Self-Administered Training Pack

Critical Care Minimum Data Set (CCMDS)

Self-Administered

Training Pack

The Collection of the Critical Care HRG Subset has been approved by the Review of Central Returns Steering Committee - ROCR. The ROCR reference number is:

ROCR/OR/0163.

Prepared by Stuart Gordon (Performance Management Consultant) and Mandy Chequers (Critical Care Audit & Project Lead Nurse)

Issue 1: November 2005 (Pre-release check by John Morris September 2005)


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Introduction The aim of this Training Pack is to ensure that you collect and input critical care data accurately, regularly and consistently, using the required standardised format. By the time you have worked through the Training Pack you will:

1. Understand the nature of the CCMDS, the reasons for data collection, and

which data fields are mandatory and optional. 2. Be familiar with different types of data, and where they are sourced. 3. Be familiar with the coding system. 4. Know how to code raw data accurately, and how to enter the data into the

relevant field. 5. Know who is responsible locally for collecting and inputting the data set, and

identify the most appropriate times to input the data.

The five learning outcomes listed above each have a section in the Training Pack, which includes 14 practical exercises to help you deal with data collection more efficiently and effectively. The initial exercises are to help you familiarise yourself with the whole data set; the remaining exercises deal with mandatory data fields only. Further information on mandatory and optional data fields is provided in Section 1 overleaf. You should write the answers to each exercise directly on the pages of the Training Pack. You can check your answers using the accompanying Answer Book, which also contains guidance notes to help you with some of the exercises. If you are completely new to data collection and have no clinical training, then you should work though the whole Training Pack from start to finish. It will be useful to have an experienced member of staff available to answer any queries and to help with those exercises that need to be completed with a colleague. If you have previous experience of data collection, then there is no need to complete every exercise. Use the Training Pack as a refresher tool, skipping over any material with which you are already familiar, and concentrating on the areas you do not recognise.

Self-Administered Training Pack

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1. The nature of the CCMDS; reasons for data collection; mandatory and optional data fields

What is a data set? A data set is a collection of information, grouped and classified in particular ways. The information contained within a data set gives an overall picture of a particular event – in this case, what happens to a patient when s/he is admitted to a Critical Care Unit, or receives critical care in a temporary area. Why is this data set being introduced? The CCMDS replaces a previous data set called the Augmented Care Period (ACP). The main reason for introducing the new data set is a change in the way critical care is funded. The introduction of a Payment by Results (PbR) system means that the ACP no longer contains the appropriate range of information to accurately identify the resource consumption of different critical care episodes. Hence the CCMDS contains more detailed information about the level of support required and the range of organs supported. The information that is collected is grouped in blocks of data called Healthcare Resource Groups (HRGs), which can then be used to direct the correct levels of funding towards different areas of patient care. The aim of the new system is to use accurate data collection to ensure that funding is allocated appropriately. What kinds of data are required for the CCMDS? The CCMDS contains 34 fields, which are listed in Table 1 (see overleaf). The main groups of data collected are:

• demographic data to identify the patient and hospital; • admission data about the patient’s length of stay; • data about the type and level of organ support required.

Some parts of the CCMDS are mandatory and must be collected by all Critical Care Units; others are optional. The 14 mandatory fields are those that support HRG/PbR, and are shaded in grey in the table. Each local Unit will decide which of the optional data fields will be collected, and then extract the 14 mandatory items for official returns. Note that the professional bodies represented on the Critical Care Information Advisory Group (CCIAG) strongly recommend that the full data set be collected as a national minimum standard. Exercises 1-4 in this Training Pack deal with all 34 data fields in order to familiarise you with the whole data set. The remainder of the exercises deal only with the mandatory items, to give you practice in recording the data required for official NHS data systems.


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Table 1: Summary of the Critical Care Minimum Data Set (CCMDS)

(mandatory items are shaded)

Item no. Name of data field Brief description 1 NHS number Unique identifier for transferable patient records and

other NHS data sets. 2 Local patient

identifier Unique identifier for other patient data held within a hospital.

3 Site code Unique identifier for hospital to allow network and commissioning analyses.

4 Code of GP practice Registered GP from patient medical record system. 5 Treatment function

code The treatment function of the consultant with primary responsibility for the patient.

6 Date of birth To provide age and an additional patient identifier. 7 Postcode Postcode of patient’s home address. 8 Critical care local

identifier Identifier for local critical care database systems to permit relational queries.

9 Critical care start date

Date that a patient first occupies a critical care bed.

10 Critical care start time

Time that a patient first occupies a critical care bed.

11 Critical care unit function

Type of critical care area to which the patient was admitted.

12 Unit bed configuration

The composition of bed types for your unit.

13 Critical care admission source

Primary admission source, e.g. same NHS hospital site; other NHS hospital site; independent hospital; non-hospital source.

14 Critical care source location

Location within the primary admission source, e.g. theatre & recovery; ward; accident & emergency; home or other residence.

15 Critical care admission type

Type of admission e.g. planned or unplanned surgical admission, medical admission or transfer.

16 Advanced respiratory support days

No. of days the patient received advanced respiratory support.

17 Basic respiratory support days

No. of days the patient received basic respiratory support.

18 Advanced cardiovascular support days

No. of days the patient received advanced cardiovascular support.

19 Basic cardiovascular support days

No. of days the patient received basic cardiovascular support.

20 Renal days No. of days patient received renal support. 21 Neurological system

support days No. of days patient received neurological system support.


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Table 1 (cont.): Critical Care Minimum Data Set

(mandatory items are shaded)

Item no. Name of data field Brief description 22 Gastro-intestinal

system support days

No. of days patient received gastro-intestinal support.

23 Dermatological system support days

No. of days patient received dermatological support.

24 Liver support days No. of days patient received liver support. 25 Organ support

maximum Maximum no. of organ systems supported at any one time during the critical care period.

26 Critical care Level 2 days

Total no. of calendar days during which Level 2 care was provided during the critical care period.



