Transcript VTE Data Collection - K-HEN

VTE Prevention
K-HEN Data Collection
& Submission
Dolores Hagan, RN BSN
K-HEN Education and Data Manager
August 2012
Objectives
• Review reporting requirements
• Review K-HEN recommended measures
• Review the specifications for monitoring
data (Inclusion and exclusion criteria)
• Discuss requirements for baseline data
• Define data entry and submission timeline
• Identify measures that may be pulled
from other systems where data is
currently being entered
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Reporting Requirements
• For each topic area chosen, hospitals are
required to submit data for at least
– One process measure AND
– One outcome measure
• Hospitals are strongly encouraged to
report on the K-HEN recommended
measures
• Additional outcome and/or process
measures may be selected and reported as
desired
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K-HEN Recommended Measures
• Purpose—standardize reporting on the same
measures across the state for robust
benchmarking capability
• Measures selected based on polling data from
the KHA Quality Conference in March 2012
• Have continued to evolve with your feedback
(Keep it coming! )
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HRET HEN Encyclopedia of Measures
• Lists all measures available in the CDS
• Defines the numerator and denominator for
each measure
• Provides a link to the source of the measure
• http://www.khen.com/Portals/16/Documents/HRET_HEN_
Encyclopedia_of_MeasuresV3.pdf
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VTE Outcome Measures
Preferred Measure: #103 Potentially
preventable VTE (JC VTE-6)
The number of patients with confirmed VTE
during hospitalization (not present at admission)
who did not receive VTE prophylaxis between
hospital admission and the day before the VTE
diagnostic testing order date
Alternate Measure: #104 Post-op PE or DVT
(All adults) (AHRQ PSI 12)
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#103 VTE Outcome Measure Criteria
• Numerator: Patients who received no VTE
prophylaxis prior to the VTE diagnostic test
order date
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#103 VTE Outcome Measure Criteria
• Denominator: Patients who developed
confirmed VTE during hospitalization
Inclusions: Discharges with an ICD-9-CM Other
Diagnosis Codes of VTE as defined in Appendix
A, Table 7.03 or 7.04
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#103 VTE Outcome Measure Criteria
Exclusions:
–
–
–
–
–
Patients less than 18 years of age
Patients who have LOS > 120
Patients with Comfort Measures Only documented
Patients enrolled in clinical trials
Patients with ICD-9-CM Principal Diagnosis Code of VTE
as defined in Appendix A, Table 7.03 or 7.04
– Patients with VTE Present at Admission
– Patients with reasons for not administering mechanical
and pharmacologic prophylaxis
– Patients without VTE confirmed by diagnostic testing
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#104 VTE Outcome Measure Criteria
• Numerator—Discharges among cases
meeting the inclusion and exclusion rules
for the denominator with ICD-9 codes for
deep vein thrombosis or pulmonary
embolism in any secondary diagnosis field
(Codes listed in Encyclopedia of Measures
and AHRQ PSI #12 documentation)
Source: AHRQ Patient Safety Indicators
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#104 VTE Outcome Measure Criteria
• Denominator—All surgical discharges age
18 and older defined by specific DRGs or
MS-DRGs and an ICD-9 code for an
operating room procedure (AHRQ Patient
Safety Indicator Appendices)
Source: AHRQ Patient Safety Indicators
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VTE Process Measures
Preferred Measure: #100 VTE patients
receiving unfractionated heparin with
dosages/platelet count monitoring by
nomogram or protocol (JC VTE-4)
Alternate Measure: #99 VTE discharge
instructions for patients with confirmed
VTE (JC VTE-5)
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#100 VTE Process Criteria
• Numerator: Patients with confirmed VTE
who have their IV UFH therapy dosages
AND platelet counts monitored according
to defined parameters such as a nomogram
or protocol
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#100 VTE Process Criteria
• Denominator—Patients with confirmed VTE
receiving IV UFH therapy
Inclusions: ICD-9 principal or other diagnosis codes
of VTE (Appendix A Table 7.03 or 7.04)
Exclusions:
–
–
–
–
< 18 years of age
LOS > 120 days
Comfort measures only documented
Enrolled in clinical trials
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#100 VTE Process Criteria
