Clinical documentation integrity (CDI) departments focus on the integrity of the clinical documentation within a health record. There are many CDI initiatives that healthcare organisations can institute depending on their unique needs. Key performance indicators (KPI) are metrics that can be analysed by organisations to monitor the progress of CDI initiatives. This information can be used to identify strategic goals, operational opportunities, support informed decision-making, and develop focused educational training.  

When monitoring CDI operations, it is important to consider leading and lagging indicators. Typically, leading indicators recognise what a CDI department is working toward (predict future success) and lagging indicators identify what has been achieved by the department (reflect past success). 

To get a complete picture of their performance, CDI departments may monitor KPIs that are internal and external to the organisation. External resources will vary by location and may include patient severity of illness scores and quality measures, while internal metrics can vary depending on the mission and focus of the CDI department. 

Tammy Combs RN, MSN, CDIP, CCS, CNE

Internal metrics may also change as the department matures and the documentation focus areas expand. These metrics should be evaluated on an ongoing basis to continually monitor a programme’s success.  

Some of the common internal metrics that are monitored for CDI departments include the following:  

- Health record review rate: A calculation of the number of health records reviewed by a CDI professional divided by the number of health records assigned for review within a defined period of time. This metric can help identify if the goal for the review rate is realistic.  
 
For example, if none of the CDI staff are meeting the goal, then it may need to be reconsidered. This information can help leadership recognise when additional staff may be needed. It is important for leaders to consider all the variables that can influence the review rate such as time spent delivering provider education, department meetings, competing responsibilities, and patient acuity.  
 

- Provider response rate: The percentage of provider responses to queries within a defined time frame. This is one of the most important metrics; if providers are not responding to queries in a timely manner, errors and omissions in the documentation can impact reimbursement, quality care, and patient outcomes. This may be monitored by CDI professional, individual providers, provider groups, or by the CDI department.  
 

- Query rate: The percentage of queries being sent to providers compared to the number of health records reviewed by the CDI professionals. This metric may be measured by the actual number of queries sent or by the number of health records requiring one or more queries. This metric can assist the organisation in determining the quality of the clinical documentation, engagement of providers, and educational opportunities.  
 
The query rate may decrease as the providers improve their clinical documentation. It can also increase again if new documentation needs occur. For example, if the CDI team begins by only sending queries that capture disease severity, then as the providers improve in this area the query rate will drop. Then if the CDI department begins reviewing documentation that impacts quality metrics the query rate may increase.  
 

- Provider agreement rate: Measurement of the number of times the provider agrees with the need for further documentation clarity, based on the queries they receive. This metric helps monitor the engagement of providers and the quality of the queries being sent. For example, if the provider has a low agreement rate, they may not be engaged with the program or they may be receiving inappropriate queries. 
  

- Denial rate: The percentage of claims that have been denied by payers within a defined time frame. This information can be further evaluated by the type of denial such as missing or incomplete documentation, inaccurate coding, and not meeting medical necessity for services provided. 

Organisations will need to determine which metrics they will monitor and develop a process for data collection and analysis. The process of data collection is vital to the accurate measurement of KPIs for the CDI department. The information may be collected through an internal, manual process, like adding the information into an Excel document. It may also be collected through automated CDI technology.  
 
If there are budgetary restraints, the information may need to be collected manually; however, this does increase the chance of error and may consume large amounts of staff time. Obtaining CDI software can help support the accuracy of data collection and free up staff time to perform more health record reviews. There are many opportunities to advance CDI efforts through the use of technology.  
 
To learn more about CDI Technology you can review the publication, Compliant CDI Technology Standards. There are also many educational opportunities available regarding the use of CDI technology, such as The Impact of Technology on Clinical Documentation Integrity Webinar Series.  

There are both quantitative and qualitative data collection methods and the type used will be dependent on the information being measured. Quantitative data is obtained through mathematical calculations and is frequently monitored by a CDI department, while qualitative data uses open-ended questions to collect data. This method might be used when interviewing providers or staff regarding their specific needs.  
 
This can also be used by manually performing quality audits on health records that have been reviewed for missed opportunity and auditing for query compliance. These quality audits are essential to the performance of the programme, some organisations may want to use external sources for auditing, such as the CDI Query Services offered by AHIMA CDI Experts. 

