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                    Critical Care Minimum Dataset
                    Frequently Asked Questions



                                                Version 6_draft_b
                                                Jun-07




7/29/2011:9:57 PM                                        1          7ef4386d-8892-47f4-bd14-6407b1ad9bd7.xls:Title
                                                                                             CCMDS FAQs




                   Please check that you are using the most recent version of the FAQs. All previous versions should be disregarded.

                        Issued by Dr John E Morris on behalf of the Critical Care Information Advisory Group, Department of Health.


   Category     Reference                     Question                                                       Answer                                   New or
                                                                                                                                                      Updated
General             0       Where have the clinical definitions come from? The Critical Care Information Advisory Group reviewed the existing
                                                                           ACP definitions and added new ones. A pragmatic view had to be
                                                                           taken in many instances to avoid too many organ support types and
                                                                           criteria. The new definitions were then tested in the pilot phase and
                                                                           amended as required.

General             0       There seems to be much greater need for         This is true. The advent of the CCMDS has placed more emphasis on
                            clinical judgment with the CCMDS, especially    recording organ system support. Although many of the organ support
                            in determining levels of care compared with     fields can be collected by simple reference to the criteria, a judgment
                            ACP, why is this?                               may be required in a few cases, e.g.neurological support in the
                                                                            presence of mechanical ventilation. Also, there is now less emphasis
                                                                            on the levels of care criteria which are broader with less precise
                                                                            boundaries. These will often require clinical assessment compared to
                                                                            the former ACP INTDAYS and DEPDAYS which were more directly
                                                                            related to organ support.

General             0       Do we have to collect both the CCMDS and        The most important task is to collect and store the CCMDS from April.
                            ACP from April 2006, the first to satisfy the   You are also strongly advised to collect ACP start and end dates until
                            new mandate and the second because our          you are informed by the Trust that the CCMDS can be exported in the
                            hospital systems cannot return the CCMDS        new XML message format (expected to be October 2006). From that
                            until October?                                  point onwards, use only CCMDS data and check that previous CCMDS
                                                                            data has been back loaded from April 2006. (Continued collection of
                                                                            ACP format start and end dates was advised in DSCN 07/2006 which
                                                                            was only published in April 2006 after the CCMDS launch).


Training Pack      0        Exercise 7, patient C, the oxygen therapy was The scenario states that the oxygen was reduced at 08:00, therefore,
                            reduced to 40% on day 2, so in the answers    by definition the higher level was present during that calendar day and
                            BRS should not be ticked.                     BRS counts. The error is in the assessment of level of care, which
                                                                          should be level 3, (BRS + BCVS).

Training Pack      0        Exercise 10, patient F, on day 6 the clinical   Correct, this is an error in the answers section.
                            note implies that the haemofiltration was
                            ongoing until 11:30, therefore this should
                            count on this day.




                                                                                       Issued by Dr John E Morris
                                                                                    Critical Care Info Advisory Group
7/29/2011                                                                                 Department of Health                                                  2
                                                                                  CCMDS FAQs




General     0   Can a CCMDS be generated for patients            Yes, if this is critical care delivered in a temporary location rather than
                receiving Level 2 care on a ward but who get     ideally moving the patient to a designated critical care bed. Organ
                better and are not admitted to a critical care   support should have continued for longer than 4 hours and have been
                area?                                            managed by critical care staff. Note that level two care can be
                                                                 provided according to the existing definitions without specific elements
                                                                 of organ support, but the reimbursement is likely to be at ward care
                                                                 levels.

General     0   Can patients who are receiving palliative care
                for symptom control and being ventilated         Yes, if they are in a designated bed and receiving advanced
                generate a CCMDS?                                respiratory support. The palliative care aspect does not influence this.

General     0   Do patients have to be linked to a hospital      Yes
                spell to generate a CCMDS?

General     0   Is the CCMDS collected only on existing beds You may be able to designate some additional beds as suitable for
                or can we designate some new beds e.g. High level 2 care ('HDU') only if they meet the designated bed criteria in full.
                care areas?                                   This may be audited by commissioners or networks. Too many
                                                             additional 'high care' beds which are not truly critical care in the current
                                                             sense, will generate excess CCMDS data and dilute the value of
                                                             subsequent HRGs for re-imbursement.

General     0   As a unit, can we send our CCMDS directly to No, it has to form part of the Admitted Care Patient Data Set
                the DH?

General     0   Where details are not known like GP, will        In general, insert zeros, but note that in some circumstances this may
                there be any specific codes to use?              cause the record to be rejected by the messaging system.

General     0   Is there a feedback loop for the CCMDS to a      The data should be available to your commissioners and periodic audit
                Trust/Network to undertake data quality          of this would be advisable to compare it to your original source data.
                control?

General     0   What is a spell in critical care?                Critical care is counted in terms of one or more CCMDS records,
                                                                 several of which can be attached to a hospital spell, which is the
                                                                 beginning to end of a consecutive period of days spent in an NHS
                                                                 hospital for one or more clinical problems.

General     0   What is a calendar day and how is it different   Practically speaking, a calendar day begins from one minute after
                from a Bed day?                                  midnight until one minute before the following midnight. Bed days are
                                                                 defined in a number of ways and could be any 24 hour period with
                                                                 specific start and end times. On this basis a bed day could also be
                                                                 equivalent to a calendar bed day.




                                                                            Issued by Dr John E Morris
                                                                         Critical Care Info Advisory Group
7/29/2011                                                                      Department of Health                                            3
                                                                                        CCMDS FAQs




Paediatrics    0   If we care for a child/adolescent in an adult       Yes, if the care is provided using one of the designated beds normally
                   critical care service can we generate a             used for adult care.
                   CCMDS?

