July 2010 Data Submission Webinar

Cynthia Cadwell, MS CNS NP CPHQLindsey Wade, MPP

LINK TO DATA SUBMISSION WEBSITEwww.nhfca.org/PatientSafetyFirst

If you don’t have a log-in, contact Lindsey Wade at lwade@hasdic.org or (858) 614-1553.

Patient Safety First…a California Partnership Health is a statewide initiative funded by Anthem Blue Cross.

All 3 Regional Hospital Associations are partners in the initiative Hospital Council of Northern & Central California (HCNCC) Hospital Association of San Diego & Imperial Counties

(HASD&IC) Hospital Association of Southern California (HASC)

The National Health Foundation (NHF), a third-party organization who will act as a “clean room” to manage the data portal, data aggregation and statewide reporting.

Patient Safety First . . .

This new partnership is unprecedented in its scale and ambition. Hospitals throughout the state of California will be linked in a coordinated effort to improve patient safety through the sharing and implementation of best practices to reduce specific morbidity and mortality and improve patient care. The three areas of focus will be: Sepsis: Reduction of mortality Perinatal Care: Reduction of elective deliveries prior to 39 weeks and

associated birth trauma Hospital Acquired Infections. Reduction of:

Catheter associated urinary tract infections (CAUTI) Central line associated blood stream infections (CLBSI), and Ventilator-associated pneumonia (VAP).

Patient Safety First . . . California Partnership for Health will build upon established peer-to-peer learning networks such as the: San Diego Patient Safety Council, Bay Area Patient Safety Collaborative (BEACON), and Southern California Patient Safety Collaborative.

The project is funded by Anthem Blue Cross for 2010-2012

Participation by Regional Association

Hospital Association # Hospitals Committed to Participate

HCNCC Currently Recruiting

HASD&IC 20

HASC 90

Patient Safety First . . .

• The San Diego Patient Safety Council has been working to improve patient safety since 2005. The Patient Safety Council is comprised of representatives from acute facilities across multiple disciplines including nurses, pharmacists, physicians and other medical experts. Members review literature, apply process improvement methods, and share best practices to obtain consensus in building a comprehensive set of recommendations and toolkits to improve patient care.

• CURRENT PROJECT: Reducing the Mortality associated with Sepsis. The San Diego Patient Safety Council’s current project is to increase early identification and treatment of severe systemic infections (sepsis) in order to reduce severity and death rates countywide, thereby improving overall patient outcomes.

Perinatal Safety Collaborative HASD&IC is in the process of reaching out to the perinatal communities in San Diego

and Imperial Counties.

HASD&ICRegional Collaboratives

Importance of Data Submission

• Data ensures that we have the ability to measure progress

• Data measurement can engage and motivate staff through analysis such as lives saved calculations

• Data measurement allows the regional collaboratives and statewide partners to adjust our course based on results

• Consistent data measurement across the regions will allow hospitals to benchmark their individual performance against their region or the entire state and is a requirement of the project funder.

Data Submission Guidelines

• Quarterly data submission Q1: January 31—March 31 Q2: April 1—June 30 Q3: July 1—September 30 Q4: October 1—December 31

• Open data submission dates.

• Goals are based on three year timeline.

• We will ask for historic data to establish a baseline, although published

sources may also be used in some cases. Exception: where no data has

been collected, will use the intersection of the trend line at the beginning of the

sample period as the baseline value or current performance.

• Condition with small number, may already have high hospital performance,

and may not be able to improve further-so we will create a threshold for

absolute high performance.

