Minutes Team Meeting June 19, 2013

Minutes from Team Meeting June 19, 2013.

1. The plan for September collection meeting is to have p:Dr. Allan Garland to present general plans to database structure changes program has been working on. Collectors are noting some small changes in their CCMDB.accdb and they are not sure why they are being done.

Central_Line_Related_Blood_stream_Infection_(CLR-BSI) Data Collection Criteria 2 issue

1. Central_Line_Related_Blood_stream_Infection_(CLR-BSI)
   • our criteria 2 on wiki for CLR_BSI is not clear to many data collectors. Need help to further clarify.
   • what are "recognized pathogens" vs non recognized pathogens?
   • if patient is colonized with MRSA or VRE, when is it considered pathogenic?
     • Options discussed:
       • clarify with Dr. Kendiss Olafson
       • questions and examples to send to Dr. Anand Kumar
       • Examples of cases to discuss and review
       • Take issues and discuss in the Task Team
   • PLAN 1:
     • Take topic to ICU database Task team.
     • one SUGGESTION: June 21.13; Trish has sent out an email to data collectors (including p:Dr. Allan Garland and Kendiss) to review and proposed we use the SAME wording for Criteria 2, make a 3rd criteria so wording is CLEARER for CLR_BSI as the Critical Care Vital Signs Monitoring.
       • Criteria 2
         • One of:
           • Temp >38 C
           • Hypotension
           • Chills
           • Signs of infection at catheter insertion/tunnel site – AND - a common skin contaminant (as listed) from TWO or MORE blood cultures drawn on separate occasions
       • Criteria 3
         • One of
           • Temp >38 C
           • Hypotension
           • Chills
           • Signs of infection at catheter insertion site – AND - a common skin contaminant (as listed) cultured from ONE blood culture - AND - a physician institutes appropriate antimicrobial therapy.
   • Plan 2:
     • Email sent to Dr. Kumar with some questions/examples. Question and reply below.
     • From: Trish Ostryzniuk, Sent: Thursday, June 20, 2013 10:48 AM, To: Anand Kumar, Subject: Previously colonized with ARO - bug question consult.
     • Hi Dr. Kumar We need your help on this. Collectors are having trouble decided when previously colonized with ARO (Antibiotic Resistant Organism), when does it become an acute infection be in septicemia or pneumonia.
       • QUESTION: Pt who is colonized with VRE or MRSA or both, and has a -ve blood cultures and sputum: if they go on to develop septicemia (+ ve blood cultures) with VRE or MRSA or both and, it appears to be an acute infection (pt starts decompensating), question is this: would VRE or MSRA be the causative agent for this infection?
       • Example 1: pt is colonized with VRE & MRSA, develops SOB, has to be intubated and the ETT secretions grow MRSA and entercocus spec. Is this an pneumonia mixed with MRSA?
       • DR. KUMAR: if culture is nothing "new", then code as culture negative but use the code COLONIZED with MRSA 99-48 OR if Dr. does say pneumonia is due to MRSA then code it as pneumonia is MRSA. Doc's are using judgment too and they are not always certain either. Let the chart reviewer who pulls these charts for further study figure it out if they can.
       • Example 2: pt is colonized with VRE, develops fever, blood cultures grow VRE, do we code it septicemia VRE?
       • DR KUMAR: Note: VRE or staph aureus should not be in blood, if it is, then the blood stream infection/septicemia/bacteremia is due to VRE or Staph A.Colonizer's don't colonize in the blood, if they are in the blood then it is pathogen up to no good and causing bacteremia/septicemia.
     • DR KUMAR:In terms of CLR BSI (central line related blood stream infections) related to MSRA, of only culture from the blood with no other pathogen, then can make an assumption that line infection is related to MSRA. THIS IS GENERALLY A DR's GUESS. The only definitive proof is if blood culture and line tip is +ve for MSRA, the definite CLR-BSI due to MSRA.

