Team Meeting June 12 2008

A team meeting has been scheduled.

Time: 12 June 2008, 11:00 - 13:00

Location: HSC, 4th floor of the John Buhler building, room 405

Please make every effort to attend this meeting if at all possible. Medicine data collectors please bring examples of where you are getting your information to complete the Katz ADL from.

Agenda

• Discuss how the MOST Score is being collected - Trish or Linda
• What the MOST Score is used for - Dr. Roberts
• Discuss discharges to ER – Julie
• Review Vital Signs project – Julie
• Review the Wiki application – Tina
• Questions and Answers - Everyone

Tina & Trish will be updating the Wiki with the answers to your questions.

If you have any other questions or concerns please send them to Linda ahead of time so we can ensure questions get addressed.

Questions/Concerns Submitted

1. Clarify definition for Hypotension NYD- it says not due to shock or post-op in the code book we don't know when to use this. Why can't we just have hypotension NYD for a code? In other words if patients don't meet the specific criteria for septic shock or hypovolemic shock or cardiogenic shock it would be NYD.

2. Clarify definition Septic Shock. (Criteria are in DX code guide for Septic Shock. The exact question here according to Gail Hall was as follows: if a patient doesn't meet the criteria for septic shock as outline in the Diagnosis code criteria for Septic shock, for example is hypothermic instead of hyperthermic, yet the physician is calling it septic shock, what is the collector suppose to do: a. follow the criteria and if they are NOT met then don't code a septic shock or b. If physician DX is the working DX and that is what they are treating, then code as septic shock or c. Use the hypotension NYD code.

• • NEEDS FURTHER FOLLOW-UP .
• TOstryzniuk 17:06, 29 July 2008 (CDT)

3. Clarify definition Cardiogenic Shock

• there are criteria to follow in diagnosis code guideline therefore I am not sure what the exact question is here?TOstryzniuk 17:06, 29 July 2008 (CDT)

4. Clarify definition Cardiac Arrests-It's impossible to see how many occur right before admission to Medicine as some patients are admitted to medicine bypassing ICU.

• Not sure what the question is here?TOstryzniuk 17:06, 29 July 2008 (CDT)

5. Clarify definition Violent behavior code - supposed to be 2nd to dementia but is used for anyone who is violent.

• Use for anyone. (note: not just tagging general bad moods here).
• Can collectors please provide examples of other reasons beside dementia that is causing violent behavior on wards????TOstryzniuk 17:06, 29 July 2008 (CDT)

6. Clarify definition Panelling or Discharge Planning why does it say in the code book primary reason for admission to ward bed?

• the reason for adding this patient status code (it is not a DX code), was to try and track those patients whose primary reason for moving to a medicine ward bed was no longer due to an acute disease process however they were waiting for other services or nursing home placement and that is the primary reason why they are still in an acute care med bed.
• discussion about these patients was that they had chronic disease condition and that was the reason why they were still in med ward beds and not sent home. Many of these patient have multiple chronic underlying diseases and the question was, how do we then decide which one was the primary one that was still keeping them in a med ward bed?
• .............more to be added here later..............````

7. Clarify definition Muscle deconditioning

8. Clarify definition Pain Control - non post op

• we are not wanting to tag every patient who is being treated for pain.
• use this code only if the reason for ICU or ward admission is due to severe out of control pain that is a primary reason for admission is for the management of severe out of control pain.

*example is Cancer patients who primary reason for admission to medicine ward is pain management. TOstryzniuk 18:08, 29 July 2008 (CDT)

9. Clarify definition Pain Control - post op - we feel it is highly overused. Most surgical patients need some degree of pain management post op. We don't need to tag everyone that is having their pain treated post-operatively. This code should only be used for those who's pain is clearly severe and out of control and because of this it is significantly contributing to the reason for ICU admission. In terms of ward admission, again if the primary problem is out of control pain this could be the primary reason a physician admits.

• the reason for having this code was that there were many patients being admitted from the recovery room who's primary reason to ICU was purely pain control and nothing else that warranted ICU admission.TOstryzniuk 18:08, 29 July 2008 (CDT)

10. Clarify definition Palliative Care - need further criteria to code correctly.

• seePalliative Care article for updated information.
• Work in progress which looks like it is getting there.
• Data Collecter contribution is encouraged.TOstryzniuk 18:08, 29 July 2008 (CDT)

1. Acute coronary insufficiency and Unstable angina (151, 152) - description in code book should be reversed

• it will stay as is so that it is consistent. Even if it is wrong, it is consistently wrong.

