Abstracting

[Shelly Demello]

Does anyone have benchmark times for abstracting Core Measures? Sepsis, global, stroke…etc

 

Aloha,

 

Shelly A. Demello RN

Quality Management

Core measure

Hilo Medical Center

808=932-2556

 

Confidentiality Notice: This email message, including any attachments, is for the sole use of the intended recipient(s) and may contain confidential and privileged information. Any unauthorized review, use, disclosure, or distribution is prohibited. If you are not the intended recipient, please contact the sender by reply e-mail and destroy all copies of the original message.

[Deborah V]

We have found that abstracting sepsis is highly variable from 20 minutes to several hours.  This is because it does not have to be principal dx so it may not be POA in which case the whole stay needs to be looked at in a rolling 6 hour window fashion to see if criteria are met at any time during stay.  Some of these charts are thousands of pages long.

I know this doesn't help in justifying your man hour needs, but we just have good employees that we value and trust are putting forth good, conscientious  effort with each chart abstracted.

[Stacey Montgomery]

We have an electronic record with a flow sheet set up to pull in the specific SIRS and Organ Dysfunction criteria for review, which significantly simplifies the process.  I look for the clinical criteria to exist within the 6 hour time frame at any point in the stay, then review documentation for the suspected infection piece.  Patients without septic shock take about 10-20 minutes to abstract, depending on whether or not I have to search for a culture and sensitivity to justify an antibiotic selection, or if I am searching for details to identify the cause of a failure, that kind of thing.  If the patient requires fluids, give it another 5-10 minutes to do the math to verify sufficient volume and check for persistent hypotension in the hour after administration.  Vasopressors are easy to abstract when needed with the electronic MAR, and providers progress notes are kept in a specific documents folder in the EHR making it pretty quick to check for documentation of the reassessment when needed. 

 

In summary, when everything is done correctly, a complete chart takes between 10 and 30 minutes (average 20). 

When things are missing, I can spend an hour or more trying to research why something failed, who was involved, where the breakdown occurred, etc.  Currently, we still have more failures than successes, so most take longer than 20 minutes.

 

I’d also like to point out that I am abstracting concurrently using the Cerner Sepsis Alerts and admitting diagnosis selection to identify possible cases.  This means I am abstracting a LOT of charts that do not end up coding out as Severe Sepsis/Septic Shock, so the abstractions are ultimately discarded.

 

Hope this info is helpful!

 

 

Stacey Montgomery, CPHQ

Quality & Risk Coordinator

Delano Regional Medical Center

Phone: (661) 721-5396

Email: mo...@drmc.com

--
You received this message because you are subscribed to the Google Groups "Hospital Quality Share" group.
To unsubscribe from this group and stop receiving emails from it, send an email to hospital-quality-...@googlegroups.com.
To post to this group, send email to hospital-qu...@googlegroups.com.
Visit this group at https://groups.google.com/group/hospital-quality-share.
For more options, visit https://groups.google.com/d/optout.