Task Team Meeting - Rolling Agenda and Minutes 2024

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Also see Task Team Meeting - Rolling Agenda and Minutes 2022

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ICU Database Task Group Meeting – February 22, 2024

  • Present: Allan, Lisa, Julie, Tina, Mindy, Pam, Mailah, Joanna, Gail
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup about the dramatic (>5-fold) abrupt rise in Stage 1 and 2 decubs at Grace ICU only starting January 2022.

  • Allan reported that to date we have ruled out the following possible explanations: (a) change in data collectors, (b) change in format for recording decub data on the Grace ICU flowsheets, (c) change in instructions to Grace ICU nurses about collecting or recording decub information.
  • The next step is going to be a meeting with Lisa, Heather Smith, Allan and the Grace ICU nursing lead and educator. Lisa is arranging it.

2. Followup on ADT assignments at St. B.

  • Specifically, when patients go: ward area --> ICU-type area of the same service.
    • The problem is that the admitting office does not change the service and so in Cognos they don't show up as having come to an ICU.
    • What SHOULD happen is that when these patients go to an ICU, that the service should change to "ICU/Cardiac surgery" or "ICU/Cardiology" or even "ICU/Medicine".
  • Allan will contact Kim LeBlanc, head of admitting at St B to discuss this.

3. Followup on prone days during COVID, which is collected as a CCI procedure code

  • Julie presented this data and we see that over 2021, 2022, 2023 there is large variation both between ICUs.
  • There was a request for this information, but seeing this variation, the requester decided not to use our data on this. So we will not pursue this further at this time.

4. Followup on the fact that a small number/fraction of records have Visit Admit DtTm recorded as AFTER Admit DtTm.

  • Julie prepared data on this and it's rare in both ICU and Medicine, and furthermore, most of them differ by <2 hrs, which WOULD be of no real consequence for calculating LOS IF we used Visit Admit DtTm to calculate LOS, which according to Tina, we do not.
  • Tina identified that we use Visit Admit DtTm as part of the visit unique identifier, and thus we should NOT be altering it in general. In particular, we should not alter it if the only problem is that it's incorrect as evidenced by being after the Admit DtTm.
  • BUT we clarified that there is one situation in which Pagasa SHOULD still alter a Visit Admit DtTm -- i.e. when there are multiple records all as part of the same hospital episode, and for some reason they don't all agree on the Visit Admit DtTm ---> in THAT case, Pagasa should correct the incorrect Visit Admit DtTm, but in order to ensure it's correct, she should do so using cut/paste. As she's away, Julie will point this out to Pagasa
  • Allan emailed the requester today (Dr. Alex Grunfeld) to explain the situation and let him know his options.

5. Followup on issue of patients who present to ED at a given hospital and have ICU team involvement while in ED, but subsequently either die in ED or are transferred to another hospital (e.g. from Grace ED to Gold surgery at HSC). Specifically the question is about if/how to include them in the ICU database, and if so exactly when to code the ICU team as beginning to provide care.

  • Barret reported that after discussion with Heather Smith, at Grace ICU they will reinforce with all attendings that they need to put in an admit slip for such patients.
  • After discussion, we determined that this is not much of an issue at HSC or St. B, so we will close consideration of this issue now.

6. New issue relating to 2 sets of ICD10 diagnosis codes relating to drugs: (a) chronic abuse/addiction, and (b) acute toxicity/overdose.

7. Next meeting March 20 at 11 am.

ICU Database Task Group Meeting – January 11, 2024

  • Present: Allan, Lisa, Stephanie, Val, Julie, Mindy, Pam, Mailah, Joanna, Gail
  • Minutes prepared by: AG
  • Action items in BOLD

1. Followup discussion about patients who have different or otherwise contradictory postal codes during a single episode of care involving hospital-to-hospital transfers. There are 2 kinds of these:

  • FIRST: one hospital record indicates a valid postal code while the other has "na" for the code. There are 2 possible scenarios here:
    • (1) We note that the postal code field should contain "na" when the patient is homeless, and that homelessness per se is a response option in the data field of pre-admit location.
      • It became clear in discussion that the collectors spend considerable effort validating homelessness, so based on that we decided that when it is present in the pre-admit location field that we will take that as correct, and that all postal codes in that episode of hospital care (i.e. across the hospital-to-hospital transfers) should be fixed to be "na" and all the pre-admit locations should be listed as "homeless".
      • Furthermore, Julie will go back and make it so all past records meet this new rule as well.
      • Lisa will alter the Wiki so that it no longer says that for homeless patients who are living at a shelter, to list the postal code of the shelter. Instead it will say to list that postal code as "na".
    • (2) None of the pre-admit locations were "homeless". We decided when this occurs, Julie/Pagasa will work to discern the true situation.
  • SECOND: both hospital records list valid, but different, postal codes.
    • In discussion it was clear that there are numerous possible explanations for this and so we decided that when this occurs, Julie/Pagasa will work to discern the true situation.

2. Followup on item#3 in the November 2023 minutes, in regards to patients who present to ED at a given hospital and have ICU team involvement while in ED, but subsequently either die in ED or are transferred to another hospital (e.g. from Grace ED to Gold surgery at HSC). Specifically the question is about if/how to include them in the ICU database, and if so exactly when to code the ICU team as beginning to provide care.