Providers are essential in CDI initiatives to improve documentation and patient outcomes, and need clear and concise documentation guidance that supports rather than distract from patient care. CDI departments may utilise unique and creative approaches to address documentation needs that support care across the continuum. CDI metrics can also be used to help educate providers on the importance of data integrity, which in turn supports provider engagement.  

To learn more about CDI KPIs, please review the Clinical Documentation Integrity Key Performance Indicators Practice Brief (ahima.org) 

AHIMA supports the ongoing needs of CDI professionals and physicians through an extensive suite of CDI education and publications. Visit the AHIMA CDI Progression Ladder website to find educational opportunities that supports all stages of a CDI professional’s career.   

 

Tammy Combs will be speaking at the Quality Management conference at Arab Health 2023. 

 

As healthcare leaders today move past the pandemic phase of COVID-19, they are faced with the daunting task of getting their quality and safety programmes back on track. They must improve quality and safety metrics while confronting financial pressures to help them turn around the financial crisis that most face today. 

The National Association for Healthcare Quality® (NAHQ) is a national leader in advancing the improvement of healthcare quality and safety. Its goal is to improve quality and safety through the single biggest lever available to healthcare leaders: the workforce. NAHQ’s extensive research has identified eight domains of quality and safety which encompass the work performed by healthcare quality professionals.  

NAHQ’s “Healthcare Quality and Safety Workforce Report, New Imperatives for Quality and Safety Mean New Imperatives for Workforce Development,” and its work with NAHQ clients via its new Workforce Accelerator® program shows that, with limited exception, the healthcare workforce is focused too narrowly on three domains of quality, at the expense of the others. This is particularly troubling because high performance in all eight domains is the key to leveraging healthcare goals of today and tomorrow.  

 

Leaders aiming to get their quality programmes on track should not plan to go back to the programmes of the past. Instead, the Healthcare Quality and Safety Workforce Report confirms that work at the advanced level being performed in quality and safety is focused predominantly on three quality domains: regulatory and accreditation, patient safety, and quality leadership and integration. The analysis also shows that there is insufficient focus on the remaining five quality domains of population health and care transitions, performance and process improvement, health data analytics, professional engagement, and quality review and accountability.  

Improving the quality and safety of healthcare in today’s complex environment requires an action orientation as well as a broader perspective of the knowledge, skills and abilities required to make improvement happen.  

Many people working in quality and safety come to this work as a second profession and/or with little formal training in quality and safety. Leaders assigning other leaders and staff to these roles have lacked a way to clearly articulate the work that needs to be done to achieve bold quality and safety goals. It is one thing to set quality goals, and it is another for organizations to prepare individuals and teams to achieve these goals.  

Stephanie Mercado, Chief Executive Officer of NAHQ

The next-level goals in healthcare require individuals to think differently about quality and how to achieve it. Mental models and organisational constructs built from historical reference points will not suffice in the future. 

A new day requires a new way to think about quality and safety and workforce readiness. To achieve next-level goals, healthcare organisation decision-makers and industry leaders should address the following: 

-  Expand and act upon quality in the broadest context, incorporating all eight domains of quality and safety included in NAHQ’s Healthcare Quality Competency Framework. Do not isolate quality functions by department or into clinical and non-clinical silos. Understand that shortcomings in one domain of the competency framework will lead to shortcomings in others.  

- Develop a proactive, clear staffing plan that articulates who is responsible for which quality and safety work at what level. Coordinate that work within and across your organisation and the continuum of care.  

- Create a workforce development programme that supports the competency and skill development of your quality staff. Engage in their continued professional development and fund it.  

- Regulatory, accreditation, and rating organisations should add new structural standards for supporting the quality and safety workforce to guarantee support systems are in place to achieve and sustain quality goals. They should support efforts to make sure relevant agencies and organisations fund needed workforce development and reward healthcare organisations that commit to intentional staffing structures, training, and certifications for quality and safety. 

-Individuals working in quality should take responsibility for advancing the domain of professional engagement and build competencies in areas most relevant to achieving career and employer goals. 

 

Stephanie Mercado, CAE, CPHQ is the Chief Executive Officer of NAHQ, and will be speaking at the Quality Management conference at Arab Health 2023. 

Stroke is the leading cause of long-term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimise the impact of acute ischemic stroke.  

