Difference between revisions of "Task Team Meeting - Rolling Agenda and Minutes 2019"

From CCMDB Wiki
Jump to navigationJump to search
m (ICU Database Task Group Meeting – June 6, 2019)
m (ICU Database Task Group Meeting – June 6, 2019)
(One intermediate revision by the same user not shown)
Line 32: Line 32:
 
*For Medicine, but not ICU, to indicate any time spent in a contingency bed (i.e. different from the Primary Service Location) will be simply indicated with a check box -- i.e. we are not going to keep track of post-arrival boarding/moves.
 
*For Medicine, but not ICU, to indicate any time spent in a contingency bed (i.e. different from the Primary Service Location) will be simply indicated with a check box -- i.e. we are not going to keep track of post-arrival boarding/moves.
 
**''more discussion to follow.  Julie will bring whiteboard of main office suggested process''.
 
**''more discussion to follow.  Julie will bring whiteboard of main office suggested process''.
**Allan was given the whiteboard with the process main office suggested.
+
**''Allan was given (took) the whiteboard with the process main office suggested''.
 
**wiki page for this will be [[Contingency locations]]
 
**wiki page for this will be [[Contingency locations]]
  
Line 87: Line 87:
 
*'''Allan has added this info to the Wiki'''.
 
*'''Allan has added this info to the Wiki'''.
  
12.  New item.  Whether in a patient whose primary admit cause is '''[[ Respiratory failure (insufficiency) NOS, acute]]''' linked to a presumed etiology (e.g. COPD exacerbation, or pneumonia) whether the ARF or the cause should get the check box for being THE SINGLE primary admission cause.   
+
12.  New item.  Whether in a patient whose primary admit cause is '''[[Respiratory failure (insufficiency) NOS, acute]]''' linked to a presumed etiology (e.g. COPD exacerbation, or pneumonia) whether the ARF or the cause should get the check box for being THE SINGLE primary admission cause.   
 
*After discussion, we '''agreed there are pros and cons of each and that either is OK.'''  
 
*After discussion, we '''agreed there are pros and cons of each and that either is OK.'''  
  
Line 93: Line 93:
 
*'''Trish will re-emphasize to all coders the expectations here.'''.
 
*'''Trish will re-emphasize to all coders the expectations here.'''.
 
*''2019-Jun-10: Wiki article updated''.   
 
*''2019-Jun-10: Wiki article updated''.   
*''2019-June-13: email sent to staff with link to article to review update collection instruction details''.  
+
*''2019-June-13: email sent to staff with link to article to review update collection instruction details:''[[Inspection, Exploration (endoscopic)]] .  
 
14.  New item.  Whether a new diagnosis is needed each time a patient is reintubated.  The answer is it depends on whether the repeat intubation is for a new or old diagnosis.   
 
14.  New item.  Whether a new diagnosis is needed each time a patient is reintubated.  The answer is it depends on whether the repeat intubation is for a new or old diagnosis.   
 
*For example if the patient was admitted and intubated for a COPD exacerbation, gets better, gets extubated and stays extubated for a few days, but then develops a new pneumonia and gets reintubated -- this would be a second, acquired, separate diagnosis.
 
*For example if the patient was admitted and intubated for a COPD exacerbation, gets better, gets extubated and stays extubated for a few days, but then develops a new pneumonia and gets reintubated -- this would be a second, acquired, separate diagnosis.
 
*But if instead the patient has a pneumonia as the original cause, seems to improve, gets extubated because he passed a SBT, but fails and gets reintubated and it’s believed the ongoing cause of the respiratory failure and reintubation is just the continuation of the original pneumonia, then no new diagnosis is indicated.
 
*But if instead the patient has a pneumonia as the original cause, seems to improve, gets extubated because he passed a SBT, but fails and gets reintubated and it’s believed the ongoing cause of the respiratory failure and reintubation is just the continuation of the original pneumonia, then no new diagnosis is indicated.
  
15.  New item.  Whether to code repeated clinical events -- e.g. multiple recurrent episodes of an arrythmia, or an abnormal sign or symptom (e.g. a lab result).   
+
15.  New item.  Whether to code repeated clinical events -- e.g. multiple recurrent episodes of an [[:Category: Arrhythmia | Arrhythmia]], or '''an abnormal sign or symptom (e.g. a lab result).'''  
 
*We realized that there can be many of these examples and that we’ll have to deal with them as they arise.  But '''we decided that for now we will address the following 3 categories:  arrythmias, signs/symptoms, and abnormal lab tests.  For ALL of these, they should only be listed in a given database record ONCE.'''
 
*We realized that there can be many of these examples and that we’ll have to deal with them as they arise.  But '''we decided that for now we will address the following 3 categories:  arrythmias, signs/symptoms, and abnormal lab tests.  For ALL of these, they should only be listed in a given database record ONCE.'''
**e.g. A person has a self-limited episode of A-fib.  It goes away and then recurs.  This should only be listed the first time.
+
**e.g. A person has a self-limited episode of A-fib.  It goes away and then recurs.  ***'''This should only be listed the first time.'''
**e.g. A person has a self-limited episode of A-fib.  It goes away but then he has an episode of V-tach.  As this is a different diagnosis, both of these should be listed, but only once each.
+
**e.g. A person has a self-limited episode of A-fib.  It goes away but then he has an episode of V-tach.   
**e.g. Patient comes in with hypokalemia.  It’s treated and remits, but the next day it recurs.  Only list it the first time.
+
***'''As this is a different diagnosis, both of these should be listed, but only once each'''.
 +
**e.g. Patient comes in with hypokalemia.  It’s treated and remits, but the next day it recurs.   
 +
***'''Only list it the first time'''.
  
 
16. Leftover item: Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases.  
 
16. Leftover item: Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases.  

Revision as of 12:22, 2019 June 13

List of items to bring to task meeting

Add to this by adding the following to the article where the problem is documented:

{{DiscussTask | explanation}}
 QuestionModification date"Modification date" is a predefined property that corresponds to the date of the last modification of a subject and is provided by Semantic MediaWiki.
Bed borrowwe want to unify this concept; started discussion today
  • pre-admission bed borrow vs post-admission bed borrow (vs current Off ward field) check box
  • also consider ECIP Ttenbergen 14:33, 2019 April 9 (CDT)
  • also related is our old concept Moves for Medicine
    we want to unify this concept; started discussion today Ttenbergen 14:33, 2019 April 9 (CDT)
  • we are seeing at Grace, a number of patients that are admitted from a GRA ward into the GRA ER under ICU care until bed is available in Grace ICU. Unlike CON or OAKs, that if patient needs ICU, and no bed, they go to ER, under ER service care until ICU bed available. At Grace, this is a bed borrow by ICU service in ER dept, but our TMP project does not have to ITEM for GRA ER for this purpose. As discussed in Task, we will likely be seeing more of this and we need to find out if ICU would like to know how much time patients spends in ER like this. We need to decide how we are going to capture this.
  • GRA_MICU-10422
  • GRA_MICU-10458
  • UPDATE: on May 2.19 we added GRA ER as item in TMP for Project Borrow arrive. At a later time we also added GRA_MICU
15 May 2019 22:39:47
Comfort Care
  • There had been a reference that this could stop when ICD10 comes. Why was that? Is it because we will start collecting Palliative care? Because that is not really the same definition...
  • We will need to update a the reference to this in Palliative_care#This_code_vs_Comfort_Care once decided.

