Data Abstraction Updates Changes effective with 1012006 discharges

1
Data Abstraction Updates Changes effective with
10/1/2006 discharges

• Surgical Care Improvement Project (SCIP)

Diana Smith, Senior Clinical IS
Specialist December 21, 2006
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Specifications Manual for National Hospital
Quality Measures

• Case Selection
• Initial selection of medical records must meet
  the following criteria
• Acute inpatient hospitalization ONLY
• All payor sources
• For topic specific populations, refer to Section
  2 (Measurement Information) and Section 4
  (Sampling Methods) of the Specifications Manual.

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Specifications Manual for National Hospital
Quality Measures

• Use the correct version of the Specifications
  Manual for National Hospital Quality Measures for
  the following
• Correct time frame for date of patients
  discharge
• Data Dictionary
• General Abstraction Guidelines
• Tables and Appendices
• Measure Information Form/Flowcharts

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Specification Manual for National Quality
Measures Version 2.1c

• Discharges 10/1/2006 Forward

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Specifications Manual for National Hospital
Quality Measures

• All SCIP Measures
• Charts must have ICD-9-CM Principal Procedure
  code from Table 5.10 to be abstracted.
• Documentation by Certified Registered Nurse
  Anesthetist (CRNA) is now included as acceptable
  physician documentation.

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Specifications Manual for National Hospital
Quality Measures

• Sampling
• Hospitals that sample must use CMS/JCAHO Sampling
  Methods (Section 4 in manual)
• Two methods of random sampling allowed
• Systematic (i.e., select one random number, and
  select subsequent numbers by using interval)
• Random (i.e., select a group of random numbers)

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Specifications Manual for National Hospital
Quality Measures

• New Sampling Methodology
• Average Quarterly Strata Population Size
• Minimum Strata Sample 16
• Maximum Strata Sample 48
• Average Monthly Strata Population Size
• Minimum Strata Sample 6
• Maximum Strata Sample 16

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Example SCIP Sampling by Quarter Q4 2006
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New SCIP Measures
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Data Dictionary Version
4.1-10/1/06
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Data Dictionary Version
4.1-10/1/06

• New SCIP Measures
• Card -2 Surgery patients on beta blocker therapy
  prior to admission who received beta blocker
  during the perioperative period
• VTE-1 Surgery patients with recommended venous
  thromboembolism prophylaxis ordered
• VTE-2 Surgery patients who received appropriate
  venous thromoembolism prophylaxis within 24 hours
  prior to surgery to 24 hours after surgery

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Data Dictionary Version
4.1-10/1/06

• New SCIP Data Elements
• Beta Blocker Current Medication
• Beta Blocker Perioperative
• Contraindications to Beta Blocker Perioperative
• Contraindication to VTE Prophylaxis
• Discharge Time
• Documented Bleeding Risk

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Data Dictionary Version
4.1-10/1/06

• New SCIP Data Elements continued
• Neuraxial Anesthesia
• Perioperative Death
• Preadmission Warfarin
• VTE Laparoscope
• VTE Prophylaxis
• VTE Timely

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Data Dictionary Version
4.1-10/1/06

• Beta Blocker Current Medication - New
• Notes for Abstraction
• If there is documentation that the beta blocker
  was a home or current medication, select
  Yes.
• If there is no documentation that the patient was
  on beta blocker therapy prior to admission or if
  unable to determine medical record documentation,
  select No.

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Data Dictionary Version
4.1-10/1/06

• Beta Blocker Perioperative - New
• Is there documentation that a beta blocker was
  received during the perioperative period?
• Options Yes or No (UTD)
• Note The perioperative period for the SCIP
  cardiac measures is defined as 24 hours prior to
  surgical incision through discharge from the post
  anesthesia care/ recovery area.

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Data Dictionary Version
4.1-10/1/06

• Contraindications to Beta Blocker-Preoperative -
  New
• Was there documentation of reasons for not
  prescribing a beta blocker during the
  perioperative period?
• Options Yes or No (UTD)
• Yes - There is documentation that the patient has
  one or more of the following reasons for not
  prescribing a beta blocker during the
  perioperative period
• Bradycardia (heart rate less than 60 bpm)
• Other reasons documented by MD, NP, PA, CRNA

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Data Dictionary Version
4.1-10/1/06

• Contraindications to VTE Prophylaxis - New
• Is there documentation by a physician (NP, PA or
  CRNA) in the medical record of contraindications
  to both pharmacological and mechanical VTE
  prophylaxis?