The incidence and prevalence of stroke in the Middle East (ME) have increased drastically in the last decade exceeding that of developed countries. A systematic review has found that the incidence rate of stroke in Middle Eastern countries is 22.7 to 250 out of 100,000 population per year between 2000 and 2014. 

RAK Hospital recently carried out a retrospective review of the data from 70 consecutive patient records admitted between April 2014 and August 2019 with a clinically confirmed diagnosis of stroke by magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), or computed tomography (CT-scan). The mean age of the patients was 55 ± 10 years with male predominance. The frequency of strokes was high in the age group of 40 to 59 years. Around 41.18 per cent of total strokes were ischemic while 2.94 per cent of patients suffered a haemorrhagic stroke.  

Dr. Sweta Adatia, Specialist Neurologist and Medical Director at RAK Hospital, UAE

Hypertension (28.3 per cent), smoking (25 per cent), and diabetes mellitus (17.5 per cent) were common risk factors associated with stroke. RAK Hospital currently has a stroke code in place that helps all people be aware of the urgency in assessing patients with acute ischemic or haemorrhagic stroke.  

Simple tools, such as NIHSS scoring, assists in the evaluation of the stroke and it is necessary to provide training to the junior doctors that assess the emergency for such scores. It is also important to monitor the progress by checking the modified Rankin scales. It is prudent to have availability of round-the-clock CT scanners or MRI if one is having a stroke programme. Equally necessary is the training of the physiotherapy staff for effective rehabilitation following the stroke, which should begin while the patient is at the hospital. 

Reperfusion therapy is the Holy Grail in treatment of the ischemic strokes, however, ‘time is brain’. The choice of the right imaging procedures is crucial for taking the decision. The time to administration of the thrombolytic and the availability of the mechanical thrombectomy decides the outcomes in acute stroke patients.  

The immediate goal of reperfusion therapy for acute ischemic stroke is to restore blood flow to the regions of the brain that are ischemic but not yet infarcted. The long-term goal is to improve outcomes by reducing stroke-related disability and mortality.  

‘Time is Brain’ reminds us that stroke is an emergency. However, the tissue window has taught us that the treatment time window still exists in late presenters. We should not give up easily and do our best in identifying the penumbra. While the time window is based on the witnessed time of a stroke event that takes place, the tissue window is the biological timing of evolving ischemia.  

Brain ischemia is a dynamic process. Each patient may tolerate the ischemia differently because of the difference in cerebral reserve, collateral circulation, size and time of an infarction. With the advent of new CT and MRI technology, we are now capable of accurately assessing such processes. 

Advanced imaging can play a crucial role in identifying patients that could benefit from endovascular intervention presenting within extended treatment time windows. A patient presenting within six hours of stroke symptom onset typically should be evaluated with non-contrast CT and CT angiogram (CTA), which could be sufficient for patient selection for thrombectomy as shown in a multicenter randomised clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands (MRCLEAN) 

Newer trials such as DWI or CTP assessment with a clinical mismatch in the triage of wake-up and late presenting strokes undergoing neurointervention with Trevo (DAWN) and endovascular therapy, following imaging evaluation for ischemic stroke 3 (DEFUSE 3), extended this time window even further. This demonstrates the benefit of endovascular thrombectomy for patients up to 24 hours following symptom onset. The imaging can identify patients with large diffusion/perfusion mismatches in whom treatment beyond the conventional six-hour treatment window can also benefit. 

The salvage ability of brain tissue largely depends on the degree of collateral perfusion of the ischemic territory. Individual patient variability in diffusion/perfusion mismatch volume on advanced imaging will direct subsequent treatment. Given this new data, the clinician and radiologist should be prepared to screen and administer thrombolytic or endovascular therapy within 24 hours of stroke onset. Time is a surrogate for stroke viability. For the high-risk group presenting from six hours to 24 hours after onset, however, accurate determination of core and viable tissue is critical.  

Recently, two published clinical trials used MRI mismatch rather than CT perfusion mismatch to guide the use of IV tPA up to patients with AIS between six and 12 hours of onset, and the outcome was positive. Both MRI-guided thrombolysis for stroke with unknown time of onset (WAKE-UP) and IV alteplase in MR-selected patients with stroke of unknown onset (MR WITNESS) trials used MRI diffusion-weighted image/fluid-attenuated inversion recovery (DWI/FLAIR) to look for the mismatch rather than a perfusion scan. 

