Task Team Meeting - Rolling Agenda and Minutes 2024

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Pneumonia, ventilator-associated (VAP) 2024-10-31 9:11:34 PM

Also see Task Team Meeting - Rolling Agenda and Minutes 2022

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ICU Database Task Group Meeting – Sep 12, 2024

1. After discussion we agreed to remove labetolol from the list of vasopressors. Lisa made this change to the Wiki.

2. New question: When to use Stroke, NOS

  • Answer: This is "NOS" in regards to not being designated as either a cerebral infarction or cerebral hemorrhage.

3. New question: Whether we want to add continuous infusions of dexmedetomidine or ketamine.

  • After discussion it was agreed that Allan will ask Bojan and Carmen

4.

5. Determining a VAP using the Pneumonia, ventilator-associated guidelines on the wiki. The VAP rates for all SBGH ICU's is higher than GGH and HSC. After reviewing the VAP cases for the third quarter of 2023 and the first and second quarter of 2024 discrepancies were noted. After meeting with all collectors the following issues have been identified.

    • determining the VAP date, is this by pathogen date, symptoms, or by CXR identification
    • clarification on the timeframe for CXR's. eg. If a new infiltrate is noted on a CXR on Sept 5, 2024, and the next CXR is Sept 16 which shows progression, would the VAP date be Sept 5? (assuming they meet the criteria) orwould we disregard this CXR altogether as it is too far from the initial? CDC uses 7 days within the first CXR where the infiltrate is id'ed
    • clarity on aspiration events. If admitted with CAP/Aspiration and in a short timeframe (outside the 48 hours) have progression on CXR and have the same bug/new bug/ or no bug can this be a VAP? Also, a pt who is extubated for a day, aspirates while extubated, and then is reintubated meets the criteria for a VAP, would this be a VAP or HAP?
    • One criteria is a change in character of sputum, or new onset of purulent sputum, we have seen documentation where the oral secretions are purulent, but the ETT secretions are mucoid. We use ETT but should we be considering oral secretions?
    • documentation variability/inconsistencies, documented as purulent on flow sheet but IPN says mucoid, variability of CXR interpretation amongst radiologists and also what the bedside team thinks (which isn't necessarily documented)
    • If a patient has LLL consolidation and subsequently consolidation is identified in the RLL is this considered progression of the initial LLL PNA or is this a new PNA?
    • While we try to improve our collection process, is there a role for the physicians to improve their knowledge of determining a VAP? and more importantly to improve their documentation? One thing we have noted that as soon as there is new infiltrate they call it a VAP, but the criteria is that is must be new AND persistent, often a second CXR is not done so it would not be called a VAP.
    • Can we somehow simplify the CDC criteria to take out some of the subjectivity? when reviewing a chart there can be other reasons why a patient's WOB may be increased or they may be hypoxemic with turns, we often look at antibiotics and if they aren't treating it can we call it a VAP? Should we be looking at all of the factors or should we just follow the criteria?
    • should we introduce the repeat infection timeframe (RIT) that CDC utilizes for healthcare associated infections? see the article https://www.cdc.gov/nhsn/pdfs/pscmanual/2psc_identifyinghais_nhsncurrent.pdf (cdc.gov) page 2-11
    • see Hospital-acquired pneumonia (HAP) in ICD10 for a clarification

ICU Database Task Group Meeting – August 1, 2024

  • Minutes prepared by: AG
  • Action items in BOLD

1. Changes to sepsis from last meeting have been made on the Wiki.

2. Changes related to cardiac arrest from last meeting have been made on the Wiki.

3. Changes to Wiki related to Kidney, acute renal failure, postprocedural have been made.

4. New question: How to code Purpura fulminans?

  • Answer: rather than being included under one of the D69.x codes (which together are "Purpura and other hemorrhagic conditions"), it is actually included under D65, i.e. Disseminated intravascular coagulation (DIC). Lisa made this change on the Wiki.

5. New question: How to code baclofen withdrawal.

6. New question: Issue relating to the I23 codes.

  • These are complications of AMI, not AMI due to these entities.
  • For clarity, Lisa made notes in all the I23 items (.1, .2, .3, .6 and .88) to this effect.

