2022.10.26 EQRS Program Working Group Meeting

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Discussion of the Peritonitis Module

PDAP Event Denominator Form_FINAL.pdf

Demographics section:

• "Date of the Event" and "Date of first use of the PD catheter" will help to round out the information on the Peritoneal catheter
• "Date of PD training completed?"
  • Geraldine asked: What if the patient doesn't actually complete training?
  • Would you just put the last date they had training?
  • There are times the patient does PD, and the catheter doesn't work, and the patient says to forget; they do not complete the PD training and never transition to home
  • This question is only for patients doing Peritoneal Dialysis
  • If a patient is in training and develops an infection, yes, we want to capture that 
  • If the patient didn't complete training and the catheter isn't working and the catheter's removed and they're doing in center training, this question would not apply
  • This information needs to be submitted for Peritoneal Dialysis patients even if going through training
  • If a Peritonitis Dialysis patient is still doing training and hasn't started dialysis at home, data needs to be submitted for the patient
  • We want to capture all instances of Peritonitis, if they're developing it while going through training, it is a concern, and this information needs to be captured
  • DCI gets patients that come to them prior to ever going on dialysis and they flush their catheters once the surgeon puts them in; then they find that the catheter or patient has Peritonitis from the surgical procedure. Since the patient is not theirs (DCI) and has not started on dialysis DCI does not need to report that Peritonitis, correct?
    • Per Lisa, that is correct
• Per Abigail - Would the group recommend adding an element to distinguish patients who are in training vs. those who are fully trained? Per Lisa - Yes, we will distinguish between who's in training and who's moved on to dialysis

Risk Factors section:

• How many days during reporting month was PD catheter in use?
  • What is the definition of "use"?
    
    • Definition is not if it is being flushed
    • It is only if it's being used
    • Per Lisa, the definitions can be provided before this is released live in the system at a level that is needed for better clarification
  • Request to have assistance on the definitions of the context (elements) used throughout the form
• In order to execute all these data elements; the front end will have to be changed
• Per Michelle Cassin (DaVita) - wanted to make it clear, this is intended for surveillance, which means anytime the patient has an active PD catheter and is under the care of a provide.  They are at risk for Peritonitis whether they are actively dialyzing or not.  They are at risk whether it's flushing under the provider, training or not training
• The question "How many days during reporting month was PD catheter in use?" puts the impression those are the days at risk
• We are trying to create a rate that's intended for surveillance. It shouldn't matter if the patient has a catheter, whether they are training, not training, using it or not, they are at risk for an infection.  We should be counting those days at risk, right?
  
  • Lisa will take this back for clarification
• Question from Geraldine - What happens if the Peritonitis actually happened outside of our ability? For example, a patient went into the hospital; they were a PD patient and while in the hospital they developed Peritonitis then going back to DCI with Peritonitis.  Will the hospital report the Peritonitis, or will DCI report the Peritonitis?
• Is there going to be a question were the episode happened?
• Will the Peritonitis be counted against the clinic or going to be recorded as a hospitalization?
• Vlad suggested to add the question: "Hospital Acquired?"
• Per Vlad - Patients are reporting to DCI the days that they're using the Peritoneal catheter and then DCI is billing from that. They do not bill if temporarily suspended
• Per Lisa - we want to differentiate between the days that the catheter is used and the days that it's been inserted
• Vlad recommends removing "Date suspended" and "Date restarted" because you can have multiple restarts and stops; also, is it really important to know? It's better to capture how many times it was suspended and for how many days each time 
• Per Dr. Dinesh Chatoth - highly recommends to clearly define the questions and content.  What is meant by suspended or paused, etc.
• PD Methods - Continuous Ambulatory Peritoneal Dialysis and Continuous Cycler-Assisted Peritoneal Dialysis
  • The EDIs already report the modality in EQRS the patient is on.  Why do they have to re-report what they were using at the time?
    • Per Lisa - that question can be taken out and rely on the system to provide it
• "Did contamination occur during the reporting month?"
  • Need to define/clarify what is meant by "contamination"
  • What happens if you contaminate it once then in a few days you contaminate it again?
  • Need to define the time and organism.  Could have a different organism each time
  • Lisa will take this question back and discuss how to better define this question
• "Who performs the PD treatment?"
  • If "other" is selected, what value should be entered here?
  • The user may enter a value such as a category that is not captured in the first 3 categories/check boxes
  • Per Vlad - this is information that DCI does not collect right now, and will have to start collecting on all patients all the time
• Mahesh expressed a concern that this form is comprehensive and has multiples of data elements.  Is there a minimal set of data elements? This will be a heavy lift in terms of field and paperwork burden; they will also need to reconfigure EMRS to include all this stuff
  • Per Lisa - this is a joint effort with the CDC in capturing what the Program/EQRS needs and the information the CDC needs
  • This concern can be further discussed with the CDC to see if some of the questions can be removed from the form
  • Abigail (CDC rep) welcomes recommendations on how the EDIs think certain elements should be defined/operationalized or further refined
  • Abigail would like feedback from this group on what they recommend a minimal set of data elements include
  • The CDC welcomes your input on both a minimal data set and how you would recommend defining those data elements to ensure data captured are meaningful and high quality
  • Manesh/Nathan will work with the other EDIs to come up with a list of items on the form they do not collect now that may be burdensome
• Geraldine pointed out there is no question on the form about assist devices (for example UV Flash or the CDX).  DCI does record in their database if a patient is using an assist device or not
  • Michelle Cassin feels both the assist device and the vendor or machine type are important to capture
  • Lisa suggested a generic question such as whether an assist device was used or not
•  "Was the patient hospitalized in the month prior to the episode?"
  • Per Vlad, DCI already captures this information in EQRS and no need to collect again on this form
• Suggested not to ask every patient about procedures every time they visit a clinic unless the patient had an event
• "Any invasive procedures in the prior month?"
  • Per Vlad - this does not belong in the Risk Factor section of the form
  • Is it necessary to ask all of these detailed procedures/medical questions?
  • Are the EDIs crossing any concerns with privacy with some of the questions being asked?
    • Per Abigail - as long as the data is being shared with CDC for public health activities, the HIPAA exemption would still apply. But we will clarify
    • There are no HIPAA limitations on sharing data with the CDC.  HIPAA has an allowance for sharing personal health information with public health authorities 
    • There is no need to request permission from the patient to share data with NHSN b/c it's a covered permission for sharing data under HIPAA 
    • Also, if anyone signed a 2728 there is disclaimer at the bottom about sharing information

