CRRT Project

Projects
Active?:	legacy
Program:	CC
Requestor:	Critical Care Program: Jodi Walker Tweed, Ryan Holland Renal Program: Dr. Joe Bueti, Dr Herman Lam
Collection start:	2016-09-19
Collection end:	2019-06-04

Legacy Content

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• Explanation: project over
• Successor: No successor was entered

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see also other pages in Category:CRRT

The CRRT project tracks wikipedia-Hemofiltration Continuous Renal Replacement Therapy CRRT use and reasons. For now the data is collected at HSC MICU and HSC SICU.

Data Collection Instructions

for which patients to code

HSC Critical Care patients only who get CRRT therapy, defined as those who have an T33 - CRRT (TISS Item) and a CRRT (incl volume removal via PRISMA device) CCI code.

how to code in CCMDB TMP

Nephrology will complete a the non-permanent health record form Renal Diagnostic Codes Checklist. This form is attached to the HSC_ICU_CRRT Consult form and will stay on the patient chart. The Nephrology attending must enter the reason(s) for CRRT in the form (i.e. primary reason will be assigned by number 1 and the secondary reason(s) if available will be assigned by number 2). Collectors simply transcribe this; no interpretation or correction against chart are required.

Enter

• Project: CRRT
• Item / Column N: enter the field marked in the form
  • there could be more than than one reason for CRRT, if so, enter additional rows
    • enter the number 1 or 2 as applicable.
      • if there is only one reason, enter 1.
      • if there is more than one reason, enter 1 for the primary reason and 2 for the rest of the reason(s)
      • if there is more than one reason and the Nephrology attending did not indicate the ranking, enter 2 in all reasons.
  • if entry is 'Form Missing' or 'Form not done'
    • see #follow-up when the data is not on the chart

options for entries

• AKI pre-renal
• AKI shock sepsis
• AKI shock no sepsis
• AKI hepatorenal
• AKI cardiorenal
• AKI contrast
• AKI drug
• AKI endogenous
• AKI exogenous
• AKI postop
• AKI thrombotic
• AKI glomerulonephritis
• AKI interstitial nephritis
• AKI urinary obstruction
• ESRD continuous CRRT
• ESRD intermittent HD
• Overdose
• Fluid reduction
• Form not done (email as per wiki)
• Form missing (email as per wiki)

follow-up when the data is not on the chart

If you enter 'Form Missing' or 'Form not done' CCMDB.accdb will remind you to email

• email Deborah Stanley, Dr. Herman Lam and Dr. Joe Bueti.
• Include:
  • Subject: CRRT Info missing
  • minimal patient identifier
  • whether sticker is missing or only not filled out

follow-up

If the patient is still in your laptop and if you are still working on the chart and then you find a filled-up HSC_ICU_CRRT Consult form in it, change the entry with the reason for CRRT.

• You are not expected to run after a chart or wait for Deborah (CRRN CRN) or the nephrologist to make sure form is filled up.
• If the profile is already complete but still the form is missing or not filled up, then submit the profile with 'Form Missing' or 'Form not done'.
• NEW-2018-Aug-22: notify the bedside nurse when you notice that a:
  • a consult form is missing or
  • the sticker on form is missing or
  • the consult form has not been completed
    • (Staff and managers aware that collectors will be doing this).

Problems Identified at HSC

• As per discussion during the Team Meeting September 20, 2018 there are several problems with the CRRT stickers here at HSC:
  • Stickers not filled out - sometimes Nephrologists write on the consult sheet, but do not fill out the sticker.
  • Stickers missing - there are various staff members working at the desks in the ICU's, not always regular clerks, so they do not always know to give the right consult sheet (with the sticker) to the Nephrologists. It is also not routine for them to ask what service a physician is from, in order to give them the correct consult sheet. The result is 'missing stickers'.
  • It seems that some Nephrologists are not aware of this study (?), because they do not ensure that the sticker is filled out or ask for the consult with the sticker attached.
  • Incomplete/missing consult forms not follow up by nephro team: The ICU collectors email the CRRT educator, as well as Dr.Lam and Dr.Bueti, but it is rare for the stickers to be 'fixed' after that email and we do not receive any further follow-up.

Stats Jan 2018 to Sept 2018

• Total CRRT in TMP: MICU 80 / completed-51% / sticker missing or no filled out 49%
• Total CRRT in TMP: SICU 43 / completed-63% / sticker missing or no filled out 37%
  • excluded in count any profile with two or more DX reason checked off.

Adding STB

• If possible, for STB, it would be optimal if the sheet that the renal attending could be put on the electronic chart. It could pop up when the orders are written for CRRT or the doctors could put it into their electronic progress notes. We may find that compliance using a paper sheet may not be good here. --LKolesar 10:48, 2016 February 9 (CST)
  • The CRRT project is piloted at HSC for now. There is no discussion yet if to be done at STB. JMojica 14:34, 2016 September 16 (CDT)

Start and Stop Dates

• Start Date from CCMDB TMP: 2016 Sept 19
  • CRRT usage from TISS only: 2016 Jan 1
  • Adding the rank of AKI diagnosis start date: 2017 May 24
• Evaluation Date: 2017 Jan 12
• End date: 2019 May 22
  • stopping was decided at regional CRRT meeting. Poor compliance to fill in stickers, mostly blank. Jodi advised of this on may 22.19

Form revision start date

• Oct 24, 2016 - HSC_ICU_CRRT Consult form will have a sticker pre-attached by unit clerk with list of Reasons for CRRT.

Data Integrity Checks (automatic list)

	App	Status
Query check CCI CRRT vs Tmp	CCMDB.accdb	retired
Query NDC zCRRT TISS no tmp	Centralized data front end.accdb	retired

Data Use

• To identify the reason(s) why CRRT therapy was requested by the attending nephrologist for quality improvement and resource utilization in the Renal Program.
• To track the CRRT usage for workload and resource utilization in the Critical Care Program.

