PWS Attachment C - Sample Algorithm.pdf

START

CLNTRIAL

1 EXCLUDED

REVSTAT

NOT = 2

REVSTAT

REVIEW STATUS (not abstracted)

0. Abstraction has not begun

1. Abstraction in progress

2. Abstraction completed w/o errors

3. TVG failure (exclusion)

4. Record contains missing data or errors

5. Administrative exclusion from all measures

TRNSFR 1

TRNSFR

Is there documentation the patient was received as a transfer from an inpatient, outpatient or emergency/observation department of an outside hospital or from an ambulatory surgery center?

1. Yes

2. No

CLNTRIAL

During this hospital stay, was the patient enrolled in a clinical trial in which patients with sepsis/septic shock were being studied?

1. Yes

2. No

Missing

Missing AGE >= 0 and < 18

>= 18

Missing

ADMDT

Valid Date

DCDT

Calculate

DCDT - ADMDT

> 120 days

>= 0 and <= 120 days

Invalid or

Missing

< 0

>= 01/01/24 and <= 06/30/24

Invalid or

Missing

Type X

AGE

Calculated field – ADMDT - BIRTHDT

ADMDT

Admission date

DCDT

Discharge date < 01/01/24 or

> 06/30/24

Pg 2

2q24 - SEP1a - Severe Sepsis 3-Hour Bundle (SEV-SEP-3HR) https://secure.wvmi.org/QUESTIONS/Specifications/Instrument Questions/Sepsis/2q24/SepsisFY2024Q2_POST.docx VHARTPSowinE Cross-Out

SEPDT2

Valid Date

Missing

SEPDT2 / SEPTM2

Enter the earliest date and time a physician/APN/PA documented the presence of severe sepsis

SEPPRES2

Missing

Or

99/99/9999

SEPTM2

Valid Time

SEPPRES2

Did a physician/APN/PA document presence of severe sepsis?

1. Yes

2. No

Type X

Pg 2

SHKPRES

Missing

Or

99:99

SHKDT

Valid Date

Missing

Missing

Or 99/99/9999

SHKTM

Valid Time

Missing

Or 99:99

Pg 3

SHKPRES

Is documentation of septic shock present in the record?

1. Yes

2. No, or unable to determine

SHKDT / SHKTM

Enter the earliest date and time a physician/APN/PA of the documented the presence of septic shock.

2q24 - SEP1a - Severe Sepsis 3-Hour Bundle (SEV-SEP-3HR)

SEPSIRS1

SEPSIRS2

SEPSIRS3

SEPSIRS4

NONE = missing and At least two = 1Type X

Missing

SEPINF 2

ANY =

Missing

SEPORG1

SEPORG2

SEPORG3

SEPORG4,SEPORG5

SEPORG6, SEPORG7

SEPORG8

SEPORG9

ANY =

Missing

ALL

= 2

SEPSISDT

Valid Date

SEPSISTM

SEPINF

Is there physician/APN/PA or nursing documentation of infection in the medical record?

1. Yes

2. No or unable to determine

Pg 4

Pg 3

Is there documentation of organ dysfunction in the medical record?

Indicate all that apply:

SEPORG1. Systolic blood pressure (SBP) < 90 mmHg or mean arterial pressure (MAP) < 65 mmHg

SEPORG2. Systolic blood pressure (SBP) decrease of more than 40 mmHg (see definitions/decision (D/D) rules)

SEPORG3. Acute respiratory failure as evidenced by a new need for invasive or non-invasive mechanical ventilation (see D/D rules)

SEPORG4. Creatinine > 2.0 (see D/D rules)

SEPORG5. Urine output < 0.5mL//kg/hour for 2 consecutive hours (see D/D rules)

SEPORG6. Total bilirubin > 2 mg/dL (34.2 mmol/L)

SEPORG7. Platelet count < 100,000

SEPORG8. INR > 1.5 or aPTT > 60 seconds (see D/D rules)

SEPORG9. Lactate > 18.0 mg/dL (>2 mmol/L)

1. Yes

2. No

EXCLUDED

SEPPRES2

NONE = missing and

Less than two = 1

Valid Time

Or

99:99

SEPSISDT /

SEPSISTM

Enter the earliest date and time on which the final criterion was met to establish the presence of severe sepsis.