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Data Dictionary Version
4.1-10/1/06

• Discharge Time - New
• What was the time (military time) the patient was
  discharged from acute care, left against medical
  advice (AMA), or expired during this stay?
• Note Do not use the time the discharge order
  was written as it may not represent the actual
  time of discharge.

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Data Dictionary Version
4.1-10/1/06

• Discharge Time - New
• Notes for Abstraction
• Use the priority order listed in data sources
  for patients who are discharged from acute care,
  left AMA, or transferred to another facility.
• Nurses Notes
• Discharge or transfer form
• Face sheet
• UB-92, Field Location 21 use if unable to
  locate discharge time on the other priority forms.

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Data Dictionary Version
4.1-10/1/06

• Discharge Time - New
• Notes for Abstraction (contd)
• For patients who expire (priority order)
• - Resuscitation record
• Physician progress notes
• Physician orders
• Nurses notes
• Use the time of death as discharge time

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Data Dictionary Version
4.1-10/1/06

• Documented Bleeding Risk - New
• Is there any documentation by the physician
  (NP,PA, OR CRNA) of a risk of bleeding?
• Options Yes or No
• Inclusions
• Risk for bleeding
• Bleeding risk
• Note Patient may still be eligible for
  mechanical prophylaxis unless contraindications
  to both mechanical and pharmacological
  prophylaxis are documented.

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Data Dictionary Version
4.1-10/1/06

• Neuraxial Anesthesia - New
• Definition
• Anesthesia defined as medication administered
  into the epidural space or spinal canal to block
  sensations of pain
• Notes for Abstraction
• Inclusions
• Epidural
• Spinal
• Intrathecal anesthesia

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Data Dictionary Version
4.1-10/1/06

• Perioperative Death - New
• Is there documentation that the patient expired
  during the time frame from surgical incision
  through discharge from the post anesthesia
  care/recovery area?
• Options Yes or No (UTD)
• Note For this data element, the time frame for
  perioperative death is from surgical incision
  through discharge from the post anesthesia
  care/recovery area.

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Data Dictionary Version
4.1-10/1/06

• Preadmission Warfarin - New
• Notes for Abstraction
• If there is documentation that warfarin was a
  home or current medication, select Yes.
• If warfarin was listed as a home or current
  medication, but put on hold prior to surgery,
  select Yes.

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Data Dictionary Version
4.1-10/1/06

• VTE Laparoscope - New
• Was the procedure performed entirely by
  laparoscope?
• Options Yes or No (UTD)
• Notes for Abstraction ICD-9-CM codes may not be
  a reliable source to determine if the procedure
  was performed entirely by laparoscope.

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Data Dictionary Version
4.1-10/1/06

• Venous Thromboembolism (VTE) Prophylaxis - New
• What venous thromboembolism prophylaxis was
  ordered during this admission?
• Notes for Abstraction
• Prophylaxis can be ordered any time during this
  admission.
• Only acceptable data source Physician orders

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Data Dictionary Version
4.1-10/1/06

• VTE Timely - New
• Is there documentation that the ordered VTE
  prophylaxis was received within 24 hours prior to
  surgical incision time to 24 hours after surgery
  end time?
• Answer Yes if there is documentation the
  patient received VTE prophylaxis within the above
  parameters.
• Answer No if no documentation of above or
  unable to determine from medical record
  documentation.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 1 3
• Antibiotics are collected from admission through
  first 48 hours post-op (72 hours for CABG or
  Other Cardiac).
• Antibiotics given in the ED for patients
  eventually admitted should be collected.
• Clarification for Antibiotic Administration Time
  states collect the time the infusion (IV) was
  started and Perfusion record has been added as a
  data source.
• For Antibiotic Allergy, a physician documented
  reason for not administering the antibiotic will
  now be accepted.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 1 3
• Antibiotic Received now collected for SCIP and
  contains the information previously collected
  with Antibiotics During Stay and Antibiotics
  Prior to Arrival. Those 2 elements have been
  removed.
• Admission Diagnosis of Infection and Early
  Antibiotics are removed.