11. There currently is no codes for: hematuria- we have lots of people who are getting CBI for hematuria NYD.

• Hematuria is a symptom it is not a diagnosis, therefore we willnot add it as a code. TOstryzniuk 18:54, 24 June 2008 (CDT)

12. ADL.

1. • assessment for feeding; when a person arrives to the unit within the first 24 hours NPO either for a test or for GI Bleed does this qualify as Dependant?
   • The KATZ says 'Dependant is assistance to eat; does not eat (I interpret this to include NPO); must be fed; fed partly or completely by NG or IV.(Linda)
   • ADL assessement is based on the capablity of a patient if he was "allowed" to perform the activity he would be able to. If restricted due to hospital policy or for procedure or surgery, then assess feeding as UNASSISTED.TOstryzniuk 19:05, 24 June 2008 (CDT.
2. Continence for assessment; does the use of a foley from home or within the first 24 hours qualify as Dependant. The KATZ states "Dependant as assistance; incontinent or catheter used (as with the use of a foley).ADL link.

• • Please see KATZ ADL article which should now addressed all ADL questions above. TOstryzniuk 17:06, 29 July 2008 (CDT)

13. Will a position be created to focus on quality control through chart audits to ensure our data is consistent? It would be nice to have some feed back.

• There have been discussion at the Regional Database Steering Meetings. If anything changes we wil let you know.TOstryzniuk 18:08, 29 July 2008 (CDT)

14. The Diagnostic coding book would benefit from a thorough "overhaul" to itemize specific criteria for coding definitions. As a group each month we could perform audits in each Dx category with the goal of talking about codes etc in order to all understand when and where to use them.

• this has been discussed numerous times over the years. Program in working through "priorities" and has been discussing options.

15. Possible impacts of the new Code Blue policy at HSC?

• what exactly is the question/concern here? TOstryzniuk 17:06, 29 July 2008 (CDT)

Meeting Notes

Dr. Roberts:

Discussed the MOST score. MOST stand for Medical Outcome Stratification and Triage. The MOST score is a risk stratification tool that generates a probability of an adverse outcome for a patient. Early stratification of medical patients for risk of subsequent physiologic collapse, cardiac arrest and death may have potential benefits for determining the type of care environment to which a patient is initially admitted. (ICU, step-up unit etc.). The score is obtain at or near the time of of acceptance to the medicine service. The equation is derived from the Charlson Comorbid index, the Glascow Coma Score, the KATZ ADL assessement, systolic BP, heart rate, respiratory rate, white blood cell count, the sex of the patient and their age. With these variable the equation can predict the likelihood of the patient having an adverse outcome such as death, a cardiac arrest and readmission or admission to an ICU. This equation was validated based on data collected at HSC, SBGH, the Grace and Victoria hospital on over 11,000 patients admitted to medical units in 2004/2005. There is no existing tool that can make such prediction for non ICU patients. This makes this equation and the research conducted by Dr. Roberts and Julie with the support of the data collection team extremely valuable and powerful.

Because the MOST score can be used to predict negative outcomes the intention is to try and use it to prevent them. As we continue to monitor the MOST score and consider how to apply it as a intervention tool it is critical that the ongoing integrity of the data is consistent. This is why there was some concern when the 2008 data indicated a significant change in the MOST score values at HSC and SBGH. This promoted the need to review the medicine data collection standards.

Trish:

Discussed how the MOST score elements were to be collected as of December 2007 at which time some of the old vital sign data fields were removed and clear guidelines were provided for the collection of the ADL and the other MOST score elements which started January 1, 2007. This information can be found by clicking on this MOST link.

Trish clarified that it is not supposed to be the worst assessment values observed prior to a patient being admitted to a ward rather the value closest to the decision to admit to medicine service. If there were no score documented 48 hours prior to admissions then it should be the closed score post admission. If no assessment value was recored withing 48 hours pre admission or 48 hours post than the data collector should assume normal.

