Performance Activity and Quality Division Clinical Casemix Handbook 2012-2014 Version 3.0 improving care managing resources delivering quality © Department of Health, State of Western Australia (2012). Copyright to this material produced by the Western Australian Department of Health belongs to the State of Western Australia, under the provisions of the Copyright Act 1968 (Commonwealth Australia). Apart from any fair dealing for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Performance Activity and Quality Division, Department of Health Western Australia. The Department of Health is under no obligation to grant this permission. Please acknowledge the Department of Health Western Australia when reproducing or quoting material from this source. Important Disclaimer: All information and content in this Material is provided in good faith by the Department of Health Western Australia, and is based on sources believed to be reliable and accurate at the time of development. The State of Western Australia, the Department of Health Western Australia, and their respective officers, employees and agents, do not accept legal liability or responsibility for the Material, or any consequences arising from its use. To request permission to reproduce these materials, please contact the Performance Activity and Quality Division at [email protected] These materials are regularly updated. For the latest version go to the ABF/ABM intranet site at http://activity or the internet site at www.health.wa.gov.au/activity ISBN: 978-978-192-184-1 Clinical Casemix Handbook 2012-2014 Version 3.0 Contents Foreword 3 Acknowledgements 4 1.Introduction 5 1.1 Why is this important? 1.2 The documentation process from patient admission to end data 2. Casemix, coding and DRGs 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 What is casemix? What is clinical coding? What are complication and co-morbidity codes (CCs)? What are diagnosis related groups (DRGs)? DRG structure How is a DRG assigned? Clinical information audit program Costing and funding of health care The ABF operating model 3. Clinical documentation 5 6 7 7 7 9 10 10 10 13 13 15 17 3.1 Clinical incidents and adverse events 19 4. Clinical handover 21 5. Completing the discharge summary 23 5.1 Guidelines for completing a good discharge summary 5.1.1 Content 5.1.2Clarity 5.1.3Sequencing 5.2 Requirements of the discharge summary 5.2.1 Principal diagnoses 5.2.2 Past history 5.2.3 Presenting problem 5.2.4 Additional diagnoses 5.2.5Operations/procedures 5.2.6 Relevant investigation result 5.2.7 Treatment and progress 5.2.8 Medication 5.2.9 Future plan of management 6. Sample discharge summary 1 24 24 24 25 26 27 27 27 29 31 34 34 34 34 35 Clinical Casemix Handbook 2012-2014 Version 3.0 Clinical case studies 39 Common complications and co-morbidities 49 Appendixes 51 Appendix A AR-DRG major diagnostic categories Appendix B The AR-DRG classification system B.1Structure B.2 Broad group B.3 Adjacent DRG B.4 Split indicator B.5 AR-DRG treatment of severity B.6 Example 1: DRG assignment B.7 Example 2: DRG assignment B.8 Impact of CCs on cost signature 51 52 52 52 52 53 53 54 55 56 Appendix C 57 Glossary References 59 2 Clinical Casemix Handbook 2012-2014 Version 3.0 Foreword Clinical documentation plays an important role in ensuring the quality and safety of patient care as well as contributing to medical research and the delivery of evidence based care. Producing accurate clinical documentation which captures consistent and transparent information about how a patient has been cared for is a fundamental aspect of a clinician’s role. Activity Based Funding and Management (ABF/ABM) was introduced in 2010 as the new way of managing the health service in WA. Ultimately ABF/ABM will ensure health resources flow to where they are most needed. ABF/ABM relies on timely and accurate information about patients and their care to ensure the ongoing delivery of safe high quality care to the community of WA. This information will enable the community, clinicians, public servants and Government to make informed decisions about how and where we deliver healthcare across WA. Working together, each of us has a role to play in delivering excellence in healthcare to the people of Western Australia. This booklet has been developed to support all clinicians in that aspect of their work. 3 Clinical Casemix Handbook 2012-2014 Version 3.0 Acknowledgements This document was developed by the Activity Based Funding and Management Team within the Performance Activity and Quality Division of Department of Health. The team would like to thank staff across WA Health for their contributions. In particular, the team extends a thank you to colleagues from Health Services, Health Networks and the Postgraduate Medical Council of Western Australia. We also acknowledge the authors of the Alfred Casemix Clinical Handbook 10th Edition (2009 – 2010)(1), and the National Centre for Classification in Health – University of Sydney (2003). Good Clinical Documentation Guide, on which this handbook was based. Finally, the purpose of activity based health improvement reform is to improve health services and hospitals for WA patients, communities and populations. We acknowledge and thank them as our partners in improvement. Activity Based Funding and Management Team September 2012 Intranet: http://activity Internet: www.health.wa.gov.au/activity 4 Clinical Casemix Handbook 2012-2014 Version 3.0 1. Introduction 1.1 Why is this important? The quality of the information in a patient’s medical record is a key element of the safety and quality of the care we deliver. Accurate and timely health information is vital to safe and effective handover of care between healthcare professionals. Good documentation ensures that all clinical staff caring for patients in present or future episodes has access to the records they need to optimally care for the patient. Problems with communication, and in particular documentation, are widely recognised as major contributing factors in the occurrence of sentinel events.(10) Casemix and Diagnosis Related Groups (DRGs) are used to collect, classify, code, count and cost the diverse range of care that is provided in our hospitals. This facilitates organising the health system as efficiently and effectively as possible so that we can provide safe high quality care to the WA community. It is important for clinicians to understand this because: It impacts on how services are funded – we need an accurate picture of the services we provide so we can ensure services are funded properly. It impacts on how services are delivered and the workforce required to deliver them – future plans for clinical services are based on information about the current and future health needs of the community. The handbook outlines the clinical coding process, from its use of diagnoses and complications or co-morbidities to determine care and complexity levels, to the final assignment of DRGs. It shows how the DRG is then used to drive the Activity Based Funding and Management approach. One of the key components of this resource is highlighting the importance of accurately documenting clinical information in the patient’s medical record and producing an accurate and timely discharge summary. The information you create as part of a patient’s medical record is used in many different ways. Health information should be legible, timely and accurate. It is essential for safe and effective communication between health professionals. 5 Clinical Casemix Handbook 2012-2014 Version 3.0 1.2 The documentation process from patient admission to end data Documentation related to episode of care Discharge summary completion Assignment of ICD-10-AM codes for diseases and procedures Abstraction of information from the clinical record Assignment of DRGs National Centre for Classification in Health. 2003(2) 6 Casemix, coding and DRGs Casemix, coding and DRGs Clinical Casemix Handbook 2012-2014 Version 3.0 2. Casemix, coding and DRGs This section provides some background to explain how the information in the medical record is used in determining the activity and funding levels within a hospital or health service. It covers casemix classification systems, clinical coding, costing and funding. 2.1 What is casemix? Casemix refers to the range and types of patients (the mix of cases) treated by a hospital or other health service. It provides a way of describing and comparing hospitals and other services, thereby assisting in planning and management of a health care system. Casemix classifications put patients into clinically meaningful groups that use similar health care resources. By doing so, the clinical activity, quality and costefficiency of different hospitals can be compared. However, the introduction of an activity based funding (ABF) framework in WA is not just about hospital casemix. It can include community care and/or chronic disease programs, preventive health programs, shared maternity care, subacute and step down care, living well when older, education, training, research and other services. Casemix data is used for many purposes, including; clinical research, funding and financial management, identifying epidemiological patterns and disease trends, reviewing resource consumption, workforce and facilities planning, monitoring quality of care, and making comparisons between facilities, areas and states. 2.2 What is clinical coding? Coding involves reviewing and extracting information from the medical record based on documented clinical information and translating this clinical information into code. Information coded includes: principal diagnosis other primary diagnoses co-morbidities relevant to the admission complications procedures performed (both therapeutic and diagnostic). 7 Clinical Casemix Handbook 2012-2014 Version 3.0 Through accurate documentation, the clinical coder can translate information into a series of alphanumerical and/or numerical codes to reflect the complete clinical picture. Clinical coders use the International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification (ICD –10-AM), 7th Edition – 1 July 2010. ICD-10-AM consists of: A disease classification based on the World Health Organisation’s publication ICD-10 with modifications to ensure a current and appropriate classification for Australian clinical practice. An Australian procedure classification, the Australian Classification of Health Interventions (ACHI), which is based on the Medicare Benefits Schedule (MBS). Australian Coding Standards (ACS); a set of specific rules, which aim to standardise clinical coding practice nationally, covering both general principles and specific specialty issues(3). 