28 Critical care discharge status

Reason the patient being discharged.

29 Critical care discharge destination

Primary discharge destination, e.g. same NHS hospital site; other NHS hospital site; independent hospital; non-hospital source.

30 Critical care discharge location

Location within the primary discharge destination, e.g. ward; adult critical care bed, paediatric critical care area; home or other residence.

31 Critical care discharge ready date

The date on which the patient is ready for discharge.

32 Critical care discharge ready time

The time at which the patient is ready for discharge.

33 Critical care discharge date

Actual date patient is discharged.

34 Critical care discharge time

Actual time patient is discharged.


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Exercise 1: uses of the data set The main reason for introducing the data set is described on page 3. In this exercise, you are asked to examine the use of the data to particular groups within the hospital and the wider health community. Think of as many uses as you can and write them under each of the headings below. Then compare your answers with those given in the Answer Book. What are the uses of the data to: Patients? Critical Care Staff? Hospital Managers? NHS Managers and the NHS Executive? The Government?


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Exercise 2: reasons for collecting the data The CCMDS summary gives a brief description of each data field but not a reason why the data are collected. In this exercise, you will try to identify reasons why each data field is collected, picking out the reasons from a prepared list. Example As an example, here is a list of the first seven data fields (which contain demographic information not unique to CCMDS):

Item no. Name of data field 1 NHS number 2 Local patient identifier 3 Site code of treatment 4 Code of GP practice 5 Treatment function code 6 Date of birth 7 Postcode of usual address

Table 2: Demographic Data Fields

And here are some possible reasons for collecting that data: 1. Identifies the date or time a patient first occupies a critical care bed. 2. Identifies patient data held within a critical care unit. 3. Identifies the function of the consultant with primary responsibility for the patient. 4. Useful as an additional way of identifying the patient. 5. Identifies the patient if admitted to different hospitals. 6. Identifies patient data held within a single hospital. 7. Helps to show the severity of the illness. 8. Provides the age of the patient. 9. Identifies a patient’s GP. 10. Allows the hospital to be identified if there is more than one hospital with critical

care facilities in the NHS Trust. 11. Allows geographical analysis If we try to match the reasons listed above with the corresponding data fields, we arrive at the table below, where the right hand column contains the numbers representing the reasons why that data field is collected. Note that each reason can be used once, more than once, or not at all.

Item no. Name of data field Reasons for collection 1 NHS number 5 2 Local patient identifier 6, 4 3 Site code of treatment 5,10 4 Code of GP practice 9 5 Treatment function code 3 6 Date of birth 8,4 7 Postcode of usual address 11

Table 3: Reasons for collecting demographic data


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Exercise 2a: Mandatory data Fourteen of the data fields are classed as ‘mandatory’, which means their collection is compulsory because the information they contain is essential to knowing the resource consumption of each critical care episode. The mandatory fields are unique to CCMDS, and are not collected as part of any other data set. In addition to the general reason given above, each data field has a more specific reason for its collection. Below is a list of possible reasons for collecting the mandatory data. Try to match each data field with the corresponding reason(s), and then write the relevant numbers in the right hand column (like the example on the previous page). Each reason can be used once, more than once, or not at all. 1. Used to examine the workload of different critical care areas into which patients

are admitted. 2. Identifies the total length of time a patient spends in the critical care unit. 3. Shows type of organ that required support on a particular day. 4. Useful in analysing workloads and managing equipment. 5. Identifies the length of time a patient requires detailed observation or intervention. 6. Indicates when a patient first occupied a critical care bed. 7. Indicates the level of organ support that is necessary on a particular day. 8. Helps to show the severity of the illness. 9. Helps to determine resource consumption. 10. Identifies the length of time a patient requires support for multi-organ failure. 11. Helps cross reference data and place in order same day admissions

Mandatory Data Fields Item no. Name of data field Reasons for collection

8 Critical care local identifier 9 Critical care start date 11 Critical care unit function 16 Advanced respiratory support days 17 Basic respiratory support days 18 Advanced cardiovascular support

days

19 Basic cardiovascular support days 20 Renal days 21 Neurological system support days 23 Dermatological system support days 24 Liver support days 26 Critical care Level 2 days* 27 Critical care Level 3 days* 33 Critical care discharge date

Table 4: Reasons for collecting mandatory data


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*See p.7-8 of the Answer Book for definitions of Level 2 and Level 3 days.


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Exercise 2b: Optional data The collection of remaining data in the CCMDS is optional, and will be decided locally within each Critical Care Unit (although as previously mentioned on page 3, the CCIAG strongly recommend that the full data set be collected as a national minimum standard). For those units committed to collecting ICNARC data (Intensive Care National Audit and Research Centre), this should be made easier because ICNARC data set version 3 will include access to all the CCMDS items. For the next exercise, simply tick the data fields in the right hand column that will be collected in your Unit. You will need to do this exercise with a colleague. If the data fields that are to be collected have already been agreed, then speak to someone who already inputs the data to ensure you tick the correct fields. Also find out why it was decided to collect some data but not others – what is its significance? If the optional data fields have not yet been agreed in your Unit, find out when agreement is likely to be reached and make sure you are told what has been decided. If appropriate, you may be involved in these discussions yourself.

Table 5: Optional data fields

Optional Data Fields

Item no.

Name of data

field

Brief description

Tick if collected in

your unit 10 Critical care start

time Time that a patient first occupies a critical care bed.

12 Unit bed configuration

The composition of bed types for your unit.

13 Critical care admission source

Primary admission source, e.g. same NHS hospital site; other NHS hospital site; independent hospital; non-hospital source.

14 Critical care source location

Location within the primary admission source, e.g. theatre & recovery; ward; accident & emergency; home or other residence.

15 Critical care admission type

Type of admission e.g. planned or unplanned surgical admission, medical admission or transfer.

22 Gastro-intestinal system support days

No. of days patient received gastro-intestinal support.