Admission      1   Why is the NHS number (and other PAS                They are mandated elsewhere. They have been listed as part of the
                   items) not stated as mandatory?                     CCMDS to highlight the fact that if these data are collected and
                                                                       exported for analysis remote from hospital systems then the PAS items
                                                                       have to be part of each patient record.

Site code of   3   Does each unit in a trust have a separate           No, this refers only to the Trust's NHS code. Note that different units
treatment          code?                                               within a trust can be identified by local codes generated for CCMDS
                                                                       item 8, Critical Care Local Identifier.

Admission      4   For GP, will the Doctor's name do?                  The required data is actually the practice code of the patient's GP, but
                                                                       if this is not available via PAS, then it would be wise to note down the
                                                                       GP's name or practice for encoding later.

Admission      5   Consultant code or Treatment Function Code? The required data is now the treatment function of the consultant with
                                                               patient responsibility at the beginning of the spell that contains the
                                                               critical care episode. This will capture a more precise specialty
                                                               function for the reason for admission in the majority of cases, e.g. the
                                                               consultant my be registered as a general surgeon, but may be
                                                               providing a vascular, or gastro-intestinal treatment function. Note that
                                                               this is not the same as the ACPSPEF, which was intended to record
                                                               the specialty of the consultant with critical care responsibility. CCIAG
                                                               decided that this was no longer useful information and not worthy of
                                                               further collection.

Admission      8   Critical care local identifier, - why is this now   Unfortunately, CCIAG was prevented from mandating a full CCMDS
                   a mandatory item?                                   that included time data. The inclusion of a locally generated sequential
                                                                       number is the only way that two or more critical care admissions
                                                                       occurring on the same day can be differentiated in the HRG subset of
                                                                       14 items that were authorised.

Admission      8   Critical care local identifier, - who will be       This is a local, trust decision, however, if each critical care area
                   responsible for creating this number,               collecting CCMDS has its own numbering system with unit identifier,
                   especially where there are several critical         then there will be an obvious difference in these fields between
                   care areas in one institution?                      CCMDS records arriving at PAS for the same patient on the same day.
                                                                       A refinement might be to use the admission time as part of the local
                                                                       identifier, e.g. ABCunit/334/16:30, or simply the ICNARC number if this
                                                                       is collected.




                                                                                 Issued by Dr John E Morris
                                                                              Critical Care Info Advisory Group
7/29/2011                                                                           Department of Health                                          4
                                                                                     CCMDS FAQs




Admission   8   Critical care local identifier - will recording a   If the move is genuinely to a separate unit, then sequential CCMDS
                separate CCMDS for transfer to a different          records should correctly reflect the patient pathway and total activity,
                local unit on the same day lead to episode          this may be a 'fact of life' in certain institutions. There may be an
                inflation, e.g. all patients routinely discharged   increase in the number of CCMDS records, but these should be easily
                from ICU to HDU will have their critical care       differentiated within the data. In terms of re-imbursement, an 'extra
                doubled?                                            day' would be created and this will be the subject of further guidance
                                                                    from the Payments by Results team.

Admission   9   In the case of a patient who is cared for by the No, these are technically two separate locations. Use code '90' for the
                critical care team in A&E for longer than 4      first CCMDS.
                hours and is subsequently admitted to an ICU
                or HDU, should one CCMDS be collected
                commencing with the start of care in the A&E?


Admission   9   Should we try to admit critically ill patients      No, clinical governance issues would need to be very carefully
                awaiting transfer or admission in A&E to a          addressed so that optimum patient care is being delivered and that
                designated critical care bed in recovery or         secondary information issues do not influence decisions to move
                                                                                                                                                N
                other clinical area in order to capture CCMDS       unstable patients uneccessarily.
                data?

Admission   9   How can critical care activity be captured if a     Although an infrequent occurrence, this is important data. At present,
                patient receives critical care for more than 4      there is no information mechanism for collecting this data and linking it
                hours in A&E, but subsequently dies or is           to in-patient data or HRGs. This issue has been referred to the
                                                                                                                                                N
                transferred without being registered as an in-      Emergency Care Department in the DoH.
                patient?

Admission   9   When does the CCMDS period start, at first          It is admission and discharge from a designated critical care facility
                contact with the patient or when in a critical      (unit or beds). CCIAG took the view that it was much easier to
                care bed? Surely the former should be               demarcate critical care periods using admission and discharge from
                correct to be in tune with 'critical care without   identified beds. It also abandoned early attempts to include data on
                walls?'                                             the pre-admission and follow up phases of critical care as this
                                                                    seriously enlarged and complicated a minimum data set. The
                                                                    principles behind critical care without walls remain intact but will need
                                                                    to be the subject of other data sets.




                                                                               Issued by Dr John E Morris
                                                                            Critical Care Info Advisory Group
7/29/2011                                                                         Department of Health                                              5
                                                                                  CCMDS FAQs




Admission   9   A patient receiving NIV on a respiratory ward - Yes, but only if the beds are designated as critical care (see other
                is this a CCMDS event?                          related FAQ). Such patients are receiving a form of critical care and
                                                                are in many cases being kept from ICU admission by a higher level of
                                                                treatment on a specialised ward. These wards could be configured as
                                                                medical HDUs for the patients on NIV who should therefore have the
                                                                CCMDS completed. Note, however, that they are only likely to score
                                                                one organ support (basic respiratory) unless they routinely have
                                                                arterial lines placed which at present is not common practice. If the
                                                                location does not meet the designated bed criteria, use code ' 90 '

Admission   9   What is a 'designated critical care bed'?        There is no precise definition for this within the CCMDS documents
                                                                 other than the general statements provided. Until further definitions
                                                                 have been agreed, it is advised that users should refer to the basic
                                                                 descriptions of ICU and HDU beds provided in earlier DoH guidance
                                                                 (Guidelines on Admission and Discharge for Intensive and High
                                                                 Dependency Care ,DoH 1996). These will be re-published on the
                                                                 CCMDS website). A table in this document describes the basic
                                                                 requirements for both types of critical care bed. Where these
                                                                 conditions are not met and approved by the local Critical Care Delivery
                                                                 Group or Network, there is scope within the CCMDS to use unit
                                                                 function codes '90' and '91,' to temporarily designate a bed for critical
                                                                 care use. It is assumed that these data would then be the subject of
                                                                 local analysis.