Dr. Roberts:

1. Asked each hospitals Medicine data collectors to report on how they were collecting the ADLs now and at the time of the initial MOST score study:
2. Grace-Used to document the worst within 24 hours of admission and changed to the closest assessment to admission. Try if possible to derive the ADL from the ER notes but the majority of the time it is taken from nursing notes within 24 hour of the patients admission to the ward.
3. Vic-Used to document the worst within 24 hours of admission and changed to the closest assessment to admission. Read the ER notes since OT and PT are greatly involved in patient care they do the ADL assessment and it is consistently well done prior to the ward admission.
4. HSC-It used to be based on the worst within 24 hours of admission. Some switch to the way the patient was prior to admission others are using the closest assessment to the time of admission.
5. SBGH-It used to be based on the worst within 24 hours of admission. All collectors changed to the way the patient was just prior to the hospital admissions. This information is collected as part of the ER history.

Questions to Dr. Roberts:

1. If a patient is sedated or paralyzing drugs are used what should their GCS be? It should be based on there non sedated state not chemically altered.
2. If a patient had a stroke and can't talk but can communicate what should their score be? The verbal score should be 5 points - oriented.
3. Does NPO qualify as dependent for feeding? No
4. Does dysphagia qualify as dependent for feeding? Yes
5. Does a foly qualify as dependent? No if it is for convenience.
6. If a patient has a pre-existing "cognitive impairment" what should their GCS be? If they are operating at their regular level of functionality it should be 15.
7. If their is no clearly recorded history of a previous stroke or MI but the EKG interpretation or CT scan reports a "prior" event should it still be recorded as a commorbidity? Yes

Tina Reviewed how to navigated around the Wiki and discussed how to use the Wiki tool.

Questions Answered By Trish

These are the answers to the submitted questions. Any definitional questions that are highlighted in blue are linked to the on-line definition, so please click on the link.

1. Clarify definition for Hypotension NYD- it says not due to shock or post-op in the code book we don't know when to use this. Why can't we just have hypotension NYD for a code? In other words if patients don't meet the specific criteria for septic shock or hypovolemic shock or cardiogenic shock it would be NYD.
2. Clarify definition Septic Shock
3. Clarify definition Cardiogenic Shock
4. Clarify definition Cardiac/Respiratory Arrests-It's impossible to see how many occur right before admission to Medicine as some patients are admitted to medicine bypassing ICU
5. Clarify definition Violent behavior code - supposed to be 2nd to dementia but is used for anyone who is violent
6. Clarify definition Panelling or Discharge Planning why does it say in the code book primary reason for admission to ward bed?
7. Clarify definition
   • Muscle deconditioning
   • Pain Control - non post op
   • Pain Control - post op - we feel it is highly overused
8. Clarify definition Palliative Care - need criteria to follow
9. Acute coronary insufficiency and Unstable angina (151, 152) - description in code book should be reversed
10. There currently is no codes for: hematuria-we have lots of people who are getting CBI for hematuria NYD. Hematuria is a symptom not a diagnosisTOstryzniuk 19:12, 24 June 2008 (CDT).
11. Regarding the KATZ ADL
    • assessment for feeding; when a person arrives to the unit within the first 24 hours NPO either for a test or for GI Bleed does this qualify as Dependant?
    • The KATZ says 'Dependant is assistance to eat; does not eat (I (Linda)interpret this to include NPO); must be fed; fed partly or completely by NG or IV. Answered above by Dr. Roberts.
    • NPO-Unassisted. ADL assessment is based on the capability of a patient if he was allowed to perform the activity he would be able to. TOstryzniuk 19:15, 24 June 2008 (CDT)
    • Continence for assessment; does the use of a foley from home or within the first 24 hours qualify as Dependant. The KATZ states "Dependant as assistance; incontinent or cathether used (as with the use of a foley). Answered above by Dr. Roberts
    • If foley is inserted for convience to measure then assess and independant. If inserted because patient unable to control bladder function, then code as major assistance.TOstryzniuk 19:18, 24 June 2008 (CDT)
12. Will a position be created to focus on quality control through chart audits to ensure our data is consistent? It would be nice to have some feed back.
13. The Diagnostic coding book would benefit from a thorough "overhaul" to itemize specific criteria for coding definitions. As a group each month we could perform audits in each dx category with the goal of talking about codes etc in order to all understand when and where to use them. The Wiki may be the best way to do this.
14. Possible impacts of the new Code Blue policy at HSC