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Data Dictionary Version
4.1-10/1/06

• SCIP-Inf-1, 2, 3, 4 7
• Infection Prior to Anesthesia and Postoperative
  Infection
• Definition Change
• Its no longer, Was the patient being treated
  for an infection?
• Now its, Did the patient have an infection
  during this hospitalization prior to the
  principal procedure?
• Penetrating abdominal trauma has been added to
  Inclusion list for Infection Prior to Anesthesia.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 1 Antibiotic Timing
• SCIP Inf 3 Antibiotic Discontinuation
• SCIP Inf 6 Appropriate Hair Removal
• No clinical changes made to these measures.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 2 Appropriate Antibiotic Prophylaxis
• Updated Medication Table
• Cefamandole and Cefmetazole have been removed
  from recommended antibiotic table.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 3 - 4 Surgery End Date/Time
• If a patient leaves the OR with an open incision,
  use the date and time of the initial procedure.
• Do not use the date and time the patient returns
  to the OR for closure.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 4 Normoglycemia in Cardiac Surgery
  Patients
• Clarifications to Glucose POD1 and Glucose POD2
• Laboratory values of blood glucose take
  precedence over bedside values when collected at
  the same time.
• When two or more values qualify as the closest to
  0600 am, the earliest value should be collected.

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Data Dictionary Version
4.1-10/1/06

• SCIP Inf 7 Normothermia in Colorectal Surgery
  Patients
• Temperature Value
• Add to the Inclusions
• Skin surface temperatures
• Temporal artery temperatures
• Remove from the Exclusions
• Skin surface temperature

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Data Dictionary Version
4.1-10/1/06

• Appendix A ICD-9-CM Code Tables
• Tables 5.17 5.24 added to provide the provide
  the ICD-9-CM Procedure codes used to determine
  the measure-specific population for VTE-1 and
  VTE-2
• Exclusion Tables are
• Table 5.09 Infections
• Table 5.14 Burns
• Table 5.15 Transplants

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Data Dictionary Version
4.1-10/1/06

• VTE ICD-9-CM Code Tables
• 5.17 Intracranial Neurosurgery
• 5.18 Elective Spinal Surgery
• 5.19 General Surgery
• 5.20 Gynecological Surgery
• 5.21 Urological Surgery
• 5.22 Elective Total Hip Replacement
• 5.23 Elective Total Knee Replacement
• 5.24 Hip Fracture Surgery

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Data Dictionary Version
4.1-10/1/06

• Appendix C Medication Tables
• Updated Medication Table
• Table 2.14 added For Quinolones - Parental

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Data Dictionary Version
4.1-10/1/06

• Appendix H Miscellaneous Tables
• Table 1.9 removed Surgery Performed During Stay.
• Table 2.1 added for VTE Prophylaxis Inclusion.
• Table 2.2 added for VTE Prophylaxis Exclusion.

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SCIP and Validation
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SCIP and Validation

• All measures submitted to QIO Clinical Warehouse
  are subject to validation, but not all are
  included within the scoring aspect.
• Refer to the Data Validation tab on QualityNet
  for the Data Validation Inclusion List posted
  11/28/2006.

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SCIP and Validation

• Only elements identified within the listed time
  periods will be scored
• SIP measures will continue as usual through
  06/30/2006 discharges.
• SCIP measures will begin being scored beginning
  with 07/01/2006 discharges.

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SCIP and Validation

• For discharges 07/01/2006-12/31/06 the SCIP Inf-4
  thru 7 will be validated (educational comments
  provided) but NOT included in the score.
• This educational information will provide
  feedback to providers on their abstractions and
  allows them to become familiar with the elements
  and scoring.

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SCIP and Validation

• Beginning with 01/01/07 discharges this document
  will be updated again and scoring may be
  included.
• After 01/01/07 discharges, if these elements are
  tagged and blank they will be counted as
  mismatches.

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SCIP and Validation

• If your vendor is submitting your data to the
  Clinical Data Warehouse and does not have these
  questions tagged, it will not adversely affect
  validation.
• If the elements are tagged, this tells the
  warehouse to expect these elements and that
  your vendor will be submitting them, but if this
  information is missing or blank, these will be
  counted as mismatches.

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Next Steps

• Identifying SCIP cases
• Determining sampling strategy
• Abstracting cases
• Data feedback
• Identifying areas for improvement

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Resources

• Specifications Manual for National Hospital
  Quality Measures http//xrl.us/stcp
• QualityNet Quest http//xrl.us.s4yv
• MedQIC http//xrl.us/to9y
• PHA http//www.gha.org/pha/
• GMCF http//www.gmcf.org

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The Right Care for Every Person Every Time.
This material was prepared by GMCF under contract
with the Centers for Medicare Medicaid Services
(CMS), an agency of the U.S. Department of Health
and Human Services. The contents presented do not
necessarily reflect CMS policy. Publication No.
8SOW-GA-HOSP-06-141