Task Team Meeting - Rolling Agenda and Minutes 2018

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This are the 2018 minutes, for the current minutes see Task Team Meeting - Rolling Agenda and Minutes.

ICU Database Task Group Meeting – December 28, 2018

  • Present: Allan, Joanna, Julie, Tina, Trish
  • Absent: Con, Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Question about coding VAC dressings. At the last meeting Allan indicated that since it’s a dressing that we wouldn’t code it, BUT after further consideration he’s not so sure. We could add it as a CCI picklist item: "Vacuum dressing, abdomen or trunk" --- (1.YS.14.JA-NC-N). After discussion we agreed NOT to do this at the current time, as nobody is requesting this information.

2. Regarding Admit procedures. There is a further need for clarification. Allan will add some --> DONE.

3. Julie inquired whether there is a way, for CCI chapter 3 (diagnostic radiology tests) to separate the abdomen from the pelvis. The answer is “No” given how we’ve organized chapter 3. As a result from now on, when she reports the # of abdominal ultrasound tests done, she’ll list them as “abdominal/pelvic ultrasound”.

4. More concerns arose about diagnosis of ARF/AKI -- for APACHE purposes and separately for diagnostic purposes. Allan, Tina and Trish will meet later today to mull this over -- DONE. We decided to use KDIGO definition of AKI/ARF everywhere in ICD10, including for doubling serum creatinine points in APACHE II and an AKI/ARF template has been added in all the appropriate places.

5. Tina will schedule next meeting for early January 2018.

ICU Database Task Group Meeting – December 18, 2018

  • Present: Allan, Con, Julie, Tina, Trish
  • Absent: Joanna, Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup on CCI coding to do list:

  • Tina to continue working on the “machinery” for the 5 different categories of CCI codes

2. Regarding going in and making sure that the NEW rule is listed regarding when therapeutic and diagnostic tests are done at the same sitting, we now want to code them BOTH (e.g. diagnostic cardiac cath + stenting). Allan has changed this in the main CCI Collection page, but we need to make sure it’s done elsewhere too.

3. Question of which awaiting transfer code to use when the Transfer-to location isn’t clear. Answer is to use the wastebasket code "Awaiting/transfer to other care facility (acute or chronic)".
Tina has changed "Awaiting/transfer to other care facility (acute or chronic)" to "Awaiting/delayed transfer to other care facility NOS".

4. Question about coding VAC dressings. At the meeting Allan indicated that since it’s a dressing that we wouldn’t code it, BUT after further consideration he’s not so sure. We could add it as a CCI picklist item: "Vacuum dressing, abdomen or trunk" --- (1.YS.14.JA-NC-N). Requires further discussion/decision-making (and if we decide to include it, we’ll need to remove it from the List of CCI procedures we don't code.

5. Question about jail/prison as a dispo location. Agreed to add “Institution NOS” as an additional option for dispo, to which jails and prisons will apply.
Tina has added this to s_dispo table.

6. Question about immune arthritis NOS (e.g. as after a strep infection).
Allan added code M06.4, Inflammatory/immune arthritis, NOS to wiki, Tina has added it to CCMDB.mdb.

7. Question about distinguishing CCI codes related to “internal device” vs. “external appliance”. At the meeting, Allan said (WRONGLY) that the difference is that the internal device is ENTIRELY inside the patient, while an external appliance is either entirely external or has parts both internal and external. HOWEVER, that is WRONG, and it’s almost the opposite --- an external appliance is entirely external, while an internal device includes those for which ANY PORTION is inside the body.

  • After looking more carefully at the CCI manual, it’s clear that the external appliances are all very minor things and so Allan now thinks we should REMOVE this item Installation of External Appliance from the CCI component list. Allan has made appropriate changes to the Implantation of Internal Device page. Tina has retired code

Installation of External Appliance from CCMDB.mdb.

8. Tina has scheduled next meeting for January 9, 2019.

ICU Database Task Group Meeting – December 7, 2018

  • Present: Allan, Con, Joanna, Julie, Laura, Trish
  • Absent: Tina
  • Minutes prepared by: AG
  • Action items in BOLD

This meeting was a discussion about the updated idea for organizing CCI. We decided on a schema with 2 dimensions.

1. The first dimension is about finding the code for a given procedure that was done

  • (i) First, check the CCI picklist. If the item in question is there, use it
  • (ii) If not on the picklist, attempt to create the item from CCI components (with an eye towards the List of CCI procedures we don't code
  • (iii) If you can’t code it from components, then it’s not to be coded.

2. The second dimension relates to recording the information about a given procedure which is desired. There are 3 groupings:

  • (a) "First" - Record only the date of the first occurrence. Examples: CVC placement, Arthrocentesis, Isolation
  • (b) "Count" - Record the date of first occurrence + the total count. Note that depending on the item, the count means different things. For example for PRBC transfusions, the count is the # of units. For ECMO the count is the number of calendar days on which it was done for any amount of time.
  • (c) "Each" - Record each time, with date, it’s done. Examples: Cardiac MRI (from picklist), all items created by components EXCEPT debridements (for which is recorded only the date of the first occurrence.
  • We need Tina to create the data collection “machinery” to do these.
  • We need to modify every CCI picklist Wiki page to identify WHICH of these 3 categories the items belongs to
  • Allan has the updated picklist and updated delineation of these 3 groupings for Tina.
  • Tina has implemented these, see CCI Collection Mode for details.

3. Agreed to delete these former picklist CCI items

  • Bronchial thermoplasty 1.GM.07
  • Liver dialysis 1.OA.16
  • Pharmacotherapy, antineoplastic agent, whole body 1.ZZ.35.HA-M0
  • Pharmacotherapy, immunostimulant, whole body 1.ZZ.35.HA-M7
  • Pharmacotherapy, immunosuppressive, whole body 1.ZZ.35.HA-M8
  • Obstetrical Ultrasound (diagnostic imaging) 5.AB.03
  • Obstetrical Imaging NOS (diagnostic imaging) 5.AB.05

Tina has retired these

4. Current list of procedures we will not capture (has been updated).

  • Arterial Brachial Indices (ABIs)
  • Cardioversion or defibrillation during arrest
  • Cryoprecipitate
  • Dressings (incl VAC dressings)
  • EKG
  • Fecal management system (FMS)
  • Fluoroscopy
  • Foley
  • Intubation - it is already coded as T40 - Insertion of ETT (TISS Item) for ICU and not done on the ward (without patient leaving to ICU), so it was decided not to code this.
  • Nasogastric tube (NG)/orogastric tube (OG)
  • Oxygenation
  • Phlebotomy, blood draws for lab testing
  • Plain X-rays other than AXR (abdominal plain X-ray) and CXR (plain film)
  • Suture removal
  • Whole body cooling
  • Whole body warming

5. Allan created a handful of new CCI picklist items, including:

Tina has added these to CCMDB.mdb

6. Allan modified (or seeks Tina’s help in modifying) some CCI picklist items:

7. Allan has made modifications to the Wiki pages of almost all of the CCI picklist items Tina confirmed wiki picklist items

8. After discussion it was agreed that we will change the prior rule/guideline that when a diagnostic and a therapeutic procedure were done at the same setting, that the therapeutic one “trumps” the diagnostic one and is the only one which needs to be recorded.

Tina has tagged the ones she could find for Allan, they will be on his list starting with "not just deepest"

9. Con identified that there appears to be no CCI body part representing the buttocks. Allan will seek it out --> answer is: 1.VD (T) Soft Tissue and Muscle of the Hip and Thigh which needs to be added - Tina has added this to wiki and CCMDB.mdb

ICU Database Task Group Meeting – November 26, 2018

  • Present: Allan, Con, Joanna, Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Final discussion about TTM after arrest. We agreed that the current code "Whole body cooling" will have it’s name changed to Targeted Temperature Management (TTM). Tina has done this.

2. Trish raised the question of whether we really can use the ICD-10 KDIGO definition of AKI for the APACHE II. The issue is that the KDIGO definition includes very minor AKI, and perhaps we don’t want to include such minor derangement for APACHE. Here are 4 existing definitions -- we’ll discuss more at the next Task meeting.

  • GWU APACHE II Manual -- the one we use for APACHE
    • Creatinine > 133 where it was normal at BL AND UOP < 135 mL over past 8 hrs
    • No guidance about what to do if creatinine was elevated at BL
  • KDIGO -- any of:
    • Increase in serum creatinine by 26 micromoles/L or more within 48 hours
    • Increase in serum creatinine to 1.5 times baseline or more within the last 7 days
    • UOP < 0.5 mL/kg/hour for 6 hours
  • Hou et al (Am J Med 74:243-248,1983) -- based on change in creatinine from BL:
    • BL < 177 Change ≥ 44
    • 177-439 Change ≥ 89
    • ≥440 Change ≥ 133
  • From: https://www.criticalcarenutrition.com/docs/arf.pdf -- based on change in creatinine
    • BL < 123 Change to >177
  • Only KDIGO and Hou deal with any starting situation.

3. Regarding how we collect two items in Medicine:

  • Isolation-Task -- agreed that the prior 2 categories (full vs. gloves only) will be just a single category going forward in CCI.
  • HD/PD (Dialysis Tasks) -- agreed that we will no longer collect whether these are acute vs. chronic; the diagnosis will allow for this delineation.

4. Discussion about THE DATE of a VAP. Allan will make changes to the VAP wiki page highlighting:

  • In general we want the date on which the VAP was first evident -- in retrospect. This MAY NOT BE THE DAY it was first recognized as being present in real time by the medical team.
    • e.g. An intubated patient had a CXR on Thursday showing a little wispy infiltrate on the CXR. In the absence of other signs or symptoms, on that day the team did NOT think it was infectious. But Friday the patient developed fever and leukocytosis and purulent sputum, AND the wispy infiltrate was now a big, dense consolidation. A sputum culture was sent on Friday for the first time. At this point the team began antibiotics for pneumonia. The thing here is that only in RETROSPECT did it become clear that the wispy infiltrate seen on Thursday WAS the start of the VAP. Thus, in this case the VAP appears to have clinically begun on Thursday, not Friday.
      • NOTE that IF the intubation was Tuesday or Wednesday or Thursday, then this is NOT a VAP, because the clinical onset of the pneumonia was <48 hours prior to intubation. If the intubation was Monday or prior, then it is a VAP.
  • This issue of timing can be VERY tricky -- and will always require judgement and retrospective assessment of the sequence of events.
    • e.g. Patient has had fever and leukocytosis for 5 days due to a septic gallbladder, and has been intubated that whole time. Now a new infiltrate with shows up, with purulent sputum and the team believes a new pneumonia has developed. So here you can't use the pre-existing fever and elevated WBC to identify the clinical onset, and it's the change in the CXR that makes it.
    • e.g. Patient has ARDS from multiple trauma and so the CXR has had diffuse fluffy infiltrates for a week. He's also had a low-grade fever the whole time. Now the fever becomes high-grade, the sputum becomes purulent, and though it's hard to tell for sure, the CXR seems to be a bit worse in the RUL. The team concludes a pneumonia has developed. So here, it's a judgement that the subtle change in the CXR and the change in the fever curve and the change in sputum is due to a VAP.

