Chapter 3 SETTING UP FOR SUCCESS 3.1 Where s the Data? Before you can begin collecting data for the ACS NSQIP-Pediatric, you need to determine where to find the pertinent information. Medical record systems unfortunately are not uniform from hospital to hospital but certain patterns have emerged that can be utilized to guide you in your search for Program information. Referring to people who know the hospital processes and systems best, such as your Surgeon Champion, for assistance in locating any Program information is always helpful and can save time and energy. 3.1.1 8-Day Cycle Schedule To start with, you need to determine on what date you will begin to select cases. The 8-day cycle schedule is the schedule you must follow to make certain that case selection is performed in an unbiased fashion. This schedule is located in Appendix A of the Operations Manual as well as on the ACS NSQIP website. From this schedule, you will determine the start date of when you will begin selecting cases for inclusion into the Program. Note that the cycles begin at 12:00 a.m. 3.1.2 Operative Log Once the start date for case selection has been determined, a list of surgical procedures performed beginning on that start date will need to be produced. This list is usually called the Operative Log. The Surgeon Champion, Surgical Administrator, or OR Nurse Manager can guide you to the location of this log. It is important to distinguish between an Operative Schedule and an Operative Log. The operative schedule is a list of the patients scheduled to have surgical procedures performed. The list is prepared in advance of the day of operation. The operative schedule will not have emergency and other add-on procedures listed. The operative log documents the surgical procedures that were actually performed. This list will include elective, urgent, emergent, and add-on procedures. This list is usually produced the day after surgery and can provide you with the patient s name, medical record number, procedure performed, date and time of operation, OR room number, and perhaps, the type of anesthesia administered. *It is very important that you obtain the list of surgical procedures that were performed, including any emergency procedures, NOT the surgical procedures scheduled to be performed. Version Date: July 1, 2012 3-1 ACS NSQIP-P
3.1.3 Information Necessary to Determine Case Inclusion Now that you have a list of potential cases for inclusion in the Program, you will need to apply the inclusion/exclusion criteria. To do so, you will need to find the following information: Procedure performed CPT code for the procedure performed Patient s age Surgical subspecialty This information is most often found on the operative log, with the exception of the CPT code. The CPT code is often found in the surgical department billing system. Examples of names of billing software utilized in the private sector include IDX and Star. The availability of the CPT code may be delayed for several days after the performance of the surgical procedure. If this is the case, in order to determine case inclusion, you will need to temporarily assign a CPT code to the case. Once the CPT code has been assigned by the surgical billing staff, you can then verify the code you assigned to the case. Please discuss the location of CPT codes and how to obtain access to this information with your Surgeon Champion. It is crucial to data accuracy and reliability that you obtain access to this information. In addition, it is helpful to have the most recent version of the CPT code book. In addition, if CPT coding is not timely, the ACS NSQIP website offers the functionality of a CPT code lookup. Simply enter the procedure name and search the database for the CPT code corresponding to the procedure performed. 3.1.4 Assigning the Consecutive Cases in Each Cycle Additional information needed from the operative log will be the date of operation, in room time, and OR room number to assign consecutive order of the first 35 cases for inclusion. The order is determined first by the date of the operation, and then by the time the patient is brought into the operating room, starting with the earliest time of the day through to the latest time. If multiple patients have the same in room times, utilize the OR room number (from lowest to highest) to determine the consecutive cases. 3.1.5 Patient Medical Record Once you have determined the surgical cases for inclusion and have entered the minimal data into the website or workstation, you are now ready to collect the preoperative, intraoperative, and postoperative information on each case. Access to the patient s medical record is required. The patient s medical record at your hospital may be either paper, electronic, or some combination of the two. Version Date: July 1, 2012 3-2 ACS NSQIP-P
