Respiratory Failure & Pneumonia Definitions Workgroup

Transcription

1 Respiratory Failure & Pneumonia Definitions Workgroup

2 Purpose To develop standard clinical definitions on select diagnoses & categories to be used consistently across all hospitals in Maryland Definitions will be informed by published criteria, existing hospitaldeveloped definitions and supported by industry consensus and comments from the field Definitions will not conflict with federal inpatient coding guidelines and will be applied to any occurrence of the diagnosis, not only in scenarios that might trigger a PPC Our goal is that these definitions will be considered and adopted by hospitals Medical Executive Committees 2

3 Background Under the state s waiver agreement, hospitals must meet reduction targets for Potentially Preventable Complications (PPCs) Additionally, the Health Services Cost Review Commission (HSCRC) incorporates reduction targets into payment policy Having a uniform set of clinically defining criteria may facilitate care improvement Consistency allows for both a performance comparison among hospitals and for a measurement of an individual hospital s performance improvement over time Consistency helps demonstrate that Maryland hospitals have put in time and effort to achieve clinically significant performance improvement in addition to improvement achieved through revised documentation practices 3

4 Participants HOSPITALS Johns Hopkins Lisa Grubb, Director of Quality Management, Johns Hopkins Bayview David Pearse, MD, Medical Director, Johns Hopkins Bayview Carol Ware, QI Team Leader for Special Projects, Johns Hopkins Hospital LifeBridge Health Jaime Barnes, MD, Medical Director, Critical Care Medicine, Northwest Hospital Carol McNutt, Manager & Clinical Documentation Specialist, Sinai Hospital and Northwest Hospital MedStar Health Deborah Cline, Clinical Documentation Specialist, Medstar Franklin Square Medical Center University Of Maryland Jason Birnbaum, MD, Chair, Medicine Department & ICU Director, UM Upper Chesapeake & Harford Memorial Tina Simmons, Quality Manager, UM Upper Chesapeake Medical Center Peninsula Regional Medical Center Robert Chasse, MD, Critical Care Medical Director, Peninsula Susan Elerding, Medical Staff Clinical Quality Coordinator, Peninsula Lisa Gray, Clinical Documentation Specialist, Peninsula Gwyndle Kravec, Executive Director Health Information Management, Privacy Officer, Peninsula Charles Silvia, MD, Vice President of Medical Affairs & Chief Medical Officer, Peninsula Christopher Snyder, Chief Medical Information & Quality Officer, Peninsula Michelle A. Taylor, Business Intelligence & Clinical Analytics, Peninsula STAFF Maryland Hospital Association Nicole Stallings, Vice President Justin Ziombra RN, Analyst Berkeley Research Group Joni Dion, Associate Director Kristen Geissler, Managing Director 4

5 Phase 1 Meeting Calendar UTI PPCs 65, 66 Delayed Renal PPCs 24, 25 February 23 OB PPCs 55, 56, 57, 58 March 5 Respiratory PPCs 3, 4, 5, 6 February 19 March 10 All meetings to be held from 8:30 11:30 at MHA 5

6 Meeting Workflow Schedule Meeting 2, February 19: Review feedback from stakeholders and update draft definitions Homework prior to Meeting 3: Draft definitions will be submitted to hospital field for comment Meeting 3, March 10: Review comments Finalize definitions 6

7 Key Takeaways From First Meeting and Workgroup Feedback

8 Respiratory Failure 1 of 2 The group decided that relying principally on lab results and pulse oximetry to define respiratory failure is problematic for four reasons: 1) Many patients are not receiving routine ABGs 2) Some patients, particularly those in post-operative recovery, may have an abnormal ABG, however the result often normalizes in a short period of time and is not necessarily indicative of respiratory failure 3) Some patients with chronic respiratory conditions have baseline ABGs that are abnormal 4) Defining respiratory failure principally through ABG results is more appropriate as a retrospective screen for chart reviews and studies. A more comprehensive definition of respiratory failure would provide clinicians with a useful prospective tool The workgroup concluded that the defining criteria for respiratory failure may include lab values and other signs, but should also incorporate the severity of intervention required The workgroup concluded that respiratory failure occurs when a patient has a need for either a mechanical ventilator or a moderate support intervention (such as BiPAP, CPAP, or High Flow Therapy) for ventilation and gas exchange This criteria excludes post-surgical patients 8