Denominator Exclusions:
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< 18 years of age
LOS > 120 days
Comfort measures only documented
Enrolled in clinical trials
Discharged to a health care facility for hospice care;
home for hospice care; AMA; another hospital
– Expired
– Patients not without VTE confirmed by diagnositic
testing
– Patients without UFH therapy administration
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#99 VTE Process Criteria
• Numerator—Patients with documentation
that they or their caregivers were given
written discharge instructions or other
educational material about warfarin that
addressed all of the following:
– Compliance issues
– Dietary advice
– Follow-up monitoring
– Potential for adverse drug reactions and
interactions
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#99 VTE Process Criteria
• Denominator—Patients with confirmed VTE
discharged on warfarin therapy
Inclusions:
– Discharges with an ICD-9-CM Principal or Other
Diagnosis Codes of VTE as defined in Appendix
A, Table 7.03 or 7.04
– Discharged to home, home care or court/law
enforcement
– Discharged to home for hospice care
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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#99 VTE Process Criteria
Exclusions:
– Patients less than 18 years of age
– Patients who have a length of stay greater than
120 days
– Patients enrolled in clinical trials
– Patients without Warfarin Prescribed at
Discharge
– Patients without VTE confirmed by diagnostic
testing
Source: JC Specifications Manual for National Hospital Inpatient Quality Measures v4.1.1
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Baseline Data
• Only submitted one time
• For all topic areas except Readmissions:
– Baseline data is from 2011 prior to January 1, 2012
– May be the entire calendar year of 2011 or any other
period within the year (a month, a quarter, etc)
– Enter your specific period beginning and ending
dates
• Readmission Baseline Data
– Preferably CY 2011
– May use Jan – Jun 2012 if 2011 data is not available
• If no baseline data is available, do not enter anything for
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baseline—begin with monitoring data
VTE Data Entry
Complete baseline
data entry by
August 31!
• Data should be entered on a monthly basis as
much as possible
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VTE 2012 Monthly Data Entry Schedule
Monitoring Month
Data Entry Available
Data Entry Complete
January
Immediately
As soon as possible*
February
Immediately
As soon as possible*
March
Immediately
As soon as possible*
April
Immediately
As soon as possible*
May
Immediately
As soon as possible*
June
Immediately
As soon as possible*
July
August 1, 2012
August 31, 2012
August
September 1, 2012
September 30, 2012
September
October 1, 2012
October 31, 2012
October
November 1, 2012
November 30, 2012
November
December 1, 2012
December 31, 2012
December
January 1, 2013
January 31, 2013
*If data is available
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Comprehensive Data System (CDS)
• Link to HRET training webinar for CDS
located on K-HEN website under Data Page
• https://www.hretcds.org/Login.aspx
• Data coordinator receives initial login and
creates hospital’s users
– At least two data administrators
– As many data entry users as needed
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Measure Selection
• Review the K-HEN Recommended
Measures and the HRET Encyclopedia of
Measures
• Determine which measures you will report
Remember you MUST report on at least one
process and one outcome measure
per topic area selected
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Measure Enrollment
• Enroll in the measures that you are
reporting
• Select Admin  Measure Enrollment
– Select the topic area
– Select/deselect and save the measures that
you will be reporting on
– This will narrow your choices for data entry to
only those selected
– You may reselect those measures at a later
time if desired
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Data Collection & Entry
• Review the numerator and denominator
criteria for the measures selected
• Collect and compile the data
• Sign on to the CDS
– Select Data Entry tab
– Select the topic from the drop  Select Next
– Find the appropriate measure  Select Enter
Data
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Baseline Data Entry
• Defaults to the Baseline tab
• Enter the Measurement start and end dates  Select
‘Add’
• Under ‘Data Entry’ column, Select ‘Go’
• Was data collected for this measurement period? 