8 Clinical Casemix Handbook 2012-2014 Version 3.0 2.3 What are complication and co-morbidity codes (CCs)? Complication and co-morbidity (CC) codes are additional diagnoses that are likely to result in significantly greater resource consumption during an inpatient episode. Each of these additional diagnoses is assigned a complication and co-morbidity Level (CCL) and from these, a patient care complexity Level (PCCL) is then calculated and assigned for every record. The PCCL is a measure of the cumulative effect of a patient’s complications and co-morbidities. Adjacent DRGs have differing levels of resource consumption and are split on the basis of the PCCL, malignancy, same day status, mental health status and mode of separation. A complication is a condition not present on admission which arises during the patient stay, or is the result of a procedure or treatment during the stay. Examples are: embolism drug reaction urinary tract infection (UTI) post-operative infections. A co-morbidity is a condition that exists at the time of admission, which affects patients care in terms of requiring: therapeutic treatment diagnostic procedures increased clinical care and/or monitoring. One or more of the above factors will generally result in an extended length of stay. The inclusion or exclusion of CCs has a dramatic impact on the DRG assigned and therefore an appropriate remuneration for the resources used, especially under an activity based funding framework. It is crucial that any complications of treatment or surgery, and any relevant additional diagnoses are documented, to ensure accurate DRG assignment with subsequent appropriate funding to the health service. For more detailed information refer to Appendix A: Common complications and co-morbidities. 9 Clinical Casemix Handbook 2012-2014 Version 3.0 2.4 What are diagnosis related groups (DRGs)? Diagnosis Related Groups (DRGs) are commonly used as the basis of an inpatient classification system. Australian Refined Diagnosis Related Groups (AR-DRGs) are refined for use in Australia and provide a clinically meaningful way of relating types of patients treated in a hospital to the resources required to treat them. AR-DRGs use information in the patient’s hospital record such as diagnoses, procedures, co-morbidities, complications, and age to classify the patient. Relevant diagnoses and procedures are coded for each admitted patient episode and the combination of codes for each episode guide its assignment to a DRG by way of using DRG grouper software. 2.5 DRG structure This indicates the Major Diagnostic Category (MDC) to which the DRG belongs There are 23 MDCs E 6 5 A This indicates the partition to which the DRG belongs 01–39 surgical 40–59 other 60–99 medical Split indicator ranks the resource consumption of a DRG A highest consumption B second highest C third highest D fourth highest Z no split Example: DRG E65A – Chronic Obstructive Airways Disease with Catastrophic CC E: MDC – respiratory System, 65: medical, A: split ranking it as highest resource within the DRG65 group. 2.6 How is a DRG assigned? Clinical coders assign ICD-10-AM codes to the episode of care which are entered onto the hospital’s patient administration system. The DRG grouper (software) generates a DRG for each inpatient episode, based on the provided codes and other patient information. Diagram 2 displays the DRG classification process. AR-DRG version 6 incorporates 698 AR-DRGs, most of which are organised into 23 Major Diagnostic Categories (MDCs) – generally based on body systems (see Appendix A). Each MDC contains three partitions – surgical, other and medical DRGs. The presence or absence of operating room and non-operating room procedures is generally responsible for the assignment of a record to one or the other of these partitions. For more detailed information refer to the section Common complications and co-morbidities. 10 Clinical Casemix Handbook 2012-2014 Version 3.0 For some MDCs and DRGs there are variables, other than ICD-10-AM codes, which may affect DRG assignment. These variables are: patient age and sex length of stay same day status admission weight for infants aged <365 days mental health legal status mode of separation. Note: Ethnicity and/or Indigenous status have no bearing on DRG assignment. Prior to allocation to a MDC, pre-MDC processing occurs, which identifies and assigns very high cost DRGs for the following conditions: age <28 days age <1 year with an admission weight <2,500g principal or secondary diagnosis of HIV or related condition liver, heart, lung, bone marrow or multiple organ transplant significant trauma >1 body site ECMO without cardiac surgery tracheostomy/MV > 95 hours. 11 Clinical Casemix Handbook 2012-2014 Version 3.0 Diagram 2: Typical DRG classification process(2) Diagnoses and procedures coded using ICD-10-AM Identify principal diagnosis Assigned to a Major Diagnostic Category (MDC) (23 groups) Exceptions •Age <28 days •Age <1 year with an admission weight <2,500g •Principal or secondary diagnosis of HIV or related condition •Liver, heart, lung, bone marrow or multiple organ transplant •Significant trauma >1 body site ECMO without cardiac surgery •Tracheostomy/MV > 95 hours Assigned to Pre-MDC DRG Check for significant OR procedure NO Check for non-OR procedure NO YES YES MEDICAL PARTITION OTHER PARTITION SURGICAL PARTITION Grouped according to principal diagnosis, e.g. neoplasm, specific conditions, symptoms, other Grouped according to principal diagnosis and non-OR procedure Grouped according to type of surgery, e.g. major, minor, other, unrelated to principal diagnosis Checked for: CC, age, other split Checked for: CC, age, other split Checked for: CC, age, other split DRG assigned DRG assigned DRG assigned 12 Clinical Casemix Handbook 2012-2014 Version 3.0 2.7 Clinical information audit program The Performance Activity and Quality Division regularly conduct clinical information audits of public hospital inpatient episodes. The aim of these audits is to examine the inpatient data, with emphasis on accuracy of ICD-10 coding and AR-DRG assignment. Episodes randomly selected for audit are re-coded from the source data at hospital level through review of the discharge summaries and the medical records. These audits provide an opportunity to enhance communication between clinicians and clinical coders, raising any anomalies in the ICD-10-AM classification, AR-DRG grouper or relative weights assigned to DRGs. These anomalies may be reported to the relevant State and Commonwealth bodies for consideration in the revision processes for future versions of the classification and/or grouper software. The audits are conducted by a small team of nationally accredited auditors from the Business and Financial Modelling Directorate. Audits allow us to develop a number of guidelines on how to accurately document diagnoses and procedures to ensure that the hospital is adequately reimbursed for the patients treated. Accuracy of coded patient information can improve with: Greater understanding by clinical coders of disease processes, interventional techniques, and clinical practice relevant to their particular hospital. Enhanced understanding of the hospital’s casemix and activity based funding profile. Greater understanding by clinicians of what coders require from discharge summaries and inpatient notes, in order to comprehensively code a patient’s episode. A better understanding by clinicians, coders and Health Information Managers, of the DRG allocation process and factors influencing accurate DRG assignment. 2.8 Costing and funding of health care The DRG cost is determined through patient level clinical costing which is undertaken regularly at Health Service level by dedicated costing staff. Patient level costing is the output of a modelling process by which costs are allocated to individual episodes of care. For example when a patient has a CT scan at the imaging department, the cost of that scan is matched to that patient episode. The process ensures that the Department of Health submits patient costed data to the Federal Government’s National Hospital Cost Data Collection (NHCDC) and provides local data for the WA activity based operating model development and implementation. 13 Clinical Casemix Handbook 2012-2014 Version 3.0 WA public hospitals are funded based on the level and type of activity they are expected to provide. Inpatient activity is classified into DRGs, measured as weighted separations, which are then used for funding purposes. Each DRG has a weight which is a measure of the cost of treatment of the average inpatient in the DRG. This weight reflects the expected resource intensity of the cases that fall into that DRG, relative to all other DRGs. These weights are called “Weighted Activity Units” (WAUs). These are developed for each category of services which are funded on an activity basis. These include inpatient, outpatient and emergency department activity. The weighted activity unit (WAU) of a knee replacement admission (4.1442) will have a greater weight than that of a dialysis admission (0.1324) due to the greater complexity and costs involved. The ABF allocation for health services is determined by multiplying the price by the volume of activity, expressed in weighted activity units (WAU). The WAU is the national weighted activity unit (NWAU) as determined by the Independent Hospital Pricing Authority (IHPA) , based on national classifications for inpatient, emergency department and hospital based outpatient services.(4) Table 1, below demonstrates how complexity of care, captured through clinical coding, is reimbursed at a higher rate to reflect the higher costs which are incurred in delivering that care. This complexity is identified in the medical record through the documenting of diagnoses, particularly complications and co-morbidities. Table 1: Example of payment for DRG I12 Infection/Inflammation of Bone and Joint with Miscellaneous Musculoskeletal procedure DRG Complexity I12A with catastrophic co-morbidity and/or complication LBP HBP WAU Price Payment 8 74 7.6248 $5,135 $39,153 I12B with severe or moderate co-morbidity and/or complication 4 42 4.4288 $5,135 $22,742 I12C without co-morbidity and/or complication 2 19 2.5905 $5,135 $13,302 LBP: low boundary point HBP: high boundary point WAU: weighted activity unit Calculated using Independent Hospital Pricing Authority (11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013 (4) state efficient price of $5135 14 Clinical Casemix Handbook 2012-2014 Version 3.0 2.9 The ABF operating model A patient’s Length of Stay is an important factor in the calculation of the hospital’s resource use. In the ABF operating model an average length of stay (ALOS) is determined for each DRG; along with a low-boundary point (one third of the ALOS) and a high boundary point (three times the ALOS). These length of stay boundaries have been determined to enable exceptional episodes to be identified and funded appropriately. In Diagram 3 the funding (red line) illustrates how it is likely that the costs of providing care to long stay patients will exceed the payment the hospital receives. The average cost per episode (the green line) illustrates the direct link between the length of a patient’s stay in hospital and the costs of providing that care: A reduction in the length of stay for inlier episodes improves the efficiency of a hospital. The funding model for core or central activity has built in incentives to encourage early discharge where appropriate. If a patient is discharged before the average length of stay the health service keeps the credit for the full episode payment. Episodes with above average length of stay will tend to be more costly than the average patient within that DRG. Diagram 3: Inpatient Cost Modelling: DRG Inpatient cost signature(4) 2012-2013 state efficient price of $513 Inlier/central episodes have nights of stay within or on the low and high boundary points and all inlier/central episodes within each DRG are funded at the same rate 15 Clinical Casemix Handbook 2012-2014 This page has been left intentionally blank 16 Version 3.0 Clinical Casemix Handbook 2012-2014 Version 3.0 3. Clinical documentation The primary benefit of good documentation is to support the provision of high quality and safe patient care. It ensures that all clinical staff caring for patients in present or future episodes have access to the records they need to optimally care for the patient.