Admission   9   If the outreach service managed a patient with Yes, using temporary code ' 90 '. The scenario here is of a patient
                level 2 or 3 care on a ward for more than four who should be managed in a designated critical care facility after a
                hours, should a CCMDS be completed?            reasonable period of initial assessment and resuscitation set arbitrarily
                                                               at four hours. As an example, if the outreach or critical care staff were
                                                               supporting ward based care for a patient with a recently inserted CVP
                                                               line and receiving 50% supplementary oxygen who has been waiting
                                                               for a critical care bed for more than four hours, then this is reasonably
                                                               viewed as an 'out-of-unit' critical care episode. Clearly, there is not the
                                                               intention to capture all level 2 care throughout the hospital that is not
                                                               part of the critical care service.

Admission   9   If some patients are routinely kept in a post-   Yes, use code ' 91 ' if the area cannot be designated according to
                operative recovery ward for more than four       1996 DoH guidelines, (see designated bed FAQ). If the recovery ward
                hours e.g. to stabilise after major vascular     is routinely organised to be able to provide this level of extended post
                surgery, should a CCMDS be recorded?             op care, then it can be viewed as functioning like a surgical HDU.
                                                                 Therefore such patients should have CCMDS recorded. Unit type
                                                                 code '02' is probably more appropriate than the non-standard code '91'




                                                                            Issued by Dr John E Morris
                                                                         Critical Care Info Advisory Group
7/29/2011                                                                      Department of Health                                          6
                                                                                         CCMDS FAQs




Admission   9    If a patient moves between the HDU and ICU             The data is mainly about the patient, not the location. The differing
                 parts of a joint unit, does a separate CCMDS           levels of care can be collected within the same CCMDS record and in
                 have to be collected?                                  this scenario, only one needs to be collected.

Admission   11   Why is unit function a mandatory item, will this No, this is primarily needed to provide a filter field for adult critical care
                 affect funding?                                  HRGs but can also be used to provide data on quality of care by
                                                                  analysing the temporary location codes.

Admission   11   If a patient moves from HDU to ICU and back            Yes, each location has a separate identifier and although the data
                 again in a day, do we raise a CCMDS for all            collection for this may seem pedantic, the resources of two units were
                 locations?                                             required in this scenario.

Admission   11   Can a CCMDS be generated while a patient is In some circumstances, yes. If the patient has received organ support
                 in an Accident department?                  delivered by critical care staff and has stayed for more than four hours
                                                             pending admission to designated critical care bed or transfer out. Use
                                                             temporary location code '90'. Thus, for example, a patient in cardiac
                                                             failure on greater than 50 % inspired oxygen who has been seen by
                                                             the A&E team and subsequently admitted to an acute medical ward
                                                             does NOT require a CCMDS.

Admission   11   Do burn patients in a burn centre generate a           Yes, use code '08' in 'Critical Care Unit Function'
                 CCMDS?

Admission   11   Can a burns ward be designated as a critical No, the beds need to fulfill the defintion of a designated critical care
                 care location on the basis of regular use of bed and not simply the frequency of organ support.
                                                                                                                                                   N
                 complex dressings and high inspired oxygen?

Admission   11   Can a CCMDS be generated while a patient is Yes, use code '11' in 'Critical Care Unit Function' if this is appropriate.
                 in a Liver unit?                            It is expected that the majority of general organ support functions that
                                                             occur in these units will be captured through the CCMDS.

Admission   11   In a major incident or a need to escalate              Yes, if these beds can be classified as temporary, '90' or '91'. Note
                 capacity, can patients in these short term             that for critical care re-imbursement to occur, defined organ support
                 beds generate a CCMDS?                                 would need to be provided. There is also the assumption that these
                                                                        patients should be moved to a designated critical care bed at the
                                                                        earliest opportunity.

Admission   11   If a critically ill patient is temporarily placed in   Yes, use code '90' (assuming the patient is being cared for by critical
                 a cardiac care unit to avoid transfer, should          care staff).
                                                                                                                                                   N
                 this generate a separate CCMDS?




                                                                                   Issued by Dr John E Morris
                                                                                Critical Care Info Advisory Group
7/29/2011                                                                             Department of Health                                             7
                                                                                     CCMDS FAQs




Admission   11   We have some specialist areas, eg                 No. Multi-organ support by itself does not indicate the use of
                 'emergency heart centres' where there is          conventional critical care services, e.g. this can occur in operating
                 often routine multi-organ support according to    theatres, coronary care and other specialist areas. If critical care
                 CCMDS definition. Should these be                 resources are genuinely being deployed to care for these patients on a
                                                                                                                                                  N
                 designated temporary locations?                   temporary basis, then use codes 90 or 91. If critical care resources
                                                                   are being deployed on a regular basis, then consider designating the
                                                                   beds as a critical care beds (see above), i.e. being managed within the
                                                                   critical care service of that hospital.
Admission   13   If a patient is moved to a different hospital but Yes, use code '02' in 'Critical Care Admission Source'
                 in the same Trust, can we generate a new
                 CCMDS?

