for severe fecal impaction requiring inpatient treatment.

Diagnosis: Dehydration / Gastroenteritis

  • Admission Criteria – check ANY that apply
    • [ ] Symptomatic dehydration
    • [ ] Abnormal electrolytes
    • [ ] Poor oral intake
    • [ ] IV fluid therapy required
  • High risk for worsening dehydration requiring inpatient hydration and monitoring.

Diagnosis: Diabetic Ketoacidosis

  • Admission Criteria – check ANY that apply
    • [ ] Glucose >200 mg/dL
    • [ ] Ketones present
    • [ ] Anion gap >18
    • [ ] pH <7.2
    • [ ] Bicarbonate <10
    • [ ] Continuous insulin infusion required
  • High risk for metabolic instability and cerebral edema.

Diagnosis: Failure to Thrive

  • Admission Criteria – check ANY that apply
    • [ ] Severe malnutrition
    • [ ] Weight <70% predicted weight for height
    • [ ] Failure of outpatient management
    • [ ] Medically complex child
  • High risk for worsening malnutrition requiring inpatient nutritional support.

Diagnosis: Pneumonia

  • Admission Criteria – check ANY that apply
    • [ ] Oxygen saturation <90%
    • [ ] Increased work of breathing
    • [ ] Tachypnea for age
    • [ ] Multilobar pneumonia
    • [ ] Pleural effusion or empyema
  • High risk for respiratory failure requiring inpatient antibiotic therapy.

Diagnosis: Seizure Disorder

  • Admission Criteria – check ANY that apply
    • [ ] Status epilepticus
    • [ ] ≥2 seizures within 24 hours
    • [ ] Change from baseline seizure pattern
    • [ ] Continuous EEG monitoring required
  • High risk for recurrent seizures requiring inpatient neurologic monitoring.

Diagnosis: Sepsis

  • Admission Criteria – check ANY that apply
    • [ ] Suspected infection with SIRS
    • [ ] Organ dysfunction
    • [ ] Abnormal temperature
    • [ ] Altered mental status
  • High risk for septic shock requiring inpatient treatment.

Diagnosis: Sickle Cell Disease

  • Admission Criteria – check ANY that apply
    • [ ] Acute pain crisis requiring IV analgesia
    • [ ] Acute chest syndrome
    • [ ] Splenic sequestration
    • [ ] Fever ≥38.5°C
  • High risk for respiratory complications and severe anemia requiring inpatient monitoring.
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