(2) Good clinical documentation also ensures reliable information is available for other purposes such as research, planning, and in providing the information required to produce quality coded clinical data to be used in activity based funding. It is therefore in the best interest of every patient and provider that the medical record contains complete and accurate documentation of each episode of care. Ensuring that clinical information is documented in the medical record is crucial for safe and high quality patient care. It also facilitates coding and accurate DRG assignment and subsequent appropriate funding to the health service. 17 Clinical Casemix Handbook 2012-2014 Version 3.0 The following are general guidelines for clinical documentation. You should also refer to your health service policies for details any local requirements. Please ensure: documentation is complete daily progress notes or care plans are documented a discharge summary is completed at the time of discharge. Where clinically relevant, the following information should be included in every health record: history – presenting problem; history of presenting problem; other past history; personal history; and family history examination diagnoses management discharge planning procedures anaesthetic record progress notes discharge summary outpatient and Emergency Department notes. Use commonly accepted terminology and abbreviations Spell out abbreviations when there could be confusion as to its meaning, for example; PE – pulmonary embolism or pleural effusion? Avoid the use of eponyms unless its use is clear or commonly accepted, for example; Jaboulay procedure – gastroenterostomy or repair of hydrocele? Avoid the use of observational descriptions versus defined diagnostic terms, for example; Operation report states “Turbid Fluid in abdominal cavity”. The surgeon is generally referring to “infective peritonitis”. Please document ‘peritonitis’ as this a recognised coding term and its inclusion impacts on the DRG assignment. Another example is type 1 or type 2 respiratory failure. This is another widely used clinical term. However, the only terms in ICD-10-AM are acute, chronic or unspecified respiratory failure. These terms (type 1 or type 2) will be coded to ‘unspecified respiratory failure’ which has no complexity level, whereas “acute” and “chronic” have significant complexity levels as additional diagnoses, impacting on the DRG classification. 18 Clinical Casemix Handbook 2012-2014 Version 3.0 Timeliness of documentation is important The accuracy of clinical documentation is improved if the information is recorded as soon as possible. Ensuring the timely completion of discharge summaries also improves communication with other healthcare practitioners. Write legibly Communication with other healthcare practitioners and clinical coders is improved when documentation is legible. Work closely with clinical coders The coder and clinician working together will improve the standard of both coding and documentation. “Improving documentation it is about making the patient’s journey through the health care system safer and smoother – it is not about making the coder’s life easier. ” Dr Ted Stewart-Wynne, Director Medical Services, Royal Perth Hospital 3.1 Clinical incidents and adverse events Preventable adverse events continue to occur in all healthcare systems in the world, including WA Health. These cause significant distress to patients, carers and their families, and add unnecessary cost to the taxpayer. Modelling undertaken by WA Health suggests that the annual cost attributable to preventable adverse events in WA is as high as $170 million(10). All adverse events should be factually documented in the patient’s medical record and discharge summary thus ensuring accurate coding and inclusion in DRG classification. Clinical incidents, adverse events and sentinel events are to be reported and managed in accordance with the current Clinical Incident Management Policy(6). 19 Clinical Casemix Handbook 2012-2014 Version 3.0 Clinician and coder collaboration delivers quality Respiratory Medicine – Sir Charles Gairdner Hospital 2012 The Respiratory Medicine team at Sir Charles Gairdner Hospital recognised the importance of reporting correct activity levels in an ABF/M environment. They approached the Clinical Coding Coordinator to enquire into the accuracy of coding and whether the effort of their clinical input would be worthwhile. After reviewing the medical record, if the clinical coders had any concerns and felt they were not being provided with the full clinical picture to enable the case to be coded correctly, they agreed to pass them on for clinical review. Approximately 20% of respiratory cases were reviewed. Of the cases that required amending, subsequent DRG reclassification equated to a 30% increase in expected revenue. Not only did this highlight the need to educate clinical staff in the importance of accurate documentation, it also highlighted that clinicians were unlikely to attain the skills and expertise of the clinical coders. By working together, coders and clinicians have created a valuable partnership and subsequent plans have been made for them to meet weekly to review selected cases. A similar process was undertaken within a surgical unit at SCGH with almost identical findings and outcome. An unexpected outcome from this process was the discovery that the electronic discharge summary software sorted the diagnoses into alphabetical order regardless of the order they had been entered. For example: the principal diagnosis was not appearing first with other diagnosis following in order of importance. This was not only hindering the coding process but also the quality of the discharge summary information provided to ongoing care providers. This issue has since been addressed and the Principal Diagnosis is now clearly separated from other diagnoses. “Working with the team of coders not only demonstrably improves the accuracy of capturing clinical activity levels, but also provides useful insights into the quality of documentation by junior staff, as well as an appreciation of how attention to details in describing the individual aspects of an episode of care is vital to defining the bigger picture of the overall admission. We also found that experienced coders can reliably identify cases which require additional clinical input as opposed to needing clinicians to double check every case”. Clinical Coding Coordinator, Sharon Linton and Dr W. Chin Dr. Weng Chin, Respiratory Physician, SCGH 20 Clinical Casemix Handbook 2012-2014 Version 3.0 4. Clinical handover Clinical handover is the transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis(5). “Clinical handover is a high risk area for patient safety” and a priority area for patient safety improvement for the WA health system(9). Good clinical handover is essential for protecting patient safety Clinical handovers include, but are not limited to: escalation of the deteriorating patient shift-to-shift handover intra-hospital transfer transfer from one inpatient facility to another discharge from an inpatient facility. Two important evidence-based principles for best practice in handover are emerging: face-to-face communication and documentation. Problems with communication, and in particular documentation, are widely recognised as major contributing factors in the occurrence of sentinel events.(10) The aim of clinical handover is to achieve the effective communication of high-quality, relevant clinical information at any time when responsibility and accountability for patient care is transferred. Standardisation of handover, as part of a comprehensive, system-wide strategy, aids effective, concise and inclusive communication in all clinical situations and contributes to improved patient safety(9). It is recommended that clinical handovers initiated by WA Health staff: are supported by education are structured according to the iSoBAR(8) tool (see back page) use pre-prepared documentation are conducted in an appropriate environment (i.e. minimise interruptions, access to patient information), using an appropriate modality (i.e. face to face, telephone, written). 21 Clinical Casemix Handbook 2012-2014 This page has been left intentionally blank 22 Version 3.0 Completing the discharge summary Completing the discharge summary Clinical Casemix Handbook 2012-2014 Version 3.0 5. Completing the discharge summary The discharge summary may be the only form of communication that accompanies the patient to the next setting of care. Delayed or inaccurate communication between hospital-based and primary care physicians at hospital discharge may negatively affect continuity of care and contribute to adverse events. The hospital discharge summary is the primary document communicating a patient’s care plan to the post-hospital care team. The diagnoses and procedures documented on the discharge summary should accurately describe why the patient was admitted to hospital and how they were treated. As well as clinician to clinician communication, this forms the basis for assignment of codes by the clinical coder, along with reference to all other documentation pertaining to the admission. This section outlines the importance of ensuring the discharge summary is well structured, as well as accurate and timely. 23 Clinical Casemix Handbook 2012-2014 Version 3.0 5.1 Guidelines for completing a good discharge summary This section highlights the key elements to a well structured discharge summary: Content: information should be accurate and comprehensive Clarity: information should be clear and concise Sequencing: information should be structured in a logical and helpful way to ease communication. 5.1.1 Content Ensure that the patient’s conditions and diagnoses are documented and substantiated throughout the medical record, not just in the discharge summary i.e. in progress notes, investigation results. Clinical coders require documented evidence of a particular condition being treated during the episode of care before assigning the corresponding code. Note any complications that may have arisen and their cause if known. Document any clinical incident, adverse event or sentinel event that may have arisen during the patient’s stay in hospital. (Note that only facts should be documented.). Document cause of death e.g. respiratory failure, renal failure. Document all diagnostic and therapeutic interventions, described as specifically as possible. Include past medical/surgical history and future progress/management. 5.1.2 Clarity Itemise each diagnosis which should be coded. Diagnoses which need to be abstracted from long descriptive paragraphs could be missed. Ensure that diagnoses documented in the progress notes are also documented in the discharge summary. If this is not done, the correct diagnosis may be missed by clinical coders. Example 1 “Tissue removed at debridement, post-hemiarthroplasty, grew pseudomonas and enterococcus”. A diagnosis of infection was intended. However, the term “infection” was not listed and the appropriate code was not assigned. Make references to results pending. The clinical coding may require updating when all results are finally reviewed. Avoid non-standardised terminology e.g. “dyscopia”. Specify how accidents happen and where they occur e.g. slipped on pathway at home, fall from ladder at work. Medical abbreviations, acronyms and eponyms may be used, as long as they have standard well-recognised meanings. Any ambiguity should be avoided. 