7. Some issues regarding higher rate of VAP at ICMS than any other ICU

  • Lisa did manual chart review of the ICMS VAPs and found that a substantial number were not true (i.e. false-positive identifications). Though even removing those the rate at ICMS was still higher than elsewhere.
  • A potentially relevant issue has to do with repeat VAP events during a single admission.
    • Lisa pointed out that CDC guidance is that at least 14 days must pass after VAP onset before consideration for another VAP episode. We don't currently have this rule.
  • A relevant issue is how they're reported, i.e. as per patient or per 1000 vent-days. If different ICUs had substantially different distributions of vent-days, this could be part of the explanation --> Julie to see if vent-day distributions differ by ICU.
  • We will come back to this issue.

ICU Database Task Group Meeting – May 22, 2024

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

1. After continued discussion we agreed on the following changes to Sepsis (SIRS due to infection, without acute organ failure), Severe Sepsis, and Shock, septic:

  • We will generally update from our prior usage of Sepsis-2 guidelines. This includes removing SIRS (Systemic Inflammatory Response Syndrome) from consideration for sepsis-related entities.
  • We will delete from further coding what in Sepsis-2 was called "sepsis", i.e. Sepsis (SIRS due to infection, without acute organ failure)
  • We will continue to use the entities Severe Sepsis and Shock, septic -- except we will modify the criteria for acute, infection-induced organ dysfunction to be the 6 CDC Adult Sepsis Episode (ASE) criteria:
    • (1) Serum lactate >=2.0 mmol/L
    • (2) Use of any of the following vasopressors: norepi, dopamine, epinephrine, phenylephrine or vasopressin
    • (3) Use of invasive mechanical ventilation -- noninvasive ventilation does not count
    • (4) Doubling of serum creatinine relative to baseline
      • "baseline" can be a value prior to hospitalization, or if that's not available, use the BEST value from the entire current hospitalization
      • this criterion does not apply if the person had end-stage renal disease prior to hospitalization, i.e. chronically
    • (5)Total bilirubin >=34.2 AND at least a doubling from baseline
      • "baseline" can be a value prior to hospitalization, or if that's not available, use the BEST value from the entire current hospitalization
    • (6) Platelet count <100 AND >=50% fall from the baseline value
      • "baseline" can be a value prior to hospitalization, or if that's not available, use the BEST value from the entire current hospitalization
  • Allan made changes to Template:ICD10 Guideline Sepsis about all this

2. New item: Whether Cardiac arrest should always be the primary admit diagnosis, when present.

  • After discussion we reiterated prior decision that in general the primary admit diagnosis should be chosen (from among all things present and related to admission) as the most severe entity. When a cardiac arrest is one such entity, it may well be deemed the most severe, but that will not literally always be the case.
  • It is well known that this isn't always unambiguous, and indeed studies have shown that different expert chart readers can choose different entities as primary.
  • While it is incumbent on the users of our data to understand the data they're requesting, we can and should make this point to those who request data including the primary admit diagnosis.
  • Lisa to make this change on the Wiki

3. New item: How to adjudicate whether Kidney, acute renal failure, postprocedural is actually related to the procedure?

  • This is a clinical determination. While onset longer after the procedure does make it decreasingly likely to be related, there is no firm cutoff time. Lisa to make this change on the wiki.

4. Next meeting June 13, 2024 at 10 am.

ICU Database Task Group Meeting – April 24, 2024

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

1. Jen Ziegler needs Wiki access, Tina/Lisa will obtain it for her. Done April 24, 2024

2. Lisa related that the data collectors are having weekly Coding Review meetings, with questions that remain being put on the Task Group wiki page.

3. New item: For the definition of Shock, septic , are BOTH pressors and lactate>2 required?

  • There are different definitions of septic shock, and Jen will look them up to help inform our decision on this.

4. New item: After discussion we agreed that a diagnosis that in retrospect was clearly "brewing" at admission but did not reach the threshold for being present until after admission would be coded as an Admit Diagnoses rather than an Acquired Diagnosis as long as it became fully evident within 6 hours of admission. Allan changed the Wiki page on this.