VAP = ventilator-associated pneumoniaCLBSI = central line associated blood stream infectionsCAUTI = catheter-associated urinary tract infections

Snapshot: Data Measures

Focus Area Clinical Outcome Measured

Perinatal Care • Percentage of elective deliveries at <39 weeks gestational age weeks Birth trauma rate per 1,000 live births

Sepsis • Sepsis mortality rate

Hospital Acquired Infections: CAUTI CLBSI VAP

CAUTI rate per 1,000 patient days CLBSI rate per 1,000 central line days VAP rate per 1,000 ventilator days

Snapshot: Goals

Focus Area 3-Year Goals

Perinatal Care• Elective Deliveries Prior to 39 weeks• Birth Trauma

• Reduce elective deliveries prior to 39 weeks to 5% or less Reduce associated birth trauma by 25%

Sepsis 30% reduction in mortality

Hospital Acquired Infections: CAUTI CLBSI VAP

Zero infections

VAP = ventilator-associated pneumoniaCLBSI = central line associated blood stream infectionsCAUTI = catheter-associated urinary tract infections

SepsisBasics for Outcome Measures

Statewide Data Measure: Sepsis Mortality Rate

Data Source: Hospital Discharge DataNo statewide standard measure exists, therefore we provide a list of the ICD-9 codes recommended by the INLP (Integrated Nurse Leadership Program with the California Health Care Foundation). There is a separate attachment with all the codes.

Baseline: 2009 data results by quarter

Goal: 30% reduction in mortality within 3 years (Dec. 2012)

Patients who will be included in this data collection will be identified by discharge ICD-9 codes. The ICD-9 codes will be emailed to you in a separate excel document, which is also available on the data submission website. The goal being measured is mortality related to sepsis.

Sepsis Mortality Rate Calculation

# of patients who expired

# of sepsis patients X 100

Defining Sepsis

SepsisPrimary & Secondary Diagnoses

Primary Diagnosis: Commonly used sepsis codes (38.0 38.9 Septicemia codes) should be run as a primary range. About 90% of the sepsis cases are coded using this range of codes.

Secondary Diagnosis: Additional sepsis codes should be run as a secondary diagnosis. Running these codes will identify additional cases. (995.92 Severe Sepsis – one organ failure or 785.52 Septic shock)

Defining SepsisPopulation Inclusion Criteria

POPULATION INCLUSION CRITERIA

Per discharge data, all Patients 18 years of age or older

AND At least one of the ICD-9 codes from

Table 1 coded at discharge (Any patient with one of these ICD 9 codes.)

AND/OR At least one ICD-9 code from Table 2

PLUS At least one ICD-9 code from Table 3

coded at discharge. (Any patient with these combinations of ICD-9 codes.)

MORTALITY DEFINITION

Actual Mortality Number of discharged patients

identified in population who expired

Mortality Rate Percentage of discharged patients in

population who expired

Perinatal Gestational Age Delivery Basics for Outcome Measures

Definition: Percentage of elective deliveries at <39 weeks gestational age

Source: Data may reside in various places including sources such as: Hospital information system, Birth log, Medical Record

Baseline: 2009 results data by quarter

Goal: Reduce elective deliveries prior to 39 weeks gestational age to 5% or less within 3 years.

Perinatal Gestational Age Delivery Rate Calculation

# of elective deliveries at <39 weeks gestational age

# of elective singleton live births meeting criteria

Perinatal Gestational Age Delivery Population Inclusion Criteria

POPULATION INCLUSION CRITERIA

The number of elective* singleton live births meeting the following criteria: Gestational Age by best clinical estimate (usually US confirming LMP):

documented at 37+0 to 38+6 weeks inclusive (37-44 weeks)

*"Elective" = scheduled birth either CS or induction.  Induction includes all forms of induction: Oxytocin, prostaglandin, Foley, and AROM when not in labor. Elective CS also means that the woman is not in labor. Many repeat CS

are done in early labor but will not have an ICD9 code for labor as that does not exist. (See attachment for codes.)

Exclusions: Indications for delivery that make it not elective are the ACOG list or a woman with spontaneous labor on admission.

Definition: Birth trauma rate per 1,000 live births

Source: Hospital information system- administrative data, code based.

Baseline: 2009 results data by quarter

Goal: Reduce associated birth trauma by 25% within 3 years.

