Transcript Stage 2: Introduction to study for clinicians and additional patient

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1
Stage 2
INTRODUCTION
FOR CLINICIANS
AND ADDITIONAL
PATIENT & STAY
CHARACTERISTICS
CURRENT CLASSIFICATIONS
FOR EMERGENCY CARE
Current emergency care classifications used for ABF:
• Urgency Related Groups (URG): based on triage, disposition and
diagnosis
• Urgency Disposition Groups (UDG): based on triage and disposition
Both considered interim classifications
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CURRENT CLASSIFICATIONS
FOR EMERGENCY CARE
Limitations of URGs and UDGs
• Both rely on triage
‒ Good indicator of urgency, but not complexity and/ or severity
‒ Principal purpose is to manage workflow and prioritisation within
emergency departments
‒ Inconsistency in its application between emergency departments (i.e.
urgency is a relative concept)
• Both rely on disposition
‒ Inconsistent with goal of avoiding admission where this is appropriate
(i.e. does not reflect additional resources that may have gone in to
treating a patient to avoid admission)
• Other
‒ Limited clinical meaning
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INVESTIGATIVE REVIEW
Investigative review of classification systems for
emergency care commissioned by IHPA in 2013
•
•
•
•
Reviewed classifications developed/ used in Australia and other countries
Extensive clinical consultation
Analysis of existing cost data
Conclusions:
1. New classification needed to replace the URGs/UDGs
2. Should be based on a high quality costing study
3. Need to ensure any new data elements required for the new classification
are able to be collected efficiently, minimising the impact on clinicians in
particular
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AIMS OF CURRENT STUDY
The current study involves both a costing study and development of a
classification system.
Key aims of the costing study:
• Significantly improve estimates of costs at the patient level (emergency
department stay) compared with current NHCDC.
• Collect information on patient characteristics (in addition to those routinely
collected) that has the potential to explain variation in costs between
patients.
• Review routinely collected information submitted towards the study to
ensure that it is good quality.
Key aims of the classification development component:
• Develop, empirically test, and recommend a classification for emergency
care which improves:
• Explanation and prediction of variation in cost of emergency
department stays.
• Clinical meaning.
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DATA COLLECTION COMPONENTS
Part A: Service level
characteristics
Examples:
• General characteristics
• Staffing levels by shift
• Configuration (e.g. number of
bays, treatment areas)
Part B : Clinician time
Collected over a 2 week period
• Time allocated by patients
• Time by types of
activity/procedure
Part D : Cost data
• Emergency department stays
• Inputs for costing systems
• Subsequent admitted patient
episodes
Part C : Patient/stay
characteristics
• Routinely collected data:
ED stay: presentation date/time,
clinical care commencement
date/time, ED diagnosis
Subsequent admission: admitted
patients NMDS
Additional data
Collected over a 4 week period. e.g.:
• Diagnosis modifiers
• Investigations/procedures
• Time by treatment area
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ADDITIONAL PATIENT & STAY
CHARACTERISTICS
Why new data elements?
• The 2014 Investigative review of classification systems for emergency
care indicated the need for: Greater prominence given to measures of
severity, assessment and treatment complexity, co-morbidities and
dependency.
• Consultations indicated a need to consider a range of potential
classification items, including presenting problem/complaints and
procedures/investigations.
• The intention is to test these additional items together with those
already routinely collected, to identify which work best in explaining
and predicting variation in cost, and also which contribute to
improving clinical meaning of the classifications.
• The study also provides an opportunity to examine data collection
effort of these items.
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ADDITIONAL PATIENT & STAY
CHARACTERISTICS
Element
Routinely
collected
Diagnosis