5. Discussion of diagnostic radiology of the spine/vertebrae. Currently the collectors are forced (e.g. for CT spine) to do CT of each body segment (neck, thorax, etc). To fix this we will add one more “body part” to CCI Chapter 3. It will be “3.AW” and titled “(I) Spinal Cord and/or Vertebrae (any segments)”. Tina has added this.

6. Question arose of how to code mixed and/or unknown overdoses. It was decided to use Drug or biological substance/agent NOS, overdose/toxicity, and info was added to the page to make this clear -- DONE.

7. Question arose about specifically coding intravenous drug abuse. Allan looked it up and there is no coding for the ROUTE of drug abuse in ICD10.

8. Julie queried whether it’s still desired to collect not only WHETHER a bed borrow occurred (for which there’s a check box) but also the dates. Allan will ask Bojan what he needs -- DONE, Bojan indicated that just the check box is OK.

9. Regarding congenital renal cystic disorders OTHER than Polycystic Kidneys. After discussion it was agreed that we won’t have a separate code for those, but include them under Q64 = Urinary system NOS, congenital malformation

10. Followup about “NOS” wastebaskets for all of the drug and substance codes in ICD10. There are still questions that Allan and Tina will address.

11. Followup from 10/31/2018 Task meeting: Allan to work towards implementation machinery for CCI for procedures done in the ward/ICU (see those earlier task minutes).


Items left over from prior weeks, for Allan/Tina to do:

  • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
  • Ensure we can code in ICD10 ischemia of any body part
  • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
  • Work on a new PIA

Next Task Group Meeting: December 18 at 11:30 am

ICU Database Task Group Meeting – November 8, 2018

  • Present: Allan, Con, Joanna, Laura, Tina, Trish
  • Absent: Julie
  • Minutes prepared by: AG
  • Action items in BOLD

1. After discussion we recognized that, since the only type of whole body cooling we’re going to track is TTM, and that TTM can include either cooling or warming, that instead of a cooling code we should see if ICD10 has a TTM code.

  • Allan will check on this --> DONE, but CCI does not have a code for TTM after cardiac arrest. THUS, he recommends that we adapt the current code for "Whole body cooling" to solely represent TTM after cardiac arrest, even changing its name. This plan fits well since we had already decided that we'd only use this code for cooling after cardiac arrest.
  • Current codes:

2. Joanna raised some confusion about the definition of VAP. It is the current CDC definition but differs from our prior definition -- for example sputum cultures are no longer part of the criteria. The main uncertainty was how to figure out whether signs (e.g. fever, elevated WBC) that are part of the case definition are due to pneumonia, versus another infectious or noninfectious process. The answer is: Don’t worry about that. Don’t overthink the formal criteria -- i.e. the criteria are present or absent as written; trying to ascertain causality is not part of the case definition. Somebody needs to add this to the Wiki, and probably also to the central line infection article too.

3. The question was raised of how to code anti-NMDA receptor encephalitis. It turns out that this is already identified in the Wiki as falling under the code Encephalitis, meningoencephalitis, myelitis, encephalomyelitis, noninfectious. However, this brought up the more general point that as we go along in using ICD-10 and CCI, coders should make notes in existing pages of what code they’re using for an entity which doesn’t have it’s own, separate code. Perhaps Tina could add this to the Wiki". (done-Ttenbergen 20:05, 2018 November 8 (CST))

4. Regarding burns. Currently we only have codes for 1st, 2nd, 3rd or unspecified degree of burn and we should have a way to code the % of body surface area involved.

  • Allan has now done this and sent the info to Tina -- the answer is that there are a family of codes (T31.00-T31.90) that represent the % of body surface area burned; these should never be used alone but linked to the code(s) that represent the type of thermal or chemical burns present (T30.xx codes for 1st, 2nd, 3rd degree or unspecified) - Tina added these

5. Question was raised about what to code for unit/ICU disposition when a patient goes off to a procedure area (e.g. OR, cath lab, dialysis) and dies there. After discussion we agreed that the rule will be: If the person was expected to return to the unit after the procedure, then the dispo is death. If the person was NOT expected to return to the unit after the procedure, then the dispo is transfer to the procedure area.

6. Followup about “NOS” wastebaskets for all of the drug and substance codes in ICD10. There are still questions that Allan and Tina will address.

7. Followup from 10/31/2018 Task meeting: Allan to work towards implementation machinery for CCI for procedures done in the ward/ICU (see those earlier task minutes).


Items left over from prior weeks, for Allan/Tina to do:

  • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
  • Ensure we can code in ICD10 ischemia of any body part
  • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
  • Work on a new PIA
  • Next Task Group Meeting: November 26 at 1pm

ICU Database Task Group Meeting – October 31, 2018

  • Present: Allan, Con, Joanna, Julie, Laura, Tina, Trish
  • Absent:
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup about “NOS” wastebaskets for all of the drug and substance codes in ICD10. There are still questions that Allan and Tina will address.

2. Continued consideration about what (and how) to do CCI coding for procedures done IN the patients unit/ward.

  • After discussion we recognized that we will need to create machinery to code 3 different categories of such procedures:
    • (i) Those coded every time they occur -- recorded with dates. Example is EGD
    • (ii) Those for which we mainly want total counts -- record the first date in which done, plus the total count over the entire admission. Example is CXR, ABG. For this one there is needed software/data entry “machinery” that Tina/Trish/etc will talk about offline.
    • (iii) Those for which we would ‘’prefer’’ the # of days on which it was done. Examples are noninvasive mechanical ventilation, dialysis, ECMO. However, after discussion we decided that in order to reduce the workload on the data collectors, we will only collect the date of the first use. We could reconsider adding # of days for these at a later point in time.
  • There was also discussion of which in-unit/ward procedures to capture:
    • We agreed that Chest tube, left in places should be captured.
    • Ideas presented included: everything done with an endoscope +
      • The current picklist list OR
      • Things done that included inserting a needle or scalpel into a nonvascular body space (e.g. pleural, peritoneal) or organ (e.g. kidney, pancreas) + a modified picklist
      • Allan will contemplate these choices.

Items left over from prior weeks, for Allan/Tina to do:

  • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
  • Ensure we can code in ICD10 ischemia of any body part
  • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
  • Work on a new PIA

Next Task Group Meeting: November 8 at 11 am

ICU Database Task Group Meeting – October 23, 2018

  • Present: Allan, Con, Joanna, Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup regarding Oct 3 discussion about Pulmonary-renal syndromes which are not further identified.

  • Allan reported that he made a new Wiki article Pulmonary-Renal Syndrome in ICD10.
  • We recognized that the causative disorders (e.g. Wegener’s, Goodpasture’s, Lupus, etc) are multisystem, immune-mediated disorders for which listing the disorder will NOT generally identify the manifestations from which the person is suffering. This can also be true for cancers and some other disorders
    • So we agreed that we will modify the rules regarding listing signs/symptoms when they are manifestations of disorders where the manifestations aren’t clear just from the diagnosis alone. Such manifestations might include true ICD10 diagnoses (e.g. renal failure) but also might include ICD10 signs and symtoms codes (e.g. hematuria) for which the current rule is that these should only be coded if the underlying diagnosis is unknown.
    • Thus, Tina will modify Template:ICD10 Guideline Signs Symptoms Test Results not needed when cause known. (Done)

2. New item: How to code transfers into a unit or hospital for continued postoperative care.

  • Agreed to code the diagnosis as Surgical follow-up care PLUS include the operative procedure in the Admit Procedure bin, removing FOR THIS USAGE ONLY the usual rule for Admit Procedure that they must have occurred within the prior 24 hours. For this usage, there is no time limit on when the procedure was done but nonetheless it must include the judgement that the reason for this admission was “routine” followup surgical care related to that procedure --- AS OPPOSED TO admission for some complication of that procedure.
    • If instead the admission was for a complication of that procedure, and not routine followup surgical care, then instead code the complication as the admit diagnosis, and code procedure as a Comorbid Diagnosis using one of the “History of” ICD10 diagnosis codes.
  • Tina to make Wiki changes regarding this. - Done, created Template:ICD10 Guideline follow up Care only and applied it to Surgical follow-up care and Admit Procedure.

3. Allan and Tina to continue reworking the CCI coding

4. Followup about “NOS” wastebaskets for all of the drug and substance codes in ICD10. Allan reported that these all exist, and that he has improved the explanation in ICD10 Guideline for drugs and substances. But there are still questions that Allan and Tina will address.


Items left over from prior weeks, for Allan/Tina to do:

  • Revise the APACHE diagnosis admission coding -- some of them need CCI codes included. Email sent by Julie.
  • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
  • Ensure we can code in ICD10 ischemia of any body part
  • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
  • Work on a new PIA

ICU Database Task Group Meeting – October 3, 2018

  • Present: Allan, Con, Julie, Laura, Tina, Trish
  • Absent: Joanna
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup on whether we need to have special reminders embedded in the data entry software on the laptops for:

  • so how would Julie Report, using only CCI, ACUTE vs CRONIC Dialysis using CCI? Would it be sufficient for Medicine to just know who had HD or PD rather than if acute or chronic HD? She would now have to start tying into ICD10 renal codes to determine if HD is acute or chronic? This is a bit task to do.
  • same issue for PD (Peritoneal dialysis), and for Isolation, infectious--Trish Ostryzniuk 15:57, 2018 November 20 (CST)
  • Allan reported that for ICU, regarding Targeted Temperature Management (Targeted Temperature Management (TTM)) in setting of cardiac arrest, Bojan Paunovic indicated that they do still want it, but that if we believe we can get those items without a special procedure for doing so, that’s OK.
    • This should mean that we can stop coding BRR.

