Task Team Meeting - Rolling Agenda and Minutes 2024

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Gangrene, NOS	can we use this code for necrosis or necrotic wounds? Lisa Kaita 11:57, 2024 April 17 (CDT) discussed at April 24 TASK Allan will give this thought and address it at next TASK Lisa Kaita 20:01, 2024 April 24 (CDT)	2024-04-25 1:01:29 AM
Query s tmp Boarding Loc ER delay reasonable	There are many false positives due to ICU delays shorter than 30 mins. Do we want to change anything about that threshold? Discussed with Julie and Lisa today but can't remember the outcome. Ttenbergen 10:58, 2024 April 24 (CDT) No we are fine with the thresholds, collectors are not happy about how many times the soft check prompts them, at least 3 when checking off the box, and then a couple more when we complete the file, you were going to think about this more Lisa Kaita 15:59, 2024 April 24 (CDT)	2024-04-24 8:59:31 PM
Sepsis (SIRS due to infection, without acute organ failure)	How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT) discussed at TASK April 24, Dr Ziegler is researching various definitions of septic shock and will speak to this at next TASK Lisa Kaita 19:57, 2024 April 24 (CDT)	2019-03-09 9:24:42 PM
Severe sepsis	How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT) discussed at TASK April 24, Dr Ziegler is researching various definitions of septic shock and will speak to this at next TASK Lisa Kaita 19:57, 2024 April 24 (CDT)	2019-10-31 3:04:29 PM
Severe sepsis	How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT) discussed at TASK April 24, Dr Ziegler is researching various definitions of septic shock and will speak to this at next TASK Lisa Kaita 19:57, 2024 April 24 (CDT)	2022-02-17 10:56:05 PM
Shock, septic	How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT) discussed at TASK April 24, Dr Ziegler is researching various definitions of septic shock and will speak to this at next TASK Lisa Kaita 19:57, 2024 April 24 (CDT)	2019-01-10 7:32:04 PM
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)	2024-04-08 4:27:53 PM
Stroke, NOS	we need clarification on when to use this code, eg. if there is a history where it says a history of stroke, or if on CT they comment remote lacunar infarcts? Lisa Kaita 12:01, 2024 April 17 (CDT)	2024-04-17 5:01:53 PM
Template:ICD10 Guideline Sepsis	How hard of a rule is lactate >2? If they meet the criteria for septic shock with the exception of a high enough lactate, can we code septic shock Lisa Kaita 12:17, 2024 April 17 (CDT) discussed at TASK April 24, Dr Ziegler is researching various definitions of septic shock and will speak to this at next TASK Lisa Kaita 19:57, 2024 April 24 (CDT)	2024-04-25 12:57:46 AM

Also see Task Team Meeting - Rolling Agenda and Minutes 2022

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ICU Database Task Group Meeting – April 24, 2024

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

1. Jen Ziegler needs Wiki access, Tina/Lisa will obtain it for her. Done April 24, 2024

2. Lisa related that the data collectors are having weekly Coding Review meetings, with questions that remain being put on the Task Group wiki page.

3. New item: For the definition of Shock, septic , are BOTH pressors and lactate>2 required?

• There are different definitions of septic shock, and Jen will look them up to help inform our decision on this.

4. New item: After discussion we agreed that a diagnosis that in retrospect was clearly "brewing" at admission but did not reach the threshold for being present until after admission would be coded as an Admit Diagnoses rather than an Acquired Diagnosis as long as it became fully evident within 6 hours of admission. Allan changed the Wiki page on this.

5. New item: Regarding necrotic open wounds and whether they should be coded as Gangrene, NOS

• This is difficult as a necrotic open wound may be due to severe infection of the wound, rather than truly being gangrene, which is due to lack of perfusion to a body part.
• For traumatic open wounds (e.g. Thorax, open wound, injury/trauma this INCLUDES necrotic wounds. But for nontraumatic open wounds there is no general code or group of codes equivalent to those trauma codes.
• There are, however, some appropriate specific codes that include necrotic nontraumatic wounds -- these include Diabetes mellitus chronic complication: Foot ulcer, and the multiple codes for decubitus ulcers. For OTHER types of necrotic, nontraumatic wounds use Skin ulcer, NOS.

6. New item: How to code an iatrogenic nontraumatic Hemothorax or hemopneumothorax, nontraumatic:

• After discussion we decided that for this purpose we will combine Hemothorax or hemopneumothorax, nontraumatic with Iatrogenic, puncture or laceration, related to a procedure or surgery NOS. Lisa has made the change on the Wiki.

7. New item: For the various hypothermia codes (Hypothermia, due to exposure/low environmental temperature,Hypothermia, not due to low environmental temperature/exposure) is there a temperature threshold that should be used.

• After discussion we agreed that the answer is NO. Hypothermia codes should be used if the body temperature is low AND either (a) active rewarming is used, including simple methods such as a bearhugger, or (b) the patient has clinically relevant consequences of the hypothermia. Lisa made change to the Wiki.

8. Followup on item#6 from the prior meeting: whether ET-tube balloon rupture should be considered as Failed/difficult intubation, or complication of intubation‎, or complication of intubation.