Perinatal Birth Trauma Rate Calculation

# of neonates discharged with an ICD-9CM code for birth trauma

# of all live newborns x 1000

Perinatal Birth TraumaBasics for Outcome Measures

Perinatal Birth Trauma Population Inclusion Criteria

POPULATION INCLUSION CRITERIA

Birth trauma diagnosis codes (see attached) Excludes infants with subdural or vertebral hemorrhage and diagnosis of pre-term

infant < 2,500 gram and < 37 weeks or </= 34 weeks. Excludes infants with injury to skeleton and any diagnosis of osteogenesis imperfect .

AHRQ – PSI 17 http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=12733

CAUTI Basics for Outcome Measures

Definition: Catheter Associated Urinary Tract Infection Rate, hospital acquired

Source: Hospital infection Preventionist captured from the medical record. A collection of positive blood cultures. NOTE: Routine information submitted to NHSN.

Baseline: 2009 results data by quarter

Goal: Zero catheter associated UTI’s within 3 years

CAUTI Rate Calculation

# of CAUTI

# of patient days X 1,000

Note: The CDC uses catheter days and not patient days as a denominator. There is a critical variance in an organization’s ability to capture the catheter information globally and know where all patients with catheters reside, creating reliability issues with the denominator

CLBSI Basics for Outcome Measures

Definition: CLBSI rate per 1,000 central line days. Use CDC definitions, attached and available here: www.cdc.gov/ncidod/dhqp/pdf/nhsn/NHSN_Manual_PatientSafetyProtocol_CURRENT.pdf

Source: Collection of cases via the infection Preventionist. NOTE: Routine information submitted to NHSN.

Baseline: 2009 results data by quarter

Goal: Zero infections within 3 years

CLBSI Rate Calculation

# of CLBSI cases in the hospital

# of central line days hospital wide

VAP Basics for Outcome Measures

Definition: VAP rate per 1,000 ventilator days. Use CDC definitions, attached and available here: www.cdc.gov/ncidod/dhqp/pdf/nhsn/NHSN_Manual_PatientSafetyProtocol_CURRENT.pdf

Source: Collection of cases via the Infection Preventionist. NOTE: Routine information submitted to NHSN.

Baseline: 2009 results data by quarter

Goal: Zero infections within 3 years

CLBSI Rate Calculation

# of VAP cases in the hospital

# of ventilator days

Hospital Data Contacts

Each hospital should provide their regional association with one data contact, who will receive a log-in and password for the data website.

The data contact is responsible for ensuring timely and accurate data submission and can disseminate login information to appropriate staff.

All individuals responsible for data entry should be trained to use the database prior to entering data.

If you don’t have a log-in, contact Lindsey Wade at lwade@hasdic.org

or (858) 614-1553.

Database & Data Security

The database can only be accessed using a log-in and password.

Each hospital’s data contact will receive this information.

If a data contact changes, a new password and log-in will be created and distributed.

All data entered is private, and will be de-identified for dissemination and reporting purposes. Please see the terms and conditions page for more information.

Please note data can be edited at any time by the data contact if necessary.

Data Entry

There are Two Separate Internal Links for Data Submission Within the Website:

All Measures CAUTI CLBSI Sepsis VAP

Perinatal Measures Perinatal Birth Trauma Perinatal Gestational age deliveries <39 weeks gestational age

Resources on the Data Website

Allows You to Create Reports Comparison Graphs Data Tables (export to excel)

Includes Materials Measure Definitions ICD-9 Codes Joint Commissions Specifications Manual

Data Submission Websitewww.nhfca.org/PatientSafetyFirst

HASD&IC Contacts

Please don’t hesitate to contact us with any questions!

Cynthia Cadwell, MS CNS NP CPHQVice President, Quality and Performance ImprovementCCadwell@hasdic.org(858) 614-1541

Lindsey Wade, MPPDirector, Health Policy & Patient SafetyLWade@hasdic.org (858) 614-1553