JALT Meeting - Rolling Agenda and Minutes 2022

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JALT Meeting – November 30, 2022

• Present: Julie, Allan, Lisa, Tina
• Emails: LKaita@hsc.mb.ca; allan.garland@umanitoba.ca; JMojica@hsc.mb.ca;TTENBERGEN@hsc.mb.ca
• Minutes prepared by: AG
• Action items in BOLD

1. Followup about APACHE 2 Scoring

• Possible issue: When Allan summed the APS elements he got a slightly different mean value from the automatically calculated version. Julie to check on her automated calculation
• Tina and Julie will remove one of the (now identical) fields "ApTotal_Chronic" and "chronic_pts".

2. Visit_Admit_DtTm differences within same admission

• Tina reports that she has not received any such issues from Pagasa, and it's not clear if (a) there haven't been any vs. (b) there have been some but Pagasa has been dealing with them herself.
• Tina to ask Pagasa about this. If 'b' then we DO want them sent to Tina so she can send them to Charity to see if they can be fixed withing ADT/Cognos.
  • Tina emailed Pagasa Ttenbergen 11:22, 2022 December 8 (CST)

3. BedHeldEnd DtTm - Per the last JALT meeting, the frequency of people leaving AMA (esp from ward) is not low. And, per Lisa, most of these are without notice. Thus it is not a trivial issue that there is a nontrivial difference between when the patient actually stops being under care vs. when the bed is released for reassignment.

• We agreed this mandates keeping track of both of these dates/times. Furthermore, a similar phenomenon occurs when a patient is sent to another hospital for a procedure, expecting to return (so the bed from the sending site is held) but then does not return.
• These 2 situations are easy for the DCs to identify and they always do so.
• So we will distinguish between:
  • (a) Actual time under care, which is from Admit DtTm to the patient's Dispo DtTm -- we'll call this the patient's length of stay
  • (b) What we'll call "Bed Assigned Time", i.e. from Admit DtTm to the time when the bed is released for reassignment, which we will call "BedHeldEndTime". This latter is generally available from Cognos (ADT), and Tina will create machinery to record BedHeldEndTime as a temp item. As above, this will ONLY be recorded in the situations when a patient leaves AMA but the bed is held for a bit hoping they come back (but they never do so) , or patient goes elsewhere for a procedure expecting them to return so bed is held but they never do come back.
    • There will be 2 versions of BedHeldEndTime, i.e. BedHeldEndTime/AMA and BedHeldEndTime/Procedure.

4. Repeat item, regarding how to record time spent waiting for transfer (after Transfer Ready DtTm):

• We had previously decided to: (a) ignore such transfer delays <2 hrs, but (b) for all delays >=2 hrs to use the actual delay time.
• But this seems to conflict with the prior national Vital Signs Monitoring program (which is now defunct) which substracted 2 hrs from all actual delay intervals.
• Allan's rationale for not subtracting 2 hrs is as follows: While there are seemingly obligate delays in transferring a patient out (sending site getting the patient ready to travel and ensuring personnel are available, getting bed cleaned an ready in the accepting site and ensuring personnel are available) the concept of any given interval for these to occur is counter to the concept that we can and should always be striving to make out systems more efficient and reduce those delays.
• So, today Allan emailed Carmen, Rosanne and Bojan to get their input on this.

5. New question: How to deal with transfer delay in a recent case where patient in ICU was made ACP/C and then palliative ---> didn't die and indeed improved --> reversed the ACP/C and patient left ICU alive 7 days later.

• After discussion, we agreed that this is an extremely rare occurrence, and that rather than make a new rule for it, we will stick with the existing rule that transfer delays be calculated from when first transfer ready until the patient leaves. And also, this example is not fundamentally different from when a patient is ready to leave but gets sicker and the transfer is cancelled.

6. New question: Julie identified that there are cases (esp at St. B ICUs) where ER is the first boarding loc but within a few minutes (or sometimes simultaneous with) that boarding loc, a 2nd boarding loc of ICU is recorded.

• We think this most likely is a phenomenon of incomplete charts and so at our next JALT meeting Julie will let us know if this still occurs (and the # of them) in complete charts. Also, Lisa will ask the ICU DCs at St. B about this.

7. Next JALT meeting Januar 11, 2023 at 10 am -- this may be our last JALT meeting.

JALT Meeting – November 16, 2022

• Present: Julie, Allan, Lisa, Tina
• Emails: LKaita@hsc.mb.ca; allan.garland@umanitoba.ca; JMojica@hsc.mb.ca;TTENBERGEN@hsc.mb.ca
• Minutes prepared by: AG
• Action items in BOLD

1. About APACHE 2 Scoring -- i.e. 2019 to 2022 there was an approximate 5 point rise in mean APACHE 2 scores limited to Grace Hospital (pre=Aug2019-Aug 2020 vs. post=Aug 2021-Aug 2022).

