Task Team Meeting - Rolling Agenda and Minutes 2023

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These are the minutes for 2023, for 2024 see Task Team Meeting - Rolling Agenda and Minutes 2024.

ICU Database Task Group Meeting – November 23, 2023

  • Present: Allan, Pagasa, Pam, Joanna, Barret, Julie, Brynn, Mailah, Val, Gail
  • Minutes prepared by: AG
  • Action items in BOLD

1. Regarding the prior idea to expand our ICD-10 coding to include ALL actual ICD-10-CA codes.

  • Lisa reports that while this was generally supported in talking to the data collectors, there was also a sense that we should delay further discussion on this until a more opportune time.

2. Julie reports that she has noted some patients who have different or otherwise contradictory postal codes during a single episode of care.

  • We note that postal codes derive from the ADT/Cognos system.
  • As it's unlikely that more than a trivial number of patients are moving residences over such a short timespan, we need more details about this and Julie will obtain such information for us to discuss at the next Task meeting.

3. An issue arose about patients who present to ED at a given hospital and have ICU team involvement while there, but subsequently either die in ED or are transferred to another hospital (e.g. from Grace ED to Gold surgery at HSC). Specifically the question is about if/how to include them in the ICU database, and if so exactly when to code the ICU team as beginning to provide care.

  • This question is complicated by a wide range of types of care provided by the ICU team in ED. It continuously spans from consultation with small actual involvement, all the way up to functionally taking over care while in ICU. While the latter should be included in the ICU database, the former should not. And of course there's everything in between.
  • Part of this is that putting in an ICU admission for such a patient in ED results in the ICU team having to write a discharge summary and transfer note -- which is paperwork we'd seek to avoid.
  • For Grace we discussed 2 possible solutions, both involving the ICU attending making a judgement for ED patients in whom they are contributing to care whether or not to count that person as "being on the ICU service" even if she/he never gets to an ICU in that hospital:
    • Actually put in an ICU admission
    • Don't put in an ICU admission, but record such patients in a separate portion of the ICU logbook.
    • Barret will discuss this with Heather Smith and report back at the next Task meeting.
  • After we come up with a solution for Grace, we will need to discuss solutions for HSC and St. B.

4. About coding decubitus ulcers.

  • We validated that when an acquired diagnosis should be entered for both de novo decubs that develop in ICU, and for progression of pre-existing decubs (e.g. from Stage 2 to Stage 3).
  • We also looked at data on ICU-acquired decubs from Grace over time. This arose because the rate of such ulcers developing or worsening in the Grace ICU seem much higher than in other ICUs. It is not clear whether Grace is high or other ICUs are low. Upon further assessment, these rates rose precipitously from last quarter of 2021 to the 1st quarter of 2022. Most likely this coincides with some change in how decubs are recorded.
    • Gail will seek information about if/how such changes in recording of decubs may have happened from Jan 2022 onwards.

ICU Database Task Group Meeting – October 26, 2023

  • Present: Allan, Pagasa, Pam, Joanna, Brynn, Mindy, Stephanie, Val,
  • Minutes prepared by: AG
  • Action items in BOLD

1. New question about A81.2 Progressive Multifocal Leukoencephalopathy (PML) (caused by JC virus). A recent case highlighted (as already listed in the Wiki) that there are causes other than JC virus. Accordingly, we agreed that: we will change the name to remove the "caused by JC virus" portion. Also, Allan altered the Wiki accordingly.

2. There was a discussion about the idea of expanding our ICD10 coding to include ALL codes, not just the reduced version we've been using. Various collectors commented that it is not rare that they find a specific ICD10 code online for a given entity, but have to "shoehorn" it into some "NOS" code or other. On the other hand, it would mean expanding and needing collectors to know the full list of 16,000 ICD10 codes. Allan will notify Lisa of this, and ask her to discuss it with the collector group.. The collectors met on Nov 9, 2023 with Julie present, Tina was not available but discussed it with Lisa and Julie at another meeting. In general, all collectors agree it is a good idea, however given all the changes it was felt it was best to defer this to a later date. Consideration needs to be given to wiki articles, reporting etc.

