MSQC 2020: Program, Variable and Definition Updates

MSQC 2020: Program, Variable and Definition Updates

Effective: January 1 - December 31, 2020 Operation Dates

Contents

General Program Changes............................................................................................................................................ 2 Case Admin Tab............................................................................................................................................................... 3 Demographics ................................................................................................................................................................. 3 Insurance .......................................................................................................................................................................... 3 Surgical Profile................................................................................................................................................................. 3 Preop Tab ......................................................................................................................................................................... 3 Intraop Tab ....................................................................................................................................................................... 3 Prophylactic IV ABX......................................................................................................................................................... 4 Postop Tab........................................................................................................................................................................ 4 Labs .................................................................................................................................................................................... 4 Postop Occurrences ....................................................................................................................................................... 4 Postop Events .................................................................................................................................................................. 5 Hysterectomy Variables................................................................................................................................................. 6 Colorectal Cancer............................................................................................................................................................ 6 Whipple Tab ..................................................................................................................................................................... 6 Hernia Tab ........................................................................................................................................................................ 7 ERP ..................................................................................................................................................................................... 7 Pain .................................................................................................................................................................................... 7 Opioid Use ........................................................................................................................................................................ 8 Follow Up .......................................................................................................................................................................... 8

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General Program Changes

? Variables ? minimal Core variable reductions and additions (22 cases for full volume sites. ? 30 day follow up/patient reported outcomes paper letter & email ? modified to align across all (email, letter, workstation tabs); added more skip logic to 30 day PROs email; updated follow up letter to be more concise and improved readability for patients

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Case Admin Tab

? Previously called Admin tab ? All users can mark their own case ineligible along with the reason. MSQC CSC's will be monitoring

this. ? All users can enter case comments here (up to 500 characters) ? New: Is this a MACS case? This is only for the MACS abstractors to use for their cases for tracking ? New "Case Completed" button will be here. This must be selected before the cases will be

considered complete. Comments or an error message in the tab will appear for anything that was not completed before the button can be selected.

Demographics

? No changes

Insurance

? No Changes

Surgical Profile

? Added 2 new ICD-10 codes (K45.0, K46.0) for bowel obstruction to be used with 44005, 44020, 44050, 44055, 44180 (44021 retired in 2020)

? Admission to Hospital Date: o Corrected programming so Admission Date can be entered after Operation Date. See Variable Option "Enter the hospital admission date in mm/dd/yyyy format as assigned by the institution, even if it is after the operation date". This changed in 2019, but programming would not allow the correct date to be entered in 2019. o Clarified in definition this is admission to acute care, not to ED or observation

Preop Tab

? Disseminated Cancer: Added to Yes: Information is obtained within 30 days following the Principal Operative Procedure indicating disseminated cancer was present at the time of the Principal Operative Procedure (does not need to be related to the Principal Operative Procedure)

? Preop Sepsis updated date on Sepsis tool; added examples of chronic conditions in signs/symptom and organ dysfunction criteria.

Intraop Tab

? Wound Class: o clarified where to classify fecal contamination, necrosis, gangrene and added examples in Dirty/Infected-Class 4 o updated wound class decision tree o added Note #3: Chronic inflammation, closed drainage and presence or creation of colostomy do not change wound class (example: chronic inflammation can be present in clean and clean/contaminated wounds at baseline)

? Surgical Approach: o Clarified in Notes, ostomy takedown during robotic or laparoscopic cases, an open incision is made around the ostomy to take it down and is still considered a laparoscopic/robotic case since it is a normal part of the procedure.

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o Removed wording from hand-assist options #5 and 13- "Report this option if there is mention of use of gelport or handport, regardless of whether there is use of "handassisted" language". The surgeon should describe the hand inserted into the abdomen to palpate, manipulate, mobilize and/or dissect tissue in tandem with laparoscopic/robotic instruments when reporting `hand-assisted' as the surgical approach.

? Instruments, gloves and/or gowns changed at closing: also capture Exception if the case was not an open laparotomy or extracorporeal anastomosis bowel case in addition to Emergent case

? Bowel Anastomosis Technique (Minimally Invasive approach): added CPT code 44210 capture extracorporeal vs intracorporeal; added guidance to send op report to DHL before selecting "Unable to Determine".

? Anesthesia Technique: Added "Unknown" option and changed to required ? Removed variable related to Antibiotics "If participating in Colectomy Care Pathway QI..."