    28 March 2019 15:16:59
    Direct Data Access for RIS/PACSZ) Should we pursue this now? Where would it be on our priorities? It might be related to CCI coding.23 April 2019 13:34:51
    Height and weightZ) decided to revisit SOFA scoring 6 months after ICD10 so same should likely go for this.26 January 2019 01:38:46
    Isolation, infectiousFor patients who are admitted and have pre existing MRSA to code infectious isolation as an acquired CCI code is counterintuitive if it is present and treated with isolation on admission. Pre existing colonization would be included as an ADMIT DX if treated with isolation, and the isolation would be included as an admit CCI procedure.
    • I agree, it does feel counterintuitive, but if we are following the WIKI guidelines, it seems like this is how we are supposed to code it. I think their is currently a lot of discrepancy in how this is being coded.
      • there seems to be confusion all around when to code something as an admit vs acquired vs comorbid. One example we have seen, someone comes in to ICU with stab would injury to heart, has had cardiac arrests, and is in shock. We see the trauma injury to heart coded as comordid. Need to discuss collection instruction tweek that would help
        • Allan recently updated Admit Procedure with info that is relevant to this. I wonder if the instructions on this page are just a remnant from an earlier iteration of the Admit instructions. As I read the current ones, you would not code this. But yes, good we are taking it to Task...
    17 May 2019 20:49:05
    LOS Medicine per ward stayHi Dr. Garland,A thought came up after the last Task meeting related to the discussion on using Service LOS vs. Physical bed LOS (location). We also have A/D/H service patients go to the ward D5. This ward is typically less acute and patients will transfer to D5 from all of the medicine wards (A4/H4/D4/B3/H7). The patients retain their service (A/D/H) while they are on D5, some patients will switch attending (to the D5 Attending), others will stay with the same Attending they had prior to arrival on D5, but the service will remain the same. The Attendings on D5 do not have a specific service and, there is no rule as to which patients switch to the D5 attending. Some patients will be discharged from D5 still under the same Attending that cared for them prior to arrival on D5. When patients leave A4/D4/H4/B3/H7 their profiles are completed (discharged) by the designated ward collector and a new profile is created by the D5 collector.Thanks, Val Penner, May 16.19
    ward LOS vs Service LOS - Val Penner - HSC-D5 follow up from May 7 task meeting- May 16.19
    16 May 2019 21:00:13
    Previous Location field
    • In the instructions above it says to select "other - known but not listed" this is not in the dropdown as an option.
    • Turns out location missing/unknown wasn't implemented either. Is there any concern if we implement this now?
    4 June 2019 17:57:25
    Previous Service field
    • The Registry Patient Type field was replaced by the Previous Service field, how will the patient types be derived from the previous service field? the s_previous_service table must have a column defining the patient type.
      • Patient Type is Surgical if previous service is Cardiac Surgery, General surgery ,etc.,
      • Patient type is Cardiac if previous service is Cardiology,
      • what about Patient type Medical? if Ob/Gyne or Emergency Medicine, is it Medical type? how about critical care?
      • It was also mentioned earlier to use the diagnosis instead, can we begin working on this? --JMojica 15:48, 2019 May 21 (CDT)
      • If I remember right it the Registry Patient Type data was supposed to be inferred from several fields, not just Previous Service field, but I can't remember the details either. We can absolutely add a column for this to s_previous_service table once we know what we need. Ttenbergen 12:49, 2019 June 4 (CDT)
    4 June 2019 17:49:53
    Query check ICD10 mechanism vs traumasee DA above if this has not been addressed before Task.
    The outcome of this might cause a change to Template:ICD10 Guideline Iatrogenic and/or Template:ICD10 Guideline Trauma w mechanism
    Now that this query is actually running (as of May 9) we are getting false positives where the following medical or iatrogenic things are asking for a mechanism:

    Laura suggested using Mechanism of injury: other NOS, but do we want something more specific.

      • Another possibility would be to introduce the concept of "potential trauma" and change the cross check similar to potential infection. We would need to identify all dxs on the wiki that are potential traumas and might need to be coded with mechanisms. Or, we could decide to do away with this cross check because it's too much trouble? Ttenbergen 20:28, 2019 May 27 (CDT)
    6 June 2019 17:22:18
    SOFA scoringZ) decided to revisit 6 months after ICD1017 November 2018 22:23:53
    Sex fieldIf EPR stores current, and a lot of our data comes only from EPR or chart, then for any patients where we don't have a previous, recognizable encounter, we may not be storing their sex assigned at birth even now. Is this true? If so, do we want to change how we treat this field as a result?9 March 2019 22:01:27
    Transitional CareIs this part of any reports? Ttenbergen 10:03, 2017 November 9 (CST)
  • I recently had a patient discharged to Misericordia Transitional Care Unit. Should we be adding this as an option to our dispo field? The only other options were Winnipeg PCH or Institution NOS.Mlagadi 10:41, 2019 May 2 (CDT)
    • Flagging for Julie, since what we should collect should really be driven by what people want ask. Julie, if you prefer pls flag for the task meeting by replacing the first line of the discussion with DiscussTask.

    • I had a discharge to Misercordia Hospital yesterday, and the notes indicated that it was a “transitional care unit”. My only options from the Dispo drop down would be “Institution, NOS”, or “Winnipeg PCH”. I usually put PCH for all of my transfers to Misericordia, but I’m not sure this is the most accurate in this situation. The patient did not have a paneling code, nor was paneling ever mentioned. --Michelle - May 2.19
    15 May 2019 22:57:55

    See Task Team Meeting - Rolling Agenda and Minutes 2018 for previous year's minutes.

    ICU Database Task Group Meeting – June 6, 2019

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

    1. There was more discussion of options for dealing with the related issues (in both Medicine and ICU) of bed borrowing and EMIP, i.e. “boarding” -- specifically PRIOR to arriving in the primary service location. Allan related that he spoke to Nick Hajadiacos and that the Medicine program would like BOTH the total time spent boarding, and the time spent boarding in ED. Thus, we agreed to:

    • For both Medicine and ICU we will collect the following times:
      • (a) Accepted by service -- may call it something like “Service Accept Date/Time”
      • (b) Arrived in primary service location, where if they never did arrive in that location this will be set to the disposition time -- may call it something like “Primary Service Location Arrival Date/Time”
      • (c) Arrived in a “contigency” bed where this is defined as a non-ED bed on which the patient is boarding in the hope/expectation that he/she will eventually obtain a bed in the Primary Service Location. We’ll call this something like “Boarding Bed Arrival Date/Time”
        • For ICUs the list of contingency beds will include: PACU, ED, and all other ICUs
        • For Medicine the list of contingency beds will be, e.g. Contingency bed/HSC, etc. That is to say we will include all contingency beds in a given hospital as “one thing”.
    • For Medicine, the primary location to which a person will be assigned before they get a bed in that primary location (i.e. while boarding in ED or in a contingency bed) will be the expected primary ward.
    • Thus, for Medicine, for patients who never got to their Parimary Service Location, i.e. what used to be called EMIP, will now be the time interval between Service Accept Date/Time and Boarding Bed Arrival Date/Time, and the ward assigned will be the expected primary ward (based on the service to which he/she was accepted).
    • For ICU, as we are already collecting data that indicates all moves, we will continue to do that.
    • For Medicine, but not ICU, to indicate any time spent in a contingency bed (i.e. different from the Primary Service Location) will be simply indicated with a check box -- i.e. we are not going to keep track of post-arrival boarding/moves.
      • more discussion to follow. Julie will bring whiteboard of main office suggested process.
      • Allan was given (took) the whiteboard with the process main office suggested.
      • wiki page for this will be Contingency locations

    2. Followup. In response to prior item of no ICD10 code for generic autoimmune disease, in fact we already had a code for this, i.e D89.9 = Disorder of the immune system, NOS.