While multiple parameters need to be considered when deciding when a patient should receive reperfusion treatment, the most important factors include the time window between symptom onset and the presentation and imaging-based assessment of perfusion collateral flow. If the patient has a proximal vessel occlusion on CTA, no intracranial haemorrhage and an Alberta stroke programme early CT score (ASPECT) score of >6, he or she may benefit from intra-arterial (IA) therapy. If available, CTP and MRI can be useful. Magnetic resonance imaging is the most sensitive and specific imaging modality for determination of infarct core and viable penumbral tissue.  

In the near future, artificial intelligence may help assess the presence of a penumbra faster and with more precision. Already many such automated software cloud-based programs are available, which assist the physician in making an informed decision.  

 

References available on request. 

 

Dr. Sweta Adatia, MBBS, MD, DNB, FACP, MBA, is a Specialist Neurologist and Medical Director at RAK Hospital, UAE. She is speaking at the Internal Medicine conference at Arab Health 2023. 

Prehospital anaesthesia is fundamentally different from planned anaesthesia in the operating theatre. In the prehospital setting such as the air ambulance, it becomes an emergency and an unplanned procedure, as the patient's medical history is often unknown, and it is assumed that the patient is not fasting. Acute hypoxia or hypovolemia is common in this patient clientele and requires special care in the choice of anaesthesia.  

The spatial conditions in the patient's home environment, in public spaces, as well as in the ambulance, helicopter, or air ambulance are problematic and incomparable to those in the operating theatre. This poses a challenge to the attending physician, as well as the supporting staff, who are trained inconsistently, depending on the country. For this reason, comprehensive exercise of the team with simulator-based training is essential.  

In order to perform prehospital anaesthesia safely, the colleagues involved need not only sound knowledge of the physiology and pathophysiology of emergency anaesthesia, but also of team leadership, decision-making and other factors of communication, the so-called "soft skills".  

Jörn Adler is the Medical Supervisor at Luxemborg Air Rescue in Luxembourg

To discuss all these aspects, the author of this article has searched the international literature and compiled the results. Various aspects of the Canadian, English and German guidelines for prehospital anaesthesia are discussed as examples:  

Aspect Crew Resource Management 

The above-mentioned peculiarities, such as time pressure, difficult general conditions, non-fasting and unstable patients are factors that lead us to expect an increased rate of difficult intubations. Therefore, it seems more important to create standard conditions, if possible, and to establish a standardised procedure. An airway algorithm and checklists can help to increase safety here.  

First team time-out or the “10 for 10” 

This refers to a "10-second break to plan the next 10 minutes”. Once the indication for induction of anaesthesia and intubation has been established, it must now be communicated within the team — why anaesthesia is necessary, where it will be performed, how will it prepared, and what tasks will be assigned to the team members. The preparation time should be used for preoxygenation.  

Goal: Optimisation of the framework conditions  

Despite the time pressure during emergency intubation, standard conditions should be established whenever possible. Conditions are always better in a well-lit ambulance than on the street or in the patient's bathroom, for example. 

In any case, minimum requirements should be warranted, The suction unit should be easily accessible and its functionality checked; a safe, or better two well-running venous accesses should be established, standard monitoring with SpO2, ECG, non-invasive blood pressure measurement and capnometry should be available and ventilation with increased FiO2 should be possible.  

The patient should be positioned optimally in an improved Jackson position. If injuries to the cervical spine are suspected, manipulations of the cervical spine should be avoided or minimised. Under manual inline fixation, these patients can be gently intubated with the aid of the hyper angulated blade of the video laryngoscope. In obese patients, it may be helpful to elevate the entire upper body (ramped position). 

Preoxygenation  

The best possible preoxygenation of the patient also increases the window of opportunity for action in the rescue service, should the airway unexpectedly appear difficult. The aim of preoxygenation is denitrogenating, i.e., replacing the nitrogen component of the functional residual capacity (FRC) with oxygen to create an intrapulmonary oxygen reservoir.  

Medication for induction of anaesthesia 

A potent fast-acting analgesic, a suitable hypnotic and a fast-acting muscle relaxant are needed for the induction of anaesthesia. An essential prerequisite for low-risk intubation is ensuring sufficient depth of anaesthesia. Insufficient depth of anaesthesia is the most common cause of difficult intubation and significantly increases the risk of vomiting and aspiration.  