2. Followup about how to code arterial embolism or thrombosis. Allan reported back that currently I74 covers thromboembolic disease of ALL arteries except: coronary, cerebral, mesenteric, renal, pulmonary (which have their own codes). Furthermore, that if we want, we could further separate I74 into: of upper extremeties (I74.2), of lower extremeties (I74.3) and of other arteries (I74.8). After discussion we agreed NOT to do so at this time, as nobody is asking for that further level of specificity.

3. Followup about calculating GFR for the 5 stages of CKD. Allan reported that he has put a link and instructions in each of Stages 1-4 into those Wiki articles that lets collectors use the MDRD equation to calculate GFR from age, sex, creatinine and race (as white vs. black) -- with decision to use “white” by default, AND for the creatinine value, to use the most recent, pre-hospital, “stable” value available.

4. Followup about “NOS” wastebaskets for all of the drug and substance codes in ICD10. Allan reported that these all exist, and that he has improved the explanation in ICD10 Guideline for drugs and substances. But there are still questions that Allan and Tina will address.

5. There was a long discussion about which in-unit procedures to code and which to count.

  • Laura suggested that it will be feasible to COUNT only ABG, VBG and CXR -- and for all other in-unit procedures we want to capture to record them individually and each time with dates.
  • However, further discussion brought to light that the entire situation of which in-unit procedures to track is confusing to the collectors. Specifically they’re confused not only by what we have said we’ll track, but also by what we said we will NOT track. It was decided that Allan will ponder this important issue further.

6. New question: Pulmonary-renal syndromes which are not further identified --- e.g. not specifically Wegener’s or Goodpastures or a collagen-vascular disease-related syndrome. Allan will check on how to do this --> DONE, new Wiki article Pulmonary-Renal Syndrome in ICD10

7. There was discussion about the wish of many data collectors to redo the naming of the CCI picklist. It was decided that Trish will organize trying to do so, and then show it to Allan.

Items left over from prior weeks, for Allan to do:

    • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
    • Ensure we can code in ICD10 ischemia of any body part
    • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
    • Work on a new PIA
    • Rework all the comorbid coding

Next Task Group Meeting: October 17, 9am

ICU Database Task Group Meeting – September 11, 2018

  • Present: Allan, Con, Joanna, Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Regarding endocarditis codes. Still to do is for Tina to change the current code name "Endocarditis, infective, acute or subacute" to Endocarditis, infective, chronic. (Done. Ttenbergen 14:02, 2018 September 13 (CDT))

2. Further discussion about deciding if/when CCI procedures can be an Admit Procedure:

  • After our last discussion on this, Allan altered the wording, but we recognized today it was insufficient. Allan will make additional, clarifying, changes to this Wiki article. --> DONE.

3. Followup on whether, going forward, we need to have special reminders embedded in the data entry software on the laptops for:

  • The 5 Medicine ward “tasks”, there is currently a specific Yes/No reminder box which must be completed.
  • In ICU, Targeted Temperature Management in setting of cardiac arrest,
  • Allan sent email to Nick Hajadiakos and Bojan Paunovic, asking, respectively, if/how they use this information and whether special approaches to ensuring THESE items is still warranted --> Bojan answered back “no” for the TTM. Still waiting answer from Nick.
    • Tina brought up that there are likely others, emailed them to Allan.

4. Question of how to code diagnosis/es relating to copious respiratory secretions, mucus plugging, problems clearing secretions, and atelectasis and/or respiratory failure/insufficiency from these problems.

5. Question was raised about how to code arterial embolism or thrombosis. Allan to look into it --> Answer: Currently Thrombosis or embolism of artery, NOS (I74) covers thromboembolic disease of ALL arteries except: coronary, cerebral, mesenteric, renal, pulmonary. If we want, we could further separate I74 into: of upper extremeties (I74.2), of lower extremeties (I74.3) and of other arteries (I74.8). To discuss at next meeting

6. Question was raised about calculating GFR for the 5 stages of CKD. Decision was to in each of those Wiki articles, to put a reference to a website that will use the MDRD equation to calculate GFR from age, sex, creatinine and race (as white vs. black) -- with decision to use “white” by default, AND for the creatinine value, to use the most recent, pre-hospital, “stable” value available --> DONE by AG.

7. Question was raised about what code to use for admission to IICU for the most common reason of ongoing respiratory failure. Agreed that the right one is Respiratory failure (insufficiency), chronic. Furthermore, that when an ICU patient is unable to get off the ventilator and is going to go to IICU for this reason, it’s appropriate on the ICU record to include this ICD10 diagnosis as an acquired diagnosis. Allan added these notes to that Wiki article.

8. Question about the need for “NOS” wastebaskets for all of the drug and substance codes in ICD10. Allan has ensured that these exist, and furthermore, he has improved the explanations in ICD10 Guideline for drugs and substances.

9. After discussion it was agreed NOT to add a Patient copier button to allow wholesale transfer from 1 record to another record of demographics or comorbidities.

Items left over from prior weeks, for Allan to do:

  • Provide Tina with the list of these things we want to count the number of, without dates. Laura’s suggestion is that these just be ABC, VBG and CXR -- that for all other things we count, including dates is no problem.
  • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
  • Ensure we can code in ICD10 ischemia of any body part
  • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
  • Work on a new PIA
  • Rework all the comorbid coding

Next Task Group Meeting: September 26 at 10 am

ICU Database Task Group Meeting – August 28, 2018

  • Present: Allan, Con, Joanna, Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Regarding prosthetic valve endocarditis: Laura identified that the T82.6 code appears to be the only code for this entity, but is confusing because it’s called “Iatrogenic, infection, heart valve prosthesis (incl prosthetic valve endocarditis)”.

2. Item raised about if/how to code, for patients with a past history of cancer that is believed completely cured, WHICH cancer it was. After discussion it was agreed that there is no easy way to do this in ICD10, and so we will not try. Users who want to follow-up individuals with cured cancers can use this code Past history, cancer (any type), believed cured, and then perform chart review to identify which cancer it was.

3. Item raised about procedures that occur prior to admission but are causally related to the admission.

  • The current instructions say that to include a procedure (CCI coding) prior to admission in the “bin” of procedures related to admission, it must have: (a) occurred within 24 hrs of admission AND (b) be causally related to the reason for admission.
  • Laura identified that some coders seem to be including diagnostic tests (e.g. CXR) for this --- after discussion we agreed that doing so is incorrect, AND that the confusion likely is about whether a diagnostic test IDENTIFIED the problem for which the patient was then admitted vs. actually being causitive. Laura will add info to the Wiki making this distinction.

4. Item raised about whether or not to have an ICD10 code for Respiratory arrest. While there is one (R09.2), in the past it has proven difficult to clearly identify this entity, especially to know whether a patient stopped breathing before the heart stopped, or the reverse. Allan will ponder this, including seeking whether there is an agreed-upon, and operationalizable clinical definition for this entity --> While the usual definition is prolonged apnea, it seems clear that operationally the only way to distinguish this from cardiac arrest or cardiopulmonary arrest is that someone was present and directly observed that prolonged apnea occurred first. Thus, Allan recommends we keep this code, but with a definition that requires that prolonged apnea occurred either by itself, or prior to cardiac arrest -- he has put this information into the Wiki page for Respiratory arrest

5. Laura raised two issues that are about implementation, not about which ICD10 or CCI codes to used.

  • They both have to do with specific reminders that currently exist to ensure these items are completed, one way or another, and that unless going forward we implement something similar that the completeness of these data elements will likely fall.
    • For the 5 Medicine ward “tasks”, there is currently a specific Yes/No reminder box which must be completed.
    • For cardiac arrest, there is currently a specific Yes/No reminder about Targeted Temperature Management.
  • The implementation question is if/how to do this once we change over to ICD10/CCI -- after discussion we agreed that the first thing to do is for Allan to ask Nick Hajadiakos, and Bojan Paunovic, respectively, just if/how they use this information and whether special approaches to ensuring THESE items is still warranted.

5. There was a question of why, for ICD10, we need to give priority numbers to diagnoses separately within the 3 “bins”. Tina clarified that the reason is not that those sequential numbers have any instrinsic importance, but rather that since any diagnoses can be a Combined ICD10 codes, we need to separately identify the separate combos.

6. We had yet another discussion about how to capture Avoidable days, using the “transfer ready” identifier.

  • We recognized that “transfer ready” actually means “transfer ready to a lower level of care”, where there are just 3 levels: highest includes ICUs and CCUs; intermediate is IICU; lowest is any ward (teaching and nonteaching grouped together)
  • Furthermore, we reiterated that, although it is sometimes not at all clear, we are seeking the INTENT of the transfer, i.e. if the intent was to have a patient go to a lower level of care, we WILL consider those days as Avoidable days, even if when the patient is actually transferred he/she goes to the same level of care.
  • Tina is still concerned about eliminating the CTU/NTU distinction in some scenarios but not in others, would like to further discuss Eliminating distinction between different ward types.

6. Items left over from prior weeks, for Allan and/or Tina to do:

  • Allan to do list:
    • Provide Tina with the list of these things we want to count the number of, without dates. Laura’s suggestion is that these just be ABC, VBG and CXR -- that for all other things we count, including dates is no problem.
    • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
    • Ensure we can code in ICD10 ischemia of any body part
    • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
    • Work on a new PIA
    • Work on Template:ICD10 Guideline drugs and susbstances.

Next Task Group Meeting: September 11 at 10 am

ICU Database Task Group Meeting – July 25, 2018

  • Present: Allan, Con, Joanna, Julie, Laura, Tina, Trish
  • Absent:
  • Minutes prepared by: AG
  • Action items in BOLD

1. New item: Criteria for UTI due to urinary catheter. After discussion it was decided that Allan will add to this Wiki page the CDC definition -- DONE.

2. Question raised regarding whether, in light of the fact that culture positive respiratory secretions are NOT part of the CDC definition of this diagnosis, they can nonetheless be used for identifying the organism -- answer is YES and Allan has added this to the Wiki page and Tina has updated CCMDB to include it.

3. Clarification about coding colonization with resistant organisms, and resulting isolation.

  • The codes for colonization are: Colonized with organism (not infected) + the bug + (if applicable) the code for resistance
  • The code for isolation is Isolation, infectious
  • As the former of these is a diagnosis (ICD10) code and the latter is a procedure (CCI) -- therefore, these will not be made into a formal “combination code”.

4. Identification that ICD10 code Delivery by caesarean section (O82) is actually a procedure and thus seems out of place, and that there IS a CCI code for it Cesarean section delivery (therapeutic) (5.MD.60). Therefore, Tina should delete the ICD10 code for this, and we should just use the CCI code.