    • Allan has added to this Wiki page a note that it includes nonspecific autoimmune diseases.

    3. Followup. It was previously agreed that we will change the rule for recording Radiation Therapy under CCI to be recorded only the first date it occurs during an admission. Tina has changed this on wiki and in ccmdb.

    4. Followup. The number of chest X-rays, ABGs and transfusions have dramatically fallen since switching to ICD10/CCI.

    • For transfusions Joanna pointed out that this could be real for FFP and platelets, as we changed the rule of what constitutes one unit.
    • For Xrays and ABGs, it’s likely that this is a problem with the coders not following the current rules with the current laptop “machinery” to capture all of them.
      • To deal with this, Trish will re-emphasize to all coders the expectations for recording ALL of these.
      • 2019-May-27: an email was sent out to collectors in regards to this matter.

    Collectors were advised when doing CCI's, to keep eye on FAR left of row in after selecting CCI item. This tell you how or if it should be counted. Also sent a link to review CCI Collection Mode Wiki article. Trish Ostryzniuk 11:33, 2019 June 13 (CDT)

    5. Followup. Regarding our new categorization of death (Death to morgue, Death with organ donor to OR, Death with brain death to another ICU). Contrary to what is written in the prior task group minutes, since brain dead organ donors are rare, in calculating ICU-specific death rates, we will not remove people admitted with brain death as an ADMISSION diagnosis from the numerator and denominator (which would be the rigorously correct thing to do).

    6. Leftover item. As we are now collecting lab data in ICUs and wards, and we don’t want to double count them, we agreed that when patients transfer from one collecting site to another that we need coordination as regards time leaving/arriving.

    • We decided that Tina, Trish, Con and Joanna (and possibly other collectors) will discuss a preferred approach to this, which we’ll discuss at next Task meeting.

    7. New item. Due to it’s cost, the program wants us to collect CAR-T (Chimeric Antigen Receptor T-Cell) treatment data. This is technically a procedure so will need a CCI code, but like prior chemotherapy we will want to capture it as a past history diagnosis too.

    8. New item. How to code assault with the assaulter’s own body (e.g. fists, feet). The answer is we’ll add a new item: Y04, “Mechanism of injury: assault with bodily force”.

    • Tina to add this mechanism.

    9. New item. We agreed to remove R06.7, Sneezing -- from the list of signs/symptoms

    • Tina will removed this from IDC10.

    10. New item. There’s a need for a code for nonspecific obstruction of the upper airways. We will use J39.8 and call it “Upper airway obstruction, NOS”. That entry must include a notation that other, more specific options may include:

    11. New item. How to code neutropenic enterocolitis. Answer:

    12. New item. Whether in a patient whose primary admit cause is Respiratory failure (insufficiency) NOS, acute linked to a presumed etiology (e.g. COPD exacerbation, or pneumonia) whether the ARF or the cause should get the check box for being THE SINGLE primary admission cause.

    • After discussion, we agreed there are pros and cons of each and that either is OK.

    13. New item. It’s been brought to the group’s attention that the coders are sometimes coding every level reached with an endoscopy. Inspection, Exploration (endoscopic). This is contrary to the guideline to only code the furthest area reached.

    • Trish will re-emphasize to all coders the expectations here..
    • 2019-Jun-10: Wiki article updated.
    • 2019-June-13: email sent to staff with link to article to review update collection instruction details:Inspection, Exploration (endoscopic) .

    14. New item. Whether a new diagnosis is needed each time a patient is reintubated. The answer is it depends on whether the repeat intubation is for a new or old diagnosis.

    • For example if the patient was admitted and intubated for a COPD exacerbation, gets better, gets extubated and stays extubated for a few days, but then develops a new pneumonia and gets reintubated -- this would be a second, acquired, separate diagnosis.
    • But if instead the patient has a pneumonia as the original cause, seems to improve, gets extubated because he passed a SBT, but fails and gets reintubated and it’s believed the ongoing cause of the respiratory failure and reintubation is just the continuation of the original pneumonia, then no new diagnosis is indicated.

    15. New item. Whether to code repeated clinical events -- e.g. multiple recurrent episodes of an Arrhythmia, or an abnormal sign or symptom (e.g. a lab result).

    • We realized that there can be many of these examples and that we’ll have to deal with them as they arise. But we decided that for now we will address the following 3 categories: arrythmias, signs/symptoms, and abnormal lab tests. For ALL of these, they should only be listed in a given database record ONCE.
      • e.g. A person has a self-limited episode of A-fib. It goes away and then recurs. ***This should only be listed the first time.
      • e.g. A person has a self-limited episode of A-fib. It goes away but then he has an episode of V-tach.
        • As this is a different diagnosis, both of these should be listed, but only once each.
      • e.g. Patient comes in with hypokalemia. It’s treated and remits, but the next day it recurs.
        • Only list it the first time.

    16. Leftover item: Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases.

    • Allan reports he’s continuing to try and contact Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    Next Meeting -- June 12 at 11 am.

    ICU Database Task Group Meeting – May 23, 2019

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

    1. There was more discussion of options for dealing with the related issues (in both Medicine and ICU) of Bed borrowing and EMIP, i.e. “boarding”. A sticking point is the important question of whether or not the Medicine program needs/wants to separate out time spent waiting for a ward bed in ED, from the total time spent waiting for a ward bed (ED plus so-called contingency beds). Allan will contact Nick Hajiadacos and ask ---> Answer: They want both the total time prior to arriving in their destination bed AND the amount of that time spent specifically waiting in ED.

    2. Julie indicated that she would like to routinely obtain, for the Minimal dataset, the Accept DtTms and Arrive DtTms. This information is in the ADT system to which the collectors have access. Trish & Tina will work to make this happen.

    3. New item. There is no ICD10 code for generic autoimmune disease. This is relevant because, apparently, it occurs that a diagnosis is made of an autoimmune disease without a specific name or a specific organ. Allan will look this up  Answer is that we already had a code for this, i.e D89.9 = Disorder of the immune system, NOS. Allan has added to this Wiki page a note that it includes nonspecific autoimmune diseases. We could also consider modifying it’s name to something like: Disorder of the immune system, NOS (including autoimmune disease).

    4. New item. It was agreed that we will change the rule for recording Radiation Therapy under CCI to be recorded only the first date it occurs during an admission. Tina will make that change.

