JALT Meeting - Rolling Agenda and Minutes 2022

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HSC-GA7S JALT
  • This same location has different levels of care over time. Currently the s_level_of_care table can only accommodate one, ie changes over time can't be included in it. My first thought was to include start and end times for this, but what if patients from both programs were boarding on a given unit at the same time? Can that happen? The very concept that these are boarding locations kind of means crazy things could go on. How do we best accommodate this? Would we always know as a physical location (especially a boarding one) changes LOC? Ttenbergen 13:53, 2022 October 13 (CDT)
2022-11-03 10:31:16 PM
JALT Meeting - Rolling Agenda and Minutes 2023 JALT
  • For CC Reports, ER Delay for LE 30 minutes, ignore (treat as zero) and GT 30 minutes, use actual ER Delay. N is number of cases where previous location is from own ER, CC reports Mean ER Delay as Total ER delays/N and Median ER based on N. Prior to Oct 2020, we calculate ER delay as Arrive Dttm - Accept Dttm. But there are cases where Accept Dttm is missing, therefore ER Delay is missing and these missing are not included in N. Are all these correct? --JMojica 17:36, 2023 February 13 (CST)
  • For Medicine Reports, I am reporting LOS (mean, std, total, min, max) per Boarding LOC which includes ER . Should the GT 30 mins threshold be applied for ER boarding loc or use actual ER LOS? do we need to follow the same rule for both CC and Med? --JMojica 17:36, 2023 February 13 (CST)
  • 2023-03-26 10:21:37 PM
    Non-standard ICD10 Diagnoses Dx grouping
  • With our addition of codes, collectors may use one of our codes rather than the closest standard ICD10 code. In that case, the dx would not show up in the range. How should we address this? The most likely candidates above seem Bronchiolitis obliterans organizing pneumonia (BOOP, cryptogenic organizing pneumonia (COP)) and SARS (severe acute respiratory syndrome)
    • AG REPLY -- for this nonstd BOOP code, there are no existing issues regarding any of the comorbid groups (e.g. Charlson)
      • Allan, could you confirm that that this is what we found when we looked into BOOP.
  • AG REPLY --- so far Tina the only 2 U-codes that would ever be a primary dx are U04 and U14.68 -- which belong respectively to ICD10 chapters J and E. But whenever we add a new U-code we need to remember to decide which chapter (if any) it needs to be included under. Tina to add to template.
    • I can't add this to the template, this is not how templates work, they won't warn me as I start a new dx page. We'd need to remember this some other way. And I just saw other dxs that might fit in here: Diabetes mellitus acute complication: Non-ketotic hyperosmolar state, Asystole, Pulseless Electrical Activity (PEA)
    • Actually, neither BOOP nor SARS would currently be captured by our APACHE Acute Dxs in ICD10 codes filter - they likely should be. So this is still an issue and we would miss them if we did something similar. How do we fix it for the Apache codes and prevent this problem going fwd? Ttenbergen 15:22, 2022 June 30 (CDT)
      • Discussed at JALT, Allan will review. Ttenbergen 10:32, 2022 August 24 (CDT)
        • Allan sent an email 2022-10-02 that provides a new inclusion list for some of these. Nothing for APACHE or Charlson Comos, but additions for APACHE Acute Dxs in ICD10 codes. Tina needs to process the additions into S ICD10 APACHE Dx patterns table. Ttenbergen 16:54, 2022 October 27 (CDT)
        • Additionally, Tina will provide Allan the filter info as it's stored in Access so that future updates aren't confusing. Ttenbergen 17:00, 2022 October 27 (CDT)
        • Additionally we need some way to make sure we consider this when we add dxs. Ttenbergen 17:00, 2022 October 27 (CDT)
  • figured out that the structure of APACHE Acute Dxs in ICD10 codes is way different than I had thought and that my current implementation can't accommodate it, reviewing with Julie. Ttenbergen 23:09, 2022 October 27 (CDT)
  • 2022-10-28 4:09:28 AM
    Query check tmp BedHeld JALT
  • Checked JALT_Meeting_-_Rolling_Agenda_and_Minutes_2023#JALT_Meeting_–_January_11/12,_2023 and there are no details there... did we decline this check? Ttenbergen 16:02, 2023 February 2 (CST)
  • 2023-02-02 10:02:53 PM

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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.