5. After discussion we agreed that the best and most realistic “go live” target date for switching over to ICD10 and CCI is 1/1/2018.

6. Items left over from prior weeks, for Allan and/or Tina to do:

  • Allan to do list:
    • Provide Tina with the list of these things we want to count the number of, without dates
    • Define what is/isn’t included in a given body part
  • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
    • Ensure we can code in ICD10 ischemia of any body part
    • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
    • Work on a new PIA
    • Work on Template:ICD10 Guideline drugs and susbstances.

Next Task Group Meeting: August 28 at 11 am

ICU Database Task Group Meeting – July 12, 2018

  • Present: Allan, Con, Joanna, Julie, Laura, Tina, Trish
  • Absent: none
  • Minutes prepared by: AG
  • Action items in BOLD

1. New collector issues:

2. Regarding CCI picklist item "Defibrillator, insertion (transcutaneous, epicardial leads)" (now Defibrillator, insertion) -- Allan to review what’s in parentheses -- done, fixed (should have said endocardial leads, not epicardial leads)

3. Confusion about CCI picklist code "Cardiac CT or CT angiogram" (now Cardiac CT or Cardiac CT angiogram (with or without coronary arteries)). To clarify we should change the name to “Cardiac CT or Cardiac CT angiogram w/ or w/o coronary arteries”. (done - TT)

4. Discussion about ordering of levels of care. We decided that: (a) teaching and nonteaching wards will have the same level, (b) anyone in an ICU who has been deemed able to go to IICU is “transfer ready” even if that person hasn’t been put on the IICU waiting list. - Tina will need to change in Transfer_Ready_DtTm_field#Hierarchy_of_levels_of_care and confirm that nothing related to this will break. Not done yet. see Eliminating distinction between different ward types for more info

5. Items left over from prior weeks, for Allan and/or Tina to do:

  • Allan to do list:
    • Provide Tina with the list of these things we want to count the number of
    • Define what is/isn’t included in a given body part
    • Ensure that the same subdivisions are available for all the portions of all the different limbs (e.g. skin, soft tissue, joint, bones, etc).
    • Ensure we can code in ICD10 ischemia of any body part
    • Clarify distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization
    • Work on a new PIA
    • Work on Template:ICD10 Guideline drugs and substances.

Next Task Group Meeting: July 25 at 11 am

ICU Database Task Group Meeting – June 27, 2018

  • Present: Allan, Con, Joanna, Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Continued discussion about how to code “bed borrowing” (Project Borrow arrive).

  • At the 6/20/2018 meeting we had decided to code Type 1 bed borrowing (borrow bed only) in ICUs and wards, and Type 2 bed borrowing (borrow bed and service) in ICUs only. But after considerable additional discussion including Julie, Trish and Tina, it was recognized that most of that plan is impractical. Therefore, we agreed that we will only track ‘’’Type 1 borrowing of bed only (including starting, stopping, restarting), and only in ICUs’’’.

2. There was a robust discussion about collector confusion regarding CCI. It included:

  • Revisting the question of the pros and cons of using the FULL CCI, vs. the condensed version we are now trialing. Finally it was decided to continue working with the condensed version
  • It was recognized that we have work to do in improving the Wiki documentation of the elements and specific codes in CCI. This is particularly the case for defining what is/isn’t included in a given body part. Allan will work on this
  • We need to be consistent in use of arm vs. upper limb, and leg vs. lower limb. **(Tina has changed "lower limb" pxs to "leg" and "upper limb" ones to "arm")
  • We need to go back and ensure consistency of limb portions, e.g. arm, wrist, hand, fingers -- e.g. try to ensure that the same subdivisions are available for all portions (e.g. skin, soft tissue, joint, bones, etc). Allan will work on this
  • Per the #ICU Database Task Group Meeting – June 20, 2018 discussion of whether to go back and include the 3rd CCI menu item (“how it was done”), Julie will continue perusing CCI info, after which we will (likely) present this question to the Steering Committee
  • Tina will add wiki link for CCI codes in CCMDB.mdb
  • Clarification templates (Tina made and added to individual pages, Allan will define)
  • Tina made categories for soft tissue CCI, nerve CCI, etc., made templates, added templates to the soft tissue and bone/joint pages

3. There was identification of the need to enable coding in ICD10 of Category:Ischemia of any body part. Allan will work on this

4. Left over collector issue: To clarify the distinction between

Allan to ponder this further

5. Allan to continue working on ICD10 Guideline for drugs and substances.

6. Items left over from prior weeks, for Allan and/or Tina to do:

Next Task Group Meeting: July 12 at 11 am

ICU Database Task Group Meeting – June 20, 2018

  • Present: Allan, Con, Joanna, Julie, Laura, Tina, Trish
  • Absent: none
  • Minutes prepared by: AG
  • Action items in BOLD

1. Continued discussion about items we are counting the number of certain things done: certain radiology tests, blood products, ABG, VBG and echos.

  • We clarified that for those items we currently count, switching to using CCI input where we identify the # of each thing done each day takes about 10-fold longer than the current delineation of total counts only. This then amounts to about 10-12 minutes longer for this per patient.
  • We therefore decided that we will not change the way we do these counts now, but reconsider in 6-12 months.
  • Allan will provide Tina with the list of these things we want to count

2. Continued discussion about how to code “bed borrowing”. After discussion we agreed that:

  • In ICUs we will code both types of bed borrowing:

**”Type 1” = borrowing of bed only. And for these we will track starting, stopping, restarting, etc. **”Type 2” = borrowing of bed AND the service. For these we will only code the initiation of it -- because of the difficulty of judging when (for example) an SICU patient boarding in MICU and on the MICU service transitions from being a “SICU-type” patient to being an “MICU-type” patient, and thus would no longer be bed borrowing. *On wards we will only track Type 1 borrows, and then only the initiation of it.

3. New issue relating to CCI: Laura identified that without using the 3rd “menu item” in CCI (i.e. how it was done), that different procedures appear the same. As example, both placement of a Blakemore tube and variceal banding for hemorrhage control are both coded the same, using only the first 2 menu items in CCI. After discussion, we agreed that:

  • The enormously greater difficulty of coding CCI inherent in using the 3rd menu item is not a good idea for us.
  • We will have Julie to some perusing of CCI, and then (likely) present this issue to the Steering Committee.

4. Left over collector issue: To clarify the distinction between Cardiac pressure measurements via catheter (done in cath lab) and CCI coding for a cardiac catheterization. Allan to ponder this further.

5. Allan to continue working on ICD10 Guideline for drugs and substances.

6. Allan to redefine Px Type to change admit from "related" to causative.

7. Items left over from prior weeks, for Allan and/or Tina to do:

  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.

Next Task Group Meeting: June 27, 2018 at 11:00 pm

ICU Database Task Group Meeting – June 11, 2018

  • Present: Allan, Con, Joanna, Julie, Laura, Tina, Trish
  • Absent:
  • Minutes prepared by: AG
  • Action items in BOLD

1. Converting Lab Counts to CCI - Continued discussion about items we are counting the number of certain things done: certain radiology tests, blood products, ABG, VBG and echos. Allan reported that the Database Steering Committee endorsed the idea of shifting all these counts over to CCI, in order to also acquire timing and distribution of them in addition to the total counts. In response to continued concern about the extra burden of work from shifting these counts to CCI, we decided that Trish will work with some of the data collectors to obtain a better estimate of the extra work it would entail. We will discuss this more next meeting.

2. Bed borrow - Continued discussion about how to code “bed borrowing”.

  • The current approach apparently DOES enable tracking of both: (a) borrowing of bed only and (b) borrowing of a bed and the service. However, it does so only for the St. Boniface CCU borrowing beds in ICMS or ICCS.
  • After discussion it was agreed that Trish, Julie and Tina will sort out whether that existing machinery can be generalized so that: (a) it can be used for any ICU doing either kind of bed borrowing from any other ICU, (b) allow a unit director to answer the question “How many of the bed-days in my unit were used with people from other units, and which units were those that borrowed my beds?”, and (c) allow a unit director to answer the question “How many bed-days for patients who should have been in MY ICU were spent physically in another ICU, and which units were they in?”

3. Following up on if/how/when -- for acute respiratory failure patients who stay in the hospital a long time and appear to transition to chronic respiratory failure -- to code that. This relates to 2 ICD10 codes: Chronic dependence on mechanical ventilator and Respiratory failure (insufficiency), chronic.

  • After discussion it was decided that:
    • We WILL allow someone who started with acute respiratory failure to be subsequently coded as having developed (as an acquired diagnosis) Respiratory failure (insufficiency), chronic. And that the delineation that this occurred will be a clinical decision, made by the data collectors.
    • We WILL allow someone who started with acute respiratory failure to be subsequently coded as having developed (as an acquired diagnosis), Chronic dependence on mechanical ventilator. But here, the rule will be that in order for this to occur, the patient must have been on mechanical ventilation for 90 consecutive days without extubation or spontaneous breathing.

4. Left over collector issue: To clarify the distinction between Cardiac pressure measurements done via a catheter in cath lab and CCI coding for a cardiac catheterization(Cardiac pressure measurements via catheter (done in cath lab)/Angiogram, coronary (diagnostic cardiac catheterization)). Allan to ponder this further.

5. Allan to work on Template:ICD10 Guideline drugs and substances.

6. Items left over from prior weeks, for Allan and/or Tina to do:

  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.

Next Task Group Meeting: June 20, 2018 at 11:00 pm

ICU Database Task Group Meeting – May 17, 2018

  • Present: Allan, Con, Julie, Laura, Tina
  • Absent: Trish
  • Minutes prepared by: AG
  • Action items in BOLD

1. Converting Lab Counts to CCI - Continued discussion about items we are counting the number of certain things done: certain radiology tests, blood products, ABG, VBG and echos. Allan reported that the Database Steering Committee endorsed the idea of shifting all these counts over to CCI, in order to also acquire timing and distribution of them in addition to the total counts. In response to continued concern about the extra burden of work from shifting these counts to CCI, we decided that Trish will work with some of the data collectors to obtain a better estimate of the extra work it would entail.