5. New item: Regarding necrotic open wounds and whether they should be coded as Gangrene, NOS

  • This is difficult as a necrotic open wound may be due to severe infection of the wound, rather than truly being gangrene, which is due to lack of perfusion to a body part.
  • For traumatic open wounds (e.g. Thorax, open wound, injury/trauma this INCLUDES necrotic wounds. But for nontraumatic open wounds there is no general code or group of codes equivalent to those trauma codes.
  • There are, however, some appropriate specific codes that include necrotic nontraumatic wounds -- these include Diabetes mellitus chronic complication: Foot ulcer, and the multiple codes for decubitus ulcers. For OTHER types of necrotic, nontraumatic wounds use Skin ulcer, NOS.

6. New item: How to code an iatrogenic nontraumatic Hemothorax or hemopneumothorax, nontraumatic:

7. New item: For the various hypothermia codes (Hypothermia, due to exposure/low environmental temperature,Hypothermia, not due to low environmental temperature/exposure) is there a temperature threshold that should be used.

  • After discussion we agreed that the answer is NO. Hypothermia codes should be used if the body temperature is low AND either (a) active rewarming is used, including simple methods such as a bearhugger, or (b) the patient has clinically relevant consequences of the hypothermia. Lisa made change to the Wiki.

8. Followup on item#6 from the prior meeting: whether ET-tube balloon rupture should be considered as Failed/difficult intubation, or complication of intubation‎, or complication of intubation.

  • Discussion centered around whether to code this if there were no real complications related to the rupture, or if it was not due to an iatrogenic event such as over-inflating the balloon. It was finally decided that even just replacing the tube is a recognition by the team that there COULD be a consequence, even if it has not occurred yet. So again this code can be used even if the rupture was just due to breakdown of the device (i.e. no iatrogenic issue) and even without a clear clinical consequence IF the tube was replaced.

9. New item: Rewording of what is now called Q-wave (transmural) and non-Q-wave (subendocarial or non-transmural) MI.

10. Next meeting is May 22 at 11 am.

ICU Database Task Group Meeting – March 20, 2024

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

1. Followup about the >5-fold, abrupt rise in Stage 1 and 2 decubs at Grace ICU only starting January 2022.

  • Allan reported that a Zoom meeting was held, including himself, Lisa, Julie, and the nursing leadership (Tatiana, Chantal) at Grace ICU. Discussion included:
    • The bedside nurses do not specifically record the location/stage of decub. Instead they use free text to describe skin issues, and thereafter our data collectors interpret the free text. Thus, there are two places for misinterpretation and errors. This is true in all the ICUs, not just Grace.
    • We agreed that it'd be optimal for the location where bedside nurses record skin issues to have check boxes for each of Stage 1-4 decubs, BUT, changing paper documentation that's included in official hospital charting is a long process. We will, however, push for including such including such changes when the appropriate documents come up for revision in the future.
    • We agreed that for now, we will not be able to figure out what accounted for the dramatic rise in January 2022 at Grace. Instead, we agreed that the effort should be to in-service all ICU nurses at all sites on: (a) the Staging of decubs, and (b) instructing them to explicitly document decubs by stage (e.g. Stage 2 over coccyx; Stage 4 over left heel).
    • This is already occurring at Grace ICU
    • For the other ICUs, the plan is that it will go through the OIT committee. Julie informed us that that group did begin to discuss it, and after today's meeting Allan spoke with Carment Hrymak highlighting all of this. She indicated that OIT is considering no longer tracking Stage 1 decubs, especially since they are the most subtle and most prone to erroneous identification.
  • It was observed that this is also a problem in Medicine wards. Given the greater number of people involved in Medicine, and the lack of a Quality/OIT infrastructure, we decided to see if the problem can be first fixed in ICUs and then go on to wards from there.

2. Followup on ADT assignments at St. B.

  • Specifically, when patients go: ward area --> ICU-type area of the same service.
    • The problem is that the admitting office does not change the service and so in Cognos they don't show up as having come to an ICU.
    • What SHOULD happen is that when these patients go to an ICU, that the service should change to "ICU/Cardiac surgery" or "ICU/Cardiology" or even "ICU/Medicine".
  • Allan reported that he spoke with Kim LeBlanc, head of admitting at St B.
    • She related that for such transfers, the admitting office is NOT currently involved in making the entries in ADT, this is done by the unit clerk, and she is not even certain whether it is done by the sending or receiving clerk. However, she will look into it and get back to Allan.