3. Next meeting will be Nov 23@1100

New Items:

ICU Database Task Group Meeting – August 31, 2023

  • Present: Allan, Julie, Tina, Pagasa, Pam, Lisa, Joanna, Brynn, Gail, Stephanie, Val, Mindy
  • Minutes prepared by: AG
  • Action items in BOLD

1. Question was raised about dealing with Neuro, Nephro or Onc patients who start out in ED and then are admitted to a Medicine ward. Allan modified the Definition of a Medicine Laptop Admission to clarify this.

2. Next meeting at 11 am on September 28 at 11 am.

ICU Database Task Group Meeting – July 27, 2023

  • Present: Allan, Julie, Tina, Pagasa, Pam, Lisa, Joanna, Brynn, Gail, Mailah
  • Minutes prepared by: AG
  • Action items in BOLD

1. Question was raised specifically about Heart and/or coronary arteries, diagnostic imaging, abnormal, specifically about how/when to use it. But in fact this issue applies to all the ICD10 codes relating to signs and symptoms (R00-R94, inclusive).

  • These codes are to be used only when such a sign or symptom (which include diagnostic testing of all sorts) is present but without a specific diagnosis code available. For example, if a cardiac cath is abnormal showing CAD, then one would not code Heart and/or coronary arteries, diagnostic imaging, abnormal but might instead code Coronary artery disease, chronic. As this applies to all such codes, Allan will ask Tina to make sure that a template is applied to all the specific codes indicating this.

2. Question was raised about how to code syphilitic infection of the globe of the eye. Answer is Endophthalmitis, infectious with the organism being Treponema pallidum.

3. Next meeting at 11 am on August 30, 2023.

ICU Database Task Group Meeting – June 22, 2023

  • Present: Allan, Julie, Tina, Pagasa, Mindy, Michelle, Val, Pam, Stephanie, Lisa, Joanna, Brynn
  • Minutes prepared by: AG
  • Action items in BOLD

1. Transition to Database Server#Shared Health - Allan updated the group about work being pursued for both possible options, i.e. through Digital Health, and through the University of Manitoba. The former is further ahead in both planning and implementation, although no final decision has been made.

2. ABG Data - No additional followup on last report from Heather Smith about working to get ABGs at Grace Hospital to be included in the Lab Info System (LIS).

3. Allan reported that there is a plan to add the Brandon ICU to our ICU database. The biggest impediment is funding, but leadership in Brandon hopes this will come through in 2024 or 2025.

4. As regards Thoracic endovascular aneurysm repair the question arose of whether the Action should be "Repair" or "Excision with reconstruction/replacement". After reading more about the procedure, Repair is correct. Allan has modified the Wiki page to explain this.

5. Question was asked how to code the MAZE procedure for atrial fibrillation. As it is a subtype of Atrial Ablation, it should be coded the same way (using Destruction code - wiki has been updated).

6. Question was asked about why we record each GI endoscopy but only the first ERCP (endoscopic retrograde cholangiopancreatography). After discussion we agreed that we SHOULD record all ERCPs. Tina has changed the Wiki and CCMDB accordingly.

7. Question was asked about the presence on List of CCI procedures we don't code of "Lavage, Therapeutic". After discussion we clarified that while we should code all exploratory laparotomies (which by definition must include taking some sort of look inside the peritoneum), we will not code Theapeutic Lavage which involves serially instilling and draining fluid.

8. Question was asked about whether to code multiple skin graft procedures. Answer is Yes.

9. Regarding skin grafting, it was clarified that the organ used should be (T) Skin, NOS/

10. Question was asked about how to code a primary malignancy of 1 paired organ (e.g. lung, breast, etc) that is metastatic to the other in the pair. Answer was to code both the primary and the metastatic codes, and link them together. 'Tina has updated Template:ICD10 Guideline Combined dx metastasis primary and removed the question from Lung, metastatic malignancy to it (also code primary site)

11. Question was asked about how to code nosocomial influenza pneumonia. After discussion we agreed that it should have 2 codes, both as Acquired Diagnosis: (a) Influenza pneumonia (which has an implied organism) and (b) Nosocomial infection, NOS with the organism being Influenza virus NOS -- should almost never be used. But since these 3 codes cannot be all linked together (due to Influenza pneumonia doesn't allow an organism), 'a' and 'b' should have different priorities.

12. Next meeting July 19 at 11am.

ICU Database Task Group Meeting – April 19, 2023

  • Present: Allan, Julie, Tina, Pagasa, Mindy, Michelle, Gail, Barret, Val, Pam
  • Minutes prepared by: AG
  • Action items in BOLD

1. Transition to Database Server#Shared Health - Nothing new about either of the possible alternative options for hosting the database.