25 Organ support maximum

Maximum no. of organ systems supported at any one time during the critical care period.

28 Critical care discharge status

Reason the patient being discharged.

29 Critical care discharge destination

Primary discharge destination, e.g. same NHS hospital site; other NHS hospital site; independent hospital; non-hospital source.

30 Critical care discharge location

Location within the primary discharge destination, e.g. ward; adult critical care bed, paediatric critical care area; home or other residence.

31 Critical care discharge ready date

The date on which the patient is ready for discharge.

32 Critical care discharge ready time

The time at which the patient is ready for discharge.

34 Critical care discharge time

Actual time patient is discharged.


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2. Different types of data and where they are sourced

This section will focus on the mandatory data fields, plus the demographic data fields (item nos. 1-7) which are not unique to the CCMDS, but will be needed to identify the patient, hospital, critical care unit, and type of treatment being provided. These are listed in Table 6.

Table 6: Mandatory data fields (shaded) and demographic data

Item no. Name of data field Brief description 1 NHS number Unique identifier for transferable patient records and

other NHS data sets. 2 Local patient

identifier Unique identifier for other patient data held within a hospital.


4 Code of GP practice Registered GP from patient medical record system. 5 Treatment function

code The treatment function of the consultant with primary responsibility for the patient.

6 Date of birth To provide age and an additional patient identifier. 7 Postcode Postcode of patient’s home address. 8 Critical care local

identifier Identifier for local critical care database systems to permit relational queries.













20 Renal days No. of days patient received renal support. 21 Neurological system

support days No. of days patient received neurological system support.



24 Liver support days No. of days patient received liver support. 26 Critical care Level 2

days Total no. of calendar days during which Level 2 care was provided during the critical care period.






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By looking at the table, it can be seen that different categories of data are used in the data set, for example:

• identification data (e.g. NHS number, site code, date of birth) • data that identifies time and place (e.g. date of admission, time spent in a

critical care bed, date of discharge) • data that indicates the level of support required (e.g. which organ systems

were supported and for how long) In the following exercise, you will learn about the three main sources of the above groups of data, which are

• the Patient Administration System (PAS) • clinical records (paper and electronic) • hospital or critical care staff

Exercise 3: Data sources In order to complete this exercise, you will need to work with a colleague who has experience of inputting data or has knowledge of the data sources. In Table 7, the data sources have been placed in the left hand column. With the help of your colleague, put the relevant item nos. from Table 6 into the correct box in the middle column of Table 7. Where a data field has more than one possible source, put the item no. in all the relevant boxes. Find out exactly where each of the data sources can be located within your hospital, and write your answers in the right hand column. If the data is on an electronic database, find out exactly how to navigate to the required data, and which terminal you should use. If the data are kept as paper records, find out where they are kept and how they are arranged. If the data are known by a nurse or other member of staff, find out who is the best person to supply the information you need (normally the Critical Care Senior Nurse or Consultant). 2

Name of data source Data fields that may be obtained from this source

Where is this data source located within your hospital?

Patient Administration System (PAS)

Clinical records (kept as paper notes)

Clinical records (kept electronically)

Hospital or critical care staff

Table 7: Data sources


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3. The coding system A code is a series of numbers or letters which summarise particular pieces of data. Each category of data needs to be coded in a particular way to ensure standardisation across all Critical Care Units. Some codes are very familiar to us because they are used in everyday life: for example, we are all used to writing the time ‘twenty past nine in the morning’ as 09:20 or 9.20am. In the next exercise you will look in detail at the whole CCMDS to help you become familiar with the codes that are used to record each data field. Exercise 4: Data codes: true or false? In Tables 8a and 8b below, the fourth column specifies how each data field in the CCMDS must be coded – except that some of the instructions are deliberately incorrect. Look through the full CCMDS that accompanies this Training Pack and compare each of the stated codes with those listed in Table 8a and 8b. Whenever you spot a code that has not been correctly described, write the correct description in the right hand column. Then check your answers in the Answer Book.

Table 8a: Demographic data codes – with deliberate mistakes Item no.

Demographic data fields

Brief description of data field

Code description – true or false?

If code description is incorrect, write

correct description here.

1 NHS number Unique identifier for transferable patient records and other NHS data sets.

A code consisting of both numbers and letters.

2 Local patient identifier

Unique identifier for other patient data held within a hospital.




4 Code of GP practice

Registered GP from patient medical record system.


5 Treatment function code

The treatment function of the consultant with primary responsibility for the patient.


6 Date of birth To provide age and an additional patient identifier.

Use the format DD/MM/YY

7 Postcode of usual address

To track source of patient

Post Office format


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Table 8b: Mandatory data codes – with deliberate mistakes

Item no.

Mandatory data fields





8 Critical care local identifier

Optional identifier for local critical care database systems to permit relational queries.

A code that could consist of both numbers and letters.



Use the format CCYY/MM/DD



A two digit code from 01 to 12



A three digit code from 000 to 998.










20 Renal days No. of days patient received renal support.


21 Neurological system support days

No. of days patient received neurological system support.





24 Liver support days

No. of days patient received liver support.












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4. Coding raw data and entering it into the relevant field The previous exercises have all been to familiarise you with the CCMDS and prepare you to record accurate information about critical care patients. You should now be in a position to code raw data that is given to you. ‘Raw data’ is simply information that has not yet been classified in any way, such as the information provided in the scenarios for the following exercises. Exercises 5-13 provide scenarios about nine fictitious patients. For each exercise, your task is to read the scenario and enter the correct codes in the data collection form at the bottom of the page:

• If the patient has received organ support and Level 2 or 3 care on particular day(s), place a cross (x) in the relevant columns of the answer grid.

• Write the total number of days in the correct format in the ‘Total’ column.

• To practise filling out the start date and discharge date in the correct format,

use today’s date as the discharge date and work out the start date from that. e.g. If today’s date is 25 October 2006 and the Critical Care episode lasted four days, the start date would be 2006-10-22 and the discharge date would be 2006-10-25.