Prophylactic IV ABX

? Reworded the variable for clarity, but did not change the content

Postop Tab

? No Changes

Labs

? Added under Include: Lab values which are within the MSQC Range which is typically the lower and uppermost limit of human viable lab values (not the same as normal laboratory ranges)

Postop Occurrences

Postop Occurrence Date

Postop Occurrencehow many times to capture?

Changed to a Timeframe instead of capturing exact date: 1 - POD 0-7 (early complication) 2 - POD 8-30 (late complication) See each variable for detailed criteria. Assign only the highest level or highest intervention in the 30 days after surgery for these postop occurrences (do not assign multiple occurrences):

SSI (highest level) Postop Sepsis & Severe Sepsis/Septic Shock (highest level) Anastomotic Leak (highest intervention)

Assign only the first occurrence in the 30 days after surgery for these postop occurrences (do not assign multiple occurrences):

Pneumonia (* this may be 2nd occurrence depending on POA and RIT) Pulmonary Embolism Urinary Tract Infection ? Postop (* this may be 2nd occurrence depending on POA and RIT) Stroke or CVA Cardiac Arrest Requiring CPR Myocardial Infarction DVT Requiring Therapy C-difficile

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Ileus Requiring NG or NPO

NHSN variables-annual updates Postop Ileus

Pneumonia/UTI

DVT requiring therapy Postop Sepsis ? PATOS- Yes/No ? # of Transfusions ? Anastomotic Leak

highest intervention

No date or timeframe is required: RBC Transfusion (only enter total units in 72 hours postop)

SSI ? no changes in criteria. reorganized layout, removed duplicate notes. PNA- no changes in criteria. UTI- no changes in criteria. Added New Exclusion Criteria to definition: Patients with a preoperative history of: motility disorders of the intestine or stomach, dysmotility, gastroparesis, or chronic colonic inertia. This history may be found in the preoperative H&P, problem/diagnosis list. Clarified Note #3- Present on Admission (POA): If DOO falls within POA timeframe, do not assign that occurrence of pneumonia/UTI (but a second occurrence could be assigned Added confirmation via doppler/ultrasound is acceptable to definition Revised table Criteria #1 to: Recent history of new infection source, within the 30 days following the principal operative procedure Changed these child questions to required if SSI, Postop Transfusions and/or Anastomotic Leak are selected

Postop Events

? Added new Variable: Was this ED or urgent care visit likely related to the principal surgical

procedure? Y/N/Unknown

? Grouped ICD-10 codes and CPT codes into buckets. Select the one most fitting option. Numerous

examples in definition and an Excel spreadsheet on Workstation as a guide, not the source of

truth.

Return to ED/ Reason for ED or

1-Pain

Urgent Care

Urgent Care Visit

2-Infection

3-Wound Issue

4-Cardiovascular/Respiratory

5-GI

6-GU/Renal

7-Issue related to surgery, not listed above

8-Other acute medical condition

9-Exacerbation of chronic condition

Readmission

Reason for

1-Pain

Readmission

2-Infection

3-Wound Issue

4-Cardiovascular/Respiratory

5-GI

6-GU/Renal

7-Issue related to surgery, not listed above

8-Other acute medical condition

9-Exacerbation of chronic condition

Return to OR

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What was the Return to OR procedure performed?

Reason for Return to OR

1-Staged procedure 2-Colon/Small Bowel resection, repair or revision 3-Organ resection (other than bowel) 4-Organ repair (other than bowel) 5-Exploratory Laparotomy/Laparoscopy/Washout/I&D/ Debridement 6-Other procedure(s) 1-Infection 2-Bleeding 3-Complications occurring at the original surgical site [including those related to an anastomosis or wound] 4-Small bowel obstruction 5-Other issue related to principal operative procedure 6-Other issue not related to principal operative procedure

Hysterectomy Variables

? Preop Uterine Size ? changed "ultrasound" to "radiology"

Colorectal Cancer

? Clarified Adenocarcinoma variable options: 1. Adenocarcinoma is the tumor type, and the portion of the bowel with the cancer is removed 2. Adenocarcinoma is the tumor type, and the portion of the bowel with the cancer is NOT removed [and added examples of these types of cases]

? TME Grade- added in Note 1: TME Grade can also be called "Macroscopic Intactness of Mesorectum"

Whipple Tab

? Open for all sites and will open for Whipple cases (CPT 48150, 48152, 48153, 48154, 48999-for

lap/robot Whipple only).

