Critical Care Program Quality Indicator Report

Reports
Report:	Critical Care Program Quality Indicator Report
StartDtTm:	2016-10-01
EndDtTm:
Contact Person :	Carmen Hrymak
Recipients:	Distribution of Annual and Quarterly Reports
Frequency:	quarterly
MailingList:	Distribution of Annual and Quarterly Reports
Data Dependencies :	Age • Avoidable Days (Critical Care) • Beds occupied by transferrable patients (Critical Care) • CXR • Creatinine (labs) • Delirium days • Duration of Mechanical Ventilation • ICU Acquired Antibiotic Resistant Organism (ARO) rate • ICU Acquired Catheter-associated Urinary Tract Infection (CAUTI) rate • ICU Acquired Sepsis • ICU Acquired Ulcer Rate • ICU Diagnosis APACHE Category Rate • ICU Interfacility Transfer • ICU Primary Diagnosis ICD10 Chapter Rate • ICU Resource Utilization - Creatinine Tests • LOS Per Service • Length of Time for Transfer from ED to ICU within same facility • Night Time Discharges • Nursing Workload • Over Census at Midnight • Patient flow • Primary Admit Diagnosis • Readmission Rate to ICU • Severity of illness • Transfer Delay (Critical Care) • Unit Mortality • Ventilated patient flow • Ventilator Associated Pneumonia Rate • Ventilator Utilization Ratio
SASFiles:	<path for SAS files>

 

• Cargo

• Categories

• Default form:

Also known as "Outcomes Improvement Team Quarterly ICU Report" or "Directors Quarterly Report (Critical Care)".

Contents

There are multiple versions of this report that essentially contain the same Indicators but has them aggregated slightly differently.

Critical Care Program Quality Indicator Report

(also refer as the Regional Report)

• contains 30 Indicators cumulative of all units except HSC CCU, STB ACCU and STB CICU
• Started Oct 2016 by Kendiss Olafson (except HSC CCU, STB ACCU and STB ICCS which started Jan 2019)
• End Date -

Individual ICU Quality Indicator Report

• contains 30 Indicators for each unit namely, HSC MICU, HSC SICU, HSC_IICU, STB MICU, STB ACCU, STB CICU, GRA MICU

• Dropped units are HSC CCU (June2019), CON ICU (June2019), Seven Oaks ICU (Sept2019), VIC ICU (Sept2017)
• Started Oct 2016 by Kendiss Olafson (except HSC CCU, STB ACCU and STB CICU which started Jan 2019)
• End Date -

WRHA Critical Care Quality Indicator Report

• contains comparison among all units of the Indicators' means (of last 2yrs monthly or quarterly data)
• each page also contains the individual unit chart over time.
• Start date - Oct 2016 by Kendiss Olafson (except HSC CCU, STB ACCU and STB CICU which started Jan 2019)
• End Date -

Distribution

Distribution of Annual and Quarterly Reports

File Locations

• Hard Copy of Report until Dec 2016 kept at desk of Database Program Statistician, Julie Mojica
• Electronic copy of report:
  • Tabular : S:\MED\CCMED\​S:\MED\CCMED\Reports\CriticalCareReport
  • Graphical: R:\Critical Care QIT\Director_Report\Report

Legacy

Tabular Report

• Tabular report
  • Report Label- Critical Care Activity Summary Report for the current quarter for each Unit
  • Start Date - 2003
  • End Date - Sept 2016 for all units (except HSC CCU, STB ACCU and STB CICU which ended Dec 2018)
  • Part of the tabular report continues to be reported
    • label as Critical Care Comparative Report for the current quarter
    • one table containing 13 summary activity Indicators of individual units for the current quarter
    • second table containing the Ventilator Associated Pneumonia Rates and Central Line Associated Blood-Stream Infection (CLA-BSI) ratesof all for the current quarter
    • the Critical Care Comparative Report is saved as pdf file and uploaded to Critical Care Sharepoint ExtraNet

