Condition H Collaborative

Table of Measures for Hospital Reporting

The measures consist of core measures required by each hospital.

Measures for Hospital Reporting

Measure Effectiveness
Measure / Description / Numerator / Denominator / Frequency/Data Collection / Goal/ Comments / Tools/Resource
Efferent
Core / Codes Outside ICU / Percentage of all codes occurring outside the ICU
Code: Patients requiring cardiopulmonary resuscitation or intubation
Calculate as: (numerator/ denominator); as a percentage / In-hospital codes that occur outside the ICU
Numerator Exclusions:
Codes occurring in the ED / All in-hospital codes
Denominator Exclusions:Codes occurring in the ED / 1 month
Data Collection Strategy:Each month, determine the location each code occurs from code logs and records. Establish a process to identify all calls to the RRS. One possible data collection strategy: Each call to the RRS should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and used as the source of the data. / Goal: 50% decrease
Decrease the number of patients who are coding within your facility outside of the ICU and ED. / See sample Data Collection Tool
See IHI 100,000 Lives Campaign, How-To Guide: Rapid Response Teams (Appendix C, p. 26)
Core / Utilization of RRS / Number of calls to the RRS / Number of calls to the RRS
Numerator Exclusions: None
The numerator includes all calls to the RRS. / N/A / Typically, this is done in monthly increments, but teams might find it useful initially to track this information weekly (i.e., period of 1 week, every week, measuring calls per week). Once your team is well established, you can move the measurement period to monthly (i.e., period of 1 month, every month, measuring calls per month). Data submitted to IHI should be aggregated to monthly.
Data Collection Strategy:Establish a process to identify all calls to the RRS. One possible data collection strategy: Each call to the RRS should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and serve as the source of the data. / Goal: Increase the use of the RRS over time. (This is an organization-specific measure; it is not suggested to compare across organizations, so there is no absolute goal.) / See sample Data Collection Tool
See IHI 100,000 Lives Campaign, How-To Guide: Rapid Response Teams (Appendix C, p. 28)
Core / Utilization of RRSActivated by Patients and Family Members / Number of calls to the RRS activated by patient or family member / Number of calls to the RRSactivated by a patient or family member
Numerator Exclusions: None
The numerator includes all calls to the RRS that are initiated by a patient or family member. / N/A / 1 month
Data Collection Strategy: Establish a process to identify all calls made by a patient or family member to the RRS. One possible data collection strategy: Each call to the RRS should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and serve as the source of the data. / This is an organization-specific measure; it is not suggested to compare across organizations, so there is no absolute goal. / See sample Data Collection Tool
Measure Effectiveness
Measure / Description / Numerator / Denominator / Frequency/Data Collection / Goal/ Comments / Tools/Resource (Binder Tab XX)
Quality Improvement
Core / Codes per 1,000 discharges / The number of codes per 1,000 inpatient discharges
Code: Patients requiring cardiopulmonary resuscitation or intubation
Calculate as: (numerator/ denominator) x 1000; as a number of codes per 1,000 inpatient discharges / Total inpatient codes
Numerator Exclusions:
Codes occurring in the ED / Total inpatient discharges
Denominator Exclusions:
  • Stillbirths
  • Deaths in the ED of ED-only patients
An ED-only patient is one who receives care in the ED but has not been admitted to the hospital.
Stillbirths and ED-only deaths are generally not considered inpatient discharges; we have noted them explicitly for clarification. / 1 month
Data Collection Strategy:Obtain numerator and denominator from hospital information systems or other reliable sources monthly as soon as discharge and death data are available. / Goal: Short term, reduce by 25%. Long term, reduce by 50%. / See sample Data Collection Tool
See IHI 100,000 Lives Campaign, How-To Guide: Rapid Response Teams (Appendix C, p. 24)
Core / Acute care inpatient mortality rate / Number of in-hospital deaths in acute care inpatient population divided by the number
Acute care inpatient is on who is discharged from acute care inpatient status.
Calculate as: (numerator/ denominator); as a percentage / Number of acute care inpatient deaths / Number of acute care inpatient discharges
Denominator Exclusions: This measure is focused on acute care inpatient deaths and, therefore, by definition the following patients are excluded from the calculation:
  • ED-only patients who are not admitted as inpatients
  • Observation patients who are not admitted as inpatients
  • Short-stay patients who are not admitted as inpatients
These exclusion populations are not considered by most U.S. hospitals to be acute care inpatients. / Monthly
Data Collection Strategy:Obtain numerator and denominator from hospital information systems or other reliable sources monthly as soon as discharge and death data are available.
For patient populations not explicitly excluded, for whom it is not clear whether they should be considered acute care inpatients, consider patients discharged with a completed UB-92 form included and those discharged with the form excluded.
Typically, it is recommended to exclude all DNR patients from this statistic. / Goal: Decrease hospital mortality by 10%.
For consistency, hospitals that include any of the exclusion populations in their individualdefinition of acute care inpatients should exclude these populations for this measure. All acute care inpatients should be included, even in cases where mortality-reducing improvements are not appropriate, such as comfort care patients who are coded as acute care inpatient. / See sample Data Collection Tool
Optional / Patient Satisfaction Indicator #1: Provided Clear Direction / Number of respondents who felt they were given clear direction regarding Condition H
Calculate as: (numerator/ denominator); as a percentage / Number of respondents who ‘agree’ or ‘strongly agree’ that they were given clear direction regarding Condition H / Number of respondents / 1 month
Data Collection Strategy: Establish a process to identify all calls to the RRS. One possible data collection strategy: Each call to the RRS should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and serve as the source of the data. / Goal: 100% of respondents ‘agree’ or ‘strongly agree’ that they were given clear direction regarding Condition H / See sample Data Collection Tool
Optional / Patient Satisfaction Indicator #2: Felt Comfortable / Number of respondents who felt comfortable calling a Condition H
Calculate as: (numerator/ denominator); as a percentage / Number of respondents who ‘agree’ or ‘strongly agree’ that they felt comfortable calling a Condition H / Number of respondents / 1 month
Data Collection Strategy: Establish a process to identify all calls to the RRS. One possible data collection strategy: Each call to the RRS should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and serve as the source of the data. / Goal: 100% of respondents ‘agree’ or ‘strongly agree’ that they felt comfortable calling a Condition H / See sample Data Collection Tool
Optional / Patient Indicator #4: Needs Met Post Condition H Call / Number of respondents who felt their needs or theneeds of their loved one was met post a Condition H call
Calculate as: (numerator/ denominator); as a percentage / Number of respondents who ‘agree’ or ‘strongly agree’ that their needs or the needs of their loved one was met post a Condition H call / Number of respondents / 1 month
Data Collection Strategy: Establish a process to identify all calls to the RRS. One possible data collection strategy: Each call to the RRS should result in the completion of a documentation form or record. These records should be kept in a central location (paper log book, electronic record, etc.) and serve as the source of the data. / Goal: 100% of respondents ‘agree’ or ‘strongly agree’ that their needs or the needs of their loved one was met post a Condition H call / See sample Data Collection Tool