2. Bed borrow - There was a long, follow-up discussion about if/how to code “bed borrowing”.

  • Allan made the following suggestion of “machinery” to handle bed borrowing:
    • There are 2 sorts of bed borrowing when a TypeA patient should be in UnitA but is boarded in UnitB
      • (1) Patient is in Unit B but still under the care of TeamA -- this is coded in the database as a UnitA patient
      • (2) Patient is in Unit B and under the care of TeamB -- this is coded in the database as a UnitB patient
    • Here’s what they’re borrowing:
      • For ‘1’ the patient is just borrowing a bed
      • For ‘2’ the patient is borrowing a bed AND the service, i.e. TeamB
    • To capture all of this, we need to create 2 PAIRS of parameters -- that can be coded at a given time each and every day (e.g. noon). The pairs are a Flag + a FlaggedUnitcode
      • (a) Flag1 indicates that on the given day the patient is borrowing a bed -- the Unit code indicates WHERE that bed is.
      • (b) Flag2 indicates that on the given day the patient is borrowing a bed & service -- the Unit code indicates WHERE that patient would otherwise be located
    • Example: A=ACCU B=ICMS
      • In situation#1, set Flag1=1 and FlaggedUnitCode=ICMS
      • In situation#2, set Flag2=1 and FlaggedUnitCode=ACCU
  • Further discussion highlighted that the same information will likely be possible with identifying one of the 2 parameter pairs indicated above, but ALSO including a date/time --- so that instead of recording the bed borrowing situation each day, when either of the 2 bed borrowing scenarios occurs, we code the date/time of it BEGINNING and date/time of it ENDING. Allan will further ponder this alternative and we will discuss more at our next Task Group meeting.

3. Discussion about keeping track of amounts of blood products transfused. We made the following decisions, after Allan spoke to Ryan Zarychanski:

  • For Transfusion of PRBC, Transfusion of plasma products and Transfusion of platelets: We will quantify the quantity transfused just as is done by Canadian Blood Services -- i.e. as “units” given, where each unit given is accompanied by a unique STICKER which is placed on the Blood Products Administration Record in hospital charts. Consequences of this are that, going forward:
    • What the blood bank calls a single adult transfusion unit of platelets is what in the past has been called a “five pack”.
    • What the blood bank calls a single unit of FFP is what we will track for that product, NOT the number of liters of the product.
  • For Transfusion of albumin we will only track whether ANY albumin, of any concentration and in any volume, was given on a given day.

4. New collector issue: If/how/when -- for acute respiratory failure patients who stay in the hospital a long time and appear to transition to chronic respiratory failure -- to code that. Options include Chronic dependence on mechanical ventilator and Respiratory failure (insufficiency), chronic. Allan will ponder this further.

5. New collector issue: To clarify the distinction between Cardiac pressure measurements via catheter (done in cath lab) and CCI coding for a cardiac catheterization. Allan will ponder this further.

6. Items left over from prior weeks, for Allan and/or Tina to do:

  • To the current list of procedures performed in the unit that will be coded only the first time they’re done, we will add: chest tube, ECMO, Continuous hemodialysis, cardioversion, IABP, temporary pacemaker placement
  • Working on a new PIA
  • Check the editing done on Pneumonia, ventilator-associated (VAP).


Next Task Group Meeting: June 11, 2018 at 11:00 am

ICU Database Task Group Meeting – May 9, 2018

  • Present: Allan, Con, Julie, Laura, Tina, Trish
  • Absent: none
  • Minutes prepared by: AG
  • Action items in BOLD

1. Converting Lab Counts to CCI - Continued discussion about items we are counting the number of certain things done: certain radiology tests, blood products, ABG, VBG and echos. Allan reported that the Database Steering Committee endorsed the idea of shifting all these counts over to CCI, in order to also acquire timing and distribution of them in addition to the total counts. In response to continued concern about the extra burden of work from shifting these counts to CCI, we decided that Trish will work with some of the data collectors to obtain a better estimate of the extra work it would entail.

2. Bed borrow - There was a long discussion about if/how to code “bed borrowing”.

  • This takes two separate forms: (i) patient of type A who “should” be in unitA, but there’s no capacity there, so pt is put in UnitB but continues under the care of TeamA, (ii) patient of type A who “should” be in unitA, but there’s no capacity there, so pt is put in UnitB and is under the care of TeamB. A starting point for this is that in both cases, the patient is unit the patient is assigned to in the database is according to the Medical Team taking care of them, not their physical location.
  • Although this has arisen mainly as regards A=cardiology, this can happen more generally, and we would like (if possible), a generic solution.
    • This has been discussed a lot in the past, but abandoned because of the complexity involved with switches of service and switches of physical location.
  • Allan will work on this problem and report back to the group.

3. CCI_Collection#Procedures_only_coded_once_pre_ward_stay - In response to issues raised by Laura about therapeutic procedure coding, we decided that to the current list of procedures performed in the unit that will be coded only the first time they’re done, we will add: chest tube, ECMO, Continuous hemodialysis, cardioversion, IABP, temporary pacemaker placement' (see CCI_Collection#Procedures_only_coded_once_pre_ward_stay)

4. Items left over from prior weeks, for Allan to do:

  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.
  • Add TPN to CCI picklist

5. We further discussed the Medical/Surgical/Cardiac coding of reason for admission. We agreed that the exact purpose of use of this delineation would dictate the algorithm used for assigning it. Since we are unsure if/how this is being used, before going further we will discuss at the Steering Committee.

Next Task Group Meeting: May 17, 2018 at 10:00 pm

ICU Database Task Group Meeting – April 25, 2018

  • Present: Allan, Con, , Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Multifactorial discussion about Julie’s reporting of top diagnoses.

  • After discussion we agreed that when the #1 priority Admit Diagnosis is a combined code (i.e. 2 or more linked codes), we will have the data collectors check the box Dx Primary of the combined codes is Primary Admit Diagnosis.
  • For reporting to Medicine, Julie will choose that code to report. For reporting to ICU, she will do as she always does, including ALL admit diagnoses in the algorithm to identify the APACHE II diagnosis category that is “worst”, i.e. associated with the highest hospital mortality.

2. Translation of Dx Data from CCMDB schema to ICD10/CCI - Allan reported that when queried about whether to “map” the old coding schema to the new one, Paunovic, Hajidiacos, Zarychanski, and Walker-Tweed all agreed that rather than mapping (which will require users using data that spans the transition to be familiar with the limits of the mapping), we will code pre-change data using the old schema and post-change data using the new schema.

3. Converting Lab Counts to CCI - Discussion about items we are counting the number of. These are presently: certain radiology tests, blood products, ABG, VBG and echos. The question is whether or not to change all of these simple counts to CCI coding. The issue is to continue “pure counting” where we just record the number over the entire admission vs. using CCI to code the timing of them all.

  • A preliminary report was that Laura (absent today) did a comparison of “pure counting” vs. using CCI to code ABGs -- and that the latter took MUCH more time. However, details weren’t clear and before we make a decision we need to obtain them from Laura. Thus, we’ll discuss more next time.

4. Outreach efforts - After discussion we agreed that Allan will offer at the next Dept of Medicine Executive Committee that he and Julie will offer to provide a 15 minute summary to each section in Internal Medicine, at their section meetings, of the 2 databases.

5. Discussion of Outcomes Improvement Team Symposium poster. We agreed that the best use of this outreach would be to include a few examples of the data available, and specifically how it can be used for QI.

6. Further discussion of the pathogen list. We decided that:

  • Tina has added a new bug code representing "Mixed pathogens, speciation not done or reported"
  • Added a note to Infectious organism, unknown and to "Mixed pathogens, speciation not done or reported" explaining that “mixed normal flora” should be coded as Infectious organism, unknown, i.e. the same as negative cultures.

7. Items left over from prior weeks, for Allan to do:

  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.
  • Add TPN to CCI picklist

8. Registry Patient Type - We further discussed the Medical/Surgical/Cardiac coding of reason for admission. We agreed that the exact purpose of use of this delineation would dictate the algorithm used for assigning it. Since we are unsure if/how this is being used, before going further we will discuss at the Steering Committee.

Next Task Group Meeting: May 9, 2018 at 1:00 pm

ICU Database Task Group Meeting – April 4, 2018

  • Present: Allan, Con, , Julie, Laura, Tina, Trish
  • Minutes prepared by: AG
  • Action items in BOLD

1. Regarding Chapter 1 of CCI. After discussion, we agreed that while we still do NOT want to extend our CCI coding to the 3rd level (i.e. how the thing was done), we do have a need to dig deeper into the 2nd level category of “Pharmacotherapy”. Specifically, we at least want to have a subcategory of “Pharmacotherapy, thrombolytic agent”. And furthermore, there are >50 other existing subcategories of Pharmacotherapy that we may want to use in the future. Thus, for now we agreed we’ll change the name of Pharmacotherapy to “Pharmacotherapy NOS” and add to the 2nd level Pharmacotherapy, thrombolytic agent. ( Has been added. Ttenbergen 12:48, 2018 April 11 (CDT))

2. Regarding the ICD10 item U22.9 Infectious organism, unknown we recognized that it includes two situations, that previously were coded separately: (a) cultures sent but were negative, and (b) no cultures sent. Allan will modify the wiki page to reflect this explicitly.

3. Regarding picklists for ICD10. We agreed that we will NOT have such picklists. But given the particular issues with Hemorrhage or Bleeding in ICD10 When There is No Specific Code such as retroperitoneal hemorrhage, Allan will make a wiki page that discusses how to use combined codes to make these entities.

4. Agreed that we DO want the CCI Picklist. Next time we’ll discuss it.

5. Discussion about how to organize ICD10 codes for Julie’s regular reports (Reporting from ICD10/CCI). The issue is that she reports the distribution of the main admission diagnosis, but that going forward some entities cannot be captured with a single ICD10 code. For example, retroperitoneal hemorrhage is coded as a combination of Hemorrhage, NOS and Retroperitoneal area, diagnostic imaging, abnormal. This leads to uncertainty about which of a combination entity to report.

  • We recognized 4 main options:
    • (i) Allow the data collectors to make a judgement about which of the combined ICD10 codes is “worst” and use that as the main diagnosis, or (ii) allow
    • (ii) Allow multiple ICD10 codes to “jointly” be identified as the “main diagnosis” -- so that the denominator for reporting will no longer be patients, but will be the number of main diagnoses. Furthermore, the delineation of combined ICD10 codes mutually coded as the main diagnosis will not “remain together” in the reporting.
    • (iii) Allow multiple ICD10 codes to “jointly” be identified as the “main diagnosis” -- but here report them as the combination. The problem here is that there will be so many combinations that the reporting may become untenable.
    • (iv) Report main diagnoses by ICD10 blocks not individual ICD10 diagnoses. This solution still will need to deal, however, with combination diagnosis reporting.
  • It was agreed that the users of these routine reports must help us understand what they need/want. To this end, Allan will discuss this with Bojan (and possibly the group of ICU medical directors), and we’ll bring it to the Database Steering Committee.