Admission   14   Is a patient transferred from an HDU to an         No, use code 11 - adult level 2 critical care bed
                 ICU coming from an intermediate care area?

Admission   15   Critical care admission type - repatriation, the   Repatriation should be viewed as a type of planned re-admission
                 definition is very specific in that the patient    which is different from other forms of re-admission, (e.g. that due to
                 has had to have originated in the admitting        relapse in the patient's condition). It is best to be pragmatic with this
                 hospital and is being returned there. What         definition and a view has been taken that it is reasonable to include
                 about others, e.g. patients returning to their     patients who have originated from your hospital or area and not just
                 'local' hospital after having gone direct to a     your unit (as stated in the data standard).
                 tertiary care centre, or in its other meaning
                 where the patient may have been out of the
                 UK?

Admission   15   Critical care admission type - what if an          If the surgery is urgent then it would be reasonable to record this as an
                 anaesthetist requests a critical care bed for a    unplanned admission, it is probably the combination of the surgery and
                 patient who has significant risk factors that      any significant co morbidity that counts as 'unexpected acute illness'
                 have only been identified a few hours before       as stated in the definition. Alternatively, if this represents optimal care
                 theatre?                                           in a scheduled patient with significant comorbidity but who has not
                                                                    been previously notified to the unit, then the criteria would be; could
                                                                    the patient be reasonably deferred if there was no bed? If yes, but
                                                                    fortuitously there is a bed, then this would be planned. If 'no' and a lot
                                                                    of trouble is taken to accommodate rather than cancel, then as far as
                                                                    the unit is concerned, this is unplanned.

Admission   15   The definitions regarding planned and              This is most likely the case with ICNARC Version 2 data set. The
                 unplanned admissions are different from            CCMDS and ICNARC Version 3 are now equivalent or can be mapped
                 those used by ICNARC - why?                        between data sets.

Admission   15   If a patient is re-admitted to the same unit       No, a re-admission requires a separate CCMDS, even though this may
                 within a calendar day, is the existing CCMDS       appear to result in double counting of the days of care.                      N
                 episode re-opened?




                                                                               Issued by Dr John E Morris
                                                                            Critical Care Info Advisory Group
7/29/2011                                                                         Department of Health                                                8


                                                                                                                    Ventilation
                                                                                                                                         ARS
                                                                                         Trans-laryngeal           BiPAP or CPAP
                                                                                     CCMDS FAQs




Respiratory   16   "CPAP applied via tracheal tube" = Advanced No, on the grounds that 'tracheal tube' is taken to mean via the trans-
                   Respiratory Support, does this mean that    laryngeal route.
                   patients with tracheostomy who are still
                   receiving CPAP satisfy this criterion?

Respiratory   17   Does a patient who needs a tracheostomy for      This is a level one patient. It has been agreed that the word 'intubated'
                   airway care because of respiratory muscle        is taken to refer to trans-laryngeal methods only, this is the spirit of the
                   weakness following a critical illness count as   definition. On this basis, patients who have tracheostomy for long term
                   basic respiratory care? This could be            airway access will not satisfy this particular criterion.
                   required for several weeks after ICU
                   discharge!
Respiratory   17   Summary algorithm that explains the                                                              Ventilation
                   differences between basic and advanced                                                                                ARS
                                                                                         Trans-laryngeal           BiPAP or CPAP
                   airway procedures.
                                                                    INTUBATION?                                     No Ventilation       BRS
                                                                                         Tracheostomy              Ventilation           ARS       U
                                                                                                                     BiPAP
                                                                                                                   CPAP                  BRS
                                                                                       No ventilation, long term
                                                                                                                          No ARS or BRS
                                                                                       airway access only
Respiratory   17   Where basic respiratory support has been         On the basis of clinical judgement, until the patient is deemed to have
                   recorded because the patient has been            recovered normal protective airway reflexes and adequate respiration.
                   recently extubated following mechanical          Pragmatically, this should not be for longer than one calendar day after
                   ventilation, how long can this category be       the day of extubation.
                   recorded?

Respiratory   17   Is the criteria for BRS over 50% oxygen or       According to the definition 'more than 50%', so precisely 50% would
                   50% oxygen or more                               not count. In practice, most delivery and measurement systems are
                                                                    not that accurate, so if a delivery device was set at 50%, it is quite
                                                                    likely that fractionally more than 50% would actually be delivered for
                                                                    part of the time!

Respiratory   17   Do patients receiving NIV on a general ward      No, because the ward bed is not a designated critical care bed. It
                   generate a CCMDS?                                might be possible to collect a CCMDS if this seen as a critical care
                                                                    episode with defined organ support in a temporary location prior to
                                                                    admission to a critical care bed. If this a frequent occurrence,
                                                                    consideration should be given to configuring such beds as a properly
                                                                    resourced respiratory support unit.




                                                                               Issued by Dr John E Morris
                                                                            Critical Care Info Advisory Group
7/29/2011                                                                         Department of Health                                                 9
                                                                                          CCMDS FAQs




Cardiovascular   18   It has been stated that the CCMDS should not       Yes, this would seem above and beyond 'conventional coronary care'.
                      be used for patients in conventional coronary      There is not a specific location code for this specialist area but
                      or cardiac care. We have a dedicated level 2       depending on the predominant outcome you could use 'medical adult
                      area for unstable cardiac patients who may be      patients, unspecified specialty' or 'cardiac surgical patients
                      awaiting surgery. We use balloon pumping,          predominate'.
                      vasoactive drugs and temporary pacemakers,
                      surely these are critical care patients and
                      should have the CCMDS collected?