TISS28 items 46-49 - 2300 hrs items

1. TISS28 is not only used to monitor bedside nurse workload trends, by administration and management, it is also used by Critical Care Vital Signs Monitoring and ICU Quality Improvement team for research and monitoring for quality of patient care.
2. every 3-4 month the data collectors are asked to provide a summary of observed issues with completion of TISS forms. This information feed back to ICU Nursing Director p:Jodi Walker Tweed, review with the QI officer p:Basil Evan, ICU managers in the region. Manager then review with their staff and QI Officer review with Nursing Educators.
3. p:Julie Mojica presented a brief Comparative Analysis of TISS28 items 46-49 vs CRN Data collection
   • Period: Jan-Mar 31.13 (90 days)
   • CRN use to count daily number of central lines, ventilated patients and ETT's since 2007 and fax them to main database office. As of Jan 1.13 this information was included on the TISS28 for (items 46-49). Also items 28 & 29.
   • January 1.13 to beginning of May 6.13, Julie did a comparative analysis from TISS28 vs CRN daily sheets.
   • Difference ranges from 70-90%. The main reason for the difference is the COLLECTION TIMES. TISS28 counts at 2300 hrs and CRN sheets counts were generally sometimes in the morning each day. Could not conclude if data on CRN sheet or TISS28 sheets was more reliable.
4. Database Steering Committee proposed and different type of audit.
   • an independant auditor will collect data on a specific date VS bedside nurse collection at each site in Region
   • data collector at a site will be notificed not to edit or add to TISS28 for items 46-49 for a specific date by Trish.
5. Quality control of TISS data provided by bedside nurses continues to be a significant burden of workload on the data collector at each site. The degree and amount of edits, additions, correction etc., varies from site to site. Some collectors do a high degree of quality control on each TISS, others do minimal corrections. The degree of quality control required has not been specified therefore, not consistent, and is dependant on the collector who does it.
6. RE: Long stay patient and turning in TISS form after second page is started: Critical Care Vital Signs Monitoring and ICU QI team is wanting data sooner rather than later, particularily related to certain items on TISS. There has been a request that collector not hold on to all the TISS forms until patient is discharged from unit if LOS is 10 days or more. For some units this has been challenging that they are not able to do weekly QA check of TISS before submitting. IF the ICU starts to accept TISS AS IS with missing days and incomplete data we would need a way on form and in TISS database tag this.
   • Plan
   • discuss at ICU database Task meeting what should be the minimal standards of quality control on TISS forms?
     • Should we just spec out specific items on form that must be quality checked: example, top of form, dates, specific items that are used for CCMVS and ICU QI team?
     • Should we just accept the other items on TISS AS IS and let units takes responsiblity for poor TISS scores?
     • is there some way to keep track of collector edits,changes or additon on TISS forms and be able to tally amount of changes actually made in order to actually report ICU's bedside lack of effort in completing a TISS form realiably?
     • the independant TISS audit started in June 2013, to be reported and reviewed by Steering Commitee when it is completed.

Overstay Project Bed day reduction in medicine program

1. Presented by Linda Hathout
2. approximate decrease in mean LOS of 2.1 days
3. statistically significant change.
4. miracle that process works
   • How?
     • data pretty good
     • staff that are excellent in analyzing data
     • cooperation from various program disciplines
     • ownership of problem and increase accountablity (transition coordinator)
     • excellent support from data collector at each site!
     • reduction of panelling from hospitals and increase panelling from Home. Better for patient to be panelled from home
     • increase supports as needed to enable patient to return to home
     • reduction in number of unnecessary consults for home care and increase in number of appropriate consults
5. ISSUE: Collectors state that the ADMIT from items if often MISSED on Discharge Planning Screening Tool (DPST) for and that it should be a question with a number 7 by it, otherwise often missed and collect has to chase. Bedside nurse have request this change at HSC as per p:Pat Stein.
   • Linda Hathout stated that the final DPSTform to be work on over the summer months of 2013. Clearer worded is needed.
6. Statistician p:Julie Mojica is able to capture READMIT when linking databases if patient is from a unit we are collecting on. This is in regards to some comment about capturing the number of FAILED DISCHARGES (sorry, don't recall all of discussion on this point).
7. p:Debbie Page-Newton Requested to have the stats for the number of bed days/beds saved as a result of the OverstayProject. It would also be beneficial if someone could figure out what that translates to in terms of actual dollars and cents saved. I think that generally people can relate to, and are more impressed by the amount of money saved.

