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IHI Learning Lab Pre-Work Session L14

The Hidden Harm of Non-Ventilator Hospital-Acquired Pneumonia (NV-HAP)

December 4, 2016 1:00 pm – 4:30 pm

Welcome to IHI session L14. We are excited to spend time with you learning and sharing about the #1 hidden harm in hospitals.

This is a flipped classroom session, therefore we are requesting that you bring some data and information about your hospital.

Items to bring to the class:

Laptop or Tablet

Samples or photos of oral care supplies from your facility- both ICU and floor units – don’t forget any denture care products, if you have

Samples of any patient education materials regarding oral

Please research and bring the following data from your hospital(s):

For your hospital(s), for the first half of 2016 – January 1 to June 30, 2016.

1. adult patients discharges

2. adult patient days

3. your hospital(s)’s prevalence of non-ventilator hospital-acquired pneumonia ( NV-HAP) for the first half of 2016 – January 1 to June 30, 2016.

Instructions for how to query your ICD-10 codes are at the end of this document.

If you have any questions, please do not hesitate to email:

Barbara Quinn

Bring this data on NV-HAP at your facility, January 1, 2016 – June 30, 2016 (No PHI please)

  1. Adult patient discharges -January 1, 2016 – June 30, 2016
  2. Adult patient days -January 1, 2016 – June 30, 2016
  3. Prevalence of pneumonia

Here’s how:

1. Search the ICD-10 codes for pneumonia as a Secondary Diagnosis

2. Filter the results to identify pneumonia NOT Present on Admission

3. If possible, also include fields for … Discharge DispositionReadmit 30 days

Sample Table

Principal Diagnosis / Principal Dx Code / Secondary Pneumonia Diagnosis / 2nd Dx Code / POA Y/N / Discharge Disposition / Unit Location & Name / 30 Day Readmission Y/N
MECH COM ORTH DEV NEC / T84129A / PNEU D/T METH SUS STAPH / J15.211 / N / EXPIRED / ORTHO 4N / N
ACUTE KIDNEY FAILURE / N179 / PNEU UNSP ORG / J18.9 / N / ROUTINE DC HOME / MEDICAL 3W / Y
SADDLE EMBOLUS / I7401 / OTHER BACT PNEU / J15.8 / N / DC TO LONG TERM ACUTE / CICU / N

4. If possible, also locate the unit and name of the location where the pneumonia was diagnosed.

ICD 10 PNEUMONIA CODES – Search for these codes, and not present on admission

Definition / ICD-10
Adenoviral pneumonia / J12.0
Parainfluenza virus pneu / J12.2
Pneu due to SARS / J12.81
Pneu due to Hemophilus influenza / J14
Pneu due to Klebsiella / J15.0
Pneu due to Pseudomonas / J15.1
Pneu due to Staphylococcus / J15.20
Pneu due to Methicilinn sus Staphylococcus A / J15.211
Pneu due to Methicillin Resis Staphylococcus A / J15.212
Pneu due to other Staphylococcus / J15.29
Pneu due to Strep B / J15.3
Pneu due to Other Strep / J15.4
Pneu due to e.Coli / J15.5
Pneu due to Other gram Neg Bact / J15.6
Pneu due to Mycoplasma Pneumonae / J15.7
Other Bact Pneumonia / J15.8
Bact. Pneu, unspecified / J15.9
Pneu due to Other Spec Infec Organisms / J16.8
Pneu in Diseases Classified Elsewhere / J17
Bronchopneumonia, unspec. / J18.0
Lobar Pneu / J18.1
Hypostatic Pneu, unspec. / J18.2
Other Pneu, Organism unspec. / J18.8
Pneu, unspec. Organism / J18.9