Cardiovascular   18   Pulse contour analysis is designed not to be       It has been classified as advanced cardiovascular support because it
                      very invasive only requiring an arterial line,     requires not only an arterial line, but more expensive equipment and
                      therefore should it be basic cardiovascular        trained staff to interpret the data.
                      support?

Cardiovascular   18   Patients resuscitated after cardiac arrest etc.,   It is a catch-all for patients who have survived initial advanced life
                      what is the intention of this criterion for        support and where a decision has been made to continue close
                      advanced CVS support?                              observation within a critical care environment. Some of these patients
                                                                         may be admitted to a critical care area, conscious, with an IVI and
                                                                         supplementary oxygen and for full monitoring, but little else. It is
                                                                         suggested that this criterion would not normally be expected for longer
                                                                         than one calendar day in most critical care areas. Clearly, if the post-
                                                                         arrest patient remains ventilated or has invasive monitoring, other
                                                                         organ support criteria assume greater importance. ( Note that coronary
                                                                         care activity is collected within the appropriate cardiac care data and
                                                                         HRGs).

Cardiovascular   18   Temporary pacemakers' following cardiac            Only if they are fulfilling the other criteria of a critical care episode,
                      surgery are a frequent occurrence and again        specifically that they are occupying a designated critical care bed.
                      these patients are sometimes nursed in ward        Note that the data for these patients and the corresponding HRGs are
                      areas. CCMDS defines these patients as             almost certainly processed through existing cardiac diseases HRGs.
                      'ACVS' . Do you want these patients receiving
                      this treatment to be included in the data
                      collection?

Cardiovascular   19   In the criteria for basic support, there is a      No, there must be an indwelling arterial line.
                      statement about sampling of arterial blood,
                      can this be intermittent arterial stabs to qualify
                      for this level of support?

Cardiovascular   19   A patient having a high dose rate of               No, if this is the only vasoactive intravenous drug, then it remains by
                      intravenous noradrenaline would presumably         definition as basic cardiovascular support. (The increased resource
                      be very sick, does this score as advanced          consumption of such a very sick patient are likely to be captured in
                      cardiovascular support?                            other organ support categories).




                                                                                    Issued by Dr John E Morris
                                                                                 Critical Care Info Advisory Group
7/29/2011                                                                              Department of Health                                           10
                                                                                           CCMDS FAQs




Cardiovascular   19   Why is treatment of hypovolaemia rather than       In simple terms, because patients can be hypovolaemic but not
                      hypotension used as a criteria?                    hypotensive. The definition also requires there to be circulatory
                                                                         instability needing intervention. This criteria would not be satisfied for
                                                                         example by a surgical patient being gently re-hydrated because of post-
                                                                         operative vomiting but who has an otherwise normal circulation.

Cardiovascular   19   If drugs are given to control a high blood         If they are intravenous they would count. This interprets the phrase
                      pressure, does this meet the criteria for          'supporting blood pressure, cardiac output and organ perfusion' in a
                      intravenous vasoactive drugs                       more general sense.

Cardiovascular   19   Would intravenous potassium and                    Only bolus doses to treat acute onset arrhythmias would satisfy the
                      magnesium be classified as drugs used to           definition. (If given with other drugs such as noradrenaline, this would
                                                                                                                                                      N
                      control cardiac arrhythmias?                       also count as multiple vasoactive or rhythm controlloing).

Cardiovascular   19   Do anti-platelet drugs, anticoagulants and         Not in the current definitions.
                      thrombolytic treatment count as
                      cardiovascular support?

Cardiovascular   19   Critically ill obstetric patients with eclampsia   Intravenous labetolol would definitely satisfy 'intravenous drugs to
                      may need magnesium infusions and/or                control cardiac arrhythmias', therefore a BCVS criterion, (you can
                      labetalol, but these are not included in           expect tachyarrhythmias in uncontrolled hypertension). 'Single
                      definitions of neurological support or             intravenous vasoactive drug used to support arterial pressure, cardiac
                      cardiovascular support.                            output, or organ perfusion' could be interpreted liberally in that it is
                                                                         definitely an IV vasoactive drug and although support is primarily taken
                                                                         to mean keeping BP up, it could be argued as supporting/providing a
                                                                         normal BP. Many severe eclamptics have at least an arterial line in
                                                                         situ and that counts for this category. Neurological Support; 'severely
                                                                         agitated or epileptic patients requiring constant nursing attention
                                                                         and/or heavy sedation' is one of the bullet points for this category.
                                                                         Again it is stretching the definition a little but, the administration of
                                                                         magnesium to prevent the severe fitting that could occur if untreated
                                                                         would also be acceptable. (Also, use code 12 in critical care unit
                                                                         function; 'obstetric patients predominate' if this is appropriate for a
                                                                         specialist unit).


Renal            20   Does a patient on emergency haemodialysis          Yes. For the purposes of the CCMDS, renal support is defined as
                      require the CCMDS to be collected                  acute renal replacement therapy and if this is delivered in any
                                                                         designated critical care bed then a CCMDS should be completed.




                                                                                    Issued by Dr John E Morris
                                                                                 Critical Care Info Advisory Group
7/29/2011                                                                              Department of Health                                               11
                                                                                        CCMDS FAQs




Renal          20   Can routine dialyses of chronic renal failure     If the renal replacement therapy is a regular treatment for a patient in
                    patients be recorded via the CCMDS?               chronic renal failure, e.g. within a dialyses unit, this must not be
                                                                      captured in a CCMDS. If however, a patient with pre-existing chronic
                                                                      renal failure is receiving treatment for another illness in a critical care
                                                                      unit, any RRT provided using the unit's resources will be captured as
                                                                      renal support within the CCMDS.