    5. New item. Apparently, the number of chest X-rays recorded has dramatically fallen since switching to ICD10/CCI. As this is not likely due to an actual fall in CXRs, it’s almost certainly due to failure of coders to code them. Same has occurred with transfusions and ABGs. To deal with this, Trish will re-emphasize to all coders the expectations for recording ALL of these.

    6. New item. This relates to our new categorization of death (Death to morgue, Death with organ donor to OR, Death with brain death to another ICU). Specifically, we had previously decided that for brain death cases who become donors, to count the end of the ICU admission as the time of brain death. But it is now pointed out that this fails to consider the workload after brain death for nurses. Thus we agreed to alter that rule such that we will instead count the end of the ICU admission as when that brain dead person actually leaves ICU (for morgue or another ICU or OR) ----> but that Julie will alter her code so that people admitted with brain death as an ADMISSION diagnosis will not be counted in the numerator or denominator for death rates.

    7. Leftover item. As we are now collecting lab data in ICUs and wards, and we don’t want to double count them, we agreed that when patients transfer from one collecting site to another that we need coordination as regards time leaving/arriving. We decided that the Tina, Trish, Con and Joanna (and possibly other collectors) will discuss a preferred approach to this, which we’ll discuss at next Task meeting.

    8. Leftover item: Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Allan reports he’s continuing to try and contact Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    Next Meeting -- June 6 at 11 am.

    ICU Database Task Group Meeting – May 7, 2019

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

    1. Most of this meeting was taken up with discussing options for dealing with the related issues (in both Medicine and ICU) of bed borrowing and EMIP, i.e. “boarding”.

    • An important difference between Medicine and ICU is that for the former we do not always know where the eventual service location will be before they arrive, while for the latter we do. This is because there are Medicine teams that can admit to one of several final locations, and what we keep track of is the final ward/location, not the team. This fact will necessitate some difference between how we handle boarding.
    • After much discussion we decided that Allan will ponder this further and we’ll discuss more at the next Task meeting. Allan’s suggestion for next meeting is that we put in place the following data “machinery”:
      • ICU:
        • Record the accept time, time of arrival at the final ICU location, and the disposition time. The interval between accept and arrival times is the “Boarding Time”. Interval between the accept and dispo times is the “Service LOS”, and is used to calculate the “Service Census”. Interval between the arrival and dispo times is the “Bed Occupancy LOS” and is used to calculate the “Bed Census”. For patients who never get to the final ICU location, the time of arrival is set at the dispo time, ensuring that Bed Occupancy LOS is zero. One example of bed borrowing is the MICU patient who is boarded in SICU and taken care of during that bed borrowing time by MICU team.
        • The current check box used to identify boarding during any part of care will have it’s purpose altered to indicate a patient who AFTER arrival in their final ICU location are sent elsewhere to board for any period(s) of time, while still cared for by the original ICU team.
        • Make a new field, called something like “Boarding Location” that for ICU has options: ED, PACU, Ward, Other. When a given patient is boarded in multiple locations prior to getting to the eventual ICU, we record the FIRST such location only.
      • Medicine:
        • Record the accept time, time of arrival at the final ward location, and the disposition time. For patients who never get to the final ward location, the time of arrival is set at the dispo time. The interval between accept and arrival times is the “Boarding Time”. The interval between the arrival and dispo times is the “Bed Occupancy LOS” and is used to calculate the “Bed Census”.
        • Now we diverge between those who DO vs. DO NOT get to a final ward location.
          • For those who DO get to a final ward location, we do just as we did for ICU: Interval between the accept and dispo times is the “Service LOS”, and is used to calculate the “Service Census”. Boarding Locations will have options: ED, and a list of wards that requires further discussion. Again, when a given patient is boarded in multiple locations prior to getting to the eventual ward site, we record the FIRST such location only.
          • For those who NEVER got to a final ward location: Interval between accep and dispo times is either “EMIP Time” or another title we choose. Since NOT all these will be boarded in ED, using EMIP time makes a link with current nomenclature, but is not fully accurate.

    2. Julie indicated that she would like to routinely obtain, for the Minimal Dataset, the accept and admit times. This information is in the ADT system to which the collectors have access. Trish & Tina will work to make this happen.

    3. There was a discussion about the CCI guidelines for which procedures to code that occurred PRIOR to actual arrival/admission.

    • For example, many collectors are coding transfusions and central lines done prior to admit. It appears the lack of clarity is around this criterion in Admit Procedure: “was directly related to an Admit Diagnosis
    • We decided that this criterion will be augmented to indicate to INCLUDE therapeutic procedures but only include diagnostic procedures if they led to a complication that was related to admission. Allan has made this change.

    4. Leftover item. As we are now collecting lab data in ICUs and wards, and we don’t want to double count them, we agreed that when patients transfer from one collecting site to another that we need coordination as regards time leaving/arriving. We decided that the Tina, Trish, Con and Joanna (and possibly other collectors) will discuss a preferred approach to this, which we’ll discuss at next Task meeting.

    5. Leftover time: Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Allan reports he’s continuing to try and contact Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    Next Meeting -- May 23 at 11 am.

    ICU Database Task Group Meeting – April 23, 2019

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

    1. Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Allan reports he’s continuing to work with Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    2. Continued discussion of coding deaths in the setting of Brain death, ( Deceased patients article) and organ donor. Summary of decisions:

    • Redefine Length-of-Stay. From now on, for patients who experience Brain death, LOS will include time from admission to Brain death. Time in ICU spent after Brain death being evaluated/optimized for being an organ donor will not be included in LOS. But, of course, that time will be included in calculations of Bed occupancy. Julie will have to revise her SAS code to make this happen.

    Julie understood that this change was agreed to for dispo table?

    • Revise list of dispostions to now include THREE types of Dispo_field#Deceased_patients:
      • Death with transfer to morgue
      • Death with transfer to OR for organ donation
      • Death with transfer to another ICU
    • For a patient who is not yet braindead in location A and then transfers to location B with expectation of near-future Brain death or Donation after Cardiac Death (DCD)
      • In location A the dispo will be transfer to location B. The record in location B will have Admit Diagnosis of whatever is present. IF that person develops Brain death in location B, then that will be coded as an acquired diagnosis.
      • If the patient develops Brain death in location B, then the LOS in location B will only be the time from Arrive DtTm to Date and time of Brain death (The Date and time is recorded for ALL acquired DX's). For calculating this patient’s total LOS, it will be the entire time in location A + the time in location B until Brain death. Julie to change her algorithm accordingly.
    • For a patient who develops Brain death in location A, and then transfers to location B for evaluation for organ donation
      • In location A the patient will have an Acquired Diagnosis / Complication of Brain death, and their dispo will be Death with transfer to another ICU. The LOS in location A will be the date and time from arrival to the date and time of Brain death. Any time spent in location A after Brain death will be counted towards Bed occupancy but not LOS.
      • In location B the patient will have Admit Diagnosis of Brain death, and their dispo will be Death with transfer to OR for organ donation IF they go for donation. If they do not go for donation, the disop is Death with transfer to morgue. While all of this time will be included in Bed occupancy, none of it will be included in LOS (since the person was not alive).
      • For this situation, Julie will need to alter her coding for linking records into an episode of care, such that no linking will be done:
      • Regarding death rates in these records
        • It’s necessary to avoid double counting the death in location A and location B. To ensure this, Julie will alter her code such that (as directly above) there’s no linking of records with Brain deathand she will not include in the calculation any record where Brain death was an admit diagnosis.
    • For a patient who is in one location (e.g. MICU), where he develops Brain death, and then stays in that location to be evaluated/optimized for being an organ donor
      • Brain death will be an acquired diagnosis. LOS will only be the time from admit to Brain death. Time after Brain death will be counted towards bed occupancy but not LOS. Julie will alter her code to reflect this.
      • The dispo will be Death with transfer to OR for organ donation IF they go for donation and Death with transfer to morgue if not.
    • Regarding death rates in these circumstances

    3. New item. As we are now collecting lab data in ICUs and wards, and we don’t want to double count them, we agreed that when patients transfer from one collecting site to another that we need coordination as regards time leaving/arriving. We decided that the Tina, Trish, Con and Joanna (and possibly other collectors) will discuss a preferred approach to this, which we’ll discuss at next Task meeting.