Palliative care

1. as per Linda Hathout & p:Dr. Dan Roberts the DPST, should done for palliative care patients, and a color should be generated. (not sure what the final color was decided if GREEN or YELLOW? It was Green by p:Dr. Dan Roberts first email.
   • I could be wrong; my understanding is the color could be either green or yellow and coded according to the color generated by the algorithm.-- Pamela Piche
   • p:Dr. Dan Roberts: what ever we do we have to be consistent. Can't make tool too sensitive. Even with misclassifications, we pick up sufficient number of REDS to make a difference.
     • EXCEPTION: Palliative care and DC TX: if demise is imminent and anticipated within 24-36 hrs of unit admission then DO NOT complete the DPST.
       • one cannot estimate or make a judgement that a patient will for certain, die within 24-36 hrs, therefore fill out form as best you can if not certain. If died and form was filled out, patient will be excluded from analysis and any work associated with discharge planning; well, there won't be any.
   • PROPOSED: Add a subcode to code 90400 Palliative care
     • 90401 Palliative Care - demise imminent within 24-36 hrs
   • Collector must make sure that any patient admitted as Palliative or becomes Palliative after being admitted to your unit, you must include this code in your DX slots in CCMDB.accdb where appropriate.

Sending and copying DPST forms

1. stop sending a copy of DPST to Linda for: GRA, VIC and STB. To be kept on chart, though not legal document approved by MR so not sure which sites will file in MR chart.

ADL HSC_H4 - data collection challenges

1. p:Pat Stein - HSC_H4 issues with doing ADL. Information if kept on chart at each patient room. Other medicine wards at HSC do not do this. Collector must go to each and every room to get information. Often it is not done, nor is it clear or accurate. Collector must hunt around and guess most of the time. Question was asked of Medicine program in past (at Steering Meeting) as to why medicine does not adopt a standard ADL assessment form if this is an important assessment that must be made at admission? Challenging for collectors at a number of sites because documentation can be all over the place. The data collectors at HSC-H4, as well at other sites, will look into room to assess ADL if nothing on chart.

HSC office Desktop computer

1. HSC - 2 desktops died during same week. One of the deceased desktop was actually replaced with record speed by ehealth within the same week. Staff wanted to know the status of the second desktop for looking up ADT and labs. They had preferred this option than having it on laptop because laptop is to small to view ADT and lab screens. Trish has followed this up. The desktop computer is in this week and being followed up by Tom Fraser as to estimated date of set up in GF216.

Computer issues at all sites

1. Computer/laptop/IMPACS issues: Collector voiced many concerns about lost productivity due to the numerous computer problems each day. Computer crashing, freezing, rebooting, slow news and back up, or it is not working at all, security and eHelath update issues, MS Access issues, presend checker issue (slow or freezing HSC).
   • Tina confirmed that problems have be ocurring at many sites all at once for a number of months. There have been numerous dicussion with eHealth. Dr. Roberts aware.
   • we have proceeded to get extended warranties on laptops. (subitted Jun 6.13). Ehealth is looking into the type of new tool that they would allow us to purchase that they would better support.
   • Ehealth is also short of staff and small number of staff trying to help as best as they can.
   • collector advised to keep Pagasa and Trish posted of any computer problem that cut into collection time. For any regular reports or data request we can report back to administration what the delay time will have to be.

Accreditation Leading Practice Award

1. Dr.Dan Roberts explained the Recognition Leading Practice that the medicine program recieved from Accreditation Canada. Both Linda and Dan thanked the Data Collection Program Team for their contribution to this prestigous acknowlegement.
   • a. the medicine database program &
   • b. service redesign in an internal medicine program.

Linda attended the meeting award recognitions in Edmonton. Linda went the extra mile to obtained addition copies of the award and have them framed to give to Database Offices. The Main collection office, HSC_med, STB_med, VIC_med, and GRA_med got a copy to display in their office.

• thank you new team member Pamela Piche for kindly volunteering to do minutes!! Anyone who would like to make changes or add anything further, please do so. Trish Ostryzniuk 20:30, 2013 June 24 (EDT),

Next Team Meeting

• DATE: September 25, 2013
• TIME: 1400-1600 hrs (could not book earlier time)
• PLACE: HSC same place.