For certain patients, too shallow anaesthesia is also dangerous for other reasons. For example, all patients at risk of increased intracranial pressure such as traumatic brain injury (SHT) or intracranial haemorrhage (ICB) may develop coughing, pushing and other defensive reactions during intubation, which can have a devastating effect. It is often forgotten that the unconscious patient does not necessarily imply the absence of reflex. Deep anaesthesia is needed for these cases.  
 
On the other hand, deep anaesthesia is associated with a high risk of further haemodynamic deterioration, especially in the presence of cardiocirculatory instability and hypovolemia. 

Clear recommendations for certain substances or even fixed dosages are not possible due to the interindividual differences of the patients.  

The German guideline "Preclinical emergency anaesthesia" (14) suggests various protocols for typical preclinical situations as: 

- Isolated traumatic brain injury, stroke and intracranial haemorrhage 

- Hypertensive pulmonary edema, hypoxia and NIV failure 

- Cardiogenic shock, hypotension and hypoxia 

- Respiratory insufficiency 

- Trauma: hypovolemia 

Second team time-out  

Pre Rapid Sequence Induction check involves the following — are all preparations completed? Who injects the drugs? Who hands over the materials for intubation? How will the procedure be communicated? Who will cater to questions from the team?  

Implementation of the RSI  

After completing the monitoring and securing two venous accesses, if possible, the completeness of the required material should be checked. This includes an operational video laryngoscope with Macintosh and hyper-angulated blades, an endotracheal tube with a guide, stylet and/or bougie, material for fixation of the tube, a running suction pump, a resuscitation bag with mask, capnography, and a stethoscope.  

The planned fallback levels for the difficult airway must be ready: Laryngeal mask / laryngeal tube (Plan B) and the coniotomy set (Plan C). After the rapid injection of the analgesic, the hypnotic (in reverse order only in the case of ketamine) and the muscle relaxant, intermediate should be suspended in adult RSI. However, if the SpO2 is poor or cannot be measured, the patient must be ventilated carefully until the drugs take effect.  

Capnography is indispensable and required in 100 per cent of all emergency anaesthesia. Specially under difficult conditions, the immediate detection of a false intubation by means of capnometry is lifesaving for the patient.  

Managing difficult airways 

The difficult airway is not the subject of this lecture but should be briefly addressed since the induction of anaesthesia and airway management belong together. Difficult airway describes a situation in which endotracheal intubation does not succeed without problems.  

The various guidelines differ in their approach — but in summary, the principles are similar. In any case, there should be a fallback level. It is also highly emphasised that securing the airway by means of an endotracheal tube is not paramount in all cases, but much rather the oxygenation of the patient. Here is a synthesis of different guidelines:  

The German guideline emergency anaesthesia recommends using the video laryngoscope if available. The non-experienced user (less than 100 intubations under the supervision of a specialist and after that min. 10 intubations per year) should primarily use a video laryngoscope with a Macintosh-like blade. The experienced user should use a hyper-angulated blade.  

If intubation is not successful, the first step is to ensure oxygenation. A step-by-step approach is recommended.  

Step 1: Mask ventilation, ideally using a double C-grip or double manual bale handle.  

Step 2: A second intubation attempt may be useful if conditions can be optimised. This may mean deepening the anaesthesia, optimising positioning, improving relaxation or using a different blade or blade size. It may also include an external laryngeal manoeuvre such as the BURP (Backward-Upward-Rightward-Pressure) manoeuvre. It should be noted that repeated intubation attempts without optimisation of the situation by the same person are not useful and endanger the patient.  

Step 3: If intubation is still not successful, the procedure must be changed. The next stage of relapse is supraglottic airway devices such as the laryngeal mask (LM) or the laryngeal tube (LT). Only LM and LT of the second generation should be used.  

Step 4: If this is unsuccessful or if the patient cannot be intubated or ventilated in the "Cannot Ventilate, Cannot Intubate” (CVCI) situation, surgical access to the airway is  
unavoidable as the last option. In an emergency, access is as a coniotomy via the opening of the cricothyroid ligament.  
 

References available on request. 

Jörn Adler is the Medical Supervisor at Luxemborg Air Rescue in Luxembourg. He will be speaking at the Anaesthesia & Pain Management conference at Arab Health 2023.