• Julie analyzed the individual APACHE elements from "pre" to "post" and found:
  • All APS elements worsened by about 5.4 points total. The neuro subscore being about half of this worsening, with all 3 GCS elements worsening similarly
  • The age points FELL by 0.27 -- indicating a fall from pre to post of a few years in age of the average patient
  • Virtually no change in chronic health points
• THUS, from pre to post time periods it seems that the Grace ICU patients got: a bit younger but sicker. This could be consistent with more COVID patients being admitted there. In any case, this change appears real, i.e. not due to any artifact or change in coding of any single (or few) APACHE elements.
• Allan let Barret, Heather and Roseanne know these findings.
• We did seem to identify to possible problems with the automated code used to calculate APACHE subscores and total score, which Julie and Tina will check out:
  • When Allan summed the APS elements he got a slightly different mean value from the automatically calculated version
  • There are 2 apparently contradictory chronic health fields that need to be understood and adjusted if necessary, they are called "ApTotal_Chronic" and "chronic_pts".

2. About APACHE 2 Chronic Disorder coding -- Allan and Tina to Zoom to interactively resolve this issue.

3. Visit_Admit_DtTm differences within same admission -

• Tina reports that she has not received any such issues from Pagasa, and it's not clear if (a) there haven't been any vs. (b) there have been some but Pagasa has been dealing with them herself.
• Julie or Tina to ask Pagasa about this. If 'b' then we DO want them sent to Tina so she can send them to Charity to see if they can be fixed withing ADT/Cognos.

4. New item: Many ward patients who leave AMA have their beds held for as much as a day or two. We currently identify their disposition time as when they have physically left, but we recognized that for bed utilization purposes this may not be ideal. To help move our understanding of this issue forward, Julie generated the following data for the 3 current hospitals over a 5 year interval:

• AMA rates over the 5 years were:
  • HSC: 3.8-7.9%
  • STB: 1.6-5.2%
  • Grace: 1.1-4.1%
• At our next JALT meeting we will discuss whether these numbers mandate keeping track separately of timing for: (i) patient leaving the hospital and (ii) when the bed was released for reassignment.

5. Julie reported that the QI team is interested in information on use of the FMS (Fecal Management System), though they have not yet specifically requested information.

• After contacting Dan Roberts, Allan sent an an email on Nov 17 to Carmen Hrymak to ask if indeed the QI Steering Committee does want this information, and if so to obtain details and tell her to go directly through Dan to make the formal request.
• Likely what they would want is similar to how we collect TISS elements, i.e. for each patient for each day in ICU whether they had, at any time, use of a FMS.

6. Julie reported that Nephrology asked about obtaining, for CRRT patients, specifically if patients are on any form of systemic anticoagulation. Their interest is related to filter lifespan. From the email trail, it appears that they'd like to know which drug(s) the patient received. But the problem is that we only collect "Yes/No" information for any time in ICU, not specific to when the patient was on CRRT. Furthermore, we don't split out the different types of heparin.

• Allan communicated via email with Deborah Stanley (dStanley2@wrha.mb.ca) for clarification, who indicated that their group will discuss this further at their December 2022 meeting and get back to us after that.

7. Next JALT meeting Nov 30 at 11 am -- Allan sent a Zoom invite.

JALT Meeting – November 10, 2022

• Present: Julie, Allan, Lisa, Tina
• Minutes prepared by: AG
• Action items in BOLD

1. About APACHE 2 Scoring

• It was noted that over 2019-2021 there was an approximate 5 point rise in mean APACHE 2 scores limited to Grace Hospital.
• To try and understand whether this change was real, or due to some problems with APACHE scoring, Julie will analyze the components of the APACHE score in the "pre" vs. "post" period in question.

2. About APACHE 2 Chronic Disorder coding

• Per Tina's 11/3/22 email to Allan, there is still a problem with how Allan specified the ICD10 codes to be included. Tina and Allan will meet to resolve these.

3. About reporting of transfer-ready bed-days on Medicine. The issue here is that while we currently report these as of when the patient is discharged from the bed, for long-stay patients, this may "allot" those bed-days to months, quarters and occasionally even years different from when they actually occurred.

• After discussion, given that the database records of long-stay patients remain "incomplete" until discharge, and the fact that a choice does need to be made in this regard, and the fact that the usual paradigm for this kind of issue is to assign things to when the patient is discharged ---> we agreed to keep with the current reporting paradigm

4. Prior/ongoing JALT issues:

• Visit_Admit_DtTm differences within same admission - Julie to forward next few of these to Tina who will analyze them, and if it seems they're an ADT/Cognos error it may require reporting it to be fixed to Chastity.
• Update/reminder about patients (ICU>Medicine) with very short LOS. Julie did an analysis and found that virtually all of these with LOS of 15 mins or less died. Increasingly as these short LOS grow longer (say to 1-2 hrs) the % who die falls. We hypothesize that for those who don't die but have LOS<2 hrs that most are getting sent from Medicine to ICU or being transferred to a different hospital. To check this out Julie will itemize, separately for Med and ICU, the dispositions of patients with LOS of 2 hrs or less who didn't die.