24 Clinical Casemix Handbook 2012-2014 Version 3.0 Example 2 The abbreviation “PE” was used throughout the medical record and on the discharge summary and was coded as pulmonary embolus. The clinician later confirmed the intended diagnosis was pericardial effusion. Be as specific as possible in diagnosis documentation e.g. whether a condition is acute or chronic or both: whether liver disease is known to be fibrosis, cirrhosis, etc. Clinical coders will not be able to judge the clinical significance of laboratory or histopathology results, nor are they required to make these judgements. Any such findings, where significant, need to be included in an itemised diagnosis e.g. UTI – E coli. Underlining abnormal biochemistry (e.g. K, Na+), in the progress notes, will not guarantee that the condition is coded. The diagnoses should be itemised on the discharge summary (e.g. hypokalaemia, hyponatremia) if deemed clinically significant. Specify, if known, the duration or approximate duration of any loss of consciousness associated with head injury. 5.1.3 Sequencing Clear designation of the single diagnosis which best meets the definition of principal diagnosis (refer 5.2.1) is critical. All other significant diagnoses should be listed as additional. Clinical coders cannot code “?”, “possible” or differential diagnoses as the principal. Clinical coders will require guidance as to whether the most significant symptom (e.g. chest pain) or the most likely presumptive diagnosis (e.g. angina) should be coded. Avoid leading with symptoms if the underlying cause has been established. For example a principal diagnosis of “cardiac syncope - atrial fibrillation new” runs the risk of being coded primarily to a symptom code (syncope) instead of to atrial fibrillation. Trauma – in multiple injuries, sequence the single injury which poses the most severe threat to life or limb, as the principal diagnosis. Where multiple injuries are life threatening, or none of the injuries are life threatening, it is the doctor’s prerogative to select the most severe or clinically significant injury as principal diagnosis. 25 Clinical Casemix Handbook 2012-2014 Version 3.0 5.2 Requirements of the discharge summary The most important requirements of a discharge summary are that it be complete, accurate and timely. This is necessary for adequate communication between health care providers (e.g. between hospital doctors and the family general practitioner). It also ensures that each inpatient episode is coded accurately and as soon as possible after discharge. The unit and hospital activity can, thereby, be measured, analysed, and reported on a regular basis. A good discharge summary should include: principal diagnosis past history presenting problem additional diagnoses (complications or co-morbidities) operations/procedures relevant investigation results treatment and progress medications future plan of management. A complete discharge summary is required for each admitted patient episode, with the following exceptions only: healthy newborns (babies in their birth episode, with no peri-natal morbidity) recurring care episodes (e.g. same day infusions, transfusions, dialysis for treatment of the same conditions over weeks or months) – one global discharge summary covering all episodes suffices same day elective procedures where the operation report provides necessary clinical details (e.g. endoscopy). There must be supporting documentation in the discharge summary and medical record for all diagnoses and procedures. 26 Clinical Casemix Handbook 2012-2014 Version 3.0 5.2.1 Principal diagnosis The principal diagnosis is defined as; The diagnosis, established after study, to be chiefly responsible for occasioning the patient’s episode of care in hospital (or attendance at the health care facility). Clear designation of the single diagnosis which best meets the definition of principal diagnosis is critical. The phrase “after study” means after evaluation of findings to establish the condition that was chiefly responsible for occasioning the episode of care. The condition established after study may or may not confirm the admitting diagnosis. Evaluation in this context considers the results of diagnostic tests performed during the episode. It does not include information obtained from subsequent outpatient attendances or subsequent admissions. Procedures must not be recorded as a diagnosis. Tonsillectomy, arthroscopy, hysterectomy, are not acceptable principal diagnoses. The reason the patient underwent the procedure (diagnosis) should be recorded. Events must not be recorded as the principal diagnosis e.g. “fall”, “MVA”. 5.2.2 Past history Details regarding a patient’s relevant past medical and surgical history (e.g. appendicectomy, CABGs, cardiac pacemaker). 5.2.3 Presenting problem The symptom(s) which led the patient to present for treatment e.g. abdominal pain, haematemesis, chest pain. 27 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 1 – Defining the Principal Diagnosis Mrs W is an 86 year old woman, presenting for an elective booked angiogram of her femoropopliteal circulation. She has a known background of peripheral vascular disease, is an ex-smoker, and on presentation has dusky toes with small healing ulcers. At preoperative review by the anaesthetist she is found slumped in her chair, and difficult to rouse. The procedure is cancelled and she is admitted to the medical ward for investigation of fluctuating glasgow coma score, facial asymmetry and slurred speech. The provisional diagnoses on admission are ‘”TIA” Arrhythmia due to cerebral hypoperfusion”. Over the course of her five day stay, her amlodipine (for hypertension) is ceased. Her metoprolol is halved. She has dressings to her foot ulcers and is reviewed by the dietician for her ‘poor oral intake’. The evolving diagnosis (progress notes 6/11/11) is ‘likely postural hypotension secondary to meds’. Discharge Summary – Principal diagnosis: syncope secondary to meds Mrs W’s length of stay (LOS) of 5 days was above the average LOS of 2 days for the DRG she was coded to and the cost of delivering her care was more than the revenue the health service would receive for this patient’s care. A review of the documentation and coding was undertaken and “buried” in one of the paragraphs of the discharge summary was a clue to the definitive diagnosis: “postural cerebral hypoperfusion, likely secondary to medication causing postural drop”. The syncope (R55) was the presenting problem; it was not the final diagnosis after study. After coding this information the admission was reclassified to a much higher resource DRG, with a revenue increase of $3,194. Original Revised PROCEDURES 95550-00 dietician consultation DRG F73B syncope & collapse W/O CC ALOS WEIGHT 2.3 0.4999 I952 drug-induced hypotension I951 postural hypotension I7023 PVD with ulcer Z530 cancelled procedure Z8643 ex-smoker I10 hypertension R638 poor intake of food/fluid 95550-00 dietician consultation F75B Other circulatory system disorders with severe or moderate CC 4.3 1.1220 REVENUE $2,567 $5,761 DIAGNOSES R55 syncope I952 drug-induced hypotension I7023 PVD with ulcer Z530 cancelled procedure Z8643 ex-smoker I10 hypertension R638 poor intake of food/fluid Calculated using Independent Hospital Pricing Authority (11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013 (4) state efficient price of $5135 28 Clinical Casemix Handbook 2012-2014 Version 3.0 5.2.4 Additional diagnoses (complications and co-morbidities) These diagnoses affect patient care in terms of requiring (for that admission) any of the following: commencement, alteration or adjustment of therapeutic treatment diagnostic procedures increased clinical care/monitoring alteration of the standard treatment protocol for a particular procedure. Do not include past history here unless relevant to this admission. It is important to indicate how the condition was actively treated or assessed for all conditions listed as “additional diagnoses”. Additional diagnoses may be sub-categorised on discharge summaries as either complications or co-morbidities. Example Type 2 diabetes Mellitus, which has required increased monitoring during the patient’s episode of care. Chronic Obstructive airways disease where a lung scan has been performed. 29 Clinical Casemix Handbook 2012-2014 Version 3.0 Co-morbid conditions Pre-existing conditions which are clinically significant for this admission and which may in some cases be causally linked to the principal diagnosis. Example – co-morbidity Chronic kidney disease (CKD) secondary to type 2 diabetes Mellitus. Where CKD is the principal diagnosis, diabetes in this instance would be a co-morbidity. Complications A complication can best be described as a condition, not present at the time of admission, but which arises during the admission and which affects the patient’s management and/or length of stay. Example – complication Infection of surgical wound Accidental laceration of bladder during caesarean section In its broadest sense a complication can: be intimately related to the disease process result from lack of an intervention (e.g. failure to treat a condition) be related to a complex interaction between the disease process and the intervention be directly related to an intervention (e.g. (non) invasive procedures, surgery, anaesthesia, medication). Clinically relevant co-morbidities and complications can add to the cost of providing care to that patient. To ensure the health service is adequately funded for the level of complexity, it is important to ensure all relevant co-morbidities and complications are documented and coded correctly. If a condition or injury is related to a surgical/procedural intervention, rather than being related to the patient’s disease process, then this should be clearly documented in the progress notes and/or operation report and on the discharge summary e.g. ‘acute urinary retention following hernia repair, requiring catheterisation. Patient also has benign prostatic hypertrophy (BPH)’. 30 Clinical Casemix Handbook 2012-2014 Version 3.0 Based on this documentation the coder cannot correctly assign the urinary retention code as it is not clear whether the urinary retention is directly related to the surgery or is associated with BPH. Similarly, use of the term “post-op urinary retention” only advises that the retention occurred in the post operative period. Use of the terms “due to” or “secondary to” clearly define a clear causal relationship between the procedure and the urinary retention enabling the coder to capture the procedural complication. 5.2.5Operations/procedures The principal procedure is the most significant procedure that was performed for treatment of the principal diagnosis. All significant procedures undertaken from the time of admission to the time of discharge should be documented. This includes diagnostic, therapeutic and allied health procedures. 