ANY = 1

99/99/9999

Or missing

SEPSISTM Valid Date

99:99 or

Missing

COVID

Missing

EXCLUDED

COVID

At any time during the admission, is there physician/APN/PA documentation coronavirus or COVID-19 is suspected, present or confirmed?

1. Yes

2. No

Is there documentation in the medical record of two (2) or more of the following manifestations of systemic infection:

Indicate all that apply:

SEPSIRS1. Temperature >38.3 C or <36.0

C (>100.9 F or <96.8 F)

SEPSIRS2. Heart rate (pulse) >90

(tachycardia)

SEPSIRS3. Respiration >20 per minute

(tachypnea)

SEPSIRS4. White blood cell count >12,000

(leukocytosis) or <4,000

(leukopenia) or >10% bands

1. Yes

2. No

SHKPRES

CMOPLC

DCDISPO 99

1, 2, 3, 4, 5, 6, 7

CMOPLC

During the timeframe from (computer to display sepresdt/ seprestm - 6 hours) to (computer to display sepresdt/ seprestm + 6 hours) is there physician/APN/PA documentation of comfort measures only or palliative care

(see Inclusion terms below)?

1. Yes

2. No

Pg 4

EXCLUDED

Type X

Missing

DCDT

DCTM

Valid Date

Valid Time

Missing

Missing or

Invalid

Calculate

DCDT/DCTM –

SEPRESDT/SEPRESTM

> 360 min

>= 0 and

<= 360 min

Missing or

Invalid

Pg 5

EXCLUDED

Pg 5

DCDT

Discharge date:

DCTM

Discharge time:

< 0

CNTRASEVSEP

Missing CNTRASEVSEP

During the timeframe from (computer to display sepresdt/ seprestm - 6 hours) to (computer to display sepresdt/seprestm + 6 hours) is there physician/APN/PA or nursing documentation that the patient or authorized patient advocate refused either a blood draw, IV fluid administration, or IV antibiotic administration?

1. Yes

2. No or unable to determine

SEPRESDT

Valid

Date

SEPRESTM

Valid Time

Missing or

Invalid

Missing or Invalid

Type X

DCDISPO

What was the patient’s discharge disposition on the day of discharge?

1. Home

• Assisted Living Facilities (ALFs) – includes assisted living care at nursing home/facility

• Court/Law Enforcement – includes detention facilities, jails, and prison

• Home – includes board and care, domiciliary, foster or residential care, group or personal care homes, retirement communities, and homeless shelters

• Home with Home Health Services

• Outpatient Services including outpatient procedures at another hospital, outpatient Chemical Dependency Programs and Partial Hospitalization

2. Hospice – Home (or other home setting as listed in #1 (above)

3. Hospice – Health Care Facility

• General Inpatient and Respite, Residential and Skilled Facilities, and

Other Health Care Facilities

4. Acute Care Facility

• Acute Short Term General and Critical Access Hospitals

• Cancer and Children’s Hospitals

• Department of Defense and Veteran’s Administration Hospitals

5. Other Health Care Facility

• Extended or Immediate Care Facility (ECF/ICF)

• Long Term Acute Care Hospital (LTACH)

• Nursing Home or Facility including Veteran’s Administration Nursing

Facility

• Psychiatric Hospital or Psychiatric Unit of a Hospital

• Rehabilitation Facility including, but not limited to: Inpatient Rehabilitation

