Minutes Team Meeting June 19, 2013

1. The plan for September collection meeting is to have Dr. Allan Garland to present general plans to database structure changes program has been working on. Collectors are noting some small changes in their CCMDB.mdb and they are not sure why they are being done.

Central_Line_Related_Blood_stream_Infection_(CLR-BSI) Data Collection Criteria 2 issue

1. Central_Line_Related_Blood_stream_Infection_(CLR-BSI)
   • our criteria 2 on wiki for CLR_BSI is not clear to many data collectors. Need help to further clarify.
   • what are "recognized pathogens" vs non recognized pathogens?
   • if patient is colonized with MRSA or VRE, when does is it considered pathogenic?
     • Options discussed:
       • clarify with Dr. Kendiss Olafson
       • questions and examples to send to Dr. Anand Kumar
       • Examples of cases to discuss and review
       • Take issues and discuss in the ICU Database Task team
   • PLAN 1:
     • Take topic to ICU database Task team.
     • one SUGGESTION: June 21.13; Trish has sent out an email to data collectors (including Dr. Allan Garland and Kendiss) to review and proposed we use the SAME wording for Criteria 2, make a 3rd criteria so wording is CLEARER for CLR_BSI as the Cross Canada Critical Care Vital Sign Montoring Project.
       • Criteria 2
         • One of:
           • Temp >38 C
           • Hypotension
           • Chills
           • Signs of infection at catheter insertion/tunnel site – AND- a common skin contaminant (as listed) from TWO or MORE blood cultures drawn on separate occasions
       • Criteria 3
         • One of
           • Temp >38 C
           • Hypotension
           • Chills
           • Signs of infection at catheter insertion site – AND - a common skin contaminant (as listed) cultured from ONE blood culture - AND - a physician institutes appropriate antimicrobial therapy.
   • Plan 2:
     • Email sent to Dr. Kumar with some questions/examples. Question and reply below.
     • From: Trish Ostryzniuk, Sent: Thursday, June 20, 2013 10:48 AM, To: Anand Kumar, Subject: Previously colonized with ARO - bug question consult.
     • Hi Dr. Kumar We need your help on this. Collectors are having trouble decided when previously colonized with ARO (Antibiotic Resistant Organism), when does it become an acute infection be in septicemia or pneumonia.
       • QUESTION: Pt who is colonized with VRE or MRSA or both, and has a -ve blood cultures and sputum: if they go on to develop septicemia (+ ve blood cultures) with VRE or MRSA or both and, it appears to be an acute infection (pt starts decompensating), question is this: would VRE or MSRA be the causative agent for this infection?
       • Example 1: pt is colonized with VRE & MRSA, develops SOB, has to be intubated and the ETT secretions grow MRSA and entercocus spec. Is this an pneumonia mixed with MRSA?
       • DR. KUMAR: if culture is nothing "new", then code as culture negative but use the code COLONIZED with MRSA 99-48 OR if Dr. does say pneumonia is due to MRSA then code it as pneumonia is MRSA. Doc's are using judgment too and they are not always certain either. Let the chart reviewer who pulls these charts for further study figure it out if they can.
       • Example 2: pt is colonized with VRE, develops fever, blood cultures grow VRE, do we code it septicemia VRE?
       • DR KUMAR: Note: VRE or staph aureus should not be in blood, if it is, then the blood stream infection/septicemia/bacteremia is due to VRE or Staph A.Colonizer's don't colonize in the blood, if they are in the blood then it is pathogen up to no good and causing bacteremia/septicemia.
     • DR KUMAR:In terms of CLR BSI (central line related blood stream infections) related to MSRA, of only culture from the blood with no other pathogen, then can make an assumption that line infection is related to MSRA. THIS IS GENERALLY A DR's GUESS. The only definitive proof is if blood culture and line tip is +ve for MSRA, the definite CLR-BSI due to MSRA.

