Task Team Meeting - Rolling Agenda and Minutes 2019

List of items to bring to task meeting

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

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Hemothorax or hemopneumothorax, nontraumatic	Just wondering whether this code could be combined with iatrogenic causes similar to the guideline for: Guideline for Iatrogenic Pneumothorax According to our general rule of not coding iatrogenic events as traumas, code an iatrogenic pneumothorax as Iatrogenic, puncture or laceration, related to a procedure or surgery NOS Plus the most appropriate of the following; Pneumothorax, tension, nontraumatic Pneumothorax, nontension, nontraumatic Pneumothorax, nontraumatic, NOS Thanks, Pamela Piche 08:55, 2024 March 19 (CDT) Allan made the initial entry of not to use this as an iatrogenic or trauma code in 2017, so let's discuss this at TASK Lisa Kaita 15:03, 2024 April 5 (CDT)	5 April 2024 20:03:05
Iatrogenic, mechanical complication/dysfunction, internal prosthetic device or implant or graft NOS	At our last TASK meeting the decision was made to exclude spontaneous rupture of an ETT cuff or cuff leak, but we are wondering if this is correct based on what is listed in the includes section of this page and what is in Iatrogenic, mechanical complication/dysfunction, internal orthopedic prosthetic device or implant or graft or bone device and Iatrogenic, mechanical complication/dysfunction, cardiac or vascular prosthetic device or implant or graft, NOS Lisa Kaita 12:37, 2024 March 20 (CDT)	20 March 2024 17:37:32
Myocardial infarction, acute (AMI), NOS	ICD 10 has this code for STEMI: 2024 ICD-10-CM Diagnosis Code I21.3 ST elevation (STEMI) myocardial infarction of unspecified site that includes transmural (Q wave) infarction ICD 10 has this code for NSTEMI: 2024 ICD-10-CM Diagnosis Code I21.4 Non-ST elevation (NSTEMI) myocardial infarction that includes Nontransmural myocardial infarction NOS Would it be less labor intensive for collectors to be able to use these codes instead of MI codes dependent upon development (or not) of Q waves as this is problematic to determine. Thank you, Pamela Piche 07:49, 2024 April 5 (CDT) I have added this to TASK, in 2019 ICD 10 did not have STEMI/NSTEMI codes, now in the 2024 version they do, I agree with Pam can we switch to the new codes? Lisa Kaita 15:10, 2024 April 5 (CDT)	5 April 2024 20:10:42
STB ICUs VAP Rate, CLIBSI Rate Summary	IIRC we collected CAM positive (TISS Item) specifically for this, right? If so, can we stop collecting it? And can we make sure a stoppage like this in the future results in reviewing what we collect? Ttenbergen 10:02, 2024 March 20 (CDT) Delirium rate per 1000 days per unit is being reported in the OIT Reports. ---JMojica 11:49, 2024 March 20 (CDT) As in Delirium days is reported in Critical Care Program Quality Indicator Report? But that doesn't mention anything about per-1000-days. Ttenbergen 17:00, 2024 March 20 (CDT) The rate is mentioned in the succeeding definition with the delirium days as numerator. Your proposal here is to stop collecting TISS item CAM positive which I disagree because that TISS item is being used and reported as rate in OIT Report. Besides, the reason why it was dropped in in the STB VAPCLI report is because the requestor has changed. Brett Hiebert who used to request this was involved in the VAP group and another Delirium group so he asked to have both as one request. Brett had left and the VAP group filled up a new request to continue the VAP data and not on the delirium data. --JMojica 13:58, 2024 March 25 (CDT)	8 April 2024 16:27:53

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

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 be whatever acute issues are involved and Brain death

If they are not brain dead when they leave why would their admit dx be brain death? What are we doing to these people in transit?

• SMW

• Cargo

• Categories

pls have a look at Deceased_patients#organ_donor - we need to address which time to use for death in this case - actual time of death, or time they left the unit?

• SMW

• Cargo

• Categories

• For those who are declared brain dead at the Transfer from location, their diagnoses in record will include Brain death, and in addition, the 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

Julie, which reports and what linking will be affected by this, so we can update the related wiki pages? Firstly, Medicine is the only one which report linked admissions during a hospitalization. If a medicine patient happens to go to an ICU, died, an organ donor and move to another ICU , this rule is saying do not consider the second ICU. what will be the LOS of that hospitalization - I presume this rule will exclude the second ICU stay, is that correct? 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, readmission, mortality, transfer delays, occupancy which are included in the regular CC and Med 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 error, 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)

• SMW

• Cargo

• Categories

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
  • 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.

• For the former it’s Emphysema, mediastinal or interstitial -- that article explicitly says so
• For the latter it’s Disorder of peritoneum, NOS -- and that article has been modified to say so.

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:

• If it is therapeutic, then combine the joint in question with Drainage, Evacuation
• If it is diagnostic, then use CCI picklist item Arthrocentesis, diagnostic

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 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:

• This person should have Chronic kidney disease (end-stage kidney disease, ESRD), Stage 5 as a comorbid, then have CCI coding for the transplant, and THEN as an acquired diagnosis can have things like: Kidney, acute renal failure NOS and Kidney transplant, failure or rejection or unspecified complication . Allan has modified this latter article to make clear that it includes injury to the transplanted kidney of any level, total or partial or temporary. Tina will ensure that the error trapping in place allows an individual to have ESRD as a comorbid and AKI in the same record only if the person also has a CCI code for the kidney transplant OR has the ICD10 code of Past history, transplanted kidney.
• But should not use Kidney, acute renal failure, postprocedural -- as this code is for kidney failure from another type of procedure. Allan has now modified that article to make that clear.

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).

Charlson Admit Como - I have put several related pages on your list that start with the same words as this one. We need to update them to make sense with any change to this. Some still had other questions in them anyway. AG REPLY --- tina and ag to go through all the separate ICD10 codes Charlson Comorbidities in ICD10 codes that make up the 17 Charlson conditions and one by one decide if they can be included in Charlson EVEN IF they're admit or acquired diagnoses.

• SMW

• Cargo

• Categories

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)