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Critical Care Program Quality Indicator Report: Difference between revisions

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{{Report
{{Report
|Program=Critical Care
|Program=Critical Care
|StartDtTm=2016-10-01
|Frequency=quarterly
|Frequency=quarterly
|ContactPerson=<names, organization if outside of Shared Health>
|ContactPerson=Carmen Hrymak
|Recipients=[[Distribution of Annual and Quarterly Reports]]
|Recipients=[[Distribution of Annual and Quarterly Reports]]
|MailingList=[[Distribution of Annual and Quarterly Reports]]
|MailingList=[[Distribution of Annual and Quarterly Reports]]
|DataDependencies=Avoidable Days in ICU; Bed occupancy; CAM positive (TISS Item); CXR; Charlson Comorbidity Index; Creatinine (labs); Delirium days; Organ Donor; Primary Admit Diagnosis; Readmission; Transfer Delay (Critical Care); Unit Mortality
|DataDependencies=Age; Avoidable Days (Critical Care); Beds occupied by transferrable patients (Critical Care); CXR; Creatinine (labs); Delirium days; Duration of Mechanical Ventilation; ICU Acquired Antibiotic Resistant Organism (ARO) rate; ICU Acquired Catheter-associated Urinary Tract Infection (CAUTI) rate; ICU Acquired Sepsis; ICU Acquired Ulcer Rate; ICU Diagnosis APACHE Category Rate; ICU Interfacility Transfer; ICU Primary Diagnosis ICD10 Chapter Rate; ICU Resource Utilization - Creatinine Tests; LOS Per Service; Length of Time for Transfer from ED to ICU within same facility; Night Time Discharges; Nursing Workload; Over Census at Midnight; Patient flow; Primary Admit Diagnosis; Readmission Rate to ICU; Severity of illness; Transfer Delay (Critical Care); Unit Mortality; Ventilated patient flow; Ventilator Associated Pneumonia Rate; Ventilator Utilization Ratio; Pre-admit Inpatient Institution field; Intended1stSrvc
|SASFiles=<path for SAS files>
|SASFiles=<path for SAS files>
}}
}}
 
Also known as "[[Outcomes Improvement Team]] Quarterly ICU Report" or "Directors Quarterly Report (Critical Care)".  
Also known as "Outcomes Improvement Team Quarterly ICU Report" or "Directors Quarterly Report (Critical Care)".  


== Contents ==
== Contents ==
* Tabular report
There are multiple versions of this report that essentially contain the same [[Indicators]] but has them aggregated slightly differently.  
** Report Label- '''Critical Care Activity Summary Report''' for the current quarter for each Unit
** Start Date - 2003
** End Date - July 2017 for all units (except HSC CCU, STB ACCU, STB ICCS which ended Dec 2018)
** Part of the tabular report continues to be reported
*** label as '''Critical Care Comparative Report''' for the current quarter
*** one table containing  13 summary activity indicators  of individual units  for the current quarter
*** second table containing the VAP and CLBSI rates of all for the current quarter
* Graphical Report
** Report1 Label -  '''Critical Care Program Quality Indicator Report''' ( also refer as the Regional Report)
*** contains cumulative of all units except HSC CCU, STB ACCU and STB ICCS
** Report2 Label - '''Individual ICU Quality Indicator Report'''
** Report3 Label - '''WRHA Critical Care Quality Indicator Report'''
*** contains comparison of indicators among all units
**  Start date - July 2017 for all units (except HSC CCU, STB ACCU, STB ICCS which started Jan 2019)
** End Date -
** Each type of report contains 30 indicators starting Oct 2020 (Nursing workload or TISS Score per patient day was dropped).
** The indicators reported monthly are from 2 or 3 years period while those reported quarterly are from 3 years period.