31 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 2 – Specifying the Diagnoses Mr J is an 82 year old admitted to a metropolitan non-teaching hospital with increasing right shoulder pain and lower back pain with some lower limb weakness. He has a history of ‘bowel cancer’, resected in 2003 but has been well since. He is an ex-smoker. Correspondence elsewhere in the notes confirms a recto-sigmoid primary in 2003. He has an x-ray of the right shoulder which shows a large metastatic deposit in the humeral head. His bilateral lower limb weakness worsens and is later referred to in the progress notes as ‘paraplegia’. A CT scan shows a pathological fracture in the T7 vertebral body with metastases also in T8 and L2. Oncologist review 15/2/11: now has spinal cord compression with metastases in spine and humerus. He is transferred to a teaching hospital for radiotherapy and further management on 15/2/11. He returns to this site at a later date for a palliative care episode which ends with his death on 16/3/11. LOS 6 days. Discharge Summary: Principal diagnosis – metastatic bowel cancer This diagnosis was not specific regarding the condition responsible for the admission. A review of the medical record identified the following: “ Admitted with shoulder pain and LL weakness. X-ray showed large humeral head mets. CT: path # T7 and mets T8/L2”. The admission was reclassified to a higher resource DRG, with a revenue difference of $16,120. Original DIAGNOSES PROCEDURES Revised C260 neoplasm, malignant, intestine, not further specified G992 neoplastic myelopathy G952 cord compression G819 hemiplegia C795 metastases bone Z8643 ex-smoker nil DRG V6.0 G60B Digestive malignancy W/O Ccc ALOS WEIGHT REVENUE 4.7 .8918 $4,579 C795 metastases-bone M9078 bone fracture in neoplastic disease G8221 paraplegia, acute G992 neoplastic myelopathy G952 cord compression C19 recto-sigmoid primary Z8643 ex-smoker nil B60B Acute paraplegia/ quadriplegia +/- Operating Room Procedures W/0 Ccc 10.7 4.0311 $20,700 Calculated using Independent Hospital Pricing Authority (11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013 (4) state efficient price of $5135 32 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 3 – Documenting Procedures 50 year old Mr Y is a type 2 diabetic on insulin, with a past history of hypertension, dyslipidaemia, chronic kidney disease stage 4, and peripheral neuropathy. He is a smoker. He is admitted via ED with necrotic toes, for IV antibiotics and control of blood sugars. LOS 5 days. Discharge Summary: Principal diagnosis – Necrotic Diabetic Toes Procedures – IV antibiotics, control of BSL Review of documentation identified an entry in the progress notes of 22/10/10: “BSLs still uncontrolled, on the ward: debrided hallux, no anaesthetic due to PN, ulcer down to bone, and subcutaneous necrotic medial ulcer.” The most significant procedure (debridement) was omitted from the discharge summary, and the clinical coder misses it completely in the progress notes. A complete discharge summary would have provided a ‘safety net’ for the coder. After coding this information the admission was reclassified to a higher resource DRG, with a revenue increase of $15,809. Original Revised E11.73 diabetic foot ulcer R02 necrosis skin/subcut E11.42 Diabetes with peripheral neuropathy E11.22 Diabetes with established nephropathy E11.71 DM2 with multimicrovasc comps N18.4 CKD stage 4 I0 hypertension E11.65 poorly controlled DM2 Z72.0 smoker Z92.22 long-term use of insulin 90665-00 debridement skin and subcutaneous tissue K01B Operating Room Procedures for Diabetic complications W/O Ccc DIAGNOSES E11.73 diabetic foot ulcer R02 necrosis skin/subcut E11.42 Diabetes with peripheral neuropathy E11.22 Diabetes with established nephropathy E11.71 DM2 with multimicrovasc comps N18.4 CKD stage 4 I0 hypertension E11.65 poorly controlled DM2 Z72.0 smoker Z92.22 long-term use of insulin PROCEDURES nil DRG V6.0 K60B Diabetes W/O Cscc ALOS WEIGHT 4 .9712 13 4.0499 REVENUE $4,987 $20,796 Although the DRG (K01B) states operating room procedures, any procedure so classified may still be performed on the ward. Operating room in this sense is an indicator of level of service, rather than location. Calculated using Independent Hospital Pricing Authority (11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013 (4) state efficient price of $5135 33 Clinical Casemix Handbook 2012-2014 Version 3.0 5.2.6 Relevant investigation results Include the results of all investigations conducted, which are considered to have a bearing, or impact on the management of the patient during the episode of care. 5.2.7 Treatment and progress Describe in significant detail, the patient’s treatment and progress during this episode of care. 5.2.8Medications Current medications indicating the status of each medication relative to the admission status (new, increased dose, decreased dose, ceased or unchanged) with dose, duration, purpose and supply. Provide information regarding current medications indicating the status of each medication relative to the admission. Include: generic name (or brand name where relevant e.g. combination products) dose drug status (changes to therapy between pre-admission and discharge e.g. increased or decreased dose) rationale for changes surveillance requirements for interactions expected outcomes any adverse drug reactions experienced in hospital patient counselling on administration. 5.2.9 Future plan of management Describe details regarding the plans for managing the wellbeing of the patient in the future. Relevant information given to the patient e.g. activity level, wound care. Follow up arrangements including referrals to other health care providers. 34 Clinical Casemix Handbook 2012-2014 Version 3.0 6. Sample discharge summary Medical Records Copy WA Health Hospital Patient: FINE, ADAM BRUCE 189 ROYAL STREET EAST PERTH 6004 dob: 7 June 1934 Admitted: 15 May 2010 Discharged: 03 June 2010 LOS:20 days D/C Reason: Care Complete (Clinician’s Decision) D/C Destination: Private Residence – Self Caring Specialty: Department of General Medicine Consultant: HIGGINS, HENRY Principal Diagnoses: (responsible for admission) – Glaucoma Secondary Diagnoses/Complications: (which were treated or delayed discharge/progress) – Acute renal Insufficiency – Urethral Bleeding – Male – Urinary Retention – UTI Other Conditions/Problems: (active conditions/problems during this admission) – Diabetes Mellitus – Hypertension Interventions/Procedures: (during this admission) – Trabeculectomy – Cystoscopy History: Emergency admission for trabeculectomy and 5FU injection for primary open angle glaucoma with high IOP not responding to maximum medical therapy (via Eye Clinic Outpatient appointment) 35 Clinical Casemix Handbook 2012-2014 Version 3.0 Findings: IOP 38mm Hg Interpreted Summary of Significant Results: On admission: – UEC: Na 139 K 4.1 BC 25 Ur 8.5 Cr 98 Post-op: – Bladder scan >1000ml – UEC Na 140 K 4.1 BC 22 Ur 11.0 Cr 123 – Urine E Coli on 24/05/10, fully sensitive to antibiotics – CT head 27/05/10 – No acute changes / bleed / infarct On discharge: – Bloods done in Rehab Ward at the time of discharge, – FBP Hb120 WCC 8.8 Platelet 321 7.03 – Ue Na 144 K 4.0 BC 29 Ur 8.9 Cr 103 – CRP92 – MG 0.77 (0.7 – 1.10) – PO4 0.93 (0.80 – 1.50) – VIT B12 AND FOLATE NORMAL – VIT D 26 (>50 nmol/L) – TFT TSH 0.95 T4 18 Clinical Management: 1.Admitted for surgery as described above, which proceeded without complication on Thursday evening 2.Postoperatively the nursing staff noted he had a distended bladder on bladder scan, and an IDC was inserted as per protocol, draining 1750ml in 20 minutes 3.Overnight (15/5/10) the patient became confused and removed his IDC, resulting in urethral trauma and frank haematuria. Attempts to reinsert IDC failed on the ward 4.The following morning (16/5/10), Urology were consulted and an IDC inserted via flexible cytoscopy 5.Nil further problems noted postoperatively, with nil further episodes of confusion and clear urine draining via IDC 36 Clinical Casemix Handbook 2012-2014 Version 3.0 Transferred to GRU for further rehab. 1.Medically – Episodes of visual and auditory hallucinations while in the ward. Patient aware that he is hallucinating. Stated that he had similar episodes before. No records re: the above found from the old notes or from the GP. Investigated. No cause suggestive of hallucinations noted except for E coli UTI which was treated with Trimethoprim. Hallucinations subsided few days later. 2.Mobility – Remained independent in mobility and all ADL. 3.Cognition-Query re decreased cognition and STML during admission in the ward. OT and SW assessment showed no significant STML. CT scan head showed no significant change. No need for further assessment at this point in time. Social Issues: Lives alone. Normally independent with all ADL. NO SERVICES IN PLACE. Silverchain referral done for regular eye care. Things to Note: 1.Glaucoma – please encourage Mr Fine to remain compliant with glaucoma medications his right eye should be normotensive as a result of surgery but his left eye is still at risk. 2.Eye clinic follow-up 11/06/10. 3.UTI, repeat MSU if clinically relevant. 4.Mr Fine might benefit from an OP psychogeriatric review if there are further episodes of hallucinations. Information to Patient: You will need to attend the OP eye clinic on 11/06/10 Review Details: Eye Clinic follow-up 11/06/10 Copies To: Patient, Consultant, Medical Records Dr John Dolittle, WA Health Medical Centre 37 Clinical Casemix Handbook 2012-2014 Version 3.0 Discharge Medications: Medication Dosage Atorvastatin Calcium Tablets 40mg 1 at bed time Irbesartan Tablets 300mg 1 in the morning Chlorsig Eye Ointment 1% 1 in the morning 1 in the evening Gliclazide Mr Sr Tablet 30mg 1 in the morning Metformin hydrochloride Tablets 850mg 1 in the morning 1 in the evening Nifedipine Sr Tablets 30mg 1 in the morning Ocuflox Eye drops 3mg **New**right eye 1 in the morning 1 at midday 1 early evening 1 at bedtime PredForte Eye drops **New** right eye 1 in the morning 1at midday 1 at midday 1 early evening 1 at bedtime Tamsulosin hydrochloride Caps 400mcg 1 in the morning Travatan Eye drops 40mcg **New** LEFT eye 1 at bedtime 38 Reason(s) Special Instructions Clinical case studies Clinical case studies Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 4 – Mobilising after a Model of Care Patient: Principal Diagnosis: Date of Admission: Date of Discharge: Length of Stay: Mr William White Fractured Neck of Femur 09/07/2012 12/07/2012 3 days Best evidence-based practice improves quality of care for the patient Mr White, a 71 year old male living independently at home, arrives by ambulance at the Emergency Department (ED) early one morning after falling and injuring his left hip. A hip and pelvic x-ray confirms a fractured neck of femur. The ED staff commence Mr White on the Hip Fracture Clinical Pathway with a regional femoral nerve catheter inserted for pain management. Mr White is then transferred to the orthopaedic ward as a priority. He is reviewed by the orthogeriatric team for medical stabilisation before surgery later that morning. On day one after his surgery Mr White begins his multidisciplinary rehabilitation which includes daily orthogeriatric, physiotherapy and occupational therapy review. His intravenous fluids are ceased and an oral diet is introduced. His indwelling catheter is removed. Mr White sits out of bed, is mobilised and up to shower. The orthogeriatric team review Mr White and find he is medically stable and recovering well. They address his risk of osteoporosis and falls. On day three post-op Mr White is waitlisted for and transferred to a nearby rehabilitation unit. 39 Clinical Casemix Handbook 2012-2014 Version 3.0 What the doctor said “By developing, implementing and following the Hip