• Assume in all cases that the Critical Care Unit to which the patients are

admitted is for non-specific, general adult critical care.

• Do not fill in the shaded areas. To complete these exercises, you will need to have the following information to hand for reference:

• A copy of the full CCMDS.

• The mandatory data codes listed on page 5 of the Answer Book.

• The Intensive Care Society guidance on Levels of Critical Care reproduced on pages 6-8 of the Answer Book.

• Organ support definitions from the Augmented Care Period (ACP) dataset,

reproduced on page 9 of the Answer Book. When you have completed each exercise, check your answers by looking at the completed data collection forms starting on page 10 of the Answer Book. Note: Since there are at least three different software programs in use in Critical Care Units for the collection of data, this Training Pack uses a paper data collection form. This may be adapted locally, if necessary, and then used to transfer the information into the relevant software package. Training in how to input the data into particular software will vary locally depending on the program being used.


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Exercise 5

Patient A Day 1 @ 1900hrs 65 year old woman admitted to Critical Care from ward

with increased shortness of breath due to left-sided pneumonia. On admission she is drowsy, but rousable. Respiratory rate is 38; blood gases show hypoxia and hypercapnia. Temperature 38.7°C. 60% oxygen therapy, antibiotics and physiotherapy initiated.

Day 2 @ 0015hrs Patient deteriorating, respiratory rate 40-45 with worsening blood gases. Becoming less responsive and increasingly tired. Anaesthetist decides to intubate and ventilate patient.

Day 5 @ 1000hrs Condition stable. Apyrexial. Blood gases within normal

ranges. Weaning from ventilation commenced. Day 5 @ 1830hrs Patient extubated. Oxygen therapy @ 40% via face

mask. Day 6 @ 1000hrs Blood gases within normal ranges on 24% oxygen via

face mask. Ward round - decision made to transfer patient back to the ward.

Day 6 @ 1200hrs Patient transferred back to the ward. Date 1 2 3 4 5 6 7 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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Exercise 6

Patient B Day 1 @ 0600hrs 78 year old admitted to A&E with worsening asthma.

Generalised crackles and wheezes heard on auscultation and patient has a respiratory rate of 35. Blood gases show hypoxia and hypercapnia. Pyrexial at 38.5ºC. Oxygen therapy is started at 60% and physiotherapy is commenced.

Day 2 @ 1000hrs Patient’s blood gases show some improvement.

Oxygen therapy reduced to 40%. Physiotherapy continues on a regular basis ~ 2 hourly (deep breathing, encouraging patient to cough and expectorate).

Day 3 @ 1400hrs Blood gases improving further ~ patient co-operating

well with physiotherapy. Decision made to discharge patient to a general medical ward with support from Critical Care Outreach Team if required. Discharged to ward.

Date 1 2 3 4 5 6 7 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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Exercise 7

Patient C Day 1 @ 1230hrs 70 year old male admitted from theatres on 28

November 2003 following laparotomy for small bowel obstruction. Brought to critical care due to ischaemic episode (ST depression) and difficult extubation. Patient also requiring boluses of colloid to maintain urine output > 40ml/hour. On admission to unit on 60% oxygen therapy (blood gases within normal limits). Arterial and CVP lines insitu.

Day 2 @ 0800hrs Oxygen therapy now reduced to 40%. Blood gases are

within normal limits so oxygen therapy reduced further. Still requiring occasional boluses of colloid to maintain urine output > 40ml/hour.

Day3 @ 0800hrs Urine output now satisfactory. Patient

haemodynamically stable. Discharged to surgical ward. Date 1 2 3 4 5 6 7 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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Exercise 8

Patient D Day 1 @ 1500hrs 62 year old male, admitted from A&E on 18 January

2005 following witnessed cardiac arrest in community. On admission to Critical Care patient has arterial and CVP lines insitu and is haemodynamically stable. Brought to Unit ventilated and sedated.

Day 1 @ 1730hrs Patient deteriorated, low blood pressure, pulse rate

150, placed on cardiac monitoring (Lithium dilution) and commenced on single intravenous inotropes (following treatment of sinus tachycardia).

Day 2 @ 0010hrs Patient deteriorating, further cardiac arrest. Patient

certified dead at 0105hrs. Date 1 2 3 4 5 6 7 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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Exercise 9

Patient E Day 1 @ 1300hrs 20 year old female admitted from A&E on 12 October

2001 following an RTA in which she has sustained a fractured femur and head injury. Glascow coma scale of 10 and CT shows a small parietal fracture. The patient is breathing spontaneously on 28% oxygen. Cardiovascularly stable. Head injury observation chart is commenced.

Day 1 @ 1430hrs Patients GCS falls to 8 and she becomes increasingly

unresponsive. Anaesthetists immediately sedate, intubate and ventilate the patient and arrangements are made to transfer her to the nearest specialist neurosurgical unit.



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Exercise 10

Patient F Day 1 @ 1600hrs 75 year old male admitted from medical ward. Urine

output has been diminishing over the past three days. Originally admitted to hospital with history of nausea and vomiting. Lives alone and was found by neighbour. Urea and creatinine levels have been rising. Patient drowsy but rousable. States he is feeling increasingly nauseated and tired. Hypertensive. Seen by Consultant Anaesthetist who decides to commence haemofiltration as soon as possible on patient. Started on anti-hypertensive therapy. CVP and arterial lines inserted for continual monitoring.

Day 1 @ 1800hrs Haemofiltration commenced. Haemodynamically stable,

remains drowsy. Day 4 @ 1000hrs Haemofiltration continues. Patient remains

haemodynamically stable. Urea and creatinine levels reducing. Patient awake and orientated. Eating and drinking small amounts as tolerated.

Day 6 @ 1130hrs Trial off haemofiltration as urea and creatinine levels

reducing further. Patient remains awake and orientated. Appetite virtually back to normal. Urine output improving.