? This is optional but highly recommended for sites doing Whipple's

? 12-17 variables which will allow quality improvement in this surgery which has high variation in

cost and outcomes between sites

? A care pathway was developed and will be available on MSQC website asap

? Variables collected:

o Preoperative Biliary Stent

o Pancreas Texture

o Preoperative Imaging-MRI/CT

o Placement of Anastomotic Pancreatic

o Neoadjuvant Treatment

Stent

o Specific Operation Performed

o Histology

o Vascular Reconstruction

o Pancreatic Fistula/Leak

o Pancreatic Duct Size in mm

o Delayed Gastric Emptying

o How Pancreatic Duct Size was

determined

Hernia Tab

? Open for all sites and will open for abdominal wall hernia cases (CPTs 49560, 49561, 49565, 49566,

49570, 49572, 49585, 49587, 49590, 49652, 49653, 49654, 49655, 49656, 49657)

? This is optional but highly recommended for sites doing abdominal hernia repairs. Required for

sites participating in pilot who have already been notified)

? 9-17 variables - Synoptic Op Note developed which includes all the variables for surgeons to

include in the op report

? Future QI project anticipated

? Variables collected:

o Hernia Location

o Mesh Length cm

o Previous Hernia Repair

o Mesh Width cm

o Hernia Length cm

o Type of Mesh Used

o Hernia Width cm

o Brand of Mesh Used

o Mesh Used

o Mesh Fixation

o Mesh Location

o Myofascial Release Type

ERP

?

? ?

Preadmission counseling/teaching for elective cases [pain management], Intraoperative use of multimodal pain management, Postoperative order of multimodal pain management, and Postop Teaching [pain management] will be required for 2 of the targeted procedure groups for QI [they will not be required in workstation since they are not required for every case] Preadmission Teaching/Counseling ? added Pain Management option Clarified timing of Preop Clear liquids Indicate whether or not the patient was permitted or provided clear liquids AFTER midnight through 2 hours prior to surgery in room time. (This does not include `2 hours before arrival to hospital). Also added more references.

Pain

? ?

? ? ? ?

Updated variable names to make it more clear which variable in PROs (30-day email and letter) it is referring to Added 2 variable options for Satisfaction with Care, Quality of Life, Surgical Site Pain Score in the last week, and changed to required: "Patient answered Unknown" & "Patient did not respond" [these will be part of collaborative wide measure] If answer No to new variable "Have you Returned to normal daily activities", # weeks return to all normal activities will not open (this matches 30-day email and letter) Preop pain score: added new Help text "obtained from EMR" Preop opioid use within 30 days: simplified definition, this will only capture preadmission opioid use New variable: For patients not discharged same day as operation date: Was opioid administered within 24 hours before discharge? [obtained from EMR]

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Opioid Use

? Added variable options for Type of Opioid Prescribed & added help text "home" includes discharge to home or discharge to home with home health care o Hydrocodone(Norco, Vicodin, Lortab, Lorcet) o Oxycodone (OxyContin, Percocet, Roxicodone) o Codeine (Tylenol 2, 3, or 4) o Tramadol (Ultram, Ultram ER) o Other (Fentanyl, Morphine, Hydromorphone, Dilaudid, Methadone, etc) o No opioid was prescribed at discharge and patient was discharged to home o NEW option: Patient not discharged to home or not discharged by POD 30 o Unavailable -there was no prescription available in EMR or per patient

? Type of Opioid Prescribed, Opioid Dose Prescribed Unit, Opioid Dose Prescribed (in 1 tablet, 1 ml of solution or 1 patch), Total Quantity Prescribed will be required for all cases and added known/unknown options o Opioid Dose unit and Current Dose unit- added more text to clarify, and changed "ml" option to "mg/ml"

? Added "Patient did not respond" option in "Do you know how many doses taken since surgery?", and changed to required. [This will be part of collaborative wide measure]

? If prescription not filled, remaining questions are disabled

Follow Up

? Retired "Attempted pain and opioid use variable collection?" variable ? Retired Yes/No Options for Contact Methods and changed to a checkbox list which will be

required to answer (check all that apply): None Documentation Email Phone Letter Other

? Added new Help Text in "Followed for 30 days" and the method for answering Yes or No will be changed to the following (please see definition for more guidance): o Answer YES if clinical follow-up obtained through postop day 30 AND you attempted to collect patient reported outcomes via email, phone or letter. o Answer YES If patient expired on or before POD30 o Answer NO if unable to obtain full 30-day clinical follow-up. Also indicate how many days the patient was followed, such as "11". o Answer NO if you did not attempt to collect patient reported outcomes via email, phone or letter.

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