Fracture Clinical Pathway we have greatly improved patient care, reduced complications and decreased length of stay for hip fracture patients.” What does this mean under Activity Based Funding? Mr White’s diagnosis related group (DRG) was Other Hip and Femur Procedure without catastrophic or severe complications and/or co-morbidities (I08B). The DRG revenue for I08B, which is based on the average cost for the average length of stay, is $16,9911. The average length of stay for I08B is 8.33 days. Mr White’s length of stay was shorter. The health service is likely to be fully reimbursed for the cost of his care. The health service will receive a Fragility Hip Fracture Treatment premium payment of $200. What we learnt from Mr White Benefits of Best Practice By following the Hip Fracture Clinical Pathway Mr White’s clinical team were able to provide timely delivery of best practice care. He received an early comprehensive assessment, multidisciplinary care, rapid definitive treatment and early mobilisation. Delivering Quality The Orthogeriatric Model of Care ensures quality care for older patients and the most efficient length of stay. It can reduce the likelihood of complications such as delirium, urinary tract infections and constipation. These complications are uncomfortable for the patient and can increase their length of stay. Cost Effective Care The Hip Facture Pathway allowed Mr White to commence rehabilitation within days and return home within a week. A short length of stay is preferable for the patient and is also cost effective. The efficiency of the hospital is increased by reducing bed block and allowing more patients to be treated. Premium Payment Under Activity Based Funding and Management a Premium Payment Program has been designed to recognise and reward services which provide a high level of best evidence-based care. Mr. White’s care satisfied the six clinical indicators required to receive a Fragility Hip Fracture Treatment premium payment of $200. Calculated using Independent Hospital Pricing Authority(11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013(4) state efficient price of $5135 1 40 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 5 – Resourcing Roadblocks Patient: Principal Diagnosis: Date of Admission: Date of Discharge: Length of Stay: Mrs Patricia Purple Chronic obstructive pulmonary disease with acute lower respiratory infection 07/01/2012 02/03/2012 55 days Management of long stay patients is important Mrs Purple is an 80 year old woman with severe Chronic Obstructive Pulmonary Disease (COPD) on home oxygen with a full time carer. She arrives at hospital by ambulance with a reduced conscious state after experiencing significant difficulty breathing. On admission she is found to have an acute exacerbation of COPD and is treated with non-invasive ventilation (NIV). An initial wean off is unsuccessful with worsening respiratory failure and signs of right heart failure. A slower wean is initiated. While successful during the day she continues to require the NIV unit at night. On day 28 Doctors conclude Mrs Purple is medically well enough to continue her treatment from home under the proviso a NIV unit can be sourced and her carer is trained in its use. She is motivated by the opportunity to continue her treatment from home. Efforts to source the NIV unit are met with a number of roadblocks. Staff experience difficulty identifying the appropriate process to follow and the right people to engage causing Mrs Purple’s discharge date to be pushed back. She develops a urinary tract infection and is treated with antibiotics. After some negotiation, management agree to fund a monthly rental of the NIV unit. Community based assistance is sourced so that Mrs Purple’s carer can be trained. Mrs Purple is discharged on day 55. 41 Clinical Casemix Handbook 2012-2014 Version 3.0 What the Doctor said “If clinicians had the right tools available to them, including equipment and community based respiratory nurses, the management of this patient’s hospital stay could have been very different and significantly shortened.” What does this mean under Activity Based Funding? Mrs Purple’s diagnosis related group (DRG) was Respiratory System Diagnosis with Non-Invasive Ventilation (E41Z) The DRG revenue for E41Z, which is based on the average cost for the average length of stay, is $21,2461. The average length of stay for E41Z is 11 days. Mrs Purple exceeded this by 44 days. The health service is unlikely to be fully reimbursed for the cost of her care. What we learnt from Mrs Purple Proactive Discharge Planning Mrs Purple’s length of stay could have been reduced had a clear care pathway been in place earlier on. This would involve defining the resources required, the expertise to involve and at what time. Resource Management Resources such as the NIV unit have the potential to move long stay patients out of an acute inpatient setting and into home-based care. This is preferable for the patient and is also cost effective. Episode of Care Change A length of stay post 35 days is considered non-acute care. At this point Mrs Purple’s could have received a change in care type to a maintenance care DRG. This would have reduced the acute care DRG length of stay and increased funding. Cost Savings A NIV unit would cost the Health Service around $2500. The cost of providing acute inpatient care in the absence of an NIV unit is far greater. Having this unit available for COPD patients like Mrs Purple to use from home would represents a cost saving for the Health Service. It would also reduce the incidence of future readmission and potential future costs. Patient Safety Mrs Purple developed a preventable urinary tract infection causing discomfort and further treatment. Resource management can shorten a patient’s length of stay reducing their exposure to infection and risk of adverse events. Calculated using Independent Hospital Pricing Authority(11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013(4) state efficient price of $5135 1 42 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 6 – The Untimely Transfer of Information Patient: Principal Diagnosis: Date of Admission: Date of Discharge: Length of Stay: Mr Robert Red Perforation of Oesophagus 10/10/2011 30/10/2011 20 days Good clinical handover is essential for protecting patient safety Mr Red, a 69 year old man with a history of diabetes, smoking, high cholesterol and hypertension, presents at a peripheral hospital one evening with sudden onset of central chest pain associated with vomiting. Following an examination and available basic investigations, the team formulate a differential diagnosis, including acute coronary syndrome and possible oesophageal rupture, both of which require transfer to a tertiary hospital for further investigation and management. A phone conversation is made to a cardiothoracic surgeon who recommends a CT contrast swallow but this is not documented on the transfer form. When Mr Red arrives at the tertiary hospital Emergency Department the transfer documentation simply states his presenting complaint as ‘high risk chest pain for investigation.’ Mr Red is admitted under the cardiology team and undergoes serial ECGs and blood test for acute coronary syndrome. The following afternoon the possibility of oesophageal rupture due to vomiting is realised. A CT contrast is performed and reveals a lower oesophageal rupture. Mr Red is taken immediately to surgery for repair. Mr Red makes a full recovery however the delay in diagnoses and treatment contributed to development of an infection which increased his length of stay by 14 days. 43 Clinical Casemix Handbook 2012-2014 Version 3.0 What the Doctor said “The term “high risk chest pain” generally refers to pain which is thought likely to be due to a cardiac cause such as myocardial infarction or angina. In Mr Red’s case he has a number of pre-existing risk factors for heart disease therefore no question was raised regarding the potential cause for chest pain after he arrived at the tertiary hospital. We understood he had been transferred for cardiology workup. Had we known about the involvement of cardiothoracic surgery and the possibility of oesophageal perforation we could have arranged the CT scan to be done on arrival and would have made the diagnosis much earlier.” What does this mean under Activity Based Funding? Mr Red’s complicating sepsis resulted in a diagnosis related group (DRG) shift from Stomach, Oesophageal and Duodenal Procedure with severe or moderate complications and/or co morbidities (G03B) to with catastrophic complications and/or co morbidities (GO3A). What does this mean for the Health Service providing Mr Red’s care? A longer average length of stay. A greater consumption of resources. A higher average cost. What we learnt from Mr Red Good Clinical Handover Mr Red’s story highlights the importance of good clinical handover in protecting patient safety. Mr Red suffered an infection causing additional concern for his family and friends. It increased his length of stay and subsequent cost to the health service. Improving Clinical Documentation Accurate and timely clinical documentation is fundamental in the transfer of patient care from one hospital to another. Had the CT contrast swallow request been clearly documented in Mr Red’s handover he may have been diagnosed hours earlier, reducing his risk of infection and improving his outcome. Managing Resources Mr Red underwent a number of ECGs and blood tests which had already been performed at the original hospital. Repeat tests use valuable resources and time which could have otherwise been used on other patients. 44 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 7 – A Delay in Discharge Patient: Principal Diagnosis: Date of Admission: Date of Discharge: Length of Stay: Mr Gavin Grey Left ventricular failure and pneumonia 17/04/2012 25/04/2012 8 days Early engagement of a social worker when required will facilitate a timely discharge for the patient Mr Grey, an 84 year old man with heart disease and throat cancer, presents at the emergency department with shortness of breath, fever, and a productive cough. During his initial assessment the Doctor notices that Mr Grey appears quite unkempt and he is not keen to talk about his social situation. The Doctor writes a comprehensive problems list in the patient notes including ‘heart failure’ and ‘chest infection’ but does not note Mr Grey’s appearance or his attempt to gather collateral information about his social circumstances. During Mr Grey’s hospitalisation his condition gradually improves. On day five Mr Grey is medically much better but at the discharge planning meeting his family express concerns about his ability to cope at home. A social worker becomes involved and contacts Mr Grey’s daughter who reveals significant concerns that Mr Grey is not eating much, not showering and not taking all of his medications. She also suspects he is depressed since the death of his wife and has noticed some short term memory problems over the past three months. These issues require a family meeting and negotiation with Mr Grey to accept support services at home as well as a review by the psychogeriatric team. Mr Grey is discharged on day eight. What the Social Worker said “When concerns about a patient’s ability to cope at home are identified during the patient’s initial presentation, an early referral to Social Work allows the time to ascertain the full social picture, assess risk, engage family and refer to the appropriate services. In this case the patient could have been discharged on day five when he was medically ready.” 