New
Investigations
Imaging
Pathology

Pharmacy

Presenting problem*

Additional diagnoses*

Diagnosis modifiers**

Procedures**

Patient attributable clinician time

(Covered separately)
* Expected to be routinely collected by most sites
** May be routinely collected by some sites
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PRESENTING PROBLEM
Presenting problem/complaint
• To be tested as potential predictor of costs
• Small number of presenting problems account for large proportion of cases
• Evaluate the suitability of the study list for national collection
Collection of presenting problem data
• Currently collected by triage nurse and/or first attending clinician
• Current collection methods may be updated for study
‒ Local codes mapped where possible
‒ Code set to be used instead of free text
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ADDITIONAL DIAGNOSES
Additional diagnoses
• Help assess the shift from urgency to severity/complexity
• Aim is to collect this where it impacts the emergency department stay,
for example:
Primary diagnosis:
Hip fracture
Additional diagnoses:
Delirium
Collection of additional diagnoses
• There is a capacity to collect these in most, but not all ED systems.
• However, the extent of actual recording is mixed.
• Through the four-week study period, participating sites will be
required to improve the collection of additional diagnoses.
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DIAGNOSIS MODIFIERS
•
Consciousness
•
Chronic substance/alcohol dependence
or abuse
•
Body mass index flag
•
Homelessness
•
Patient unable to communicate in English
•
Mental health legal status
•
Patient distress/ confusion/ agitation
requiring one to one nursing
•
Intellectual disability
•
Patient is a residential care resident
•
Severe mental health disorder
•
Site defined diagnosis modifiers
•
Child at risk
•
•
Patient unable to self-care
Capacity for clinicians to record any other
condition/ status that led to a patient
being more complex
Guidelines for collection:
• Required element
‒ Yes/ present, No/ not present, or N/A
‒ Derived from, and substantiated by, clinical documentation
• Not applicable used for Dead on arrival, Died in emergency
department, Did not wait to be attended by a health care
professional
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DIAGNOSIS MODIFIERS
Diagnosis modifier
Definition
Consciousness
Whether a patient presenting to the emergency
department presented in an unconscious state or
became unconscious at any time during the
emergency department stay.
Distress/ confusion/
agitation requiring one-toone nursing
Whether a patient required one-to-one nursing as a
result of presenting with distress/ confusion/ agitation
or developing any of these states during their
emergency department stay.
Homelessness
Whether a patient was homeless at the time of
presentation.
Body mass index FLAG
Whether (estimated) body mass index (BMI) is
greater than 40.
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DIAGNOSIS MODIFIERS
Diagnosis modifier
Definition
Mental health legal status
Whether the person is treated in the emergency department/
service on an involuntary basis, under the relevant state or
territory mental health legislation.
Severe mental health
disorder
Whether a person treated in the emergency department has
a severe form of mental health and/ or personality disorder
that required additional resources from emergency
department staff, above those normally required to treat their
presenting problem.
Intellectual disability
Whether the person has an intellectual disability that required
additional resources from emergency department staff above
those normally required to treat their presenting problem.
Chronic substance/alcohol
dependence or abuse
Whether the person has chronic substance/alcohol
dependence or abuse – includes behavioural, cognitive and
physiological phenomena from repetitive substance use.
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DIAGNOSIS MODIFIERS
Diagnosis modifier
Definition
Unable to self-care
Whether a person is unable to self-care and this is not due
to the fact the patient is a child, and this state is not directly
related to the reason for their presentation.
Child at risk
Whether a notification has been made to relevant authorities
in relation to a child presenting to the emergency
department that has been harmed or injured, is suspected
of being harmed or injured, or is at risk of harm or injury,
due to actions or inactions of others.
Unable to communicate in
English
Whether a person treated in the emergency department/
service was unable to effectively communicate with staff in
English.
Residential care resident
Whether a person was a resident of a residential care
facility at the time of presentation.
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DIAGNOSIS MODIFIERS
Diagnosis modifier