    • https://www.cdc.gov/nhsn/hipaa/index.html

    • https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-public-health-activities/index.html

  • If a patient comes back to DCI in support of transplant many times the PD catheter is not removed, and the patient will resume PD until the kidney kicks in.  Because the patient is considered part of the transplant team and DCI is just assisting them, these patients will not be included, correct?
    • Talking about patients that have had their transplant and are now home; they are medically stable, but their kidney is still "sleeping".  They don't remove the PD catheter; they send them back to the dialysis center and so they are considered a transient until their sleeping kidney works. What is the patient gets Peritonitis?  Would the patient be counted as part of this group or is the patient considered to be Peritonitis from the transplant team?
      • Per Lisa - they will have to go back and discuss this scenario
  • AKI patients are not captured in EQRS
• "Was a prophylactic antibiotic administered prior to invasive procedure?" 
  • Dr Dinesh Chatoth mentioned they struggle to get reliable information on all of these so-called invasive procedures sometime (for example: a dental procedure is don't in a dentist's office, and clinics are not always notified)
  • Need to clearly define what is meant by "invasive"
  • Adding "Unknown" as an option may be helpful
• "Within the reporting month: Exit site infection? Tunnel infection?"
  • Vlad suggests this needs to be designed as an infection module
  • They do report infections in EQRS today, but it does not provide much information

Event Details:

• What is meant by "Event"?
  • Per Vlad does it mean Peritonitis or every time I suspected Peritonitis or did a effluent culture or is abdominal pain?
  • For the Program/EQRS it means anytime there was suspected Peritonitis
  • Lisa will take back to the CDC to discuss further for clarification

Laboratory & Diagnostic Testing:

• • Per Adrienne and Dr. Dinesh Chatoth - FKC does not collect "Imaging tests suggestive of intraabdominal process" - they don't always collect that information consistently

Signs and Symptoms:

• • Per Adrienne - FKC does not collect consistently "other evidence of intraabdominal process"
  • What is meant by "Physician documentation of evidence of peritonitis"?
    • Lisa will take this question back and discuss further

Antimicrobial Treatment:

• • Per Vlad - there could be several antibiotics
  • There should be multiple lines to document the antibiotics
  • Recommendation to also add anti-fungal prophylaxis
  • Ask whatever antimicrobial they use, what is the route?
  • Maybe able to use dropdowns in the system for treatments and route

Per Lisa - EQRS is in their PI, so they are getting ready to go into development with this form

• We do need to know what would be the minimum data set for the participants on the call
• Nathan will organize for the EDIs to get together a list of minimal data set and what they currently track
• Nathan will send something out this week to the EDIs and it will depend on how fast they respond in order to send the list to Lisa
• Lisa/EQRS will work on putting together documentation on clearly defining the elements

Next meeting scheduled for 02 Nov 2022