45 Clinical Casemix Handbook 2012-2014 Version 3.0 What the Doctor said “It is essential we build a comprehensive problem list, put them in the notes and make sure we follow through all issues related to patients when they are admitted, rather than just focus on the presentation and a single diagnosis. This is about holistic care of patients and through that timely and patient (rather than disease) focussed care.” What does this mean under Activity Based Funding? Mr Grey’s diagnosis related group (DRG) was Heart Failure and Shock without catastrophic complications and/or co morbidities (F62B). The DRG revenue for F62B, which is based on the average cost for the average length of stay, is $5,0921. The average length of stay for F62B is 5 days. Mr Grey exceeded this by 3 days. The health service is unlikely to be fully reimbursed for the cost of his care. What we learnt from Mr Grey Multidisciplinary Engagement In Mr Grey’s case engagement of a social worker ensured he was referred to the appropriate community based support services. His home situation was improved having a positive impact on his health, reducing stress on his family, reducing the likelihood of readmission and associated costs. Documentation in Progress notes Mr Grey’s problem list over time focused on his medical illness but did not include his social issues. A daily comprehensive problem list should consider the whole patient situation. All medical and emotional issues should be addressed before discharge can occur. Improved Communication Mr Grey’s potential social issues could have been communicated to a social worker at the start of his admission. He would have received a more timely assessment, reducing his length of stay and subsequent cost to the health service. Reduce Costs by Improving Quality Safe high quality care costs less in the long term. It can reduce the incidence of readmission which is better for the patient and their family and represents a potential cost saving for the health service. Calculated using Independent Hospital Pricing Authority(11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013(4) state efficient price of $5135 1 46 Clinical Casemix Handbook 2012-2014 Version 3.0 Case Study 8 – How Harmful is your Handover? Patient: Principal Diagnosis: Date of Admission: Date of Discharge: Length of Stay: Mr Gilbert Green Chronic obstructive airways disease 15/01/2012 16/03/2012 61 days Safe Handover Safe Patients Mr Green, an 88 year old man with severe Chronic Obstructive Pulmonary Disease (COPD), is brought to the emergency department one weekend with breathlessness and chest pain on breathing in. ‘Exacerbation of COPD’ and ‘Unlikely PE’ are documented in his admitting notes and Mr Green is transferred to the ward. While his risk of pulmonary embolism (PE) was assessed to be low a D-dimer blood test is ordered and returns with an elevated value. While inconclusive, a phone call is made to the on-call junior doctor to write up a dose of blood thinners until further investigations could be arranged in the morning. The dose is prescribed on the anticoagulant medication chart and administered. It is not written in the case notes or noted on the regular medication chart. At handover the next morning, following a busy night on the ward, his blood thinner medication is not discussed. Mr Green was feeling better so his specialist felt PE was unlikely and the chest pain had been due to coughing and an infective exacerbation of COPD. A few days later Mr Green falls while taking himself to the bathroom and hits his head. He is later found confused. A CT scan reveals a large subdural haematoma (a collection of blood within the skull). He is taken to theatre by a neurosurgeon and the blood is drained. He slowly improves after intensive rehabilitation for his head injury. Mr Green is discharged on day 61. 47 Clinical Casemix Handbook 2012-2014 Version 3.0 What the Doctor said “We know how easy it is to do just a brief handover when we are busy which can have potentially tragic outcomes. That is why as a consultant I insist we sit down and focus on the handover and use the iSoBAR framework to ensure all important issues are discussed.” What does this mean under Activity Based Funding? Mr Green suffered a complication unrelated to his COPD which required surgery therefore his diagnosis related group (DRG) was Operating Room Procedure unrelated to Principal Diagnosis with catastrophic complications and/or co morbidities (801A). The DRG revenue for 801A, which is based on the average cost for the average length of stay is $37,1301. The average length of stay for 801A is 21 days. Mr Green exceeded this by 40 days. The health service is unlikely to be fully reimbursed for the cost of his care. What we learnt from Mr Green Document Medication Accurate documentation and daily review of medication charts can improve patient safety and reduce costs. Mr Green’s blood thinner medication increased his risk of intracranial bleeding following his fall. The medication should have been written in his case notes and communicated during handover. Use iSoBAR Handover Mr Green may have benefited had his clinicians used the iSoBAR framework during handover (identify, situation, observation, background, agree on a plan, readback). This is a structured method of handover that supports safe patient care. Clinical Risk Management If all staff had been aware that Mr Green was on blood thinner medication they may have increased fall prevention strategies or post fall interventions. Improve Patient Journey Mr Green suffered a large subdural haematoma which increased his length of stay by many weeks. During his prolonged hospitalisation he underwent many tests, procedures and intensive rehabilitation. The impacted his quality of life and that of his family and friends. Calculated using Independent Hospital Pricing Authority(11) acute admitted patients AR-DRG v 6.x price weights and Health Activity Purchasing Intentions 2012-2013(4) state efficient price of $5135 1 48 Common complications and co-morbidities Common complications and co-morbidities Clinical Casemix Handbook 2012-2014 Version 3.0 Common complications and co-morbidities Acidosis or alkalosis, metabolic or respiratory Bronchiectasis Acute myocardial infarction, NSTEMI or STEMI Agranulocytosis Anaemia, please specify type e.g. Due to blood loss, acute or chronic, aplastic, etc. Angina pectoris, unstable or stable Atrial fibrillation or flutter Candidal infections, specify site Cardiogenic shock Cardiomyopathy, specify type Cellulitis Cerebral infarction Cirrhosis of liver (Alcoholic or Non-Alcoholic) Chronic Obstructive Pulmonary Disease Chronic viral hepatitis C, B etc Coagulation defects Complications following infusion, transfusion and therapeutic injection e.g. Transfusion reactions Congestive heart failure Decubitus (pressure) ulcer, specify stage Delirium, acute brain syndrome and underlying cause if known Diabetes mellitus (specify any micro or macro vascular complications) and type Dementia, specify type Disruption or dehiscence of wound Embolism and/or thrombosis Haemorrhage and haematoma complicating a procedure Heart valve stenosis/regurgitation Hereditary factor deficiency Hypokalaemia/hyperkalaemia Hypopituitarism Hyperosmolality and hypernatraemia/hyponatraemia Ileus Infection and inflammatory reactions due to internal devices 49 Clinical Casemix Handbook 2012-2014 Version 3.0 Intestinal obstruction (and cause if known) Impaction of intestine Interstitial pulmonary diseases Left ventricular failure Mechanical complications of any devices or implants including: Breakdown (mechanical) Displacement Leakage Malposition Obstruction Mechanical Perforation Protrusion Mechanical complication of internal joint prosthesis Pathological fractures Phlebitis and thrombophlebitis of any vessel Pleural effusion Pneumonia, specify organism is known Pneumonitis, aspiration Post procedural respiratory disorders Pulmonary collapse/atelectasis Pulmonary embolism Pulmonary hypertension, primary or secondary Renal failure, acute or chronic Renal impairment, acute or chronic Respiratory failure, acute or chronic. Note: Please specify chronicity as respiratory failure “unspecified” does not affect DRG assignment Retention of urine Sepsis, identify organism Tachycardia or other arrhythmias Thalassaemia, specify type and variant Thrombocytopenia, primary or secondary Ulcers of any site Use of Alcohol/Drugs, specify dependence, harmful use, withdrawal, withdrawal with delirium Ventricular fibrillation and flutter Wound infection following a procedure. 50 Appendixes Appendixes Clinical Casemix Handbook 2012-2014 Version 3.0 Appendix A AR-DRG major diagnostic categories AR-DRG range PreMDC A Transplant MDC A01Z-A40Z MDC Description B Nervous System B01Z-B82C C Eye C01Z-C63Z D Ear, Nose Mouth and Throat D01Z-D67B E Respiratory System E01A-E76Z F Circulatory System F01A-F76B G Digestive System G01A-G70B H Hepatobilliary System and Pancreas H01A-H64B I Musculoskeletal System and Connective Tissue I01A-I79B J Skin, Subcutaneous Tissue and Breast J01A-J69C K Endocrine, Nutritional and Metabolic Diseases and Disorders K01A-K64B L Kidney and Urinary Tract L02A-L68Z M Male reproductive System M01A-M64Z N Female reproductive System N01Z-N62Z O Pregnancy, Childbirth and the Puerperium O01A-O66Z P Newborns and other Neonates P01Z-P67D Q Blood and Blood Forming Organs and Immunological Disorders Q01Z-Q62Z R Neoplastic R01A-R64Z Infectious and Parasitic S60Z-T64C U Mental Health U40Z-U68Z V Alcohol/drug V60Z-V64Z Injuries, Poisonings and Toxic Effects of Drugs W01Z-X64B Y Burns Y01Z-Y62B Z Factors Influencing Health Status and Other Contacts with Health Services Z01A-Z65Z S, T W, X 51 Clinical Casemix Handbook 2012-2014 Version 3.0 Appendix B The AR-DRG classification system B.1Structure The AR-DRG classification system has a logic that reveals: 1.The broad group (usually the MDC) to which the DRG belongs 2.The adjacent DRG (and the adjacent DRG’s location in terms of a tripartite distribution between medical surgical and other partitions) 3.The existence/nature of splits based on resource consumption. The format of each AR-DRG number consists of four alphanumeric characters organised in terms of ‘ADDS’. These are described in the following sections(7). A D D S B.2Broad group A indicates the broad group to which the DRG belongs: Different letters of the alphabet have been used to signify the broad group while the number 8 has been used to identify a residual group of DRGs which capture atypical cases (Operating Room Procedures Unrelated to Principal Diagnosis) See Appendix A for all 23 MDCs. B.3Adjacent DRG DD identifies the partition to which the DRG belongs. 01 – 39 indicates surgical partitions 40 – 59 indicates other partitions 60 – 99 indicates medical partitions The second and third characters are digits. DRGs that begin with the same letter and share the same middle digits are called adjacent DRGs e.g. A01B and A01C. Within the surgical and other partitions, the adjacent DRGs are generally ranked from highest to lowest resource consumption e.g. B01 has higher resource consumption than B06. 