Definition
Site defined diagnosis
modifiers
Provides sites with the ability to define up to 10 additional
diagnosis modifiers. The modifiers should be clearly defined
and follow the format of other modifiers whereby:
•
CODE 1 Yes: The diagnosis modifier is applicable
to/present in the patient
•
CODE 2 No: The diagnosis modifier is NOT applicable
to/present in the patient
•
CODE 3: Other/not applicable: To be used for
circumstances defined by the site
If site defined diagnosis modifiers are used, the names and
definitions need to be provided to the FMT
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DIAGNOSIS MODIFIERS
Diagnosis modifier
Definition
Patient complexity description
A text description of a specific factor not already captured by
other data elements (e.g. additional diagnoses, diagnosis
modifiers, patient age, procedures undertaken) that made
this patient more complex to treat compared with other
patients presenting with the same condition. The factor
could be clinical, social and/or psychological.
NB: this is a voluntary data element, and maybe left blank if
sites choose not to use it.
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PROCEDURES/ACTIVITIES (EXAMPLES)
The following are examples of procedures/activities on which data will be
collected for this project. Please note these lists are samples only, and not an
exhaustive list – please refer to the Data request specification for the full list of
procedures/activities and relevant codes
Life support/respiratory
Cardiovascular
1 Assisted ventilation
2 Basic life support (CPR)
3 Cardioversion/defibrillation
4 Endotracheal intubation
5 Endotracheal extubation
6 Thoracotomy/internal cardiac massage
7 Initiation/management of non-invasive
ventilation (CPAP/BIPAP)
8 Management of intubated patient
20 Arterial cannula
21 Administration of blood/products
22 Central line
23 External cardiac pacing
24 Pacing wire insertion
25 Ionotropic or blood pressure lowering
infusion
26 Rapid IV fluid resuscitation
27 Peripheral IV insertion (IVC)
28 Thrombolysis
29 ECG
Anaesthetic
10 Procedural sedation
11 Regional block
12 Ischaemic (“Bier’s”) blocks
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PROCEDURES/ACTIVITIES (EXAMPLES)
Regional procedures
Additional activities - Nursing
30 Abscess/collection aspiration or drainage
31 Chest tube/catheter/thoracostomy
32 Fracture/dislocation reduction
33 Splint or sling application
34 Plaster (POP)/backslab application
35 Walking aid dispensation (incl. pt educ.)
36 Bandaging/strapping sprained joint
37 Foreign body removal
38 Eye irrigation
39 Joint aspiration
40 Lumbar puncture
41 Nasal packing/cautery
42 Nasogastric/PEG tube insertion
43 Pleural aspiration
44 Suprapubic catheter
45 Urethral catheter
46 Vaginal speculum examination
47 Rectal examination
48 Wound suture/stapling – simple
49 Wound suture/stapling – complex
50 Wound gluing
51 Wound cleaning and dressing
52 Peritoneal aspiration
53 Advanced patient cooling/warming setup
130 Triage
131 Initial nursing assessment
132 Clinical observations
133 Clinical discussion
134 Third party conversation
135 Nursing summation and disposition
136 Other bedside nursing care and doc.
137 Nurse chaperone
122 Family conference
123 Handover
124 Supervision/teaching
125 End of life discussion – patient &/or family/carer
Medication administration
90 Administration of insulin (IV or SC)
91 IV medication dispensing, administration, checking
92 Oral medication dispensing, administration, checking
93 Verifying and dispensing controlled medications (e.g.
opioids)
94 Patient controlled analgesia
(PCA) set-up
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PROCEDURES/ACTIVITIES (EXAMPLES)
Additional activities – Medical
Diagnostics
110 Initial treating clinician bedside evaluation
111 Initial treating clinician synthesis & documentation
112 Additional treating clinician bedside evaluation
113 Additional treating clinician synthesis &
documentation
114 Third party conversation
115 External clinician phone consultation
116 External clinician in-person consultation
117 Initial senior assessment
118 Senior review – verbal only (advice to treating
clinician)
119 Senior review – patient examined
120 Medical escort to and from imaging/CT or ward
121 Treating clinician summation and disposition
122 Family conference
123 Handover
124 Supervision/teaching
125 End of life discussion – patient &/or family/carer
80 Ordering a diagnostic test (imaging, pathology)
81 Image ordering with radiology consult
82 Blood specimen collection
83 Non-blood specimen collection
84 Clinical ultrasound (bedside)
85 Bladder scan (ultrasound)
86 Laryngoscopy (flexible or rigid)
87 Oesophagoscopy/gastroscopy (flexible or rigid)
88 Sigmoidoscopy/colonoscopy (flexible or rigid)
89 Other point of care diagnostic tests, measures or
investigations
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