Frequently Asked Questions (FAQ) CALNOC 2013 Codebook Maternal/Child and ED Service Lines QUESTION: Are the ED and Maternal/Child measures mandatory? What are the ramifications if we choose not to add them at this time? As with all of our measures, adding these Service Lines is optional based on your hospital s strategic priorities. There are no ramifications to NOT adding them, but strong value-added to your Total Facility reporting if you do add them. QUESTION: Are the ED and Maternal/Child measures submitted using the Staffing/Pt. Days/HAPU3+ Excel file or will it be a separate set of questions? These measures are submitted using the most recent Staffing/Pt Days/HAPU3+ file. We always accept late submissions. Data for these measures were first accepted for Q1 2012 QUESTION: Will we be able to compare our ED and Maternal/Child data with other hospitals? Yes, you will be able to compare your ED and Maternal/Child data in our reports like all of the other service lines. You will also be able to select a customized Total Facility report including all service lines or a selected subset and benchmark with other hospitals on the same service line combination. QUESTION: I will need new CALNOC unit codes for these new departments. Primary Site Coordinators can now create your own new units on the CALNOC website under Manage Units. QUESTION: Is CALNOC a vendor for submission to TJC and/or CMS? If not, why would we duplicate data? CALNOC has added CMS and other measures (e.g., ED throughput measures) to the data registry to give you the opportunity to use our powerful report strategies to benchmark your performance with other hospitals in a way that simply submitting for requirements does not. For a small amount of effort on your part (measures are the same as CMS and our upload is designed to be user friendly) you will have this added benchmarking benefit. QUESTION: Are there additional fees associated with adding a new unit type? CALNOC fees include ALL indicators and Unit Types. There is no additional cost. QUESTION: We already collect Falls, Pressure Ulcer and Med Admin data internally for the ED. I can get patient visits and RNs, aides data easily, but all of the patient types will take more work (boarders, AMA, LWBS, etc.) You can definitely upload our existing measures (e.g., Pressure Ulcer and Med Admin). The Skills file can also accept the new service lines for existing measures (e.g., staff hours, voluntary turnover, etc,), as well as the new measures for ED and Maternal/Child.
Adult Acute Care Telemetry Unit Type QUESTION: With the additions in the Acute Care Facility Unit Identification Code Sheet what would be the staffing ratio in determining your step-down and telemetry units? CALNOC does not use staffing ratios to determine the unit types. Each individual hospital will need to determine if they provide 3 or 4 levels of acute care. The Codebook Part II provides the following information: CALNOC unit types reflect increasingly complex patient care requirements or acuity. In this model, observation units are for patients that do not require admission to the hospital, but are treated as outpatients. Patients admitted to the hospital are assigned a level of care that reflects the complexity of their condition and care needs. Some hospitals may have 3 levels of care -- medical/surgical (with or without telemetry), step down (with or without telemetry), and critical care. Other hospitals offer 4 levels --medical/surgical (with or without telemetry), telemetry (monitored medical or surgical), step down (with or without telemetry), and critical care. Please review the specifications for each CALNOC unit type and confirm that the units in your setting are correctly labeled for CALNOC data collection and benchmarking purposes. New ED Measures QUESTION: Regarding the ED encounters and the ED CMS performance measures; will we be reviewing 100% of the patients? ED Encounters and Number of Boarded Patients should include 100% of the patients. We will be using Total Encounters as the denominator for Staffing and Falls measures instead of the Patient Days measure used for other types of units. For the CMS performance measures (median times) we re asking you to submit the same data you submit to CMS following their sample size requirements based on the population of patients per quarter that come through the ED For patients that LWBS, LBTC, and AMA, include 100% of the patients. QUESTION: Question on decision time to wheel out time. Do you include decision to admit to a Pysch unit that is a different facility until those patients have a wheel out time? Please submit the same Median Times you are submitting to CMS following CMS specifications. QUESTION: What about the observation patients that are still followed by an ED Doc in an Observation unit? Does that count against our total time? Please submit the same Median Times you are submitting to CMS following CMS specifications. New OB Unit Types Antepartum: with or without gyn, gyn surgical or post partum patients in the mix Maternal mixed unit: combining antepartum and postpartum with mother-baby couplets Labor and delivery suite (L&D) Labor, Delivery Recovery Postpartum (LDRP) Level 1 nursery Well baby or normal newborn nursery QUESTION: Our MCH unit includes antepartum, post partum, couplets with the addition of some GYN surgical. The unit also contains a few licensed pediatric beds. Data can be separated MCH/peds but not the staffing data. Can this unit now be enrolled? Please enroll as maternal mixed unit
