View source for Critical Care and Medicine Database Core Curriculum

This page is part an orientation guide for new collectors.
It gives a general overview of the data collection processes for both Medicine and ICU collectors at all sites. 

To find instructions and guidelines for specific items try using:
* The wiki search engine 
* The links provided in [[Data Collector Portal]] 
* [[:Category:Data Collection Guide]] 
* Links within CCMDB (ie. ball & chain [[File:CCMDB link icon.png]]) for the corresponding wiki page for various fields.


For more specific information see:
* [[Medicine Curriculum]] 
* [[ICU Curriculum]] 
* {{Collapsable 
| always= Site Specific Collection Details 
| full=
* [[:Category:Site Specific Collection Guide|Site Specific Collection Details]]
** [[GRA General Collection Guide]]
** [[GRA Medicine Collection Guide]]
** [[GRA ICU Collection Guide]]
** [[HSC General Collection Guide]]
** [[HSC Medicine Collection Guide]]
** [[HSC Critical Care Collection Guide]]
** [[STB General Collection Guide]]
** [[STB Medicine Collection Guide]]
** [[STB Critical Care Collection Guide]]
}}

== Introduction ==
The Critical Care and Medicine Database collects medical data on patients admitted under the Medicine and Critical Care services at HSC, St. B and GGH.

Medicine and ICU collectors review patient charts (either on EPR or paper copy) and enter data into a CCMDB program on their laptops.

== The Patient Record ==
The fundamental unit of the ICU and Medicine databases is the patient record.

A profile is created each time a patient is admitted (see [[Definition of a Critical Care Laptop Admission]], [[Definition of a Medicine Laptop Admission]]). 

Every record contains detailed information about each patient:
* Demographics: [[First Name]], [[Last Name]], [[Sex]], [[Postal Code]], [[PHIN]] and [[Chart number]], etc.
* Admission information: [[Pre-admit Inpatient Institution]], [[Previous Location]], [[Boarding Loc]], [[Service tmp entry]] etc.
* Discharge information: [[Transfer Ready DtTm tmp entry]], [[Dispo DtTm]], [[Dispo]] (discharge location or disposition)
* Coding of patient [[ICD10 Diagnoses]] and [[CCI Procedures]] (interventions) relevant to the current admission. 
* [[APACHE physiological variable collection | APACHE elements]]
* [[ADL General Collection Information| ADL information]] (for medicine collection only)
* [[Pharmacy Collection]] (for ICU collection only)
* [[TISS Item List|TISS Items]] (for ICU collection only)
* [[Lab Collection Process | Lab and imaging counts]]
* Any current temporary [[Projects]]

== Diagnostic Coding ==
Our database program uses a locally-adapted version of ICD-10 (International Classification of Diseases) to capture the pertinent diagnostic information for each patient. 

There are three elements to our coding method:


1. '''The diagnoses are divided into three “bins”.'''
* [[Comorbid Diagnosis]]- chronic conditions present prior to admission.
* [[Admit Diagnosis]]- reasons for current admission numbered in order of priority.
* [[Acquired Diagnosis / Complication]] - complications developed during the current admission, listed by date of occurrence.


2. '''The diagnostic codes range from very specific to more general.'''

The goal is to code the most specific diagnosis possible.

If a specific code does not exist, there are many “waste basket” codes that are made for virtually every body system and type of diagnosis.

For example:

* if a patient presents with a very specific diagnosis of giant cell arteritis/temporal arteritis, use the code [[Giant cell arteritis/temporal arteritis]].

* if the patient presents with a vasculitis, but it’s specific identity is not known, use the more general “waste basket” code [[Vasculopathy/vasculitis, NOS]].

Some other examples:

* [[pancreatitis, acute, due to alcohol]] is more specific than [[Pancreatitis, acute NOS]].

* [[pancreas disorder, NOS]] is more specific than [[disorder of digestive system, NOS]].


3. '''Diagnostic codes can be combined together.'''

Some diagnoses are combined together by using the same priority number.

Some reasons for such combinations are:
* Infections - combine the infection with an organism. 
** Ex.  [[Pneumonia, bacterial]] + [[Pseudomonas]].
* Traumas - combine the injury with the mechanism.
** Ex. [[aorta, abdominal, injury/trauma]] + [[mechanism of injury:            motorcyclist]].
* Identifying a manifestation and it’s cause.
** Ex. [[hyperkalemia, severe or symptomatic]] + [[kidney, acute renal                 failure NOS]].
* To construct a code which does not exist in ICD-10.
** Ex. Retroperitoneal hemorrhage/hematoma is created by combining [[retroperitoneal area, diagnostic imaging, abnormal]] + [[hemorrhage, NOS]].

== Intervention Coding ==
Our database program uses a locally-adapted version of CCI (Canadian Classification of Interventions) to capture the interventions/procedures done during the patient’s admission. 


1. CCI codes are divided into four categories:
* Therapeutic interventions: ex. amputation of ischemic limb.
* Diagnostic interventions: ex. renal biopsy.
* Obstetrical interventions: ex. induction of labour
* Imaging interventions: ex. CT head 


2. The CCI codes are collected by two methods:

* The “menu-driven” method, where the body part is combined with the intervention done to it. Ex. [[(T) Tibia, Fibula]] + [[fixation]]. 
* The “picklist” method, where certain interventions can simply be selected from a list. Ex. [[Transfusion of PRBC]]. 


3. The CCI codes are divided into two “bins”:

* Admit CCI’s - procedures done within 48 hours prior to admission.
* Acquired CCI’s - procedures done during the current admission, listed by date. 

== Collection Instructions ==
There are many other details pertaining to all elements of data collection. The following links may be helpful for both ICU and Medicine collectors:
* [[General Collection Practices]]
* [[General Diagnosis Coding Guidelines]]
* [[Collector dictionary]]
* [[Coordination of data between collectors]]
* [[Minimal Data Set]]
* [[Vacation and staff shortage collection priorities]] 

===Currently active Tmp [[:Category:Project|projects]]===
{{#ask: [[ProjectProgram::CC and Med]] [[ProjectActive::active]]
|sort=ProjectProgram
|default=There are not currently any projects
|format=broadtable
|limit=100}}

=== Data collection infrastructure ===
* [[News and backup]] and [[Sending Patients]]
* [[Troubleshooting]] IT issues
* [[CCMDB.accdb links to CCMDB wiki]]
* [[:Category:Wiki use]]

=== Administration ===
* [[:Category:Work Place Information|Work Place Information]]
* [[CCMDB | Critical Care Medicine Database Program - '''Mission statement''']]

== Related articles == 
{{Related Articles}}

[[Category: Data Collection Guide | *]]