6. Discussion about items we are counting the number of (see Converting Lab Counts to CCI). These are presently: certain radiology tests, blood products, ABG, VBG and echos. The question is whether or not to change all of these simple counts to CCI coding.

  • It will be more work, but by including dates it will dramatically improve the ability of the database to be used for assessing the course of care.
  • We decided that Allan will discuss this with Bojan, and we’ll bring it to the Database Steering Committee.

7. Allan has mapped the Nephro as “reasons for CRRT” to their ICD10 equivalents. He sent it out and next time we’ll discuss it, including how and where (HSC only or also St. B) to implement it.

8. Items left over from prior weeks, for Allan to do:

  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.
  • Add TPN to CCI picklist

9. We further discussed the Medical/Surgical/Cardiac Registry Patient Type coding of reason for admission. We agreed that the exact purpose of use of this delineation would dictate the algorithm used for assigning it. Since we are unsure if/how this is being used, before going further we will discuss this with the Steering Committee.

Next Task Group Meeting: April 11, 2018 at 2:00 pm

ICU Database Task Group Meeting – March 14, 2018

  • Present: Allan, Con, , Julie, Laura, Tina, Trish
  • Minutes prepared by: AG
  • Action items in BOLD

1. Discussion of wording for GI bleeding. After discussion we agreed:

  • We will alter K92.1 to be simply the symptom of “Melena or Hematochezia”, without any mention of site of bleeding. Likewise we’ll alter K92.0 to be simply the symptom of “Hematemeis” without mention of the site of bleeding. Allan has altered the Wiki pages, but Tina will make the necessary name changes.
  • Along with this, the instructions for coding GI bleeding will be:
    • If the site/cause is known, code that. It is OK, but not required in that case to code the symptom (Hematemsis vs. Melena or Hematochezia).
    • If the site/cause is unknown, then use code K92.2 (Gastrointestinal hemorrhage (GI bleed), not specified if lower or upper), and again it’s OK but not required to code the symptom.

2. Regarding query about Status asthmaticus. In the Canadian version, this is J45.91, not J46, which doesn’t actually exist in the Canadian version.

3. Followup from last meeting’s discussion of organisms (buglist).

  • New invented codes for bugs we want to code but don’t exist in ICD-10
    • U22.11 Stenotrophomonas species
    • U22.12 Citrobacter species
    • U22.13 Enterobacter species
    • U22.14 Acinetobacter species
  • New code invented for when the bug causing infection is unknown
      • U22.9 Infectious organism, unknown
  • We agreed to change the name of the bug code Klebsiella pneumoniae to Klebsiella species, to include all types of that genus (tho about 90% are pneumoniae)

4. There are a number of ICD10/CCI items for which Tina and Allan will meet separately from the Task Group to go over. Tina will arrange a time.

5. Allan has created a picklist of the ICD10 versions of the 100 or so most common ICU diagnoses. He will send it out and we’ll talk next time about which to include, and how to do so.

6. Allan has mapped the Nephro as “reasons for CRRT” to their ICD10 equivalents. He will send it out and we’ll talk next time about how and where (HSC only or also St. B) to implement it.

7. Items left over from prior weeks, for Allan to do:

  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.

8. Julie identified that there has been a request to track use of TPN, not only in ICUs (where it’s part of TISS), but also on wards. We identified that we can easily add this as a therapeutic procedure (CCI) as its CCI code is 1.LZ.35.HH-C6

9. At Julie’s request, we agreed to have separate “location” listings for the Invasive Radiology at HSC vs. St. B

10. We further discussed the Medical/Surgical/Cardiac coding of reason for admission. We agreed that the exact purpose of use of this delineation would dictate the algorithm used for assigning it. Since we are unsure if/how this is being used, before going further we will discuss it at the next Steering Committee meeting.

  • Next Task Group Meeting: April 4, 2018 at 11:00 am

ICU Database Task Group Meeting – March 6, 2018

  • Present: Allan, Con, Laura, Tina, Trish
  • Absent: Julie
  • Minutes prepared by: AG
  • Action items in BOLD

1. Issues related to organisms (buglist).

  • First, to deal with the fact that various users need/want to be able to code some bacteria that don’t have specific ICD10 codes, we agreed to add the ones requested (Stenotrophomonas, Citrobacter, Enterobacter, Acinetobacter) but that we will need to “invent” some new ICD10 codes. To distinguish these, we’ll use the single unused chapter letter code prefix (U) for any/all ICD10 codes we need to invent. Allan will create codes for these 4 bugs.
  • There was a discussion about how to differentially handle the situation where: (a) bug is known but it’s not on our list of specific bugs, vs. (b) the bug is unknown.
    • It was decided that when bugs are known but not specified on our bug list, we’ll use one or another of the existing wastebasket codes in ICD10:
      • Bacteria, NOS
      • Virus, NOS
      • Fungus or yeast, NOS
      • Infectious disease NOS OR for buglist organism NOS
    • But when the bug causing infection is unknown, we’ll “invent” a new ICD10 code for that situation, which will be called “Infectious organism, unknown”

2. Continued discussion about CKD coding.

  • After discussion with some data collectors, it turns out that obtaining heights and weights on everybody is not feasible. Thus calculating Creatinine clearance will not be feasible either.
  • For some, but not all, CKD patients, the Nephrology consultant writes the Creatinine clearance in the chart -- these will be the only ones we will have available.
  • We decided that we’ll code CKD as follows:
    • When there is a Creatinine clearance listed, it will be used to specify between Stages 1, 2, 3, 4, or 5.
    • When no Creatinine clearance is listed, but the patient is a known dialysis patient, we will identify him/her as CKD, Stage 5
    • For all other CKD patients, i.e. those in whom we cannot easily identify the Stage, we’ll use the wastebasket code Chronic kidney/renal disease, NOS (stage unspecified).

3. Regarding Sepsis coding, specifically whether to use the new Sepsis-3 definitions, and if so, when to start.

  • Laura has done some Sepsis-3 coding and reports it is doable.
  • After discussion, it was agreed that we WILL aim to move to Sepsis-3 identification of Sepsis and Septic shock, but that we will only implement this about 6 months after we introduce ICD10/CCI.

4. There are a number of ICD10/CCI items for which Tina and Allan will meet separately from the Task Group to go over. Tina will arrange a time.

5. Items left over from prior weeks, for Allan to do:

  • Make a picklist of the most common 20-50 ICD10 codes, for convenience
  • Identify the ICD10 code(s) that correspond to the diagnoses used by Nephro as “reasons for CRRT” for this purpose -- DONE, but still need to work out how to ensure that:
    • Whatever they code should find it’s way into our general list of diagnoses.
    • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses.
  • Working on a new PIA
  • Check the editing done on the VAP Wiki page.

Next Task Group Meeting: March 14, 2018 at 11:00 am


ICU Database Task Group Meeting – February 12, 2018

  • Present: Allan, Con, Julie, Laura, Tina, Trish
  • Absent: None
  • Minutes prepared by: AG
  • Action items in BOLD

1. Collector issue: How to code HAP, VAP and CAP in ICD10. Answers from Allan:

2. Collector issue: Metabolic derangements in ICD10.

  • We agreed that we will transfer the same thresholds used before for ICD10, but as these criteria are very strict (e.g. it’s currently not hyperkalemia unless K>6.5), we’ll add to the criteria by saying that a “hyper” or “hypo” type of metabolic derangement (specifically for Na, K, Ca, Mg, PO4, Glucose) will be defined going forward as EITHER: (a) value outside the bounds given OR, (b) was treated. Laura will make these changes to the various Wiki articles.

3. Collector issues: 3 related issues about organisms.

  • First is bugs not currently included in the “buglist” in ICD10.
    • There might be some relevant bugs not specifically code in ICD10. For example, Stenotrophomonas multophilia. We can add non-standard codes for these if we need to. To figure out what additional specific bugs we should add, we agreed:
      • Julie will send Allan a list of bug frequencies over the past 3 years, both overall and specific to VAP. These will inform specific bugs we should consider adding.
      • Allan will contact Rob Ariano regarding the VAP buglist he needs for pharmacy purposes in VAP -- done, and the bugs he'd like us to add are: Stenotrophomonas, Klebsiella, Serratia, Citrobacter, Enterobacter, Acinetobacter.
  • Second is whether to differentiate between “no cultures done” and “no positive cultures”
    • From an operational, database viewpoint, these are not different -- i.e. in both cases we have “bug not known”. As Julie told us that nobody has ever asked for a distinction between these two, we agreed that we will group these together.
  • Third is whether and how to differentiate between “bug not known” and “bug known but not in our list of specific bugs”.
    • This latter is necessary because we’ll never have specific codes for all of the thousands of known pathogens.
    • But each of the subcategories of bugs (bacteria, fungi, viruses, mycobacteria) has a “wastebasket” of NOS. THUS, when we have a bacteria, fungi, viruses, or mycobacteria that’s been identified but isn’t on our buglist, we use the appropriate NOS code (e.g. Bacteria, NOS). But when we have “bug not known” we’ll instead use Infectious disease NOS

4. Collector issue: regarding calculation of Creatinine clearance for grading CKD:

  • This requires a calculation involving: serum creatinine, age, Height and weight and sex.
    • Creatinine clearance = 1.257 * Cr^(-1.154) * Age^(-0.203) *(Weight in kg)^0.425 * (Height in cm)^0.725 * sex factor (1 for males, 0.742 for females)
  • This discussion of need for weight and height led to a more general discussion of whether we should start collecting those. Issues included:
    • They’re also needed to calculate BMI
    • They’re much less generally available on wards than ICU
  • We decided that for now we will not start collecting W and H routinely for all patients, but that Tina will create a calculator where the collector inputs serum creatinine, age, weight, height and sex, and it calculates Creatinine clearance for use in assessing the Stage of CKD (note that the creatinine that goes into that calculation should be the patients most recent chronic value).
    • polling of collectors if this information is available from chart, where in chart, if consistently available or not. See: Height and weight

6. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

7. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

8. Regarding Sepsis coding, specifically whether to use the new Sepsis-3 definitions, and if so, when to start.

  • For what was previously called Severe sepsis, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. Laura will look at the SOFA scoring grid and we’ll discuss this more next time. We’ll also contemplate making the change, but delaying it.

9. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses.

  • Allan will check the editing done on this Wiki page.

Next Task Group Meeting: March 5, 2018 at 10:00 am

ICU Database Task Group Meeting – February 1, 2018

  • Present: Allan, Con, Julie, Laura, Tina, Trish
  • Absent: None
  • Minutes prepared by: AG
  • Action items in BOLD

1. Most of this meeting was consumed discussing implementation of CCI coding for procedures. There was agreement with Allan’s proposal to simplify coding of Therapeutic Procedures by most omitting the field for “how an intervention was done”.

  • Everyone should take a look at the article on Procedure coding in ICD10/CCI’’’ (see CCI Collection instead).

2. Followup on influenza coding

  • Allan reported that Bojan indicated that the needs of the ICU Program can accept the planned alteration of our database definition of Influenza, as long as we also (as planned) also keep track separately of lab testing results and treatment.

3. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Tina will send Allan the Wiki link to this list, and Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

4. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

5. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. Laura will look at the SOFA scoring grid and we’ll discuss this more next time.

6. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses. *Laura clarified that even more than CLI, VAP requires much checking back and forth at data over time. It was decided that we would like to create wiki-based tools that will make it easier for collectors to do these tasks. The tools would incorporate the diagnosis guidelines into some sort of checklist “machinery”. Trish will assign Laura and a few other coders to work on this.

Next Task Group Meeting: February 12, 2018 at 11:30 am


ICU Database Task Group Meeting – January 17, 2018

  • Present: Allan, Con, Julie, Tina, Trish
  • Absent: Laura
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup on influenza coding

  • There is still considerable uncertainty about what we are doing and what we should be doing. The uncertainty relates to: (a) the fact that there can be three different lab tests done, one of which comes back quickly and on EMR, but the other two are done by Cadham and come back slowly and we do not have electronic access to them, (b) the needs of the WRHA appear to be different than our needs, (c) the fact that, apparently, clinicians sometimes misinterpret the meaning of the lab tests and incorrectly assume that a negative test is incontrovertable proof that influenza is not present.
  • It was agreed that we need to clarify this. Towards that end Allan will talk to Bojan about the needs of the ICU program in this regards; he will talk to the head of Cadham to see if we can develop a direct, electronic conduit to their influenza results.

2. Followup on CCI coding

  • It was agreed that for now we will suspend all activity by the data collectors in trying to do CCI coding.
  • For CCI chapters on: (i) Diagnostic radiology procedures, (ii) Non-radiology diagnostic procedures, (iii) Obstetrical procedures, and (iv) Miscellaneous Immunotherapy procedures -- simplification has been done. Everyone should take a look at the article on Procedure coding in ICD10/CCI’’’ (see CCI Collection instead).
  • Allan is going to work to simplify the CCI chapter on Therapeutic Procedures.

3. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Tina will send Allan the Wiki link to this list, and Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

4. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

5. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this more next time.

6. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses.

  • Laura clarified that even more than CLI, VAP requires much checking back and forth at data over time. It was decided that we would like to create wiki-based tools that will make it easier for collectors to do these tasks. The tools would incorporate the diagnosis guidelines into some sort of checklist “machinery”. Trish will assign Laura and a few other coders to work on this.

Next Task Group Meeting: February 1, 2018 at 11:00 am


Database Task Group Meeting December 20, 2017

  • Present: Allan, Con, Julie, Tina
  • Absent: Laura, Trish
  • Minutes prepared by: AG
  • Action items in BOLD

1. Follow-up on seeking eChart access for coder. Allan reported that after talking to a high-level administrator at Manitoba Health, that indeed we are not going to be allowed to get eChart access.

2. Regarding influenza coding. After a discussion we agreed on the following aspects of coding:

  • Unrelated to ICD-10, we will continue to record whether:
    • A lab test for influenza was done and whether it was positive or negative. If more than one test was done (at different times, or by different labs), it is considered positive during flu season IF ANY of them are reported as positive. Off of flu season it’s considered as positive only if the FINAL CADHAM result was positive (e.g. off of flu season flu tests done by the separate hospital labs are ignored).
    • Whether a “full course” of treatment was given for influenza. The usual course of oseltamivir (Tamiflu) is 5 days. But WHO and CDC recommend that in severe cases the drug should be continued until the infection is resolved or there is satisfactory clinical improvement.
  • Based on this, ICD-10 coding for influenza will be done as follows:
    • Use this website https://www.gov.mb.ca/health/publichealth/surveillance/influenza/index.html to iIdentify whether we’re in flu season or not.
    • During established flu season a person will be considered to have influenza if either of the following is true: (i) any lab test done for influenza was positive, or (ii) the patient was believed the the medical team to have influenza and given a full course of treatment (which could possibly have concluded after leaving the hospital).
    • Off flu season (before there is any reported flu in the province, and after the flu season has been declared to be over) a person can ONLY be diagnosed as having influenza if the FINAL CADHAM test result is positive. In the absence of such a final Cadham result, clinical suspicion, treatment for flu, and positive rapid tests will be considered as NOT INFLUENZA.
  • Allan put all this info into the wiki article called “Influenza in ICD10” -- done.

3. Further discussion of the ICD10 diagnosis of Palliative care.

  • We agreed to operationalize using the ICD10 code of Palliative care as any of the following 4 items:
    • 1. ACP-C status
    • 2. Had been on palliative care ‘’prior’’ to this hospital admission (i.e. at home or in the care facility)
    • 3. Is receiving active palliation. What is meant by this is (again) related to the intent of care --- so receiving aggressive symptom control measures (e.g. a morphine drip) does not consitute active palliation UNLESS the intent of the overall care at this point is control of symptoms and not cure or even prolongation of life.
    • 4. The Palliative Care Service (physician group) is seeing the patient in an ongoing fashion. This means that they have seen the patient at least twice during this admission, or that they wrote that they intended to follow but the patient died or left hospital before they could be seen a second time. Thus, if that consult team saw the patient in an initial consult but didn’t or didn’t plan to follow them longitudinally, then this item doesn’t apply.
  • Allan will modify the wiki article Palliative care to reflect this -- done.

4. Regarding discharge planning, paneling, etc.

  • We agreed on use of the following 4 Category: Awaiting/delayed transfer codes:
    • Z75.0 Awaiting/delayed transfer to home
    • Z75.1 "Awaiting/delayed transfer to other acute care facility"
    • Z75.4 "Awaiting/delayed transfer to long-term care/PCH"
    • Z75.8 "Awaiting/delayed transfer to transitional care facility"
  • We recognized that to the extent that these ICD10 codes will be identifiable by date (either by being in the bin of diagnoses related to admission, or if occuring after admission they will have an associated date) that this coding would allow us to eliminate coding the “Discharge ready” field.
  • Allan has put these into the Wiki under their respective ICD10 codes

5. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

6. Switching over to ICD-10

  • Allan is continuing work on making a set of “quick codes” for both ICD-10 and CCI, that can be chosen as unique entities, to represent procedures that are common, or difficult to otherwise figure out how to code.
  • Regarding the list of acquired complications that previously were singled out to ensure that they were coded: Trish spoke with collectors who indicated that this list is of “high profile” entities that they don’t really think they need reminding about. So, we will bring this information back to the Steering Committee, with a recommendation that there is no need to continue using this list.

7. Regarding CCI.

  • Allan presented a greatly simplified version of CCI chapter 3 (Diagnostic imaging procedures). See new wiki article Procedure coding in ICD10/CCI’’’ (see CCI Collection instead) for evolving details.
  • We recognized that for all procedures an option (to be discussed more later) is to allow a “number done” to be associated with each procedure coded for each date. Thus, for example, if 4 CXRs were done on a given day, one would only need to enter it once, but with that count saved with the item (with default being 1). We will discuss this more later, after we’ve worked through all the chapters of CCI.
  • We began what will be a series of conversations about WHICH procedures we want to code, and creating guidelines/rules around them. We identified the benefits of simple rules, and the dynamic that goes along with simplicity is that sometimes we will collect procedures that we’re not that interested in. We also agreed that the same rules should apply to ICU and wards. Today we discussed Therapeutic Procedures. In coming meetings we will discuss Diagnostic Procedures. And after all this is done, we must decide whether, in addition to the picklists, to ALSO allow for menu-based coding of other procedures.
  • We agreed that a good goal would be to be able to include all the current items on the Tasks in CCI, and so be able to dispense with the Tasks (HD, PD, trach, isolation, NIV).
  • We still need to clarify isolation. Currently we are recording 3 different levels of isolation, and none of these relate to use of a negative pressure room. Allan will talk to Bojan and Nick to clarify the needs here.

8. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

9. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this later.

10. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses. *Laura clarified that even more than CLI, VAP requires much checking back and forth at data over time. It was decided that we would like to create wiki-based tools that will make it easier for collectors to do these tasks. The tools would incorporate the diagnosis guidelines into some sort of checklist “machinery”. Trish will assign Laura and a few other coders to work on this.

Next Task Group Meeting: January 4, 2018 at 10:00 am

Database Task Group Meeting December 20, 2017

  • Present: Allan, Con, Julie, Laura, Tina, Trish
  • Absent: none Minutes prepared by: AG Action items in BOLD

1. Follow-up on seeking eChart access for coders

  • Allan and Jodi Walker-Tweed have sent a letter to Christina Van Schindler, the WRHA Chief Privacy Officer, asking for permission. Awaiting a reply.

2. Regarding influenza coding.

  • We had previously discussed two possible categories of influenza: (1) lab-confirmed and (2) suspected. But in further review of IDSA and CDC recommendations, it’s fairly complicated. The value of the tests in helping us figure out whether a person has influenza depends on: (a) how long after onset of symptoms the test was done, (b) whether the sample was upper or lower respiratory, and (c) whether the test is done in the midst of flu season, at the start of flu season, at the end of flu season, or not at all during flu season. Given all of the variation in lab interpretation, the idea of lab-confirmed vs. suspected is not being used.
  • Here is a workable approach:
    • During established flu season (defined as there has been laboratory-confirmed flu in the community), the diagnosis of influenza is mainly clinical. So, lab confirmation of any type is NOT needed to make the diagnosis. If the team says they think it’s flu, and they’re treating with a full course of tamiflu, then take that as true influenza, regardless of the results of any influenza tests, done in hospital labs or Cadham.
    • Completely off flu season (warm months, before there is any reported flu in the province, and after the flu season has been declared to be over) a person can ONLY be diagnosed as having influenza if the FINAL CADHAM test result is positive. In the absence of such a final Cadham result, clinical suspicion, treatment for flu, and positive rapid tests will be considered as NOT INFLUENZA.
    • The hard part is right at the start and end of typical flu season. In this case, use the following algorithm:
      • One or more lab tests were done (including rapid tests in hospital labs, and Cadham tests) and ‘’’any’’’ of them were positive -- then consider influenza to be present.
    • No lab tests were done, but the team says they think it’s flu, and they’re treating with a full course of tamiflu, then take that as influenza being present.
  • Allan put all this info into the wiki article called “Influenza in ICD10” -- done. Everyone is invited to take a look at this.