    4. Bed borrow - We did not get to this item (left over from April 9, 2019 minutes) today. Will do next meeting.

    Next Meeting -- May 7 at 11 am.

    ICU Database Task Group Meeting – April 9, 2019

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

    1. Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Allan reports he’s continuing to work with Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    2. Allan reports that he made modifications to the 10 pages for electrolyte disturbances (high and low: Na, K, Ca, Mg, PO4). We agreed that we'll change the name of all of them to be, for example "Hypokalemia, severe or symptomatic" in order to clarify that we're NOT identifying ALL cases where the serum level is above or below the reference range. (Done - Tina)

    3. Deceased patients - Continued discussion about coding the interrelated items of: death/disposition, brain death, and organ donor status. After discussion we agreed to solve this problem as follows:

    • First, it's only a problem when an already brain dead person is transferred elsewhere for reasons related to organ harvesting.
    • For those who are not brain dead when transferred with plans for DCD (donation after cardiac death) and organ harvesting, the Admit Diagnosis to the Transfer to location will just be whatever acute issues are involved.
    • For those who are declared brain dead at the TRANSFER FROM location, their diagnoses in record will include Brain death -- their Admit Diagnosis in the TRANSFER TO location will be Brain death and Organ donor (organ/tissue donation by the donor)
      • It's only this specific situation which is tricky, and our solution is that for records which contain the diagnosis of Brain death, Julie will change her algorithm for linking successive records such that no linking will be done:
        • in the forward time direction for a record where that diagnosis was NOT an admission diagnosis
        • in the backward time direction for a record where that diagnosis was either an admission diagnosis or a comorbid diagnosis

    2) For both Medicine and ICU database, we check the continuity of transfers by checking the admission and discharge dates, the previous locations and discharge locations (or disposition). Errors on any of these four fields will affect either LOS, Inter-facility transfers (Critical Care Inter-facility Transfer Report?, Re-admission, mortality (Mortality and readmission report?), transfer delays (Transfer Delay?), occupancy (Bed occupancy?) which are included in the regular CC (Annual report? If so we should change the name) and Med (I can't even find a link for that) reports. For ICU patient, this rule will only affect the SAS linking check program which can be modified so it will not show up as an error. How about in the ACCESS query of populate linking (Populate linking pairs) error (Pre-linking checks), this has to be changed too? In terms of diagnosis requests specific to brain dead, the counts will the include only those on acquired and not double count by including those on admit. --JMojica 10:13, 2019 April 11 (CDT)

    4. Bed borrow - We began a very long discussion about the complex, interrelated issues -- RELATED TO TIME UNDER CARE PRIOR TO ARRIVAL IN THE SERVICE LOCATION -- of: bed borrowing, bed parking, and EMIP.

    • First, we recognized that similar issues are dealt with differently in Medicine and ICU, and that different names are given to what are equivalent phenomena
    • We have tentatively agreed (more discussion needed at next Task Meeting) on this schema for dealing with any situation that occurs between service acceptance and physical arrival on the ward/unit where time is spent NOT on the Service Location:
      • We will only use the word "occupancy" to refer to the number of patients physically occupying beds at the Service Location
      • We will refer to ALL situations (for Medicine and ICU) where a patient is under care of a service but not in that service's Service Location as BED BORROWING. So, we'll do away with the terms Bed Parking, and EMIP.
      • We will use the term "Service Number" to refer to the number of patients who are being cared for by the service team, whether those people are in the Service Location or in a borrowed bed
      • We realized that what was called EMIP (and which engendered consideration of ECIP) is really just a subcategory of bed borrowing where the patient never actually did get moved to the Service Location
      • We will continue to record the ACCEPT TIME and the ARRIVAL TIME regardless of bed borrowing --- BUT when a patient is put in a borrowed bed after Accept Time but never does get moved to the Service Location, we will assign the ARRIVAL TIME in that case to be identical to the DISPO TIME
        • This ensures that the Service Number is correct, and furthermore that such a person does not contribute to calculation of the occupancy of the Service Location
      • We will make a dropdown of the BED BORROW LOCATION -- with specific options including EDs, Wards, PACUs, ICUs, and an option for "MULTIPLE" which will be used when during the duration of pre-arrival bed borrowing the person is moved from one borrowed bed to another borrowed bed.
    • Issues related to this pre-arrival bed borrowing which still need to be addressed:
      • Whether Medicine needs to know just the total time in pre-arrival bed borrowing, or it's subsets when it occurs in multiple places -- Allan to ask the GIM Section Heads and Maryanne Lynch -- email sent
      • Whether EDIS is capable of providing the time specifically spent as a borrowed bed in ED
      • In these bed borrow situation, how to assign the PRIOR LOCATION and PRIOR INPATIENT LOCATION -- Allan to contemplate this, and ensure that Randy Martens data needs remain addressed after any change
        • Allan's proposal for this: Simply keep the definitions of those items exactly as they are now. This works just fine for Bed Borrowing with ONE exception.
          • When a patient never gets to their Service Location (i.e. dies or goes home or elsewhere before that occurs): In this case the PRIOR INPATIENT LOCATION still works fine. But the PRIOR LOCATION does not, since if the patient never gets to their Service Location, there is no prior physical location -- so the solution is to just add an entry to the dropdown list of possible physical locations that covers this situation; it could be called something like "NA-Never made it to Service Location".

    5. A related topic to #4 is bed borrowing AFTER the Arrival Time on the Service Location. After discussion, and given that: (i) patients can and do (esp on Medicine) frequently get moved between bed borrow locations, and (ii) attempts in the past to keep track of all that movement failed miserably --> we agreed that what we will do, for both Medicine and ICU, is have a flag identifying that after the Arrival Time some unspecified period was spent off the Service Location, i.e. in a borrowed bed. (Depending on how we change the other definitions we might be able to re-purpose Off ward field for this; it's currently used for borrows at any time, but since pre-arrival borrows would now be marked differently we could change the definition for this. )

    ICU Database Task Group Meeting – March 28, 2019

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

    1. Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Allan reports he’s continuing to work with Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    2. Eliminating distinction between different ward types - Following up on providing the Medicine Database with information about whether ward patients are CTU or NTU. Allan reported that he has now also heard back from MaryAnne Lynch, who also indicated that she sees no reason to collect that information.