Day 7 @ 1000hrs Patient’s blood results and urine output improving

further. Patient feeling much better. Discharged to medical ward.



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Exercise 11

Patient G Day 1 @ 0500hrs Young female patient admitted from A&E on 20 July

2004 with deteriorating GCS following suspected drug overdose. Airway became compromised in A&E so immediate decision made to intubate and ventilate patient prior to admission to critical care.

Day 2 @ 0600hrs Patient remains on ventilator, opening eyes spontaneously but remains drowsy and tolerating endo-tracheal tube. Haemodynamically stable.

Day 2 @ 1100hrs Patient increasingly alert and awake. Pulling at endo-

tracheal tube. Good respiratory effort made so decision made to extubate patient.

Day 2 @ 1400hrs Patient on 28% oxygen. Alert and orientated. Insisting

on being discharged. Day 2 @ 1800hrs Self-discharge home. Date 1 2 3 4 5 6 7 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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Exercise 12

Patient H Day 1 @ 2345hrs Elderly lady admitted from A&E following burns to

upper body (> 20% body surface area) sustained in house fire. Intubated, sedated and ventilated and brought to critical care for stabilisation prior to transfer to regional burns unit. CVP and arterial lines insitu on admission to critical care. Fluid resuscitation in progress.

Day 2 @ 0100hrs Patient increasingly hypotensive and bradycardic. Fluid

resuscitation increased observation of cardiac output commenced and infusion of Noradrenaline started.

Day 2 @ 0300hrs Patient transferred to burns unit. Date 1 2 3 4 5 6 7 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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Exercise 13

Patient I Day 1 @ 1450hrs 68 year old male admitted from medical ward with

shortness of breath, query left ventricular failure and query pneumonia. Respiratory function deteriorating further, initially for a trial of CPAP (continuous positive airway pressure). X-ray performed and diagnosis of pneumonia is made. CVP and arterial lines are inserted. Urinary catheter insitu from ward.

Day 1 @ 1700hrs Blood gases show further signs of deterioration, trial of

CPAP abandoned. Patient is sedated, intubated and ventilated. Antibiotic therapy is started.

Day 1 @ 1830hrs Patient becoming increasingly hypotensive and has a

raised temperature of 38.5ºC. Requiring multiple inotropes to maintain blood pressure.

Day 2 @ 0930hrs Remains on ventilator. Still requiring multiple inotropes. Day 4 @ 0800hrs Ventilation continues. Intropes weaned off. Day 7 @ 0800hrs Ventilation continues. Tracheostomy performed. Noted

that urea and creatinine levels are steadily rising. Urine output minimal. Haemofiltration initiated.

Day 8 @ 1000hrs Becoming increasingly hypotensive. Recommenced on

inotropes. Haemofiltration and ventilation continues. Haemodynamically unstable.

Day 9 @ 0800hrs Patients condition continues to deteriorate. Ventilation,

haemofiltration and inotropes continue. Haemofiltration and inotropes discontinued after discussion with family. Patient dies at 1400hrs.

Date 1 2 3 4 5 6 7 8 9 Total Page: Of: ARS Surname BRS Hosp ID ACS CC Start Date BCS CC Unit Function Renal CC Disch Date Neuro Derm Liver L2 days L3 days


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5. Responsibility for data collection, and the most appropriate times to enter the data

The person(s) responsible for collecting data and the most appropriate times for it to be inputted will vary from place to place and therefore must be decided locally. In some Units, only one person is responsible for collecting and inputting all the data, but where two or more people are involved, it is important that everyone is clear about their role. The next exercise will help you to clarify with your colleagues who does what, and when. Exercise 14 Fill out the answer column in the following table by discussing with other staff involved in data collection

Question Answer 1. Who has overall responsibility for

data collection in your CC Unit?

2. Who else is involved, other than you, either in data collection or in entering the data? Write their names opposite, including the role of each person. (Leave blank if you are the only person involved.)

3. If the data is entered by someone who is not clinically trained, who will s/he go to with any queries? (normally a Senior Nurse or Consultant)

4. When are the most appropriate times during the week to input the data to ensure the task is undertaken regularly?

5. If you are the only person involved in data collection, how will cover be arranged when you are unavailable?

Table 9: Responsibility for data collection


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Critical Care Information Advisory Group. Department of Health.

The Augmented Care Period (ACP) data set compared with the new Critical Care Minimum Dataset (CCMDS).

ACP CCMDS Purpose:

Identified critical care activity for the first time within NHS data sets. Created a data standard for analysing activity at local, regional and national level.

Purpose:

Updated ACP data items to support monitoring of activity and policy changes following Comprehensive Critical Care plus inclusion of critical care in Payment by Results.

Structure:

14 mandatory variables with numerically coded options. (13 clinical + 1 Information system code).

Structure:

Revised 14 mandatory variables to avoid increase in data collection burden plus an additional 20 recommended data standards for optional collection.

Development:

Created by an ad hoc DoH committee with piloting in six sites and approved in February 1997.

Development:

Project led by a standing committee of NHS professionals, policy and technical experts (CCIAG) commencing in April 2002. Pilot evaluation in 30 NHS Trusts. Full time project manager employed to lead work over two years.