3. Further discussion of the ICD10 diagnosis of Palliative care.

  • This is different from the Palliative Care Service -- that refers to a group of physicians. Palliative care refers to whether the clinical plan for the patient is to provide comfort towards the end of life, not to prolong life.
  • Per Julie, the way this is being used is for reporting death rates -- specifically to remove people getting Palliative care from the denominator and numerator of death rates.
  • Accordingly, to figure out if a person should have the ICD10 diagnosis of Palliative care, we must figure out the INTENT of care. If the intent is aimed at cure and prolonging life, then the person is not in Palliative care. If the intent is primarily control of symptoms (whether the person currently has symptoms or not) and not cure or even prolongation of life, then the person is in Palliative care.
  • We will operationalize Palliative care as any of the following 4 items:
    • 1. ACP-C status
    • 2. Had been on palliative care ‘’prior’’ to this hospital admission (i.e. at home or in the care facility)
    • 3. Is receiving active palliation. What is meant by this is (again) related to the intent of care --- so receiving aggressive symptom control measures (e.g. a morphine drip) does not consitute active palliation UNLESS the intent of the overall care at this point is control of symptoms and not cure or even prolongation of life.
    • 4. The Palliative Care Service (physician group) is seeing the patient in an ongoing fashion, which means has seen them at least twice during this admission. So, if that consult team saw the patient in an initial consult but isn’t following them longitudinally, then this item doesn’t apply.
  • Allan will modify the wiki article Palliative care to reflect this -- done. Everyone is invited to take a look at this.

4. Regarding discharge planning, paneling, etc.

  • Discussion identified that there are reasons to separately classify time in hospital spent waiting to go to: long-term care facilities, home. Furthermore, with the advent of Riverridge 2, and the transition that is currently taking place in the WRHA to convert the Vic, Conc and Oaks to transition hospitals, there may be a near-future need by the Internal Medicine Program to know about time spent waiting to transfer to those. This all comes up because as of now, we have only a single ICD10 code to cover all of this. In the current database we track these via Temp, but the goal in general is (where possible) to incorporate Temp information into ICD10 and CCI codes.
  • Allan will see how we might do this in ICD10 -- here is a solution created by adapting a set of existing ICD10 codes:
      • Z75.0 Awaiting/delayed transfer to home
      • Z75.1 "Awaiting/delayed transfer to other acute care facility"
      • Z75.4 "Awaiting/delayed transfer to long-term care/PCH"
      • Z75.8 "Awaiting/delayed transfer to transitional care facility"

Allan has put these into the Wiki. Everyone is invited to take a look.

5. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Tina will send Allan the Wiki link to this list, and Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.
    • Link was provided and Allan replied in email 2017-11-18; contents integrated into CRRT#ICD10. Further discussion required since some did not have unambiguous equivalencies.

6. Switching over to ICD-10

  • Allan is continuing work on making a set of “quick codes” for both ICD-10 and CCI, that can be chosen as unique entities, to represent procedures that are common, or difficult to otherwise figure out how to code.
  • Regarding the list of acquired complications that previously were singled out to ensure that they were coded: Trish spoke with collectors who indicated that this list is of “high profile” entities that they don’t really think they need reminding about. So, we will bring this information back to the Steering Committee, with a recommendation that there is no need to continue using this list.

7. Regarding CCI.

  • It was agreed that for simplicity & consistency of coding, that for the most common and tricky codes we need a picklist. Allan will work on that.
  • We began what will be a series of conversations about WHICH procedures we want to code, and creating guidelines/rules around them. We identified the benefits of simple rules, and the dynamic that goes along with simplicity is that sometimes we will collect procedures that we’re not that interested in. We also agreed that the same rules should apply to ICU and wards. Today we discussed Therapeutic Procedures. In coming meetings we will discuss Diagnostic Procedures. And after all this is done, we must decide whether, in addition to the picklists, to ALSO allow for menu-based coding of other procedures.
  • We agreed that a good goal would be to be able to include all the current items on the Tasks in CCI, and so be able to dispense with the Tasks (HD, PD, trach, isolation, NIV).
  • After discussion about rules around which Therapeutic Procedures (chapter 1 of CCI) to collect, we came up with:
    • Include all therapeutic procedures done outside the patient’s unit
    • Include all therapeutic procedures done using an endoscope (whether inserted through an orifice, incision or wound)
    • Code the following therapeutic procedures done in the patient’s unit -- but only the FIRST time it was done during the patient’s stay on that unit:
      • arterial catheter placement
      • PEG
      • hemodialysis
      • peritoneal dialysis
      • plasmapheresis
      • non-invasive mechanical ventilation -- includes CPAP, BiPAP, and classic NIV (where a mask is connected to a regular ventilator)
      • debridement
      • tracheostomy placement (i.e. done bedside)
  • We still need to clarify isolation. Currently we are recording 3 different levels of isolation, and none of these relate to use of a negative pressure room. Allan will talk to Bojan to clarify the needs here.

8. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

9. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this more next time. -- Tabled today since Laura is not at this meeting.

10. Starting with CLI criteria, there was extensive discussion about the difficulties in adhering to criteria-based diagnoses. *Laura clarified that even more than CLI, VAP requires much checking back and forth at data over time. It was decided that we would like to create wiki-based tools that will make it easier for collectors to do these tasks. The tools would incorporate the diagnosis guidelines into some sort of checklist “machinery”. Trish will assign Laura and a few other coders to work on this.

Next Task Group Meeting: January 4, 2018 at 10:00 am

Database Task Group Meeting December 8, 2017

  • Present: Allan Garland, Con Marks, Julie Mojica, Laura Kolesar, Tina Tenbergen
  • Absent: none Minutes prepared by: AG Action items in BOLD

1. Regarding the influenza coding:

  • We discussed the possibility of going forward with 2 categories of influenza: (1) lab-confirmed and (2) suspected.
    • For lab-confirmed: we will use only the FINAL CADHAM result for this. Thus, we will have to wait for it to be finalized before we can finalize influenza coding. Specifically, we will NOT use the hospital lab rapid influenza test results, or the preliminary Cadham result. Cadham results are on eChart, but not on the regular EMR lab computer. Allan will communicate with the WRHA privacy office to try and get all the collectors eChart access.
    • For suspected: here the clinical team wrote believed that it was influenza, gave a “full course” of anti-influenza drug PLUS either: (a) no swab was sent at all, or (b) swab was sent and FINAL CADHAM result negative. Before we finalize this concept, Allan will talk to infection control.
      • Regarding a “full course of tamiflu”: The usual course of oseltamivir is 5 days. But WHO and CDC recommend that in severe cases the drug should be continued until the infection is resolved or there is satisfactory clinical improvement.
  • We will talk about this more later, and finish the wiki article called “Influenza in ICD10”.

2. Agreed that our new goal for implementing ICD10 and CCI is April 1, 2018.

3. Agreed that high-flow oxygen will NOT be considered to be CPAP or any form of non-invasive ventilation.


ITEMS FROM PRIOR MEETING THAT WE DIDN’T GET TO YET


4. Regarding Palliative care/palliative service. There is an ICD10 code for Palliative care. Allan will update the Wiki on this code, to clarify that by this code we mean a person is getting active palliative care, which may or may not concide with being ACP-C, or having a consult from the Palliative care service.

5. Regarding the list of “reasons for CRRT” that is completed by the Nephro team.

  • After discussion, we agreed that whatever they code should find it’s way into our general list of diagnoses.
  • Towards this end, we agreed that that/those code(s) should be duplicated: (a) in the Temp file for the special purpose of identifying why they were on CRRT, and (b) in our general list of diagnoses. To operationalize this, Allan will identify the ICD10 code(s) that correspond to those diagnoses used by Nephro for this purpose.

6. Regarding Sepsis coding. Allan reported that our coding will follow the new Sepsis-3 definitions.

  • This greatly simplifies identification of Septic shock, eliminates SIRS from all sepsis-related definitions, and eliminates what was previously called “sepsis” i.e. SIRS without acute organ failure.
  • For what was previously called “severe sepsis”, the new guidelines merely call “sepsis”, which is identified as acute organ failure caused by proven or presumed infection. The official guidelines operationalize new organ failure as an increase in SOFA score by 2 or more points. Since SOFA scoring is nontrivial, there was concern about whether it is practical for the data collectors to try and do this. It was decided that Laura and some other ICU coders will look at the SOFA scoring grid and we’ll discuss this more next time.

7. Switching over to ICD-10

  • A number of coders, Tina and Allan are working on Wiki articles for the new ICD10 coding schema.
  • Allan is continuing work on making a set of “quick codes” for both ICD-10 and CCI, that can be chosen as unique entities, to represent procedures that are common, or difficult to otherwise figure out how to code.
  • Regarding the list of acquired complications that previously were singled out to ensure that they were coded: Trish spoke with collectors who indicated that this list is of “high profile” entities that they don’t really think they need reminding about. So, we will bring this information back to the Steering Committee, with a recommendation that there is no need to continue using this list.

8. Regarding switching over to CCI

  • 'Allan is continuing work on CCI coding.
  • There was discussion about whether procedure coding should comprise: (a) fully flexible coding whereby every procedure is constructed by data collectors as a combination of: body part + what was done to it + how it was done, (b) ready-make CCI codes that have been pre-constructed from the native components, or (c) a combination of ready-made codes for the most common procedures, augmented by component construction of codes for the less common procedures. Towards making this decision Allan will send Tina lists of the components to peruse and start sharing with data collectors.

9. Update on seeking data on PHIN validation data, hospitalization data, and mortality data from WRHA.

  • Allan is working on the new PIA.

10. Regarding CLI and VAP criteria: Laura has reworked the articles. Allan will take a look at them.

Next Task Group Meeting: December 20, 2017 at 11:00 am

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