2. Controlling Dx Type for ICD10 codes - We agreed that this large task would be difficult, questionable, and not worth the effort.

3. ABG Data - Followup about trying to get ABGs at Grace Hospital to be included in the Lab Info System (LIS).

  • Allan reported that Heather Smith is working to arrange a Zoom meeting of the relevant parties.

4. Followup on if/how to deal with proven cases of influenza who are treated also with antibiotics for possible superimposed bacterial pneumonia. After extensive discussion we came to:

  • These are tricky because it is pretty common that before the primary (proven type) has been proven, that a patient is put on multiple types of antimicrobials -- e.g. it's flu season and patient comes in with a diffuse infiltrate and signs of infection, and the ED starts anti-viral + antibacterial drugs. What often happens is that in the next few days the team decides it was only influenza and stops the antibiotics. As it would be very very uncommon to treat a true bacterial pneumonia for <7 days, in THIS case we will use the guideline to code a bacterial pneumonia if the antibacterial agent was given for >4 days or the patient died before the 5th day of antimicrobials.
  • As per our usual practice, we will consider a diagnosis as present if the clinical team thinks it's present and are treating it, with the exception (as directly above) that the team initially treated for the possible 2nd type of pneumonia but then decided it likely was NOT present and stopped those agents.
  • Regarding use of Pneumonia, NOS versus any of Pneumonia, bacterial, Pneumonia, viral, Pneumonia, fungal/yeast
    • Pneumonia, NOS should be used when there is a presumed pneumonia but the team is unsure what kind of organism is involved (bacteria, virus, fungus). So simply not having an organism from culture doesn't necessarily mean that Pneumonia, NOS should be used. If, for example, the team is assuming that it's a bacterial pneumonia (and treating it as such), but doesn't know which bacterium, then use Pneumonia, bacterial + Infectious organism, unknown

5. Julie related that Heather Smith was seeking information going back to 2015 about surgery service patients admitted to Grace ICU. While we do have information about patients who came to ICU from OR/PACU, we don't readily know which surgery service patients came to ICU directly from a surgical ward. Allan emailed Heather to let her know what we can, and can't get for her.

6. Lisa queried how to code creation of a colostomy and whether it involved (T) Surgically Constructed Sites in Digestive and Biliary Tract. Answer is no, colostomy is coded by (T) Large Intestine with Bypass.

7. Next Task meeting May 16, 2023 at 1pm

ICU Database Task Group Meeting – Feb 2, 2023

  • Present: Allan, Gail, Julie, Mindy, Tina, Val, Pagasa, Mailah, Mindy, Brynn, Lisa, Pam
  • Minutes prepared by: AG
  • Action items in BOLD

1. Transition to Database Server#Shared Health - Nothing new about either of the possible alternative options for hosting the database.

2. Controlling Dx Type for ICD10 codes

  • We had additional discussion on whether this task is worth doing
  • Collectors generally expressed that they're not very concerned that errors occur more than rarely in coding the type/bin in which a diagnsosis belongs. However, there was general agreement that we should try to get more data on this issue, and re-discuss it next time.
  • Accordingly, Julie will generate a table where for each ICD10 code she identifies the total % that were coded in each of the 3 bins. We will use this as a first step to identify the magnitude and nature of this problem.

3. Followup item about trying to get ABGs at Grace Hospital to be included in the Lab Info System (LIS).

  • Allan reported that just today Heather Smith emailed that she's working on it. We'll follow up and if they're willing, Allan will talk to Dr. Soroko about getting it implemented.

4. New item: Many or most proven cases of influenza are treated also with antibiotics for possible superimposed bacterial pneumonia. The question is whether or not to also code bacterial pneumonia in these cases.

  • Discussion highlighted that in fact most patients presenting with proven influenza respiratory infection do NOT have bacterial pneumonia superimposed. Evidence from pandemics indicates that:
    • The most common bacterial causing superinfection are Staph aureus and Strep pneumoniae
    • Such superinfection is seen in a much greater fraction of those with severe manifestations -- e.g. in the 2009 H1N1 pandemic it's been estimated that 25-50% of severe cases had bacterial superinfection
    • Superinfection, when it occurs, generally occurs at least a few days after initial presentation
  • We decided that before deciding what to do about these cases, that Allan will see if the CDC has a good case definition for bacterial superinfection in influenza ---> There isn't one and neither could he find one elsewhere in the medical literature.
  • We'll discuss this further at the next meeting, but given that at least a substantial minority (25-50%) of those with severe manifestations of influenza pneumonia do have bacterial superinfection, the choice that's most consistent with our general philosophy of accepting a diagnosis given by the medical team, is to code them as bacterial pneumonia if the team gives antibiotics.