QUESTION: We have 6 rooms designated as LDRP, and if needed based on census the mom/baby may be moved across the hall to another set of rooms for mother/baby only. Would the entire unit be considered LDRP and we would report our data as LDRP? Yes, provided the unit is staffed as one unit. QUESTION: Will I be able to combine my whole unit as one which includes M/B, L&D, Antepatum, and Nrsy? Please enroll as Labor, Delivery Recovery Postpartum (LDRP) if the unit is staffed as one unit.. New OB Measure QUESTION: For number of deliveries, this is vaginal deliveries, correct? You're looking for inpatients with a v-code V27.0-V27.9, mother with some sort of outcome, excluding those with the c-section procedure codes 74.0-74.99? Maternal/Child Number of Deliveries includes ALL deliveries, including C-sections. Multiple births count as one delivery New Measures added to Prevalence Studies Source of Admission to Hospital: QUESTION: The categories listed on the CALNOC patient observation form and Codebook do not match the CMS admission status (now "known as point of origin") options, which are also the codes available in my electronic system, and probably everyone else's as well. The items listed on the observation forms are CMS "discharge disposition" options. The CMS codes will have more specificity than CALNOC sources of admission. We recommend using the cross walk below to determine coding for CALNOC. CALNOC Codes CMS Point of Origin Codes Same acute care institution (Rehab and SNF only) Transfer from one distinct unit to another (D) Home Non-Health Care Facility (1) Home with home care Included in 1 above (can t differentiate) Skilled nursing facility Transfer from SNF, ICF, or ALF (5) Board and care Included in 5 above (can t differentiate) Another acute care institution Transfer from a different Hospital (4) Rehabilitation Included in 4 above (can t differentiate) Other (Peds include born in this hospital) Newborn Code 5 Intra-operative Time in Hours (surgical patients only) QUESTION: For intra-operative time, if a patient has had more than one procedure (like many of our complex trauma patients), do we add up the cumulative time of all of the procedures, or just the most recent one? If a patient has more than one procedure, add up the cumulative time for all procedures during this admission or the past 2 weeks if the patient has been hospitalized longer than 2 weeks. Also include other procedures such as cath lab, interventional radiology, etc. Once the patient enters the "procedure suite/or" to prepare for their procedure, the opportunity for them to move becomes limited and they become more stationary as time moves forward to sedation and anesthesia. Time in/time out is a standard measurement in ORs and procedure suites (e.g., CV Lab, Radiology/Interventional Radiology).
QUESTION: How can we answer that if the patient was admitted for surgery but had not gone to surgery during the time the prevalence study was done? The measure only applies to surgeries done BEFORE the prevalence study was conducted. QUESTION: On the data collection form where we are asked to collect the intra-operative time in hours for surgical patients. I am thinking we will collect this data for ALL inpatients who have had some kind of surgical procedure. Is this correct? We are currently collecting these data for patients whose primary reason for hospitalization was surgical. We will review the data collected to make a decision on whether other patients should be included. QUESTION: What about patients who are admitted as medical and later have a surgical procedure? Will your data files accept OR hours on medical patients? We are currently only accepting these data for patients whose primary reason for hospitalization was surgical. We will review the data collected to make a decision on whether other patients should be included. QUESTION: Are you willing/able to accept OR hours only on those patients who have a pressure ulcer, instead of all surgical patients? At least until we can implement automated hour documentation? Please wait until you can give us OR times for all surgical patients, not just those with pressure ulcers. It s important for us to be able to compare the OR times of patients both with and without ulcers to be able to determine if OR time is actually a contributing factor to the development of ulcers. QUESTION: What about Cath angio, since many neuro patients in ICU will be in cath angio doing a long procedure but not under the OR schedule time? Please include other procedure times also. Where the procedure takes place isn't the issue, it is the time the patient spends on the "procedure table regardless of its name. You wouldn't want to exclude a patient that had a procedure done in the Cath Lab vs. the Operating Room. Once the patient enters the "procedure suite/or" to prepare for their procedure, the opportunity for them to move becomes limited and they become more stationary as time moves forward to sedation and anesthesia. Time in/time out is a standard measurement in ORs and procedure suites (e.g., CV Lab, Radiology/Interventional Radiology). Prevalence Studies in the ED QUESTION: Why is ED being added as a service line for pressure ulcers? If found in the ED, they are not considered hospital acquired, so I don t understand the point. Is it possible to observe only restraints and not observe pressure ulcers in the ED? You can certainly opt to do only restraints in the ED, but with wide variation in ED length of stay pending admission, monitoring HAPU for ED patients who often have poor gurney surfaces is important. Magnet efforts will also benefit from use of PU as an ED metric. Please include patients that have an admission order, boarded patients, and those in the ED greater than 24 hours. QUESTION: The Braden score is not typically done in our ED and these patients would fall under the "Pt admitted within 24 hrs" from the "Admission pressure ulcer risk assessment" line down, so the only information would be background information and maybe a skin assessment...
Many facilities will complete Braden Scores or other skin assessments on patients, particularly boarded or waiting for admission. QUESTION: We have always included the ED in our prevalence studies for our own internal monitoring, but we have only included those patients in the ED for whom the decision has been made to admit. We have not included patients who are in the ED for treatment and release. Will this be the criteria for CALNOC or will you want to include all patients regardless of admit status? What time window do we use? Please include patients that have an admission order, boarded patients, and those in the ED greater than 24 hours. QUESTION: Does ED include the Rapid assessment area? Do we only see patients that are waiting to be admitted to a unit? If we are to see every patient in ED, what if the majority refuse? Will that skew our numbers? Depending on the hospital s unique structure, these areas could be distinct observation units or may be included as part of the ED. Your leadership team will know how your hospital has licensed this space. QUESTION: Some patients are in ED for reasons that will not require that they disrobe. How do you envision including ED in the pressure ulcer prevalence study. Exclude these patients. Include patients that have an admission order, boarded patients, and those in the ED greater than 24 hours. For questions please contact support@calnoc.org.