9 Respiratory Failure 2 of 2 Patients requiring a milder intervention, such as oxygen delivered through a nasal cannula when physiologically required, might still be in respiratory failure, however other criteria should be considered These criteria include: 1) The patient s baseline respiratory function: The interventions detailed above are less indicative of respiratory failure in a patient who is on oxygen therapy at home and has a history of lung disease 2) The length of time the intervention is required: The longer oxygen therapy is required, the more indicative this intervention is of respiratory failure (length of time was left undefined by the workgroup) 3) Associated signs and symptoms: Tachypnea, labored breathing, cyanosis, and hypertension or hypotension are symptomatic of respiratory failure 4) Escalation: An increasing requirement for oxygen (i.e., higher FiO2) or the need for higher ventilation support (e.g. CPAP to Vent) is symptomatic of respiratory failure 9

10 Post-Operative Respiratory Insufficiency A patient ventilated in the normal post-operative period does not, in of itself, constitute a diagnosis of respiratory failure or insufficiency It is not uncommon that patients require ventilation as part of the normal course of recovery during the 48 hours following surgery For coding purposes, the intubation is not coded as respiratory failure if this is an expected outcome taking place under 48 hours post-surgery 10

11 Pneumonia The workgroup decided to use a more comprehensive definition for pneumonia than the criteria crafted by the CDC as many patients with pneumonia have a negative chest x-ray that is not necessarily followed with a CT scan The definition for pneumonia is as follows: Patient must have two of the following: Signs A Temperature > 38 or < 36 Or Leukopenia (<4000 WBC/mm3) or Leukocytosis (>12,000 WBC/mm3) Symptoms Purulent Sputum Or Cough, Dyspnea or Tachypnea Imaging A positive Chest X-Ray or CT 11

12 Aspiration Pneumonia The workgroup decided to define aspiration pneumonia as a case of pneumonia (as defined in the pneumonia criteria in the previous slide) in which the signs and symptoms last longer than 48 hours and in which aspiration was the likely cause, as determined by the provider Instances where the patient likely aspirated and displays signs and symptoms of pneumonia that resolve in 48 hours or less should be considered aspiration pneumonitis instead The code for this event would be for pneumonitis, which also would count as a Potentially Preventable Complication (PPC) 12

13 Respiratory Failure Feedback The workgroup should consider enumerating how obstructive sleep apnea and the use of CPAP at home fit into the first criteria (i.e., the patient s baseline function) The length of time may not necessarily be indicative of respiratory failure, some patients are diagnosed after only brief durations of interventions 13

14 Post-Operative Respiratory Insufficiency Feedback There were some concerns that our definition might confuse the issue in instances where patients are likely to be on a vent longer than 48 hours after surgery During the first meeting, we concluded that there weren t any types of cases where patients are routinely expected to remain on a vent longer than 48 hours Is this something we want to revisit? 14

15 Workgroup Discussion How should our initial consensus on the defining criteria for respiratory failure, post-operative respiratory insufficiency, pneumonia and aspiration pneumonia be changed? How can we make the definition for respiratory failure more objective? 15

16 Homework We will disseminate the consensus criteria for Respiratory Failure and Pneumonia that we develop here today to all hospitals We will distribute their comments to you prior to our next meeting Please consider these comments and come prepared to finalize criteria at our next meeting Our next meeting is here, on March 10 th, at 830am Thank You!! 16

17 Appendix Respiratory Failure and Pneumonia Codes

18 Respiratory Failure ICD-9-CM Codes Acute Pulmonary Edema and Respiratory Failure Acute respiratory failure Other pulmonary insufficiency, not elsewhere classified following trauma and surgery ICD-9-CM Code

19 Related ICD-9-CM Codes Other Respiratory Diagnoses Respiratory insufficiency (Dyspnea & respiratory abnormality) Acute respiratory insufficiency (Other pulmonary insufficiency) Hypercapnia (Dyspnea & respiratory abnormality) ICD-9-CM Code Hypoxemia

20 Respiratory Failure ICD-10-CM Codes Respiratory Failure Acute respiratory failure (includes respiratory failure, not otherwise specified) ICD-10 Will Require Greater Specificity To Accurately Capture The Condition Acute respiratory failure, unspecified whether with hypoxia or hypercapnia Acute respiratory failure with hypoxia Acute respiratory failure with hypercapnia Respiratory failure, unspecified, unspecified whether with hypoxia or hypercapnia Respiratory failure, unspecified with hypoxia Respiratory failure, unspecified with hypercapnia ICD-9-CM Code ICD-10-CM Code J9600 J9601 J9602 J9690 J9691 J

21 Pulmonary Insufficiency ICD-10-CM Codes Pulmonary Insufficiency Other pulmonary insufficiency, not elsewhere classified following trauma and surgery ICD-10 Will Require Greater Specificity To Accurately Capture The Condition Acute pulmonary insufficiency following thoracic surgery Acute pulmonary insufficiency following nonthoracic surgery Other chronic pulmonary insufficiency following surgery ICD-9-CM Code ICD-10-CM Code J951 J952 J953 21