3.1.5.1 Paper Medical Record: It is vitally important to understand your hospital s policy on requesting paper medical records and where they may be reviewed. There may be two types of paper record and their existence needs determination. Hospital medical record: contains the patient s inpatient or admission records. This record is usually located in the hospital medical record room. Clinic medical record: contains the patient s outpatient or clinic visit records. This record is located either in the surgical clinic or in an individual physician office. 3.1.5.2 Electronic Medical Record: There may be one or more databases that contain the patient s medical information. It may be very prudent to meet with a member of the IT Department to review the variables collected for the Program so that they may guide you to the location of the information as well as assist you in obtaining access to that information. Your Surgeon Champion may need to approve your access to these databases as many hospital databases have high levels of security. 3.2 Important Hospital Contacts You must establish a good working relationship with the following people. However, as you work to establish yourself in the SCNR position, be prepared to introduce yourself and the Program continuously when entering a new clinical or administrative area. Surgeon Champion Discuss the Program objectives. Describe your role as Surgical Clinical Nurse Reviewer (SCR). Request his/her support in any problems encountered with collecting data elements from all members of the surgical team. Request an introduction to the surgical team, including the surgical residents, at a surgical staff meeting and ask to attend these meetings regularly. Discuss your attendance at weekly Morbidity & Mortality conferences for 30-day outcomes. Tell the Surgeon Champion about the other individuals you'll be contacting to support your data collection efforts, such as the medical records staff, the ward administrator/surgical floor unit coordinators, the quality management coordinator, Infection Control, IT staff, etc. Chief of Anesthesia Discuss the Program objectives and your role as SCNR. Review the anesthesia variables collected for the Program. If needed, ask for his/her assistance in locating the variables on the intraoperative anesthesia flowsheet. Version Date: July 1, 2012 3-3 ACS NSQIP-P
Computer Support Staff (e.g. IRM, IT, IM, etc.) Request that your PC be set up with the minimum of the following Internet browser to access the website: Internet Explorer 5.0 with 128-bit encryption. It is important to have the support of this service for trouble-shooting any access problems that may occur at the local site. It may be of benefit to establish a computer support contact to assist you in locating data elements in the electronic medical record. Supervisor/Director, Medical Records It is important to know that this service can either make or break you. Discuss the Program with the MR Director, explaining the importance of accessing the medical records in a timely fashion. Inquire what the department s procedures are for requesting medical records. Ask about the possibility of obtaining medical records yourself if the department is inundated with clinical requests. It is also crucial to meet and get to know the MR staff responsible for pulling the medical records. Surgical Service Administrator The administrator should be able to provide you with a list of all surgical clinics along with the names of those running them. You will need to speak with these care providers about 30-day surgical morbidities since they see the patients after discharge. Request a monthly list of all resident physicians on the service with their corresponding postgraduate year (PGY) levels be sent to you. Discuss with the administrator the importance of obtaining metered or stamped envelopes or postage for the 30-day follow-up letters. S/he should be able to assist you in obtaining these. OR Nurse Manager Brief the OR Nurse Manager on the Program and explain your need to access the OR log for validation of operations performed and times in and out of the OR. Alert the OR staff to the importance of the accuracy and timeliness of obtaining the operative log and the intra-operative variables for both the surgical service and the ACS NSQIP Pediatric. Quality Management Coordinator and the Chief, Nursing Service It will be beneficial to brief him/her on the ACS NSQIP Pediatric and your role. Maintain contact with your professional colleagues through in-services, clinical activities and any other communications that may assist you in improving patient care through various nursing channels. Version Date: July 1, 2012 3-4 ACS NSQIP-P
Infection Control Practitioner It will be beneficial to brief him/her on the ACS NSQIP Pediatric. Use this contact to assist in the collection and reporting of postoperative surgical site infections, postoperative pneumonia, and other postoperative infections. You may also be helpful to the infection control practitioner to aid them in the accurate and complete collection of postoperative infections. 3.3 Important Surgical Meetings Morbidity and Mortality Conference Attend Morbidity and Mortality (M&M) conferences weekly. This will provide you with some of the reportable surgical morbidities. You will also be able to clarify any questions you may have concerning 30-day outcomes or whether these events fulfill the Program definitions. Surgical Staff Meeting Participate in the Surgical Staff meetings. This forum is useful for updating the surgical staff about new information or problems with data retrieval. When necessary, ask for a few minutes on the agenda to discuss these issues. This increases your visibility on the service and establishes you as part of the team. Identify areas of concern where you may be able to assist, perhaps by providing data for a small research project or for quality improvement activities. 3.4 Responsibilities and Expectations 3.4.1 Case Accrual It is the expectation of each SCNR to collect the required number of cases necessary for the statistical viability of the Program. SCR s in the ACS NSQIP-Pediatric should plan to assess and transmit 1400 cases per year, based on the 35 cases in an eight-day cycle systematic sampling plan. This is calculated as follows: There are 46 eight-day cycles in a year. The SCR will not be expected to enter data for cycles when they are on vacation. Assuming that the SCR will utilize six cycles for vacation per year, data should be collected for 40 cycles. 40 cycles x 35 cases per cycle equals 1400 cases per year. If the hospital does not perform enough ACS NSQIP-Pediatric eligible cases to meet this requirement, the SCR will mark the affected cycles as Max in the SCR Workstation. Monitoring of each site s accrual status is available for the SCR on the secured website (go to the Online Data Reports tab Weekly Accrual Report & 8-day Cycle Report). The Clinical Support Specialists at ACS NSQIP monitor the accrual rates on a weekly basis and will work with each site in streamlining the data collection process to assure appropriate accrual. Version Date: July 1, 2012 3-5 ACS NSQIP-P
