July 2010 Data Submission Webinar Cynthia Cadwell, MS CNS NP CPHQ Lindsey Wade, MPP

LINK TO DATA SUBMISSION WEBSITE If you don’t have a log-in, contact Lindsey Wade at or (858)

  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 Participation by Regional Association Hospital Association# Hospitals Committed to Participate HCNCCCurrently Recruiting HASD&IC20 HASC90 Patient Safety First...

The San Diego Patient Safety Council has been working to improve patient safety since 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&IC Regional 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 pneumonia CLBSI = central line associated blood stream infections CAUTI = catheter-associated urinary tract infections Snapshot: Data Measures Focus AreaClinical 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 Area3-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% Sepsis30% reduction in mortality Hospital Acquired Infections:  CAUTI  CLBSI  VAP Zero infections VAP = ventilator-associated pneumonia CLBSI = central line associated blood stream infections CAUTI = catheter-associated urinary tract infections

Sepsis Basics for Outcome Measures Statewide Data Measure: Sepsis Mortality Rate Data Source: Hospital Discharge Data No 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 ed 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

Sepsis Primary & Secondary Diagnoses Primary Diagnosis: Commonly used sepsis codes ( 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. ( Severe Sepsis – one organ failure or Septic shock)

Defining Sepsis Population 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 deliveries at <39 weeks gestational age # of elective singleton live births meeting criteria # 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 Trauma Basics 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

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: 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: 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 or (858)

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 Website

HASD&IC Contacts Please don’t hesitate to contact us with any questions! Cynthia Cadwell, MS CNS NP CPHQ Vice President, Quality and Performance Improvement (858) Lindsey Wade, MPP Director, Health Policy & Patient Safety (858)