  • The plan at that meeting was to start and figure out how to proceed at Grace, and thereafter to decide what to do for St. B and HSC. To get going on that, Barret was going to speak to Heather Smith.
  • As he was not able to attend today's meeting, Allan sent Barret an email today to inquire about that discussion. Awaiting reply.

3. About the dramatic and sustained increase in only Stage 1 and 2 decubitus ulcers starting January 2022, and only at Grace.

  • Gail & Mindy reported that although there had been a change in the ICU flowsheet at Grace, that this occurred before 2022, and that furthermore, the part of the new flowsheet recording decubs was identical to the old flowsheet.
  • In discussion we wondered whether this issue might be due to a change in education/guidelines for the Grace ICU nurses about identifying and recording early stage decubs. To try and get at that, Allan will directly contact the Nurse Educator at Grace ICU, Chantal Packulak.

4. Question about rationale and guidance around use/nonuse of vital signs during cardiac or pulmonary arrest for the APACHE values.

  • Allan explained the rationale for this, and augmented the Wiki page on APACHE values to explain it.
  • Beyond that, to operationalize the rule of NOT using any vitals from an arrest, the rule (which Allan included in the augmented Wiki page) will be that one can use vitals from all sources EXCEPT the Code Blue recording sheet.

5. Question about interfacility transfers between Hospital A and Hospital B when the patient is in a procedure location (e.g. cath lab, OR) in Hospital B prior to admission to Hospital B.

  • After discussion we agreed that: (a) the discharge time from Hospital A should be when the patient left to go to the procedure location, (b) the admit time to Hospital B should be when the patient was actually admitted there after the time in the procedure location, (c) in order to correctly identify EPISODES of care (i.e. with direct hospital-to-hospital transfer) she will need to look not only at the set of locations, but also the Prior Inpatient Location field. Lisa and Julie will update the Wiki accordingly.

6. Issue with the ADT assignments at St. B.

  • Specifically, when patients go: ward area --> ICU-type area of the same service
    • This could be:
      • Cardiac surgery ward --> OR --> CICU: and on cardiac surgery for all this
      • Cardiology ward --> ACCU: and on cardiology for all this
      • even sometimes Medicine ward --> ICMS
    • The problem is that the admitting office does not change the service and so in Cognos they don't show up as having come to an ICU.
    • What SHOULD happen is that when these patients go to an ICU, that the service should change to "ICU/Cardiac surgery" or "ICU/Cardiology" or even "ICU/Medicine".
  • Allan will contact Kim LeBlanc, head of admitting at St B to discuss this.

7. Next meeting is February 22, 2024 at 11 am

ICU Database Task Group Meeting – November 23, 2023

  • Present: Allan, Pagasa, Pam, Joanna, Barret, Julie, Brynn, Mailah, Val, Gail
  • Minutes prepared by: AG
  • Action items in BOLD

1. Regarding the prior idea to expand our ICD-10 coding to include ALL actual ICD-10-CA codes.

  • Lisa reports that while this was generally supported in talking to the data collectors, there was also a sense that we should delay further discussion on this until a more opportune time.

2. Julie reports that she has noted some patients who have different or otherwise contradictory postal codes during a single episode of care.

  • We note that postal codes derive from the ADT/Cognos system.
  • As it's unlikely that more than a trivial number of patients are moving residences over such a short timespan, we need more details about this and Julie will obtain such information for us to discuss at the next Task meeting.

3. An issue arose about patients who present to ED at a given hospital and have ICU team involvement while there, but subsequently either die in ED or are transferred to another hospital (e.g. from Grace ED to Gold surgery at HSC). Specifically the question is about if/how to include them in the ICU database, and if so exactly when to code the ICU team as beginning to provide care.

  • This question is complicated by a wide range of types of care provided by the ICU team in ED. It continuously spans from consultation with small actual involvement, all the way up to functionally taking over care while in ICU. While the latter should be included in the ICU database, the former should not. And of course there's everything in between.
  • Part of this is that putting in an ICU admission for such a patient in ED results in the ICU team having to write a discharge summary and transfer note -- which is paperwork we'd seek to avoid.
  • For Grace we discussed 2 possible solutions, both involving the ICU attending making a judgement for ED patients in whom they are contributing to care whether or not to count that person as "being on the ICU service" even if she/he never gets to an ICU in that hospital:
    • Actually put in an ICU admission
    • Don't put in an ICU admission, but record such patients in a separate portion of the ICU logbook.
    • Barret will discuss this with Heather Smith and report back at the next Task meeting.
  • After we come up with a solution for Grace, we will need to discuss solutions for HSC and St. B.

4. About coding decubitus ulcers.

  • We validated that when an acquired diagnosis should be entered for both de novo decubs that develop in ICU, and for progression of pre-existing decubs (e.g. from Stage 2 to Stage 3).
  • We also looked at data on ICU-acquired decubs from Grace over time. This arose because the rate of such ulcers developing or worsening in the Grace ICU seem much higher than in other ICUs. It is not clear whether Grace is high or other ICUs are low. Upon further assessment, these rates rose precipitously from last quarter of 2021 to the 1st quarter of 2022. Most likely this coincides with some change in how decubs are recorded.
    • Gail will seek information about if/how such changes in recording of decubs may have happened from Jan 2022 onwards.

2023...

Also see Task Team Meeting - Rolling Agenda and Minutes 2023