Facility/Hospital, Rehabilitation Unit of a Hospital, Chemical Dependency/

Alcohol Rehabilitation Facility

• Skilled Nursing Facility (SNF), Sub-Acute Care or Swing Bed

• Transitional Care Unit (TCU)

• Veteran’s Home

6. Expired

7. Left Against Medical Advice/AMA

99. Not documented or unable to determine

Inclusion (Or synonymous terms)

Brain death/dead Hospice Care

Comfort care Organ harvest

Comfort measures Palliative Care

Comfort measures only (CMO) Palliative Consult

Comfort only Terminal care

Do Not Resuscitate Comfort Terminal extubation

Care (DNR-CC)

End of life care Withdraw care

Hospice Withhold care

SEPRESDT

Computer to auto-fill earliest valid date entered in sepdt2, shkdt, or sepsisdt.

SEPRESTM

Computer to auto-fill earliest valid time entered in septm2, shktm, or sepsistm.

Pg 5

BIOADMINDT

Valid Date

Type X Missing

BIOADMINTM

Valid Time

Missing or

99:99

Set Variable ABXTIMING =

BIOADMINDT/BIOADMINTM

– SEPRESDT/SEPRESTM

< - 1440 or

> 180 min

>= -1440 and <= 180 min

ABXTIMING ABXTIMING

> 180 min

< -1440 min

EXCLUDED

Pg 6

Missing ANTIBIO 2

ANTIBIO

During the timeframe from (computer display sepresdt/ seprestm - 72 hours) to (computer display sepresdt/ seprestm + 3 hours) was a broad spectrum or other antibiotic administered intravenously (IV)?

1. Yes

2. No or unable to determine

FAIL

< - 4320 or

> 180 min ABXTIMINGType X

>= - 4320 and <= 180 min

BIOADMINDT

Administration Date mm/dd/yyyy

<= 3 days prior to sepresdt and <= sepresdt + 1 day

BIOADMINTM

Administration Time

UMT

<=72 hours prior to sepresdt/seprestm and

<= sepresdt/seprestm

+ 3 hours)

99/99/9999

Type X

Pg 6

BLDCULDT

Valid Date

Type X

Missing or

Invalid

BLDCULTM

Valid Time

Missing or

Invalid

< -2880 or

> 180 min

>= -2880 and <= 180 min

BLOODCUL

2 Missing

FAIL

Calculate

BLDCULDT/BLDCULTM –

SEPRESDT/SEPRESTM

Calculate

BIOADMINDT/BIOADMINTM

– BLDCULDT/BLDCULTM

< 0 min

>= 0 min

BLDCULDEL

Pg 7

Type X Missing

BLOODCUL

During the time frame from [(If bioadmindt/ bioadmintm - sepresdt/seprestm >=

-1440 and < 0, computer to display sepresdt/ seprestm - 48 hours to sepresdt/seprestm + 3 hours); else computer to display (earliest bioadmindt/ bioadmintm- 24 hours to sepresdt/ seprestm + 3 hours)], was a blood culture collected?

1. Yes

2. No or unable to determine

BLDCULDT / BLDCULTM

During the specified timeframe, enter the date and time the blood culture was collected.

BLDCULDEL

Is there documentation supporting an acceptable delay in collecting a blood culture?

1. Yes

2. No or unable to determine

FAIL

In Denominator only

(fails measure)

In Denominator and

Numerator

(passes measure)

Pg 7

LACTDT

Valid Date

Type X

Missing or

Invalid

LACTM

Valid Time

Missing or

Invalid

< -360 or

> 180 min

>= -360 and <= 180 min

LACTATE

2 Missing

Calculate

LACTDT/LACTM –

SEPRESDT/SEPRESTM

LACTATE

During the timeframe from (computer display sepresdt/seprestm - 6 hours to sepresdt/seprestm +

3 hours) was an initial lactate level drawn (or collected)?

1. Yes

2. No

LACTDT / LACTM

Enter the date and time the initial lactate level was drawn (or collected).