Renal          20   Can a CCMDS be generated for patients who         In theory, yes, in that at least single organ support is provided for an
                    receive acute renal dialysis on a renal unit?     acutely failing renal system. There may need to be local discussion as
                                                                      to whether these beds are to be regarded as designated beds for the
                                                                      purposes of critical care. If they are not, then no CCMDS is required.
                                                                      PbR would also assume that re-imbursement is provided via renal
                                                                      HRGs and it may be that these cases will be filtered out of the critical
                                                                      care PbR payment streams in the future.

Neurological   21   If a head injured patient is being ventilated     Yes, but only if you can justify at least one specific element of
                    and sedated there is obviously advanced           neurological support being provided to the patient, e.g. active cooling,
                    respiratory support but can you also count        cerebral function monitoring, nimodipine infusion. Two further
                    neurological support?                             examples may help to illustrate this point: a) A brain injured patient
                                                                      who is ventilated and has an ICP measuring device in situ on day one
                                                                      would accrue both ARS and neurological support, but if the ICP device
                                                                      was removed on day two, would only have ARS. b) A patient with
                                                                      Guillain Barre syndrome on day one is managed with mask bi-level
                                                                      pressure support but may also have a prejudiced airway which would
                                                                      accrue neurological in addition to respiratory support. On the next day,
                                                                      intubation and mechanical ventilation is required and thus reverts to
                                                                      single organ support.

Neurological   21   If a neurological patient is ventilated but has   If the agitation is a result of the neurological disorder, then this would
                    to be sedated because of agitation is this two    be neurological support, if the patient is simply resisting intubation and
                    organ support?                                    mechanical ventilation to the point of requiring sedation then this is
                                                                      part and parcel of advanced respiratory support and would not meet
                                                                      the neurological criteria.

Neurological   21   Some patients in coma take many days to           Neurological support ceases when specific neurological interventions
                    show any improvement in their GCS, when           are withdrawn, e.g. ICP monitoring, CFAM, cooling, nimodipine
                    should the neurological organ support stop        infusion, intravenous sedation to control agitation.
                    being counted?

Neurological   21   What is meant by constant nursing care?           This should be assessed as in the context of neurological care as
                                                                      described in the statement. The clinical scenario will be obvious in
                                                                      most critical care facilities.




                                                                                 Issued by Dr John E Morris
                                                                              Critical Care Info Advisory Group
7/29/2011                                                                           Department of Health                                            12
                                                                                            CCMDS FAQs




Neurological        21   There is no option to record frequent turns for   This does seem to be an incomplete area in the data collection and
                         spinal injury, or spinal care in general as       may be corrected in later releases although agreeing criteria is difficult.
                         regards organ system support.                      In the meantime, spinal injury in specialist units will probably be re-
                                                                           imbrued within the No.
                                                                           disease based HRGs.

Neurological        21   How many organs are supported if a neuro-         By definition, this has to be only the advanced respiratory support
                         trauma patient is ventilated but has no           category.
                         neurosurgical intervention/observation?

Neurological        21   Can a patient in a level 2 unit for management Yes, if the patient is in a designated bed a CCMDS can be generated
                         of an epidural generate a CCMDS?               but unless there is documented organ support as defined in the
                                                                        CCMDS, the re-imbursement is likely to be at basic ward care level.

Neurological        21   Would a patient with an External Ventricular      Yes.
                         Drain (EVD) used for drainage purposes
                         rather than for monitoring ICP be defined as                                                                                    N
                         receiving Neurological support?

Neurological        21   What do we mean by a severely agitated            As a rule of thumb, a patient who is so agitated that a nurse needs to
                         patient?                                          be in close attendance for 95% of the time to prevent the patient self
                                                                           harming or disrupting treatment.

Gastro-intestinal   22   What is the purpose of collecting this data       True, all patients should be fed one way or another! However, it is not
                         item, surely feeding is part of standard care?    counted in the currently authorised HRGs and CCIAG takes the view
                                                                           that it should not be used as an organ support in deriving levels of
                                                                           care. (It does contribute to Organ Support Maximum and may
                                                                           therefore be included in these calculations, but neither of these
                                                                                                                                                         U
                                                                           variables are part of the mandatory HRG subset). This item is used to
                                                                           note the number of cases where more invasive methods are used, e.g.
                                                                            enteral feeds and TPN which may vary considerably between unit
                                                                           types.

Gastro-intestinal   22   Would using intravenous 10% Dextrose (to          No.
                         maintain blood glucose levels until enteral
                         feeding is established) be defined as                                                                                           N
                         receiving parenteral nutrition?

Dermatological      23   What are complex dressings?                       There is no totally prescriptive answer but as a guide this would
                                                                           include vacuum system dressings for large areas of debridement or
                                                                           barrier materials applied over a wide area.




                                                                                      Issued by Dr John E Morris
                                                                                   Critical Care Info Advisory Group
7/29/2011                                                                                Department of Health                                                13
                                                                                          CCMDS FAQs




Liver           24   Liver support days -the only definition for this    CCIAG concluded that for the majority of cases, the modalities of
                     type of organ support relates to extracorporeal     treatment for liver failure patients would be covered by components
                     artificial liver systems. This does not capture     listed for the other major areas of organ support such as mechanical
                     the high intensity of other aspects of specialist   ventilation, inotropes and renal replacement therapy. The only item
                     liver care.                                         that may be a high cost predictor that was not listed and tested is the
                                                                         use of high volumes of blood components, this may be addressed in
                                                                         later releases as it applies to other examples of high cost care.

Liver           24   If a patient is having charcoal haemoperfusion Yes, if this is being used to replace liver function.
                     via a haemofiltration machine, is this liver
                     support?