Mandatory content:

Start date

ACP number

Local identifier

Source of patient

Number of intensive care days

Number of high dependency days

Location of care

Maximum number of organs supported

Mandatory content:

Start date

Local identifier

Level three days

Level two days

Critical care unit function

Advanced respiratory support days

Basic respiratory support days

Advanced CVS support days

Basic CVS support days

Renal support days

Neurological support days

Dermatological support days

Liver support days


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Specialty delivering care

Planned/unplanned status

Outcome

Disposal

End date

(+ IT system ACP present/not present)

End date


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Answer Book

and Guidance Notes


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Exercise 1: Answers

Patients • Enables funding to be allocated appropriately according to the support required

by particular groups of patients. • Enables patients’ GPs to see what has become of them. Critical Care Staff • Provides standardised information about each patient. • Enables critical care managers to keep track of the performance of their own unit

and make improvements where necessary. • Enables staff to see quickly and accurately patient information and care given. Hospital Managers • Shows how critical care services are being utilised and if patients are being

appropriately placed. • Shows how many patients go through critical care and how long they stayed. NHS Managers and the NHS Executive • Provides information for mangers at all levels and for the NHS Executive, so that

informed decisions may be made, particularly as regards funding. • Provides access to bed management and expenditure. • Provides standardised information that enables national comparisons to be made

between areas and between individual critical care units. • Enables senior managers to brief government ministers. The Government • Provides information about the number of critical care episodes and the financial

cost to the NHS. • Enables ministers to answer parliamentary questions.


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Exercise 2a: Answers

Mandatory Data Fields Item no. Name of data field Reasons for collection

8 Critical care local identifier 11 9 Critical care start date 6 11 Critical care unit function 1, 4 16 Advanced respiratory support days 3, 7, 8, 9 17 Basic respiratory support days 3, 7, 8, 9 18 Advanced cardiovascular support

days 3, 7, 8, 9

19 Basic cardiovascular support days 3, 7, 8, 9 20 Renal days 3, 7, 8, 9 21 Neurological system support days 3, 7, 8, 9 23 Dermatological system support days 3, 7, 8, 9 24 Liver support days 3, 7, 8, 9 26 Critical care Level 2 days 5, 9 27 Critical care Level 3 days 5, 9, 10 33 Critical care discharge date 2

Exercise 3: Answers

Name of data source Data fields that may be obtained from

this source

Where is this data source located within your hospital?

Patient Administration System (PAS)

1,2,4,5,6,7

Clinical records (kept as paper notes)

2,6,7,8, 18,19,20,21, 23,24,26,27,33,

Clinical records (kept electronically)

2,6,7,8,

Hospital or critical care staff

3,11,16,17,18,19,20,21,23,24,26,27,33


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Exercise 4: Answers

Table 8a: Demographic data codes Item no.

Demographic data fields





1 NHS number Unique identifier for transferable patient records and other NHS data sets.


Correct

2 Local patient identifier

Unique identifier for other patient data held within a hospital.


Correct



Correct.

4 Code of GP practice

Registered GP from patient medical record system.


Correct.

5 Treatment function code

The treatment function of the consultant with primary responsibility for the patient.


Consists of numbers only.

6 Date of birth To provide age and an additional patient identifier.

Use the format DD/MM/YY

Should be CCYY-MM-DD (conforms to e-government standard)

7 Postcode of usual address

To track source of patient

Post Office format Correct


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Table 8b: Mandatory data codes Item no.

Mandatory data fields





8 Critical care local identifier

Optional identifier for local critical care database systems to permit relational queries.

A code that could consist of both numbers and letters.




Should be CCYY-MM-DD



A two digit code from 01 to 12

plus the numbers 90 and 91













20 Renal days No. of days patient received renal support.


21 Neurological system support days

No. of days patient received neurological system support.





24 Liver support days

No. of days patient received liver support.








All should be a three digit code from 000 to 999, not 998. 999 is an additional code meaning: “Support occurred but number of days not known.”




Should be CCYY-MM-DD


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Guidance on Levels of Critical Care The guidance below is reproduced from Section 4 of the publication Levels of critical care for adult patients – standards and guidelines (Intensive Care Society, 2002), to help you to identify Level 2 and 3 support days in Exercises 5-13. The classifications have been agreed by the Department of Health through the Critical Care Advisory Group. If you wish to download the full document from the Intensive Care Society website, go to www.ics.ac.uk and click on ‘publications’ on the left of the page. Then click on ‘Download Levels of Critical Care for Adult Patients’.

EXPANDED GUIDANCE ON LEVELS OF CARE • Users should assign a level of care by referring to the headline statements in the

left hand column of the table below. • If a patient does not clearly meet the criteria for a particular level, clinical

judgement should be used to determine the most appropriate classification. If doubt remains, the higher level should be chosen.

• The examples in the right hand column are provided to assist comprehension and

are not intended to be exhaustive or prescriptive. • ACP organ support definitions used in the following tables are included on p.9 of

this Answer Book for ease of reference.

Level 0 criteria

Examples

Requires hospitalisation – needs can be met through normal ward care

Oral medication Bolus i.v. medication Patient Controlled Analgesia (PCA) Observations required less frequently than 4 hourly

Level 1 criteria

Examples

Patient recently discharged from a higher level of care

Patients in need of additional monitoring, clinical input or advice

Observations required at least 4 hourly Physiotherapy or airway suctioning required at least 6 hourly, but not more than 2 hourly

Patients requiring critical care outreach service support

Abnormal vital signs but not requiring a higher level of critical care

Patients requiring staff with special expertise and/or additional facilities for at least one aspect of critical care delivered in a general ward environment

Renal replacement therapy (stable chronic renal failure) Epidural analgesia Tracheostomy care


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Level 2 criteria

Examples

Patients needing single organ system monitoring and support (ACP definitions for patients already in receipt of single organ support are applicable to this group) (Patients in need of advanced respiratory support as the only major organ system supported due to an acute illness would normally satisfy the criteria for level 3)

Respiratory Needing more than 50% inspired oxygen within 24 hours of tracheostomy insertion Requiring non-invasive ventilation or CPAP Requiring physiotherapy or suctioning at least every 2 hours Cardiovascular Unstable, requiring continuous ECG and invasive pressure monitoring Haemodynamic instability due to hypovolaemia/haemorrhage/sepsis Requiring single infusion of vasoactive drug with appropriate monitoring Central nervous system CNS depression sufficient to prejudice airway and protective reflexes Invasive neurological monitoring Other Acute impairment of renal, electrolyte or metabolic function

Patients needing pre-operative optimisation: Requiring invasive monitoring and treatment to improve organ function