    3. Followup of coding of STDs, particularly Syphilis. The changes agreed upon at the March 6, 2019 task meeting were implemented, except that Allan is still to populate Template:ICD10 Guideline STD to explain the general coding in ICD10 -- DONE.

    4. Followup on the discussion at March 6, 2019 task meeting about defining cutoffs to identify electrolyte disturbances. The old codes for this can be found at Category:Metabolic_(old) Allan still to work on this.

    5. IICU consult - Followup on March 6, 2019 task group discussion about recording only the initial date of referral made from an ICU to IICU. The question arose of what to do when patient is in ICU#1 when referral is made and then is transferred to ICU#2 (before getting to IICU). After discussion we agreed that we will NOT also code the IICU referral in ICU#2.

    6. New question: How to code an anastamotic leak as a diagnosis, and how to code the repair as a procedure. The answer is that it is included in T81.3, i.e. Iatrogenic, dehiscence or rupture or disruption, surgical wound NOS. This article has now been augmented to reflect this inclusion.

    7. New question: How to code pneumomediastinum or pneumoperitoneum.

    8. New question: How to code Helicobacter pylori infection. An important issue here is that this bacterium is a very common colonizer and although it is the major cause of duodenal ulcers and gastric ulcers, it is present without causing any disorder in about 50% of all people. Additionally, the ONLY disease it is currently know to cause is peptic ulcers (including gastritis and duodenitis). For these reasons we will NOT add a specific bug code for it, and when such a disorder is believed due to this bug, one can combine the ulcer code with Bacteria, NOS.

    9. New issue: Query NDC_Dxs_vs_TISS_Dialysis checks that in ICU, when a diagnosis is listed that “might” require dialysis, that the TISS is checked to ensure that a dialysis code is present. The problem is that with our new KDIGO definition of AKI/ARF, the vast majority of acute renal injuries are so minor that they do NOT end up getting dialysis. Thus, after discussion it was agreed that we will remove this crosscheck. (Query NDC_Dxs_vs_TISS_Dialysis has been updated to remove this component)

    10. New question: What should be the primary (#1) diagnosis for someone transferred to D5 Medicine at HSC who is mainly there awaiting transfer to another facility (e.g. LTC home)? After discussion it was decided that if the patient has no active acute issues and is really only waiting for the transfer, then use one of the “ Awaiting/delayed transfer” codes as #1, but if there is still active treatment ongoing for an acute medical issue (e.g. finishing antibiotics for an infection) then code that issue as #1 and code the “Awaiting/delayed transfer” further down the priority list.

    11. New question: How to code aspiration of a joint. Answer is:

    12. Deceased patients - We had a long discussion about coding of the interrelated items of: death/disposition, brain death, and organ donor status.

    • This turns out to be complicated.
    • We currently have 2 death-related dispo codes, i.e. with and without organ donation. Organ donors may be alive (and remain alive), dead (i.e. braindead), or alive but they go for Donation after Cardiac Death (DCD) in the OR which is where they actually die.
    • A relevant issue here is the desire, when patient transfers from Location#1 to Location#2 (both of which we collect for) that the “TO” code for #1 matches up with the “FROM” code for #2. This is especially problematic when the person is braindead in #1, because current checks don’t allow a dead person to be transferred to another of our collected locations.
    • We discussed some approaches, including:
      • Subdivide the dispo death with donation code into: (i) death with donation went to OR and (ii) a cluster of codes that are death with donation went to specific other ICU. This would allow us to continue using the Disposition field to accurately identify unit-specific mortality rates.
      • Instead, maintain the 2-level dispo death coding, and use the ICD10 diagnosis code for braindeath to ensure accurate mortality rate calculations. This has the disadvantage that dispo codes are no longer accurate for death rates, and though Julie will know this, other users will almost certainly be confused by it.
    • After discussion, we agreed that we all need to ponder this issue, and continue discussion of it at the next task group meeting.

    13. see: Tracheostomy care

    Next Task Group Meeting: April 9 at 1pm

    ICU Database Task Group Meeting – March 6, 2019

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

    1. Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Their database is called Traceline. Allan will contact Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    2. There was further discussion about consternation in the ICUs about our switch to the current CDC criteria for VAP. Specifically that the SICU Quality Circle is concerned about the apparent rise in VAP rates that occurred. Allan will send an explanatory email to the SICU leadership about this -- DONE.

    3. Eliminating distinction between different ward types - Following up on providing the Medicine Database with information about whether ward patients are CTU or NTU. Allan reported that he heard back from the co-section heads (Griffin, VanAmeyde) who indicated that they appreciate the difficulty of collecting this data, and that the assignment has a large arbitrary element. They stated that it would be fine with them if we just recorded whether -- at the outset of any given Medicine database record -- the patient was CTU or NTU. However, Tina brought up that this may be of almost no actual value. As neither of the co-section heads place much value in this datum, Allan today left a voicemail with Maryanne Lynch to try and chat about it before we make a decision.

    4. Followup on Bojan’s wish for IICU consult information from the ICUs. Allan reported that Bojan said that the SOLE piece of information he wants is the date the consult sult is first made to IICU. Tina has updated IICU consult and CCMDB.mdb s_tmp table to stop collection of consult decision date.

    5. Regarding coding of STDs, particularly Syphilis. After discussion we agreed to switch the single existing code for syphilis, "Syphilis (due to Treponema pallidum)", from an “infection with implied pathogen”, to just being a pathogen (and changing the code's name to Treponema pallidum (Syphilis) in the process). Tina changed Treponema pallidum (Syphilis) to reflect this. That way, along with other STD-causing pathogens (e.g. Neisseria gonorrhea (gonococcus), Chlamydia trachomatis (bug responsible for regular sexually transmitted chlamydia)), we can code any type of infection. If it’s a simple cutaneous STD, you’d attach the appropriate STD pathogen to the generic code Sexually transmitted (venereal) infections, NOS. But for CNS syphilis we then have more flexibility in that we can use Encephalitis, meningoencephalitis, myelitis, encephalomyelitis, bacterial with the bug being Treponema pallidum.

    6. A discussion occurred about coding of electrolyte disturbances, e.g. Hyperkalemia. We agreed that we do NOT really want to record every time an electrolyte level is outside of the “normal range”. After discussion, we agreed that what we should do is identify thresholds for “severe” numerical disturbances, as existed before. Trish will send Allan the previously used cutoffs, and he will then come up with cutoffs to use with our ICD10 codes --- for which we will alter the names of these entities, for our purposes, to (example) “Hyperkalemia, severe”. - The old codes for this can be found at Category:Metabolic_(old)

    7. After discussion we again agreed that the construct of a “failed discharge” isn’t a proper diagnosis. Instead the reason for readmission should be coded in that readmission, and if it’s due to psychosocial (rather than medical) causes, then one can use as the admission diagnosis Problem related to unspecified psychosocial circumstances.

    8. In response to a question of if/how to code a KUB x-ray of the pelvis, we agreed it would be included as AXR (abdominal plain X-ray).

    9. For clarity, we agreed that we will alter the names of "(T) Abdominal or Pelvic Cavity, NOS" to (T) Abdominal, Pelvic or Peritoneal Cavity, NOS and of "(D) Abdominal or Pelvic Cavity, NOS" to (D) Abdominal, Pelvic or Peritoneal Cavity, NOS. Tina has changed this on wiki and in CCMDB.mdb.