3.4.1.2 Vacation Each site is allowed six eight-day cycles during which data submission is not required. However, in order to meet the Program s case submission requirements, no more than six vacation cycles should be taken during any 46 consecutive cycles. For most sites, the 46 consecutive cycles will begin with the annual participating contract start date.. The six vacation cycles are per site, not per SCNR. If a site has more than one SCR, the SCRs are responsible for the coordination of the six vacation cycles at their site. (Note: sites are not required to take the six vacation cycles). Special consideration will be made for unusual circumstances (changes in personnel, unforeseen life events, etc.). Please contact the Clinical Support Team for additional clarification and help if you have a special circumstance. 3.4.2 Systematic Sampling Process If your surgical service has a large surgical volume, the 8-day cycle schedule must be utilized in order to ensure that case sampling is systematic. Case selection must begin on Day One of each cycle and the first consecutive cases that meet Program criteria must be selected (the number of included cases as per contract). Consecutive cases are determined first by the date of surgery, then by the time the patient is brought into the OR. If there are multiple patients brought to the OR at the same documented time, utilize the OR room number (from lowest to highest) to select patients for inclusion. 3.4.3 30-day Follow-up All assessed cases must be followed out to 30 days for postoperative mortality and morbidity. Refer to the 30-day follow-up guidelines in Appendix G for details to ensure complete follow-up. It is the expectation of the Program that all reasonable attempts be made to ensure complete follow-up via medical record review, and/or contact with the patient via follow-up letter or telephone call. 3.4.4 Case Transmission Entry of Program data into the ACS NSQIP-Pediatric Workstation may be performed by the SCR, or by a trained data entry person. However, the responsibility of case completion (thus the verification of data accuracy) lies with the SCR. 3.4.5 Data Transmission Deadlines Data must be entered into the Program website/workstation on a continuous basis. The goal for each site is to complete a case with 30-day follow-up no later than 90 days after the date of surgery. Cases must be completed and saved within Version Date: July 1, 2012 3-6 ACS NSQIP-P
120 days of the date of surgery. Cases that are greater than 120 days old are locked each night. Once a case is locked, it cannot be accessed or edited. Incomplete and unsaved cases that are locked will be deleted from the ACS NSQIP-Pediatric database. Timely case accrual and completion is important in order for your data to be benchmarked against other participating site s data. Old data is not actionable data. Additionally if data is not collected and entered continuously it may be susceptible to being gathered at the last minute in anticipation of a deadline and may therefore be incomplete. The flow of data from each participating site is monitored weekly to ensure that it is being entered into the website or workstation in a timely and complete manner. If you are falling significantly behind you will be contacted by the Clinical Support Specialist. 3.4.6 Attendance and Participation on Conference Calls Pediatric SCR conference calls are held once a month. Topics discussed may include specific definition reviews, answers to clinical questions, hospital process issues, data collection issues, clinical presentations, etc. These conference calls are also important venues for the dissemination of news and information as well as sharing of ideas. Participation in these conference calls is crucial for ensuring the most upto-date information and education. 3.4.7 Attendance at the ACS NSQIP National Conference A national conference is held on an annual basis for all ACS NSQIP SCRs and Surgeon Champions. The conferences present a variety of topics, for example, recent research results, future goals of the ACS NSQIP, quality improvement initiatives from participating sites, and utilizing online reports. This conference is also an excellent opportunity to meet and network with SCRs from around the country. This conference is usually three days in length. 3.4.8 Case Studies On the secure homepage of the ACS NSQIP-Pediatric website, a case study is presented to test the SCRs on a specific data definition. These short case studies are followed by a question and multiple choice answers. Submitted answers are corrected and explanations are provided. 3.4.10 Online Resources ACS NSQIP Best Practice Guidelines and Case Studies are available on the secure website for participating sites. An online forum is also available for SCRs to discuss ideas for quality improvement and workflow strategies. Version Date: July 1, 2012 3-7 ACS NSQIP-P