Haemodynamic/respiratory resuscitation or optimisation Insertion of invasive monitoring

Patients needing extended postoperative care: Extended postoperative observation is required either because of the nature of the procedure and/or the patient’s condition. Included in this group would be patients needing short term, i.e. less than 24 hours, routine post-operative ventilation who are otherwise well with no other organ dysfunction, e.g. fast track cardiac surgery patients

Procedure Major elective surgery Emergency surgery in unstable or high-risk patient Increased risk of postoperative complications/interventions/monitoring Patient Intermediate surgery in patient >70 years or ASA III or IV (severe system disease with functional limitation or worse)

Patients needing a greater degree of observation and monitoring

Observation and monitoring that cannot be safely provided at level 1 or below, judged on the basis of clinical circumstances and ward resources

Patients moving to step-down care No longer need level 3, but not well enough to be classified as level 1 or 0

Patients with major uncorrected physiological abnormalities: These physiological abnormalities, if uncorrected, are likely to indicate a patient requiring at least level 2 care. Patients with lesser degree of abnormality or other physiological abnormalities may also require level 2 or 3 care

Respiratory rate >40 breaths/min or >30 breaths/min for >6 hours Heart rate >120 beats/min Temperature <35ºC for >1 hour Hypotension, e.g. systolic BP <80 mmHg for >1 hour Glasgow Coma Score (GCS) <10 and at risk of acute deterioration


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Level 3 criteria

Examples

Patients needing advanced respiratory monitoring and support: Excluded from this group would be patients needing short term, i.e. less than 24 hours, routine postoperative ventilation who are otherwise well with no other organ dysfunction, e.g. fast track cardiac surgery patients. If ventilatory support exceeds 24 hours, or other significant organ dysfunction develops, these patients now need level 3 care (ACP definitions for patients already in receipt of advanced respiratory support are applicable to this group)

Respiratory failure from any cause that requires invasive, positive pressure mechanical ventilatory support BIPAP via any form of tracheal tube Extracorporeal respiratory support

Patients needing monitoring and support for two or more organ systems one of which may be basic or advanced respiratory support (Note that this clarifies the apparent inconsistency between the suggested levels criteria in ‘Comprehensive Critical Care’ and existing ACP definitions) (ACP definitions for patients already in receipt of multiple organ support are applicable to this group)

SIMV or CMV and continuous intravenous vasoactive drugs SIMV or CMV and haemofiltration High risk patients undergoing major surgery who are likely to require advanced respiratory support and monitoring/support of other organ systems Continuous intravenous medication to control seizures and supplementary oxygen/airway monitoring

Patients with chronic impairment of one or more organ systems sufficient to restrict daily activities (co-morbidity) and who require support for an acute reversible failure of another organ system (ACP definitions for patients already in receipt of single organ support are applicable to this group)

Severe ischaemic heart disease and major perioperative haemorrhage COPD requiring home oxygen presenting with sepsis related to immunosuppression Angina on mild exercise and broncho-pneumonia requiring CPAP


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ORGAN SYSTEM SUPPORT DEFINITIONS FROM THE Full specification of the CCMDS

ADVANCED RESPIRATORY SUPPORT DAYS Indicated by;

• Invasive mechanical ventilatory support (excluding mask CPAP or non-invasive methods e.g. mask ventilation but including BiPAP or CPAP applied via a tracheal tube).

• Extracorporeal respiratory support

Note: Basic respiratory support is likely to occur simultaneously with the above and should not lead to both ARS and BRS being recorded during the same calendar day. ARS supersedes BRS where this occurs.

BASIC RESPIRATORY SUPPORT DAYS Indicated by one or more of the following:

• More than 50% oxygen delivered by face mask. • Close observation due to the potential for acute deterioration to the point of

needing advanced respiratory support. • Physiotherapy or suction to clear secretions at least two hourly, whether via

tracheostomy, minitracheostomy, or in the absence of an artificial airway. • Patients recently extubated after a prolonged period of intubation and

mechanical ventilation, (e.g. more than 24 hours of tracheal intubation) • Mask CPAP or non-invasive ventilation. • Patients who are intubated to protect the airway but needing no ventilatory

support and who are otherwise stable.

ADVANCED CARDIOVASCULAR SUPPORT DAYS Indicated by one or more of the following:

• Multiple intravenous vasoactive and/or rhythm controlling drugs used to support arterial pressure, cardiac output or organ perfusion.

• Patients resuscitated after cardiac arrest where intensive therapy is considered clinically appropriate.

• Observation of cardiac output and derived indices (e.g. pulmonary artery catheter, lithium dilution, pulse contour analyses, oesophageal Doppler)

• Intra aortic balloon pumping • Insertion of a temporary cardiac pacemaker (criteria valid for each day of

connection to a functioning external pacemaker unit). • Placement of a gastrointestinal tonometer

Note: Basic CVS support is likely to occur simultaneously with the above and should not lead to both ACVS and BCVS being recorded at the same calendar day. ACVS supersedes BCVS where this occurs.


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BASIC CARDIOVASCULAR SUPPORT DAYS Indicated by one or more of the following:

• Treatment of circulatory instability due to hypovolaemia from any cause • Use of a CVP line for basic monitoring or central venous access • Use of an arterial line for basic monitoring of arterial pressure or sampling of

arterial blood • Single intravenous vasoactive drug used to support arterial pressure, cardiac

output or organ perfusion • Intravenous drugs to control cardiac arrhythmias • Non-invasive measurement of cardiac output (e.g. echocardiography, thoracic

impedance)

RENAL SUPPORT DAYS Indicated by:

• Acute renal replacement therapy (e.g.haemodialysis, haemofiltration etc.)

NEUROLOGICAL SYSTEM SUPPORT DAYS Indicated by one or more of the following:

• Central nervous system depression sufficient to prejudice the airway and protective reflexes, excepting that caused by therapeutic sedation to facilitate mechanical ventilation.