    10. A question arose of how to code, in CCI, a lavage, e.g. gastric or peritoneal. Allan sought this out and it turns out that the “what was done” code used depends on the purpose of lavage. For example, if it is to warm up or cool down the body, the “what was done” codes correctly used are ones we decided NOT to include (Hypothermy; Hyperthermy). Similarly if it’s to instill medication, then the “what was done” code is another one we aren’t using (Local pharmacotherapy). THUS, it appears that for therapeutic lavages we are NOT coding those. On the other hand, for a DIAGNOSTIC lavage (as might be done for diagnosis of intraperitoneal bleeding or infection) the “what was done” is considered to be a “biopsy”, which we DO collect. Tina has added this info to List of CCI procedures we don't code, Biopsy (endoscopic), Biopsy (non-endoscopic).

    11. A question arose of if/how to code the clinical finding of “cognitive impairment” without a clear/known cause. It turns out we already have a code for this Somnolence, stupor or obtundation, as the text of this Wiki page spells out that “This code includes the vague diagnoses of: altered mental status AND decreased LOC”. Added “cognitive impairment” to Somnolence, stupor or obtundation.

    Next Task Group Meeting: March 28, 2019 at 11am

    ICU Database Task Group Meeting – February 25, 2019

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

    1. Blood Product Data - Regarding seeking to obtain all CBS data to merge in an ongoing way with our databases. Their database is called Traceline. Allan will contact Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    2. Regarding quarterly reporting of primary admit diagnoses. We have previously decided to report these by ICD10 chapter. However, we do want to pull out some particularly important diagnoses, e.g. sepsis-related diagnoses. For this purpose, Julie will extract Sepsis (SIRS due to infection, without acute organ failure) (R65.0) and Severe sepsis (R65.1) from the “R” chapter, and report those separately, noting for the remainder of “R” that it excludes those codes. Tina has updated the wiki pages to reflect this.

    3. Regarding PHIN/pseudPHINs for people with multiple such identifiers. This can occur in 3 main ways: (a) moving from OOP to MB, (b) moving from MB to OOP, and (c) a single individual having multiple PHINs. For the purpose of identifying “same person”, and uniformity, we agreed that we will capture the current/most recent identifier (PHIN or pseudoPHIN) and record prior identifiers in the Alias ID collection.

    4. An incident was noted where (at Grace) the patient qualified by CDC criteria as having a VAP, but the attending physician disagreed. Allan indicated that for diagnoses with specific criteria listed on the wiki (especially if those criteria are from CDC) that they should code them regardless of the physician’s concern. To try and deal with that concern, the collector should share the wiki page definition, and refer the physician to Allan. Allan sent out an email 2/25/2019 to all ICU attendings about this.

    5. Eliminating distinction between different ward types - Regarding coding of different types of Medicine wards. Apparently the Medicine Program wants this information, but it is very challenging because patients not only switch rooms and wards, but can switch back and forth between CTU and NTU services. Probably the best we could do here is record CTU vs. NTU at the very start of admission. Allan sent an email about this to Maryanne Lynch, Ken VanAmeyde and Paddy Griffin -- the reply from Drs. Griffin and VanAmeyde was that they are completely OK with that plan.

    6. IICU consult - Regarding the current temp project of recording IICU consult date and IICU accept date. The apparent purpose of this is for Bojan to be able to quantify the number of patient-days spent in ICU waiting for an IICU bed. However, we feel that simply summing the total intervals between IICU acceptance and (either) death or going to IICU or going elsewhere probably overestimates the actual time spent on the IICU waiting list. The reason is that these waits are often prolonged, and we have no way of recording if/when a patient is REMOVED from that waiting list. Allan opined that having the IICU attendings maintain a log of entry requests would be much more accurate and easier. Specifically, each entry could include: Patient idnetifiers, Date of initial IICU request, Sending ICU, Date of patient acceptance/refusal, Date patient removed from the IICU waiting list (for any reason). Allan discussed this with Bojan --- who said that the only information he needs is the date when the consult to IICU was first requested.

    Next Task Group Meeting: March 6, 2019 at 11am

    ICU Database Task Group Meeting – February 6, 2019

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

    1. Further consideration of reinstating CCI code Pharmacotherapy, antineoplastic agent, whole body for chemotherapy: We decided not to do so. The rationale is that what is considered chemotherapy is not quite confusing since: (a) many cytotoxic drugs are given for indications other than cancer, and (b) increasingly the drugs used for cancer are not cytotoxic but are biologics. - Tina updated Pharmacotherapy, antineoplastic agent, whole body with this info

    2. Further consideration of adding a specific ICD10 code for Intravenous drug abuse (IVDA) -- There is no ICD10 code for IVDA and at this time we decided not to add a custom code unless some user really wants this information. - Tina has added this to List of ICD10 Diagnoses we don't code

    3. Regarding coding of FFP and albumin transfusions:

    • Transfusion of FFP: After discussion we decided that when stickers are not used, that the number of units will be determined by the current procedures of Canadian Blood Services that 1 unit is approximately 250 mL.
    • Transfusion of albumin: Because it comes in different concentrations, given Laura’s concerns, we will change CCI Collection Mode to CCI collect first - Tina has updated Transfusion of albumin and CCMDB.mdb with this.
    • Blood Product Data - There was discussion about seeking to obtain all CBS data to merge in an ongoing way with our databases. Their database is called Traceline. Allan will contact Anthony Loewen (anthony.loewen@blood.ca) at CBS to pursue this.

    4. Regarding CAM coding. The current methods of collecting this data is in TISS and on the ICU flowsheet.

    • To even be evaluable for CAM assessment, a patient must be conscious. Thus, in reality, a given CAM assessment has 3 possible findings: (i) not evaluable, (ii) evaluable and CAM-positive, or (iii) evaluable and CAM-negative.
    • CAM status is currently recorded in ICUs in two places:
      • On the ICU flowsheet, as an indication of CAM-positive versus not being CAM-positive; as above the latter includes evaluable and CAM-negative or not evaluable. Of note, the ICU nurses evaluate for delerium multiple times per day.
      • On the TISS sheet, as a bubble for being CAM-positive versus not being CAM-positive. Here there is just a single yes/no bubble, so that NOT being CAM-positive can mean either that there were no evaluable assessments during that day or that there was at least one evaluable assessment and all of those were CAM-negative.
    • The users of this data (including Rakesh Arora in ICCS) are mainly counting the number of ICU days in which a patient is CAM-positive -- which of course only includes days on which there is at least one CAM-evaluable assessment.

    - Allan has updated T0 - CAM positive (TISS Item) with this info

    5. The data collectors made clear that it would be highly desirable for Wiki searching to be enhanced. Tina will ponder this and has started page Searching the wiki to document.

    6. The idea was floated to (somehow) enhance the inclusion in Wiki pages of synonyms for diagnoses. We’ll come back to this sometime later. - See Searching the wiki

    7. New question about how to code mets to the pancreas. Answer is Gastrointestinal system NOS, metastatic malignancy to it (also code primary site) and that page has been updated.