3. Followup on the fact that a small number/fraction of records have Visit Admit DtTm recorded as AFTER Admit DtTm.

  • The only new followup here is that modification was made to the Visit Admit DtTm page to make explicit that users should not consider that variable to faithfully represent the time of hospital admission.

4. New item: whether or not to code Shock, septic when there is also another possible cause of shock present.

  • Discussion included that: (a) it is possible to have multiple, simultaneous causes of shock, but usually not, (b) any non-cardiogenic shock can cause acute MI in persons with ischemic heart disease, (c) response to treatment can often help sort out whether a person with infection -- but also with another good reason for shock -- has septic shock or not.
  • To deal with this the Wiki page for Shock, septic now reads "septic shock should not be called if there is another more obvious cause for shock".

5. New item: for CCI items that include Drainage, Evacuation, how to interpret the instruction to "code each".

  • After discussion we clarified that this means to code each new drainage device that is inserted, NOT to code each time the drainage bag is emptied.

6. New item: whether ET-tube balloon rupture should be considered as Failed/difficult intubation, or complication of intubation.

7. Next meeting April 24 at 11 am

ICU Database Task Group Meeting – February 22, 2024

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

1. Followup about the dramatic (>5-fold) abrupt rise in Stage 1 and 2 decubs at Grace ICU only starting January 2022.

  • Allan reported that to date we have ruled out the following possible explanations: (a) change in data collectors, (b) change in format for recording decub data on the Grace ICU flowsheets, (c) change in instructions to Grace ICU nurses about collecting or recording decub information.
  • The next step is going to be a meeting with Lisa, Heather Smith, Allan and the Grace ICU nursing lead and educator. Lisa is arranging it.

2. Followup on ADT assignments at St. B.

  • Specifically, when patients go: ward area --> ICU-type area of the same service.
    • The problem is that the admitting office does not change the service and so in Cognos they don't show up as having come to an ICU.
    • What SHOULD happen is that when these patients go to an ICU, that the service should change to "ICU/Cardiac surgery" or "ICU/Cardiology" or even "ICU/Medicine".
  • Allan will contact Kim LeBlanc, head of admitting at St B to discuss this.

3. Followup on prone days during COVID, which is collected as a CCI procedure code

  • Julie presented this data and we see that over 2021, 2022, 2023 there is large variation both between ICUs.
  • There was a request for this information, but seeing this variation, the requester decided not to use our data on this. So we will not pursue this further at this time.

4. Followup on the fact that a small number/fraction of records have Visit Admit DtTm recorded as AFTER Admit DtTm.

  • Julie prepared data on this and it's rare in both ICU and Medicine, and furthermore, most of them differ by <2 hrs, which WOULD be of no real consequence for calculating LOS IF we used Visit Admit DtTm to calculate LOS, which according to Tina, we do not.
  • Tina identified that we use Visit Admit DtTm as part of the visit unique identifier, and thus we should NOT be altering it in general. In particular, we should not alter it if the only problem is that it's incorrect as evidenced by being after the Admit DtTm.
  • BUT we clarified that there is one situation in which Pagasa SHOULD still alter a Visit Admit DtTm -- i.e. when there are multiple records all as part of the same hospital episode, and for some reason they don't all agree on the Visit Admit DtTm ---> in THAT case, Pagasa should correct the incorrect Visit Admit DtTm, but in order to ensure it's correct, she should do so using cut/paste. As she's away, Julie will point this out to Pagasa
  • Allan emailed the requester today (Dr. Alex Grunfeld) to explain the situation and let him know his options.

5. Followup on issue of patients who present to ED at a given hospital and have ICU team involvement while in ED, 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.

  • Barret reported that after discussion with Heather Smith, at Grace ICU they will reinforce with all attendings that they need to put in an admit slip for such patients.
  • After discussion, we determined that this is not much of an issue at HSC or St. B, so we will close consideration of this issue now.

6. New issue relating to 2 sets of ICD10 diagnosis codes relating to drugs: (a) chronic abuse/addiction, and (b) acute toxicity/overdose.