Background

The patients on CRRT therapy during the stay in ICU are being tracked by a CRN in Critical Care Program since ?? (date to be asked). The CRN collects the patient names, the hospital number, the renal diagnosis for reason for CRRT, the initiation and duration of therapy in paper form. The Renal Program states that they need the demographics of patients who were on CRRT as well as the reasons why CRRT were requested by Neprologists for quality improvement, resource utilization and billing purposes. Critical Care Program shares these information to the Renal Program by faxing the hand written data sheets to them on a monthly basis.

In Jan 2013, the Critical Care Program implemented the usage of the new TISS28 form which include various nursing activities, interventions and procedures including CRRT. The bed side nurse records on the TISS form these activities if present on a daily basis for each patient during the whole duration of stay at ICU. The data collectors of the Critical Care Database quality check the entries of the TISS forms for completion and consistencies. Since the same information is being collected by the CRN and bed side nurses, a comparative analysis between the two process of data collections and an additional real time audit by an independent auditor were done. TISS CRRT had 96% matched with the real time CRRT while 85% matched with the CRN CRRT.

The Critical Care and Renal Programs made a decision last Feb 2, 2016 to consider the TISS28 as the source of CRRT data starting Jan 2016.

However TISS28 does not contain the diagnostic reasons for CRRT therapy so a request to collect this information separately by the data collectors of the Critical Care Database was made. The Renal Program had identified the possible reasons for CRRT therapy and proposed to list them in a form for the attending Nephrologist to mark. The form has been developed and in Sept 2016 has been placed together with the Nephrologist's consult for the attending Nephrologist to fill up. A meeting has been held Sept 15, 2016 with the Critical Care Manager and Statistician to begin the collection of the CRRT diagnostic reasons in the next three months Oct to Dec 2016 and the group have agreed to have the results presented on Jan 12, 2017.

Additional data

There was not space in the tmp dropdown for the full length reason as on the form, so we use a shortened version in s tmp table. To translate the shortened version to the full version, e.g. for reporting, use table s_tmp_CRRT.

Location of CRRT Related Info

x: CCMDB_Special_Projects_CRRT_Ryan&Bueti

SAS Program

• CRRT Days from TISS28 - The SAS program is in S:\MED\CCMED\​S:\MED\CCMED\Julie\CC Projects\CRRT_Ryan&Bueti\ICU_CRRT_byMonth.sas. The program generates the list of patient names, PHIN, Chart#, Date of Birth, First day on CRRT, year, month and calendar days on CRRT and total CRRT days.
• Reasons for CRRT starting Oct 2016 - are added to the SAS program above and frequencies of the reasons are presented in the report.

ICD10

We decided that we will need to keep coding this in tmp even when we move to ICD10 because:

• some reasons would require more than one code
• some reasons don't have a specific ICD10 code and would not be captured

equivalent ICD10 dxs

As emailed by Allan Garland 2017-11-18: He is comfortable with these:

• AKI pre-renal --> Prerenal uremia/state (R39.2)
• AKI shock sepsis --> Shock, septic (R57.2)
• AKI shock no sepsis --> Shock, NOS (R57.9)
• AKI hepatorenal --> Hepatorenal syndrome (K76.7)
• AKI cardiorenal --> Kidney disease, hypertensive (I12)
• AKI contrast --> Kidney, nephropathy, drug or toxin induced (N14.2) AND
  • --> Drug or biological substance/agent NOS, adverse effect (Y57.8 )
• AKI drug --> Kidney, nephropathy, drug or toxin induced (N14.2) AND
  • --> Drug or biological substance/agent NOS, adverse effect (Y57.8 )
• AKI glomerulonephritis --> Nephritic syndrome, acute (N00)
• AKI interstitial nephritis --> Kidney, tubulo-interstitial nephritis/disease (N12)
• AKI urinary obstruction --> Kidney, obstructive or reflux nephropathy/uropathy (N13.9)
• ESRD continuous CRRT --> Chronic kidney disease (end-stage renal/kidney disease, ESRD), Stage 5, GFR LT 15 (N18.5)
• ESRD intermittent HD --> Chronic kidney disease (end-stage renal/kidney disease, ESRD), Stage 5, GFR LT 15 (N18.5)
• Overdose --> Drug or biological substance/agent NOS, overdose/toxicity (T50.9)
• Fluid reduction --> Fluid overload (E87.7)

There are concerns about these:

• AKI endogenous --> Kidney, acute renal failure NOS (N17.9)
• AKI exogenous --> Kidney, acute renal failure NOS (N17.9)
• AKI postop --> Iatrogenic problem NOS, related to a surgery or procedure, NOS (T81.8)
• AKI thrombotic --> Thromboembolism/embolism, renal vein (I83.2) OR
  • --> Kidney, infarction or ischemia (N28.0)

From email:

The ones in BLACK (ie the first set) I'm comfortable with.  But note that 2 of them require 2 codes combined.
The ones in RED (ie the second set) don't have specific ICD10 codes.  I don't even know what they mean by AKI endogenous and exogenous.  And AKI thrombotic is nonspecific in that it could be EITHER of the 2 ICD10 codes I listed there.  

Note that I only here tried to find ICD10 codes for the causes. The coders would still need to code the acute kidney failure, if present. (i.e. Kidney, acute renal failure NOS, Kidney, renal failure/insufficiency/uremia, unspecified as acute or chronic or Kidney transplant, failure or rejection or unspecified complication)

Because I wasn't able to map EVERY one of their entities, we probably need to talk more about how to move forward on this item.