    8. New question about whether it is OK to code bacterial Colonized with organism (not infected) as a comorbid. Answer is Yes.

    9. After discussion relating to how diabetes might disappear, Allan has added Past history, transplanted pancreas or islet cells.

    10. New question of situation whereby: Patient with ESRD is admitted for a kidney transplant -- gets the TP -- and kidney has trouble leading to acute renal failure/insufficiency in the transplanted organ. A number of questions arose with the following answers:

    11. New question. There appear to be two conflicting ways that the Wiki indicates to code HAP. One listed in Iatrogenic, complication of medical or surgical care NOS and the other in Hospital-acquired pneumonia (HAP) in ICD10. Allan has fixed this with the correct approach being listed in the latter Wiki page.

    Next Task Group Meeting: February 13, 2019 at 11am

    ICU Database Task Group Meeting – January 24, 2019

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

    1. There is still concern about the extra workload of ICD10/CCI. We will continue to monitor this and seek pithy suggestions for reducing the workload with minimal loss of content/value.

    2. Consideration of adding Pharmacotherapy, antineoplastic agent, whole body back to the CCI list. This CCI picklist code would be 1.ZZ.35.HA-M0. At the Dec 7, 2018 task meeting we decided to eliminate it, though that item doesn’t explain why. We’ll reconsider at the next task.

    3. Consideration of adding a specific ICD10 code for IVDA -- There is no ICD10 code for IVDA. The drug abuse codes go by the drug, not the route. If we decide we really need/want this, we can add a custom code. At the next meeting we’ll discuss this.

    4. After discussion of whether we want to code CMV(+) status for organ transplants, we decided that we do not.

    5. FFP does not have stickers that come with it from Blood Services. This led to a question of how to quantify FFP for coding Transfusion of FFP.

    • Allan called the Winnipeg office of Canadian Blood Services and was told that for full units (approx. 250 mL) they do have stickers, but when they send half units that those do not have stickers. A solution appears to be to count the stickers, which should be there for whole units, but for half units, count them manually -- as 0.5 of a unit. We’ll discuss this more at the next Task meeting.

    6. Question arose of how to code Factor V Leiden mutation. Allan will look into this ---> DONE, as the Wiki page indicates this is covered in Primary hypercoagulability (thrombophilia).

    7. A complex question was raised about coding/counting CCI admit procedures that are done prior to admission, especially if done in a procedure suite on the way from one hospital ward or ICU to another hospital ward or ICU.

    • Our current criteria are listed in CCI Collection and that works fine when the patient comes to out ICU/ward from the ED or another location where we do not collect.
    • But, it’s complicated by the fact that is a patient goes from one to another of our collecting locations, that they might be counted in each place. Furthermore, a person being transferred from location A to location B may, in between, go to a procedure suite and get admit-type procedures.
    • We agreed to make 4 general rules for procedures:
      • (i) Transfer from collecting location A to collecting location B without any stop in between where procedures might occur -- all procedures done before leaving location A will be collected by location A only
      • (ii) Transfer from collecting location A to collecting location B WITH a stop in between where procedures occur -- all procedures done before leaving location A will be collected by location A only, while procedures done at the stop in between will be coded by location B only.
      • (iii) Transfer from noncollecting location A (which includes ED) to collecting location B without any stop in between where procedures might occur -- any qualifying admit procedures done before leaving location A will be collected by location B
      • (iv) Transfer from noncollecting location A (which included ED) to collecting location B WITH a stop in between where procedures occur -- all procedures done before leaving location A or during the stop in between will be coded by location B only.
    • Allan put the updated information on the wiki, and Tina moved it to CCI_Collection#Moved_patients from Admit Procedure since it applies to both admit and acquired.

    8. Tina raised the issue of the possibility of the following true timing of events: First patient accepted for admission; Second patient deemed transfer ready to a lower level of care; Last is patient arrives. It’s an issue because the current cross-check Function Dispo Chronological() does not allow Transfer Ready DtTm to occur prior to Arrival D/T. After discussion (which unfortunately Tina was not present for), we agreed that the rule should be that Transfer Ready D/T can only be coded at or after Arrival D/T. The rationale has to do with the main desire for avoidable days to refer to actual bed occupancy days avoidable.

    9. Discussion about coding Bacteremia. Although this is a finding and not an actual disease, because of it’s importance, we agreed that even though the general role is that coding findings/signs/symptoms is optional when the underlying cause is known, that for bacteremia we should ALWAYS code it when present. Furthermore, that at the discretion of the data collector, it can be linked to another presumed infection (e.g. Klebsiella pneumonia linked to Klebsiella bacteremia), but if it’s not completely clear that they’re related, to leave the bacteremia as “free standing”. Allan will modify the wiki page for Bacteremia, the sepsis template -- DONE.

    Next Task Group Meeting: February 6, 2019 at 11am

    ICU Database Task Group Meeting – January 9, 2019

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

    1. Through discussion it became clear that there’s a need to modify the Kidney, renal tubular acidosis (RTA, all types) wiki page to clarify that by definition it is not an RTA if renal failure (acute or chronic) is present. Said another way, an RTA is a metabolic acidosis due to an inability of the renal tubules to excrete hydrogen ions in the presence of a normal creatinine clearance, as indicated usually by a normal creatinine. Allan will add this to the wiki article -- DONE.

    2. There was substantial concern voiced by Con and Joanna about how long the new system is taking to code. At this point it’s as much as 4-fold longer than before. We discussed possible reasons, which include:

    • ICD10 coding, though this is possibly less burdensome than is CCI coding.
    • The biggest single issue raised was that among the 5 CCI Collection Modes:
      1. Collecting "CCI collect each" items
      2. Collecting "CCI collect count each" items
      3. Collecting "CCI collect count days" items
      4. Collecting "CCI collect count units" items
      5. Collecting "CCI collect first" items
      • We recognized that we probably could downgrade most of ‘1’ to be one of the others
      • And that for at least some of ‘2’, '3' and '4' we could downgrade to ‘5’
        • We decided today to do that for HD, PD, CRRT and ICP monitoring (Done - Tina)
        • Allan will take a look at the entire list, especially CCI Picklist, and consider further items that can be downgraded.
    • Other options for reducing workload for CCI include: (i) compressing the number of body parts, (ii) reducing and/or compressing the number of “what was done to the body part” items.
    • We’ll discuss all this at next Task meeting.

    3. Julie raised the question of Charlson items -- specifically that previously most such items were allowed to be listed either as Admit Diagnosis or Comorbid Diagnosis. (See also Controlling Dx Type for ICD10 codes) The question is what do we want to do now about this. Allan will review both Charlson’s original description, and Quan’s administrative data implementation to see what THEY did regarding this --> DONE. The intention of this coding is to identify conditions that are present prior to admission. Thus, we should include admit and even acquired (post-admit) diagnoses for those Charlson items where it's pretty clear that the condition was almost certainly present prior to admission, even if that wasn't recognized -- and th is applies for 16 of the 17 Charlson conditions, i.e. all except "Myocardial infarction", and the only reason for that one being an exception is that there is an ICD10 code for Past history, myocardial infarction (old MI).

    4. It was noted that the Template:ICD10 Guideline Como vs Admit is very confusing. Allan will work on it. (Template was added to Allan's list)