Select Yes or No
– If No, enter reason (e.g. data not available)
– If Yes, enter the numerator and denominator
– Select Save or Submit
• Save holds data in ‘temporary’ area and is not available for
reporting within the CDS
• Data may be edited by the hospital until it is submitted
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Monitoring Data Entry
• Select the Monitoring tab
• Under the Data Entry column, Select ‘Go’ for
the appropriate month
• Was data collected for this measurement
period?  Select Yes or No
• If No, enter reason (e.g. data not available)
• If Yes, enter the numerator and denominator
• Select Save or Submit
– ‘Save’ holds data in ‘temporary’ area and is available for
reporting within the CDS
– Data may be edited by the hospital until it is submitted
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Data Tidbits
• Each month should have data entered or a
reason it was not collected
• Additional training will be provided after data
has been entered and reporting is available
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Monthly Progress Report
•
•
•
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Due to K-HEN by the 10th of each month
Use template provided
One report per topic area
Report template and sample complete
report located on K-HEN website (www.khen.com) under Tools and Resources
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Project Title: ______________________________
Hospital Name: ____________________________
Date: _____________
State: _____________
Self Assessment Score, 1-5 (see AHA/HRET Assessment Scale document) = <enter score here>
Aim Statement
Aim?: (Including your How
Good and By When
statement)
Why is this project
important?:
Changes being Tested,
Implemented or Spread
(For each listed change,
indicate whether it is being
tested (T), Implemented (I)
or Spread (S))
Run Charts
Lessons Learned
(Make fonts large, title, labels, dates
and notes very simple on graphs
prior
to shrinking graphs. Should be able
to
fit 6-8 readable graphs here.
If no data are available for a particular
measures either create “empty” run
list
the name of the measure(s) to be
collected.)
(Enter summary here)
Recommendations and
Next Steps
• Enter summary here (what
do you need from Executive
Project Champion, Sponsor
at this time to move
project?)
• Recommendations
• Next steps for testing
Team Members
(Name of Project
Champion, Senior Leader
Sponsor & all other names
& roles)
© 2012 Institute for Healthcare Improvement
Sample Completed Report
Project Title: VTE Harm Reduction
( Project Champion and Senior Leadership Sponsor: Dr. Thomas Cummins)
Date: Aug 6, 2012
Self Assessment Score (1-5) = 2
Lessons Learned
Aim Statement
Run Charts
White River Medical Center will decrease
harm from hospital acquired VTE 40% by
December 31, 2013.
new EMR
•Clinical pharmacist providing
Coumadin education to patients
discharged on Coumadin (S)
•Be proactive with chart reviews
ICU VTE Prophylaxis
Hospital associate VTE is a leading cause of
hospital morbidity and morality throughout
the United States.
•Committee overload is easy to
achieve
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Rate
Changes being Tested,
Implemented or Spread
• Data collection can be difficult with a
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ICU
65
Baseline
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• Education provided to
ICU clinical lead and
nurse manager
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Jan- Feb- Mar- Apr- May- Jun12
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12
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•Clinical care coordinator reviewing
patients for VTE prophylaxis and
teach needs (I)
•Physicians to be
educated on overlap
therapy
•Continue to test feasibility of UR
assessing for VTE prophylaxis (T)
Preventable VTE
Team Members
•Dr. Thomas Cummins, CMO, Hospitalist Director
Project Champion and Senior Leadership Sponsor
•Robin Anderson, RN, BHM, CPHQ,
QM Supervisor – Team Leader
•Holly Robbins, RN, Quality Management
Specialist – Abstraction Specialist
•Gina Reves, Quality Management Specialist PI Specialist/Abstraction
•Janie Evans, BSN, Clinical Nurse Educator Nurse education
•Valerie Ragsdell, RN, Clinical Care Coordinator –
Nursing Rep
Recommendations and
Next Steps
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50
40
30
20
10
0
VT E
B aseline
Jan- F eb- M ar- A pr- M ay- Jun12
12
12
12
12
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•Plan on starting an
overall patient harm
prevention committee that
will meet monthly starting
in October which will focus
on VTE, PU, Falls,
CAUTI,CRBSI, and other
patient harm issues in one
committee to help with
committee overload
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© 2012 Institute for Healthcare Improvement
Project Assessment Scale
• http://www.khen.com/Portals/16/Documents/HRETHEN
ProjectAssessmentScale.pdf
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Homework
• Set up CDS users for your site
• Collect and enter baseline data by Aug 31
• Enter monitoring data for Jan - Jun 2012 as
available
• Enter monitoring data for Jul 2012 by Aug
31
• Complete July progress report by Aug 31
and email to [email protected]
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Questions
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