== Report versions ==
=== Critical Care Program Quality Indicator Report===
There are unit-limited versions of this, but there is also a program wide version that sumamrizes all except ACCU and ICCS (since those are cardiac).
(also refer as the Regional Report)
* contains 30 [[Indicators]] cumulative of all units except [[HSC CCU]], [[STB ACCU]] and [[STB CICU]]
* Started Oct 2016 by Kendiss Olafson (except HSC CCU, STB ACCU and STB ICCS which started Jan 2019)
* End Date -


There is also a "WRHA Critical Care QI Report" - compares across units.
===Individual ICU Quality Indicator Report===
* contains 30 [[Indicators]] for each unit namely, [[HSC MICU]], [[HSC SICU]], [[HSC_IICU]], [[STB MICU]], [[STB ACCU]], [[STB CICU]], [[GRA MICU]]
{{DJ |
** from  last five years quarterly data  starting 2025Q2
* Julie mentioned a second report: "from database request by STB which is being reported by month.--[[User:JMojica|JMojica]] 15:55, 2021 September 7 (CDT)  
** from quarterly data from 2019 to present  starting 2023Q1 until 2024Q4
** The second report you mention, is that documented as one of the [[Reports]] yet? Or is it really a version of this report so we can just list it here?
** from last 2yrs monthly or quarterly data until 2022Q4
}}
* Dropped units are HSC CCU (June2019), CON ICU (June2019), Seven Oaks ICU (Sept2019), VIC ICU (Sept2017)
* Started Oct 2016 by Kendiss Olafson (except [[HSC CCU]], [[STB ACCU]] and [[STB CICU]] which started Jan 2019)
* End Date -


{{DJ | 
===WRHA Critical Care Quality Indicator Report===
* somewhere it mentioned "Quarterly report of Delirium cases, Delirium Rates, Delirium Days and Delirium Rate Days for all ICUs in the region"; we have [[Delirium Days]] in [[Indicators]], but not the others. Are they all defined around the same concept, so that we could rename that indicator "Delirium" and describe them all in there?
* contains comparison among all units of the [[Indicators]]' means (of last 2yrs monthly or quarterly data) 
}}
* each page also contains the individual unit chart over time.
* Start date - Oct 2016 by Kendiss Olafson (except [[HSC CCU]], [[STB ACCU]] and [[STB CICU]] which started Jan 2019)
* End Date -


== Distribution ==
== Distribution ==
Line 49: Line 39:


==File Locations==
==File Locations==
*Hard Copy of Report kept at desk of Database Program [[Statistician]], [[User: JMojica|Julie Mojica]]
*Hard Copy of Report until Dec 2016 kept at desk of Database Program [[Statistician]], [[User: JMojica|Julie Mojica]]
*Electronic copy of report:
*Electronic copy of report:
** Tabular : [[X:\]]Reports\CriticalCareReport
** Tabular : {{S:\MED\MED_CCMED}}Reports\CriticalCareReport
** Graphical: R:\Critical Care QIT\Director_Report\Report
** Graphical: R:\Critical Care QIT\Director_Report\Report
== Legacy ==
===Tabular Report ===
* Tabular report
** Report Label- '''Critical Care Activity Summary Report''' for the current quarter for each Unit
** Start Date - 2003
** End Date - Sept 2016 for all units (except [[HSC CCU]], [[STB ACCU]] and [[STB CICU]] which ended Dec 2018)
** Part of the tabular report continues to be reported
*** label as '''Critical Care Comparative Report''' for the current quarter
*** one table containing  13 summary activity [[Indicators]] of individual units  for the current quarter
*** second table containing the [[Ventilator Associated Pneumonia Rate]]s and [[Central Line Associated Blood-Stream Infection (CLA-BSI) rate]]sof all for the current quarter
*** the '''Critical Care Comparative Report''' is saved as pdf file and  uploaded to [[Critical Care Sharepoint ExtraNet]]
== SAS and SQC Programs==
*First part - Run the SAS programs saved in S:\MED\MED_CCMED\Julie\SAS_CFE\CC_reports\ChartReport  in the following order:
** 1-prepCC_QI_startJan2023_WithIncompleteBedHeld.sas  - prepares the data to be used in the report and exported to excel file
*** Make sure all the data are cleaned already by the [[Data Processor]]. 
*** Update the period to current one as indicated in the program.
*** The exported excel file is saved in R:\Critical Care QIT\Director_Report\DataFile\WRHA_CriticalCare.xlsx
**** Check the  new exported excel file for suspicious data and also compare the data with common period from the excel file of previous period.
** 2-prepCCChart_demog_93_Sex_startstart2023.sas - generates the bar chart for Age Groups, Sex
** 3-prepCCChart_ApacheDxGrp_94_startJan2020.sas - generates the bar chart for eight Diagnostic Categories from APACHE II Predicted Death Model in ICD10 
** 4-prepCCChart_ICD10PrimaryDx_ChapterName_startingJuly2019.sas - generates the table of ranked primary Diagnosis using ICD10 Chapter Name
** 5-InterfacilityTransferInOut.sas - generates the stacked area plots by reasons of transfer (due to medical necessity or bed management reason) for the 3 scenarios namely,
*** transfers out from one ICU to another site's ICU;
*** transfers into an ICU from another site's ICU; and
*** transfers into an ICU from another site's Non-ICU (e.g. ER, Ward ,OR, etc.)
*Second  part - Open the SQCpack8 software to see all the listed control charts for the 26 indicators and 9 groups (i.e. 7 individual units, one Regional and WRHA subgroups)
** The chart's label/name is made plain, simple and intuitive for easy understanding (i.e. APACHE_HSC MICU, APACHE_CCRegion, APACHE_WRHA, etc.)
** All the charts are automatically updated when the excel file is updated.  But need to check each chart  for the following:
*** The need to change the Y-axis if there is any point(s) outside the Y-Axis or when the UCL or LCL are not showing in the chart.
*** Check on the X-axis if the last scale is the current period and all must be date and not datetime format.
*** Check on any outliers in the charts, go back to the data. If found questionable confirm with the data collectors.
*** Look for any change in the pattern and re-calculate the control limits.
** Once all charts are OK, select the charts  and save them as .png image on  R:\Critical Care QIT\Director_Report\Images .
*** for unit chart - use 1200 x 800,  for regional chart use - 1200 x 800, for WRHA (subgroup chart) - use 1000 x 600.
*** for the detailed chart format (font size, color, etc.), the settings are listed in R:\Critical Care QIT\Director_Report\Images\1_ChartRunnerSettingFormats.doc
*** Select charts in small groups (not all charts at once) because the software cannot handle too large number. Just continue the process until all the needed charts are saved into images.
*Third part - Go to R:\Critical Care QIT\Director_Report\Report and review all the *.pptx files
** All the inserted images in the PowerPoint files are automatically updated when the images from SQC are updated.
*** if for some reason, the image did not show up, select the INSERT tab, click PICTURES command, get the needed image from the R:\Critical Care QIT\Director_Report\Images and click INSERT AND LINK.
** Browse all the slides in the PowerPoint if OK.
** Save the PowerPoint into .pdf and save them on the subfolder labeled YYYYQQ where YYYY is year and QQ is the quarter.
** Upload all the PDF files to [[Critical Care Sharepoint ExtraNet]].
===Back up of SQC Charts===
The back-up copies of the control charts generated from SQCpack are saved in the shared file:
* R:\Critical Care QIT\Director_Report\Back_up_ByMonth
* R:\Critical Care QIT\Director_Report\Back_up_ByQtr
If want to bring back into the SQCpack, open the SQCpack software, from Menu, choose Charts and use the Inmport chart features.
== Related articles ==  
== Related articles ==  
{{Related Articles}}
{{Related Articles}}


[[Category:Reporting]]
[[Category:Reporting]]
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