SAS and SQC Programs

• First part - Run the SAS programs saved in S:\MED\MED_CCMED\Julie\SAS_CFE\CC_reports\ChartReport in the following order:
  • 1-prepCC_QI_startJan2023_WithIncompleteBedHeld.sas - prepares the data to be used in the report and exported to excel file
    • Make sure all the data are cleaned already by the Data Processor.
    • Update the period to current one as indicated in the program.
    • The exported excel file is saved in R:\Critical Care QIT\Director_Report\DataFile\WRHA_CriticalCare.xlsx
      • Check the new exported excel file for suspicious data and also compare the data with common period from the excel file of previous period.
  • 2-prepCCChart_demog_93_Sex_startstart2023.sas - generates the bar chart for Age Groups, Sex
  • 3-prepCCChart_ApacheDxGrp_94_startJan2020.sas - generates the bar chart for eight Diagnostic Categories from APACHE II Predicted Death Model in ICD10
  • 4-prepCCChart_ICD10PrimaryDx_ChapterName_startingJuly2019.sas - generates the table of ranked primary Diagnosis using ICD10 Chapter Name
  • 5-InterfacilityTransferInOut.sas - generates the stacked area plots by reasons of transfer (due to medical necessity or bed management reason) for the 3 scenarios namely,
    • transfers out from one ICU to another site's ICU;
    • transfers into an ICU from another site's ICU; and
    • transfers into an ICU from another site's Non-ICU (e.g. ER, Ward ,OR, etc.)
• Second part - Open the SQCpack8 software to see all the listed control charts for the 26 indicators and 9 groups (i.e. 7 individual units, one Regional and WRHA subgroups)
  • The chart's label/name is made plain, simple and intuitive for easy understanding (i.e. APACHE_HSC MICU, APACHE_CCRegion, APACHE_WRHA, etc.)
  • All the charts are automatically updated when the excel file is updated. But need to check each chart for the following:
    • The need to change the Y-axis if there is any point(s) outside the Y-Axis or when the UCL or LCL are not showing in the chart.
    • Check on the X-axis if the last scale is the current period and all must be date and not datetime format.
    • Check on any outliers in the charts, go back to the data. If found questionable confirm with the data collectors.
    • Look for any change in the pattern and re-calculate the control limits.
  • Once all charts are OK, select the charts and save them as .png image on R:\Critical Care QIT\Director_Report\Images .
    • for unit chart - use 1200 x 800, for regional chart use - 1200 x 800, for WRHA (subgroup chart) - use 1000 x 600.
    • for the detailed chart format (font size, color, etc.), the settings are listed in R:\Critical Care QIT\Director_Report\Images\1_ChartRunnerSettingFormats.doc
    • Select charts in small groups (not all charts at once) because the software cannot handle too large number. Just continue the process until all the needed charts are saved into images.
• Third part - Go to R:\Critical Care QIT\Director_Report\Report and review all the *.pptx files
  • All the inserted images in the PowerPoint files are automatically updated when the images from SQC are updated.
    • if for some reason, the image did not show up, select the INSERT tab, click PICTURES command, get the needed image from the R:\Critical Care QIT\Director_Report\Images and click INSERT AND LINK.
  • Browse all the slides in the PowerPoint if OK.
  • Save the PowerPoint into .pdf and save them on the subfolder labeled YYYYQQ where YYYY is year and QQ is the quarter.
  • Upload all the PDF files to Critical Care Sharepoint ExtraNet.

Back up of SQC Charts

The back-up copies of the control charts generated from SQCpack are saved in the shared file:

• R:\Critical Care QIT\Director_Report\Back_up_ByMonth
• R:\Critical Care QIT\Director_Report\Back_up_ByQtr

If want to bring back into the SQCpack, open the SQCpack software, from Menu, choose Charts and use the Inmport chart features.

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