7. Next meeting March 20 at 11 am.

ICU Database Task Group Meeting – January 11, 2024

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

1. Followup discussion about patients who have different or otherwise contradictory postal codes during a single episode of care involving hospital-to-hospital transfers. There are 2 kinds of these:

  • FIRST: one hospital record indicates a valid postal code while the other has "na" for the code. There are 2 possible scenarios here:
    • (1) We note that the postal code field should contain "na" when the patient is homeless, and that homelessness per se is a response option in the data field of pre-admit location.
      • It became clear in discussion that the collectors spend considerable effort validating homelessness, so based on that we decided that when it is present in the pre-admit location field that we will take that as correct, and that all postal codes in that episode of hospital care (i.e. across the hospital-to-hospital transfers) should be fixed to be "na" and all the pre-admit locations should be listed as "homeless".
      • Furthermore, Julie will go back and make it so all past records meet this new rule as well.
      • Lisa will alter the Wiki so that it no longer says that for homeless patients who are living at a shelter, to list the postal code of the shelter. Instead it will say to list that postal code as "na".
    • (2) None of the pre-admit locations were "homeless". We decided when this occurs, Julie/Pagasa will work to discern the true situation.
  • SECOND: both hospital records list valid, but different, postal codes.
    • In discussion it was clear that there are numerous possible explanations for this and so we decided that when this occurs, Julie/Pagasa will work to discern the true situation.

2. Followup on item#3 in the November 2023 minutes, in regards to patients who present to ED at a given hospital and have ICU team involvement while in ED, 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.

  • The plan at that meeting was to start and figure out how to proceed at Grace, and thereafter to decide what to do for St. B and HSC. To get going on that, Barret was going to speak to Heather Smith.
  • As he was not able to attend today's meeting, Allan sent Barret an email today to inquire about that discussion. Awaiting reply.

3. About the dramatic and sustained increase in only Stage 1 and 2 decubitus ulcers starting January 2022, and only at Grace.

  • Gail & Mindy reported that although there had been a change in the ICU flowsheet at Grace, that this occurred before 2022, and that furthermore, the part of the new flowsheet recording decubs was identical to the old flowsheet.
  • In discussion we wondered whether this issue might be due to a change in education/guidelines for the Grace ICU nurses about identifying and recording early stage decubs. To try and get at that, Allan will directly contact the Nurse Educator at Grace ICU, Chantal Packulak.

4. Question about rationale and guidance around use/nonuse of vital signs during cardiac or pulmonary arrest for the APACHE values.

  • Allan explained the rationale for this, and augmented the Wiki page on APACHE values to explain it.
  • Beyond that, to operationalize the rule of NOT using any vitals from an arrest, the rule (which Allan included in the augmented Wiki page) will be that one can use vitals from all sources EXCEPT the Code Blue recording sheet.

5. Question about interfacility transfers between Hospital A and Hospital B when the patient is in a procedure location (e.g. cath lab, OR) in Hospital B prior to admission to Hospital B.

  • After discussion we agreed that: (a) the discharge time from Hospital A should be when the patient left to go to the procedure location, (b) the admit time to Hospital B should be when the patient was actually admitted there after the time in the procedure location, (c) in order to correctly identify EPISODES of care (i.e. with direct hospital-to-hospital transfer) she will need to look not only at the set of locations, but also the Prior Inpatient Location field. Lisa and Julie will update the Wiki accordingly.

6. Issue with the ADT assignments at St. B.

  • Specifically, when patients go: ward area --> ICU-type area of the same service
    • This could be:
      • Cardiac surgery ward --> OR --> CICU: and on cardiac surgery for all this
      • Cardiology ward --> ACCU: and on cardiology for all this
      • even sometimes Medicine ward --> ICMS
    • The problem is that the admitting office does not change the service and so in Cognos they don't show up as having come to an ICU.
    • What SHOULD happen is that when these patients go to an ICU, that the service should change to "ICU/Cardiac surgery" or "ICU/Cardiology" or even "ICU/Medicine".
  • Allan will contact Kim LeBlanc, head of admitting at St B to discuss this.

7. Next meeting is February 22, 2024 at 11 am

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.

2023...

Also see Task Team Meeting - Rolling Agenda and Minutes 2023

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