Note: RT = respiration therapist; OT = occupational therapist; PT = physical therapist; SLP = speech–language pathologist; SW = social worker.

References

  1. Bellomo, R., Goldsmith, D., Uchino, S., Buckmaster, J., Hart, G., Opdam, H., et al. (2004, April). Prospective controlled trial of effect of medical emergency team on postoperative morbidity and mortality rates. Critical Care Medicine, 32(4), 916–921.
  2. Bellomo, R., Goldsmith, D., Uchino, S., et al. (2003). A prospective before-and-after trial of a medical emergency team. Medical Journal of Australia, 179(6), 283–287.
  3. Bristow, P. J., Hillman, K. M., Chey, T., et al. (2000, September). Rates of in-hospital arrests, deaths and intensive care admissions: The effect of a medical emergency team. Medical Journal of Australia, 173(5), 236–240.
  4. Buist, M. D., Moore, G. E., Bernard, S. A., Waxman, B. P., Anderson, J. N., & Nguyen, T. V. (2002). Effects of a medical emergency team on reduction of incidence of and mortality from unexpected cardiac arrests in hospital: Preliminary study. British Medical Journal, 324, 387–390.
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  7. DeVita, M. A., Braithwaite, R. S., Mahidhara, R., Stuart, S., Foraida, M., & Simmons, R. L. (2004). Use of medical emergency team responses to reduce hospital cardiopulmonary arrests. Quality and Safety in Health Care, 13(4), 251–254.
  8. Hillman, K., Chen, J., Cretikos, M., et al. (2005, July). Introduction of the medical emergency team (MET) system: A cluster-randomised controlled trial. Lancet, 365, 2091–2097.
  9. Kenward, G., Castle, N., Hodgetts, T., & Shaikh, L. (2004). Evaluation of a medical emergency team one year after implementation. Resuscitation, 61(3), 257–263.
  10. Kerridge, R. K., & Saul, W. P. (2003, September). The medical emergency team: Evidence-based medicine and ethics. Medical Journal of Australia, 179(6), 313–315.
  11. Parr, M. J., Hadfield, J. H., Flabouris, A., Bishop, G., & Hillman, K. (2001, July). The medical emergency team: 12 month analysis of reasons for activation, immediate outcome and not-for-resuscitation orders. Resuscitation, 50(1), 39–44.
  12. Salamonson, Y., Kariyawasam, A., van Heere, B., & O'Connor, C. (2001, May). The evolutionary process of medical emergency team (MET) implementation: Reduction in unanticipated ICU transfers. Resuscitation, 49(2), 135–141.
  13. Simmonds, T. (2005). Best-practice protocols: Implementing a rapid response system of care. Nursing Management, 36(7), 41–42,58–59.

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