• Invasive neurological monitoring e.g. ICP, jugular bulb sampling. • Severely agitated or epileptic patients requiring constant nursing attention

and/or heavy sedation.

GASTRO-INTESTINAL SYSTEM SUPPORT DAYS (not in mandatory items) Indicated by:

• Feeding with parenteral or enteral nutrition.

DERMATOLOGICAL SYSTEM SUPPORT DAYS Indicated by one or more of the following

• Patients with major skin rashes, exfoliation or burns. • Use of multiple trauma dressings • Use of complex dressings (e.g. open abdomen or large skin area)


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LIVER SUPPORT DAYS Indicated by:

• Extracorporeal liver replacement device (e.g.. MARS as manufactured by Teraklin, Rostock, Germany), bio-artificial liver or charcoal haemoperfusion


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Exercise 5: Answers Patient A Date 1 2 3 4 5 6 7 Total Page: Of: ARS x x x x 004 Surname BRS x x 002 Hosp ID ACS 000 CC Start Date BCS 000 CC Unit Function 01 Renal 000 CC Disch Date Neuro 000 Derm 000 Liver 000 L2 days x x 002 L3 days x x x x 004

Notes: Day 6 classed as Level 2 – ‘Basic Respiratory Support’ as the patient was

‘recently extubated after a prolonged period of intubation and mechanical ventilation, (e.g. more than 24 hours of tracheal intubation).’

Exercise 6: Answers Patient B Date 1 2 3 4 5 6 7 Total Page: Of: ARS 000 Surname BRS x x x 003 Hosp ID ACS 000 CC Start Date BCS 000 CC Unit Function 01 Renal 000 CC Disch Date Neuro 000 Derm 000 Liver 000 L2 days x x x 003 L3 days 000

Notes: On day 2 the patient remains at Level 2 despite oxygen therapy being

reduced to 40%. This is because the patient requires ‘Physiotherapy or suction to clear secretions at least two hourly, whether via tracheostomy, mini-tracheostomy, or in the absence of an artificial airway.’


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Exercise 7: Answers Patient C Date 1 2 3 4 5 6 7 Total Page: Of: ARS 000 Surname BRS x x 002 Hosp ID ACS 000 CC Start Date BCS x x x 003 CC Unit Function 01 Renal 000 CC Disch Date Neuro 000 Derm 000 Liver 000 L2 days x x 002 L3 days x 001

Notes: On day 1, the patient is classed as Level 3 as he needs ‘monitoring and

support for two or more organ systems one of which may be basic or advanced respiratory monitoring’ (ICS, 2002). The patient requires ‘treatment of circulatory instability due to hypovolaemia from any cause’ on days 1 & 2; and there is use of a CVP and arterial line for basic monitoring on days 1, 2 & 3.

Exercise 8: Answers Patient D Date 1 2 3 4 5 6 7 Total Page: Of: ARS x x 002 Surname BRS 000 Hosp ID ACS x x 002 CC Start Date BCS 000 CC Unit Function 01 Renal 000 CC Disch Date Neuro 000 Derm 000 Liver 000 L2 days 000 L3 days x x 002

Notes: The patient was on the unit for less than 24 hours, however as he was on

the Unit before and after midnight, this produces two calendar days.


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Exercise 9: Answers Patient E Date 1 2 3 4 5 6 7 Total Page: Of: ARS x 001 Surname BRS 000 Hosp ID ACS 000 CC Start Date BCS 000 CC Unit Function 01 Renal 000 CC Disch Date Neuro x 001 Derm 000 Liver 000 L2 days 000 L3 days x 001

Exercise 10: Answers Patient F Date 1 2 3 4 5 6 7 Total Page: Of: ARS 000 Surname BRS 000 Hosp ID ACS 000 CC Start Date BCS x x x x x x x 007 CC Unit Function 01 Renal x x x x x x 006 CC Disch Date Neuro 000 Derm 000 Liver 000 L2 days x x 002 L3 days x x x x x 005

Notes: Patient requires the use of a CVP & arterial line for basic monitoring

therefore he falls into requiring basic cardiovascular support for the seven days on the Unit. He also requires haemofiltration for five days therefore he falls into two categories requiring support and for five out of the seven days he will be classed as a Level 3 patient.


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Exercise 11: Answers Patient G Date 1 2 3 4 5 6 7 Total Page: Of: ARS x x 002 Surname BRS 000 Hosp ID ACS 000 CC Start Date BCS 000 CC Unit Function 01 Renal 000 CC Disch Date Neuro x x 002 Derm 000 Liver 000 L2 days 000 L3 days x x 002

Notes: Until the patient is awake and their neurological status can be assessed, if

they are not requiring sedation but need invasive mechanical ventilatory support they will fall into the neurological support category ‘Central nervous system depression sufficient to prejudice the airway and protective reflexes’.

Exercise 12: Answers Patient H Date 1 2 3 4 5 6 7 Total Page: Of: ARS x x 002 Surname BRS 000 Hosp ID ACS x 001 CC Start Date BCS x 001 CC Unit Function 01 Renal 000 CC Disch Date Neuro 000 Derm x x 002 Liver 000 L2 days 000 L3 days x x 002

Notes: Initially the patient falls into the Basic Cardiovascular Support category as

she has CVP & arterial lines insitu on admission plus is being treated for circulatory instability due to hypovolaemia. However, the patient soon requires cardiac output monitoring and a vasoactive infusion and therefore comes under the Acute Cardiovascular Support category. As the patient has major burns – Dermatological Support is indicated.


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Exercise 13: Answers Patient I Date 1 2 3 4 5 6 7 8 9 Total Page: Of: ARS x x x x x x x x x 009 Surname BRS 000 Hosp ID ACS x x x x x x 006 CC Start Date BCS x x x 003 CC Unit Function 01 Renal x x x 003 CC Disch Date Neuro 000 Derm 000 Liver 000 L2 days 000 L3 days x x x x x x X x x 009

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