Organ support   25   Is there a required period of time that any of
                     the individual organ support criteria are           No, in nearly all cases it is sufficient for the procedure or care activity
                     provided before they can be counted?                to have occurred only once within the calendar day. Clearly, on a
                                                                         'swings and roundabouts' principle such elements of care will vary from
                                                                         a matter of minutes to the full 24 hours. There are a few exceptions
                                                                         where it has been necessary to give some guidance, e.g. with 'recently
                                                                         extubated' it is reasonable to advise a minimum intubated period of 24
                                                                         hours indicating that the BRS category becomes relevant in this sort of
                                                                         scenario. If there is a concern that organ support numbers can be
                                                                         inflated by briefly introducing an intervention (e.g. 50% oxygen) this
                                                                         will become apparent by comparison across units and will be counter-
                                                                         productive in the pricing of the tariffs.
Organ support   25   Can the variable 'organ support maximum' be         No, see full definition, this is why it is not part of the HRG subset.
                     used to derive the HRGs?

Organ support   25   If one aspect of organ support is removed           No, if this aspect of treatment has been present at any time within the
                     from the patient's care following a morning         calendar day, then it remains in that day's total.
                     ward round, does this reduce the total for the
                     day?

Organ support   25   The definition states that organ support is         The intention is to accept the maximum number of organs supported
                     assessed at 'any one time' but in other parts       within one calendar day. To take an extreme example, it might be
                     of the data set the emphasis is on any              possible for basic respiratory followed by basic cardiovascular,
                     occurrence within a calendar day, which is          followed by renal etc to occur in sequence, but not all at the same time
                     correct?                                            within one calendar day of observation. The maximum organ support
                                                                         on this day would be '1' using the 'at any one time' criteria, but ' 2 or
                                                                         more' using the calendar day principle. It is the latter approach which
                                                                         should be adopted. Note that the basic and advanced categories of
                                                                         the same type must not be counted as two organ supports if they occur
                                                                         on the same calendar day. (The definition will be improved in later
                                                                         editions).




                                                                                    Issued by Dr John E Morris
                                                                                 Critical Care Info Advisory Group
7/29/2011                                                                              Department of Health                                            14
                                                                                         CCMDS FAQs




Organ support   25   How many times can we count both levels of          Each organ support can be recorded once per day and repeated on
                     organ support with respect to 'Organ Support        any other number of days as required. (Advanced organ support
                     Maximum' or the total organ support that            replaces basic support occurring during the same calendar day). The
                     produces HRGs?                                      variable 'Organ support maximum' simply counts the peak occurrence
                                                                         provided per calendar day and it does not matter that basic or
                                                                         advanced interventions recur on other days. Total organ support
                                                                                                                                                   N
                                                                         counted by the HRG grouper includes any occurrence (but once only)
                                                                         of each of the HRG listed organ supports to provide a total for the
                                                                         whole episode, so it does not matter if advanced and basic occur
                                                                         multiple times. The Grouper algorithm may be subject to change in the
                                                                         future.

Organ support   25   When basic respiratory and basic                    CCIAG reviewed the relationship between organ support and levels of
                     cardiovascular supports occur during the            care / HRGs in February 2007. It was concluded that the CCMDS
                     same day should they count as one organ             should continue to collect basic and advanced categories but when
                     support rather than two?                            only the basic forms occur in a single day, they should be combined to
                                                                                                                                                   N
                                                                         a value of one organ support. (Thus, the CCMDS does not change but
                                                                         Levels of Care and HRG grouping will be better aligned with users
                                                                         perceptions).

Organ support   25   Is it correct that a patient can only have ONE      Yes, advanced forms of cardiovascular and respiratory organ support
                     Respiratory ( Advance superseding Basic)            subsume the basic levels during any calendar day but the other organ
                     and similarly ONE cardiovascular, but may           support categories can be added independently during the same
                     also have renal, neurological, dermatological,      period.
                     liver or combination of these organs
                     supported regardless of where they are being
                     treated?
Level of Care   26   The CCMDS uses new and expanded organ               Levels of care, first devised in Comprehensive Critical Care and
                     support definitions while the Levels of Care        expanded/explained in ‘Levels of Critical Care for Adult Patients’
                     fields refer to the original ACP/ICS definitions,   issued by the ICS were never intended to be exactly the same as ACP
                     which is correct?                                   INTDAYS and DEPDAYS or correlate uniquely with the numbers of
                                                                         organs supported. The intellectual process that went into defining the
                                                                         ICS levels included a lot of thinking around the types of patients that
                                                                         would fit each category and not just simple counts of organ system
                                                                         support. Thus, a logical conversion from organ support counts to levels
                                                                         of care is not always possible and may not be correct in all scenarios.
                                                                         The recently expanded CCMDS organ support definitions should now
                                                                         be used for identifying the number of organ systems that are
                                                                         supported.




                                                                                   Issued by Dr John E Morris
                                                                                Critical Care Info Advisory Group
7/29/2011                                                                             Department of Health                                             15
                                                                                        CCMDS FAQs




Level of Care   26   It seems possible to have a CCMDS with level Yes, that is correct, especially if there is no invasive monitoring or
                     2 care but no organ support, e.g. level 2    requirement for high concentration oxygen therapy.
                     indicated by 'needing a greater degree of
                     observation and monitoring that cannot be
                     safely provided at level 1 or below'

Level of Care   26   Are the level of care criteria taken to reflect   No, the principle is that the levels care express the needs of the
                     the type of bed the patient occupies?             patients, not the beds they occupy, although one would hope that in
                                                                       most cases where beds are so designated, needs would equate to
                                                                       provision. Note the advice on designated beds contained elsewhere in
                                                                       the FAQs.