• Discussion centered around whether to code this if there were no real complications related to the rupture, or if it was not due to an iatrogenic event such as over-inflating the balloon. It was finally decided that even just replacing the tube is a recognition by the team that there COULD be a consequence, even if it has not occurred yet. So again this code can be used even if the rupture was just due to breakdown of the device (i.e. no iatrogenic issue) and even without a clear clinical consequence IF the tube was replaced.

9. New item: Rewording of what is now called Q-wave (transmural) and non-Q-wave (subendocarial or non-transmural) MI.

• After discussion we agreed, to be consistent with new ICD-10 wording, we will add, respectively, the words STEMI and non-STEMI to these titles:
  • Myocardial infarction (STEMI), acute (AMI), transmural (Q-wave)
  • Myocardial infarction (NSTEMI), acute (AMI), subendocardial/non-transmural (non-Q-wave)

10. Next meeting is May 22 at 11 am.

ICU Database Task Group Meeting – March 20, 2024

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

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

• Allan reported that a Zoom meeting was held, including himself, Lisa, Julie, and the nursing leadership (Tatiana, Chantal) at Grace ICU. Discussion included:
  • The bedside nurses do not specifically record the location/stage of decub. Instead they use free text to describe skin issues, and thereafter our data collectors interpret the free text. Thus, there are two places for misinterpretation and errors. This is true in all the ICUs, not just Grace.
  • We agreed that it'd be optimal for the location where bedside nurses record skin issues to have check boxes for each of Stage 1-4 decubs, BUT, changing paper documentation that's included in official hospital charting is a long process. We will, however, push for including such including such changes when the appropriate documents come up for revision in the future.
  • We agreed that for now, we will not be able to figure out what accounted for the dramatic rise in January 2022 at Grace. Instead, we agreed that the effort should be to in-service all ICU nurses at all sites on: (a) the Staging of decubs, and (b) instructing them to explicitly document decubs by stage (e.g. Stage 2 over coccyx; Stage 4 over left heel).
  • This is already occurring at Grace ICU
  • For the other ICUs, the plan is that it will go through the OIT committee. Julie informed us that that group did begin to discuss it, and after today's meeting Allan spoke with Carment Hrymak highlighting all of this. She indicated that OIT is considering no longer tracking Stage 1 decubs, especially since they are the most subtle and most prone to erroneous identification.
• It was observed that this is also a problem in Medicine wards. Given the greater number of people involved in Medicine, and the lack of a Quality/OIT infrastructure, we decided to see if the problem can be first fixed in ICUs and then go on to wards from there.

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 reported that he spoke with Kim LeBlanc, head of admitting at St B.
  • She related that for such transfers, the admitting office is NOT currently involved in making the entries in ADT, this is done by the unit clerk, and she is not even certain whether it is done by the sending or receiving clerk. However, she will look into it and get back to Allan.

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

• The only new followup here is that modification was made to the Visit Admit DtTm page to make explicit that users should not consider that variable to faithfully represent the time of hospital admission.

4. New item: whether or not to code Shock, septic when there is also another possible cause of shock present.

• Discussion included that: (a) it is possible to have multiple, simultaneous causes of shock, but usually not, (b) any non-cardiogenic shock can cause acute MI in persons with ischemic heart disease, (c) response to treatment can often help sort out whether a person with infection -- but also with another good reason for shock -- has septic shock or not.
• To deal with this the Wiki page for Shock, septic now reads "septic shock should not be called if there is another more obvious cause for shock".

5. New item: for CCI items that include Drainage, Evacuation, how to interpret the instruction to "code each".

• After discussion we clarified that this means to code each new drainage device that is inserted, NOT to code each time the drainage bag is emptied.

6. New item: whether ET-tube balloon rupture should be considered as Failed/difficult intubation, or complication of intubation.

• After discussion we agreed the answer is "no". However, IF the rupture was due to an iatrogenic event (e.g. excessive air was put into it) then it could be coded as Iatrogenic, mechanical complication/dysfunction, internal prosthetic device or implant or graft NOS .

7. Next meeting April 24 at 11 am

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.

• It has been noticed that there are records where chronic abuse/addiction are listed as Acquired Diagnoses, which is in fact very rare. Lisa is checking some of these charts for validity.
• It has been noticed that there are records where acute toxicity/overdose is listed as Acquired Diagnoses. This CAN occur in 2 ways: (i) iatrogenic, or (ii) the patient takes non-prescribed drugs or substances either while in hospital or during a day pass.
  • Allan pointed out that in a list of these compiled by Julie, most were for narcotics, and only a minority had a code also linked to it for an iatrogenic overdose/toxicity. Lisa is checking some of these for validity.
  • It was clarified that when a patient has an iatrogenic acute toxicity/overdose, collectors should link codes for: the specific drug involved (e.g. Benzodiazepine, overdose/toxicity, Drug or biological substance/agent NOS, overdose/toxicity), that it's iatrogenic i.e. Iatrogenic, complication of medical or surgical care NOS, and the consequence e.g. Somnolence, stupor or obtundation.

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