52 Clinical Casemix Handbook 2012-2014 Version 3.0 B.4Split indicator S is a split indicator that ranks DRGs within adjacent DRGs on the basis of their consumption of resources. The last character designates the relative importance of DRGs within an adjacent DRG in terms of resource consumption; any one of a number of values may be used: A highest consumption of resources within adjacent DRG B second highest consumption of resources C third highest consumption of resources D fourth highest consumption of resources Z no split for the adjacent DRG The meaning of the split indicator may be gathered from the names of the DRGs. For example: B70A Stroke and Other Cardiovascular Disorders W Catastrophic CC B70B Stroke and Other Cardiovascular Disorders W Severe CC B70C Stroke and Other Cardiovascular Disorders W/O Catastrophic or Severe CC B70D Stroke and Other Cardiovascular Disorders, Died or Transferred <5 Days E63Z Sleep Apnoea (the only DRG in adjacent DRG E63) B.5AR-DRG treatment of severity Complication and Co-morbidity Levels (CCLs) Complication and Co-morbidity Levels (CCLs) are severity weights which are given to all diagnoses. The values are: 0 = the code is not complication or co-morbidity; or the code forms part of the definition for the adjacent DRG; or the code is excluded as a complication/co-morbidity in the assigned adjacent DRG; or the code is a complication/co-morbidity, but is closely related to the principal diagnosis; or exactly the same code appears elsewhere in the record 1 = the code is a minor complication/co-morbidity 2 = the code is a moderate complication/co-morbidity 3 = the code is a severe complication/co-morbidity 4 = the code is a catastrophic complication/co-morbidity 53 Clinical Casemix Handbook 2012-2014 Version 3.0 Patient Clinical Complexity Levels (PCCLs) From these CCLs a Patient Clinical Complexity Level (PCCL) is calculated for each episode using a complex algorithm. The PCCL calculation has been designed to prevent similar conditions from being counted more than once. A PCCL value of: 0 = no CC effect 1 = minor CC 2 = moderate CC 3 = severe CC 4 = atastrophic CC B.6Example 1: DRG assignment I03B Hip replacement W/O catastrophic CC Principal Diagnosis: Other primary throsis M161 Procedure: Total arthroplasty of hip, unilateral 4931800 Other Procedure: General anaesthesia 9251429 PCCL 0 – SDX is not a CC, or is included in ADRG definition, or is excluded AR-DRG: I03B Hip replacement W/O Catastrophic CC Principal Diagnosis: Other primary coxarthrosis M161 From the principal diagnosis, a MDC can be determined i.e. Other primary coxarthrosis is classified under Musculoskeletal system and connective tissue (I). I D D S Procedure: Total arthroplasty of hip, unilateral 4931800 Other Procedure: General anaesthesia 9251429 Procedure and other procedure classify this episode under a surgical partition. A classification of 03 is assigned to demonstrate higher resource consumption. I 0 3 S 54 Clinical Casemix Handbook 2012-2014 Version 3.0 PCCL 0 – SDX is not a CC, or is included in ADRG definition, or is excluded Finally, a Patient Clinical Complexity level of 0 indicates there is no complication or co-Morbidity effect. The episode is thus given a split indicator rank B demonstrating second highest consumption of resources. Note: The split indicator rank in this case is attributed to the procedure requiring a high level of resources due to prosthetics etc rather than a high level of resources due to the risk of a high CCL. I 0 3 B B.7Example 2: DRG assignment I03A Hip replacement W Catastrophic CC Principal Diagnosis: Other primary coxarthrosis M161 Other Diagnosis: Systemic inflammatory response syndrome (SIRS) of infectious origin with acute organ failure CC, CCL = 3 R651 Procedure: Total arthroplasty of hip, unilateral 4931800 Other Procedure: General anaesthesia 9251429 PCCL 4 – SDX is a catastrophic CC AR-DRG: I03A Hip replacement W Catastrophic CC Other Diagnosis: N179 Systemic inflammatory response syndrome (SIRS) of infectious origin with acute kidney failure CC, CCL = 3 Principal diagnosis remains as in Example 3.6. Other diagnosis introduces a complication and co-morbidity level of 3 where the code is a severe CC. Procedure and Other Procedure remain as in Example 3.6. I 0 3 S 55 R651 Clinical Casemix Handbook 2012-2014 Version 3.0 PCCL 4 – SDX is a catastrophic CC Due to the added CCL level, the Patient Clinical Complexity Level is now elevated to 4 demonstrating a catastrophic CC. Therefore the DRG assignment will now be: I 0 3 A B.8Impact of CCs on cost signature In theory, a DRG with complications and co-morbidities would have higher average nights of stay,), when compared to a DRG without complications and comorbidities. DRG W Catastrophic CC DRG W/O Catastrophic CC Central Episode COST Central Episode NIGHTS OF STAY Diagram 4: Illustrates the cost signature of two adjacent DRGs, one with Catastrophic CC and one without Catastrophic CC. Note: This would be the expected effect in general terms. On a case-by-case basis, these elements may be subject to change and may not hold. 56 Clinical Casemix Handbook 2012-2014 Version 3.0 Appendix C Glossary ACCC Australian Clinical Casemix Committee ACHI Australian Classification of Health Interventions ACS Australian Coding Standards. AR-DRGs Australian Refined Diagnosis Related Groups. This DRG system has been developed to appropriately reflect clinical practice in the Australian health care environment. Casemix The types or mix of patients that a particular hospital treats. CCL Complication and co-morbidity levels: severity weights given to all associated diagnoses in order to calculate the PCCL (see below). CCs: Complication or Co-morbidities Those conditions that because of their presence with a specific principal diagnosis, would cause an increase in length of stay by at least one day. In the DRG description Preceded by W or + (with) or W/O or - (without). Co-morbidities The condition(s) that exists at the time of the admission which affect patient care in terms of requiring treatment, diagnostic procedures and increasing nurse care/ monitoring. Complications The condition(s) not present on admission, which arises during the patient’s stay which affects the treatment of the patient. Ccc Abbreviation in the DRG description for Catastrophic comorbities or complications. Preceded by W or + (with) or W/O or - (without). Scc Abbreviation in the DRG description for Severe comorbidities or complications. Preceded by W or + (with) or W/O or - (without) Cost Weight The weight assigned to a DRG which reflects the amount of hospital resources an average patient in that DRG is expected to consume for that admission relative to other DRGs. 57 Clinical Casemix Handbook 2012-2014 Version 3.0 DRG (Diagnosis Related Group) A patient classification system used to relate the number of type of patients treated in a hospital (the casemix) to the resources required by the hospital to treat those patients. DRG Grouper A software package that assigns each patient discharge one particular DRG, according to their discharge diagnosis(es) and, if applicable, procedure(s) the patient underwent during their stay, age and discharge status. ICD-10-AM International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification. The coding classification system used to classify the diagnoses and procedures of every inpatient separation. LOS Length of stay. MBS Medicare Benefits Schedule MDC (Major Diagnostic Category) 23 categories that relate to main body systems. After discharge, patient admissions are classified into an MDC (according to the ICD-10-AM code) before they are further defined and classified into a DRG. NCCC National Casemix and Classification Centre (NCCH defunct as of 1 July 2010) NOS Nights of stay. Outlier An outlier is a case, which either clinically or statistically does not fit with most of the other cases assigned to the DRG. Length of stay and/or cost are the major measures used for identification of outliers. PCCL Patient clinical complexity level: calculated on CCL combinations using an algorithm. Each DRG will have a PCCL calculated. Principal Diagnosis The condition established after study to be chiefly responsible for occasioning the admission of the patient to hospital. Procedures Diagnostic and therapeutic operations and procedures carried out whilst an inpatient. 58 Clinical Casemix Handbook 2012-2014 Version 3.0 References 1. Alfred Health. Alfred Casemix Clinical Handbook 10th Edition 2009 – 2010. 2009. 2. National Centre for Classification in Health (NCCH) – University of Sydney. The Good Clinical Documentation Guide. 2003. 3. National Casemix Classification Centre. The International Statistical Classification of Diseases and Related Health Problems, 10th Revision, Australian Modification, 7th Ed, Version 1.1, Australian Coding Standards. 2010 4. Department of Health. Health Activity Purchasing Intentions 2012-2013. Available from: http://activity/page/Publications.aspx. 5. Australian Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. Canberra: Australian Medical Association; 2006. 6. Department of Health. Clinical Incident Management Policy: Using the Advanced Incident Management System (AIMS). 2006: Available from: http://www.safetyandquality.health.wa.gov.au/policies/index.cfm. 7. Department of Health and Ageing. Australian Refined Diagnosis Related Groups, Version 6.0, Definitions Manual, Volume 1. 2008: Available from: http://www.health.gov.au/internet/main/Publishing.nsf/Content/health-casemixardrg1.htm. 8. Porteous JM, Stewart-Wynne EG, Connolly M, Crommelin PF. iSoBAR--a concept and handover checklist: the National Clinical Handover Initiative. Med J Aust. Jun 1 2009;190(11 Suppl):S152-6. 9. Australian Commission on Safety and Quality in Health Care (ACSQHC). The OSSIE guide to clinical handover improvement. Sydney: ACSQHC; 2010. 10. Department of Health. WA Sentinel Event Report 2010-2011. Available from: http://www.safetyandquality.health.wa.gov.au/policies/index.cfm. 11. Independent Hospital Pricing Authority (2012). Independent Hospital Pricing Authority National Efficient Price Determination 2012-2013, IHPA, Sydney. Available at: http://www.ihpa.gov.au/internet/ihpa/publishing.nsf/Content/home-1 59 iSoBAR IDENTIFY Introduce yourself (hospital, ward, role, job). Introduce your patient (name, DOB, age, gender, location). S SITUATION Why are you handing over? Briefly state the problem, what, when, how severe? o OBSERVATIONS Most recent vital signs and assessments* BACKGROUND Relevant information related to the patient: • current relevant medications • allergies • IV fluids • test results (date and time done, comparison to previous results) • resuscitation status • relevant social information. ASSESSMENT What do you think is happening? What is the problem (results of assessment, vital signs and symptoms)? AGREE A PLAN What is your assessment of the situation? What are you wanting (advice, orders, transfer)? What is the level of urgency? What is the plan? READBACK Clarify and check for shared understanding. Who is responsible for what and by when? READY FOR DISCHARGE What needs to be achieved for discharge and by whom? Communicate the plan with the patient/carer and ward clinical staff. i B A R * Vital signs and assessments should be relevant to the profession handing over, e.g. function level should be included for allied health professions; mental health observations and behaviour for mental health professionals. This document can be made available Produced by ABF/ABM Team © Department of Health 2012 HP012131 SEP’12 in alternative formats on request for a person with a disability.
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