Level of Care   26   There has been an increase in the number of       More emphasis has been placed in the CCMDS on organ support
                     organ systems available to count within the       compared to levels of care and it is recommended that all primary
                     CCMDS, this makes many patients who               organ support data should be collected. In response to concern about
                     intuitively are Level 2 become level 3 by         level 3 inflation, it has been decided to count basic cardiovascular and
                                                                                                                                                    U
                     definition, is this correct?                      respiratory organ supports as one where they occur together in any
                                                                       one calender day. HRG grouper design is being reviewed to reflect
                                                                       this change.

Level of Care   26   How can you record level 1 care on an HDU
                     or ICU, there is no place for this in the         The CCMDS only requires level 2 and level 3 data. There are issues
                     CCMDS?                                            around the definitions for level 1 care which make these data less
                                                                       robust. The assumption is that any days spent in a designated critical
                                                                       care bed that amount to more than those recorded as level 2 or 3, are
                                                                       by default level 1 or 0. It is likely that only level 2 and 3 days will be
                                                                       recognised from CCMDS data for reimbursement at critical care tariffs.

Level of Care   26                                                     If none of the basic aspects of critical care organ support are being
                     What happens to patients who arrive on the        provided, e.g. arterial line, CVP, then such patients have to be given
                     unit post operatively, who have no organ          zero organ support in the CCMDS. This will reduce funding but not the
                     support count but who meet the level 2 criteria   level of care classification. Some would argue that the hospital needs
                     for post operative care, e.g. increased risk of   to look at how its critical care beds are being used in these
                     post operative complications requiring close      circumstances.
                     monitoring.




                                                                                  Issued by Dr John E Morris
                                                                               Critical Care Info Advisory Group
7/29/2011                                                                            Department of Health                                               16
                                                                                          CCMDS FAQs




Level of Care   27   The levels of care guidance implies that           No. There are two issues here, firstly note that CCMDS translates into
                     routine elective post-op ventilation for less      HRGs and funding via organ support data, not levels of care.
                     than 24 hours does not meet the criteria for       Secondly, the ICS guidance does emphasise that such patients are
                     level three care. However, such patients are       otherwise stable, implying no need for any other form of organ support.
                     likely to have at least basic respiratory           If this is not the case, then simply classify as level 3 with the relevant
                     support and probably basic cardiovascular          organ support categories.
                     support (arterial line) on the day of operation
                     and the first post-op day (after midnight). This
                     would automatically be level 3 for two days, -
                     does this contradict the earlier guidance?


Level of Care   27   The ICS levels of care document has a table        The correct definition is as found in the CCMDS and the expanded
                     in the introduction which has a different          definitions table of the ICS document. There was a 'typo' in the original
                     definition for level three care compared to        Comprehensive Critical Care document which was unfortunately
                     their expanded definitions and also to the         copied to the introduction to the ICS document (and subsequently
                     CCMDS.                                             many others!). Level three care is correctly defined as; patients
                                                                        needing monitoring and support for two or more organ systems, one of
                                                                        which may be basic or advanced respiratory support.

Discharge       28   Critical care discharge status - what about the Use the option for cadaveric tissue donation, this covers both non-
                     non heart-beating donor?                        heart beating major organ donation and other donation such as
                                                                     corneas and heart valves. As experience is gained, the options for this
                                                                     field may be amended.

Discharge       31   If the patient dies on the unit, how do you        It could be argued that the patient became ready for discharge from the
                     record data in the discharge ready date and        unit at the time of death, so, rather than recording a null or the same
                     time fields?                                       date as the time the body was removed, record the date and time of
                                                                        death here. If there are considerable period of time from death the
                                                                        removal of the body, this would become apparent in the data,
                                                                        especially when the outcome code for 'patient died' is included in the
                                                                        CCMDS.

Discharge       33   When does the CCMDS episode end if a               No, the CCMDS episode ends when the patient physically leaves the
                     patient is transferred from your ICU to another    Unit.
                     taking a nurse with them? In these
                     circumstances the bed is effectively out of
                     action until they return. Should the date and
                     time of discharge now not be better given as
                     the time the nurse returns?
Discharge       33   Can we include transfer time in the 4 hours        No, the justification being that there is not a location for this aspect of
                     needed to generate a CCMDS for patients            care.
                     cared for outside of critical care. E.g. A/E?




                                                                                   Issued by Dr John E Morris
                                                                                Critical Care Info Advisory Group
7/29/2011                                                                             Department of Health                                            17
                                                                                   CCMDS FAQs




Discharge   33   When does a CCMDS finish if a patient dies        The discharge date and time has to be when the body is removed from
                 in a unit but stays on the unit for some time?    the unit. It could be assumed that there may still be elements of care
                                                                   being provided such as to bereaved relatives in this situation.

Discharge   33   Following brain stem death testing the official   The CCMDS does not contain date or time of death. Because of the
                 time of death is after the first set of tests.    resource implications the CCMDS episode should end when the body
                 When does the CCMDS episode end?                  finally leaves the unit. Depending on local practice this may be before
                                                                   or after organ donation. It will be important to check that the time of
                                                                   death entered on PAS does not override the CCMDS field.

Discharge   33   Does the ready for discharge date and time
                 start when organ support has ceased?              No, because a) it is likely that other care is continuing pending
                                                                   discharge arrangments being made and b) it is possible for a patient to
                                                                   be transferred to another unit with continuing organ support.




                                                                             Issued by Dr John E Morris
                                                                          Critical Care Info Advisory Group
7/29/2011                                                                       Department of Health                                         18

				
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