TISS28 items 46-49 - 2300 hrs items

1. TISS28 is not only to monitor bedside nurse workload trends, by administration and management, it is also used by CCVSM and ICU Quality Improvement team for research and monitoring for quality of patient care.
2. every 3-4 month the data collectors are asked to provide a summary of observed issues with completion of TISS forms. This information feed back to ICU Nursing Director Jodi Walker Tweed, review with the QI officer Basil Evan, ICU managers in the region. Manager then review with their staff and QI Officer review with Nursing Educators.
3. Julie Mojica presented a brief Comparative Analysis of TISS28 items 46-49 vs CRN Data collection
   • Period: Jan-Mar 31.13 (90 days)
   • CRN use to count daily number of central lines, ventilated patients and ETT's since 2007 and fax them to main database office. As of Jan 1.13 this information was included on the TISS28 for (items 46-49). Also items 28 & 29.
   • January 1.13 to beginning of May 6.13, Julie did a comparative analysis from TISS28 vs CRN daily sheets.
   • Difference ranges from 70-90%. The main reason for the difference is the COLLECTION TIMES. TISS28 counts at 2300 hrs and CRN sheets counts were generally sometimes in the morning each day. Could not conclude if data on CRN sheet or TISS28 sheets was more reliable.
4. Database Steering Committee proposed and different type of audit.
   • an independant auditor will collect data on a specific date VS bedside nurse collection at each site in Region
   • data collector at a site will be notificed not to edit or add to TISS28 for items 46-49 for a specific date by Trish.
5. Quality control of TISS data provided by bedside nurses continues to be a significant burden of workload on the data collector at each site. The degree and amount of edits, additions, correction etc., varies from site to site. Some collectors do a high degree of quality control on each TISS, others do minimal or corrections. The degree of quality control required has not been specified therefore, not consistent, and is dependant on the collector who does it.
6. RE: Long stay patient and turning in TISS form after second page is started: CCMSM and ICU QI team is wanting data sooner rather than later, particularily related to certain items on TISS. There has been a request that collector not hold on to all the TISS forms until patient is discharged from unit if LOS is 10 days or more. For some units this has been challenging that they are not able to do weekly QA check of TISS before submitting. IF the ICU starts to accept TISS AS IS with missing days and incomplete data we would need a way on form and in TISS database tag this.
   • Plan
   • discuss at ICU database Task meeting what should be the minimal standards of quality control on TISS forms?
     • Should we just spec out specific items on form that must be quality checked: example, top of form, dates, sepecific items that are used for CCMVS and ICU QI team?
     • Should we just accept the other items on TISS AS IS and let units takes responsiblity for poor TISS scores?
     • is there some way to keep track of collector edits,changes or additon on TISS forms and be able to tally amount of changes actually made in order to actually report ICU's bedside lack of effort in completing a TISS form realiably?
     • independant TISS audit to be reported and review by Steering Commitee when it is completed.

Overstay Project Bed day reduction in medicine program

1. Presented by Linda Hathout
2. approximate decrease in mean LOS of 1.1 days, total of 1871 bed days, about 5.13 beds at 2 hospital in Region
3. statistically significant change.
4. miracle that process works
   • How?
     • data pretty good
     • staff that are excellent in analyzing data
     • cooperation from various program disciplines
     • ownership of problem and increase accountablity (transition coordinator)
     • excellent support from data collector at each site!
     • reduction of panelling from hospitals and increase panelling from Home. Better for patient to be panelled from home
     • increase supports as needed to enable patient to return to home
     • reduction in number of unnecessary consults for home care and increase in number of appropriate consults
5. ISSUE: Collectors state that the ADMIT from items if often MISSED on Discharge Planning Screening Tool (DPST) for and that it should be a question with a number 7 by it, otherwise often missed and collect has to chase. Bedside nurse have request this change at HSC as per Pat Stein. Linda Hathout stated that final form to be work on over the summer month for any changes discussed.
   • Linda Hathout: Cleaner wording on Discharge Planning Screening Tool (DPST) | DPST

]] for admit from item.

1. • Statistician Julie Mojica is able to capture READMIT when linking databases if patient is from a unit we are collecting on. This is inregards to some comment about capturing the number of FAILED DISCHARGES (sorry, don't recall all of discussion on this point).
2. Palliative Care