5. New item: If a nontraumatic brain injury (of any cause/type) is accompanied by a small "shift" seen on brain imaging, should one also code Brain compression, including herniation?

  • Answer is "yes". Allan has altered the Wiki accordingly.

6. New item: How to code surgical amputation of a part of a leg (e.g. toes, foot).

  • Answer: Indeed we have not included in CCI the subparts of the lower limb, but as no user has ever asked for this level of detail, we agreed to stick with just having (D) Leg, NOS.

7. New item: Clarification of multiple subcategories of COVID.

  • It should not be that both asymptomatic COVID and symptomatic COVID are listed as admit diagnoses --- if so only keep the symptomatic one
  • Both asymptomatic COVID and symptomatic COVID can be listed as acquired diagnoses, but only if asymptomatic is listed first and the 2 have different dates.

ICU Database Task Group Meeting – Jan 11, 2023

  • Present: Allan, Gail, Julie, Michelle, Mindy, Stephanie, Tina, Val, Pagasa, Mailah
  • Minutes prepared by: AG
  • Action items in BOLD

1. Transition to Database Server#Shared Health - Nothing new about either of the possible alternative options for hosting the database.

2. Controlling Dx Type for ICD10 codes - Regarding the task to improve data collector diagnosis assignment into the 3 "bins" of admission diagnosis, acquired diagnosis and comorbid diagnosis.

  • Lisa indicated that for a first pass on this, she will distribute all the codes among all the collectors.

3. New item: Clarification of Pulmonary emphysema or bullous disease without COPD. Allan modified this Wiki entry to make it clearer.

4. New item: Regarding the code Sudden cardiac death (and died)

  • After discussion we recognized that we have no need to specifically code patients' cause of death. We know it occurred by virtue of the Dispo field. Thus we agreed to remove this item from the list of ICD-10 codes, and to have Julie go into all records where it has been recorded and remove it. Allan modified the Wiki page also.

5. New question: It was noticed that an error occurs if a diagnosis of Influenza is recorded (which is an implied bug) and one attempts to combine it with a Nosocomial problem code.

6. Followup item from long ago: Seeking to get ABGs at Grace Hospital to be included in the Lab Info System (LIS).

  • The last time we tried for this, in 2015, the resp therapy group at Grace was not interested in being required to manually logging this information into LIS, as IS done at HSC and St. B.
  • We think they may be more open to it now -- so today Allan emailed Heather Smith, asking her to raise it with them.
  • If they indeed are willing, Allan will talk to Dr. Soroko about getting it implemented.

7. New item: Uncertainty of when/how to use Complication of labor and delivery, NOS

  • As our database is only for adult patients, this code should not be used to indicate such a complication for a newborn. For example: During hospitalization, such a complication occurs, but it only affects the newborn and has no medical consequence for the mother --- do NOT use this code.
  • Of course, for some such complications when the newborn with a complication becomes an adult, that problem persists, e.g. Fetal Alcohol Syndrome. If that adult is then admitted, it is the specific problem (such as Fetal Alcohol Syndrome) that should be listed as a Comorbid Diagnoses -- again you would NOT code Complication of labor and delivery, NOS.
  • The only time Complication of labor and delivery, NOS would be coded is when the mother herself incurs a complication of labor or delivery, AND there is not a more specific code for the complication she suffered.
  • Allan modified this Wiki page for clarity.

8. New item: Clarification of when/how to use Oral mucositis

  • This code is for widespread or diffuse oral mucus membrane involvement -- as often occurs after some chemotherapies, and a few other causes.
  • Do not use it for localized oral lesions or involvement in just a part of the oral mucosa. In such a case code the specific cause if known, and otherwise use Disorder of oral mucosa (mouth, lips, tongue), NOS.
  • Allan has updated the Wiki to reflect this.

2022...

Also see Task Team Meeting - Rolling Agenda and Minutes 2022

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