NYSDOH Sepsis and Covid-19 Digitalized Data Collection Collaborative

NYSDOH-Adult Sepsis&COVID-19 Updated Dictionary, Appendices & CSV files, D2.0

Dear Colleague,
 
The Department is pleased to announce the release of an updated Adult Sepsis and COVID-19 Data Dictionary, (Digitalized Data Collection, D2.0) along with updated appendices and CSV code files to assist in file creation. The CSV files include ICD-10-CM, ICD-10-PCS, and National Drug Codes (NDCs) and are intended to assist hospitals in the transition to the automated abstraction process. The data dictionary can be found at:
 
https://ny.sepsis.ipro.org/dictionaries/adult
 
As a reminder, submission of data for CY2020 will no longer be accepted in the portal using Data Dictionary version 7.1 for the Adult population or version 2.1 for Pediatric population. Additional important announcements related to the upcoming changes to the Sepsis Care Improvement Initiative, including a revised timeline for implementation of automated data abstraction and a link to the October 26, 2020 webinar recording are available on the IPRO webpage under ‘Announcements’.
 
Thank you,
The New York State Department of Health Clinical Sepsis Team

NYSDOH Sepsis Audit Reports: Data corrections due by December 30, 2020

• Be sure the workbook is in tableau packaged workbook type
• Right click the file and select "unpackage"
• Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
• Click the file of choice and it will open in excel

EHR Workgroup

Update: Please note there has been a correction to dates and/or times for some of the meetings.

The Department would like to thank everyone who participated in the EHR workgroup calls over the past two weeks. For those hospitals who utilize an EHR other than Cerner, EPIC, Allscripts or Meditech, an initial call has been scheduled for November 30th, 2020.

The Department would like to continue the discussions that started on the initial workgroup calls and the below webinar events have been scheduled to assist in that facilitation. Anyone can join, and we strongly encourage hospitals to participate. Individuals interested in helping lead EHR workgroup discussions may email Sepsis.Clinical.Data@health.ny.gov ahead of the meeting.

1. General EHR Workgroup:
   November 30th, 1-2pm (for hospitals that do not have Cerner, EPIC, Allscripts, Meditech)
   Meeting link: https://meetny.webex.com/meetny/j.php?MTID=mf7da72e0d5bb2c04d54391a5c62de3a6
   Meeting number: 178 099 2584
   Join by phone: 1-518-549-0500 Local
   Access code: 178 099 2584
2. Cerner Workgroup:
   December 7th, 2-3pm
   Meeting link: https://meetny.webex.com/meetny/j.php?MTID=m07b3264054796276f275aec098780f2e
   Meeting number: 178 649 5134
   Join by phone: 1-518-549-0500 Local
   Access code: 178 649 5134
3. EPIC Workgroup:
   December 14th, 1-2pm
   Meeting link: https://meetny.webex.com/meetny/j.php?MTID=mab99af80150b7e7a8e57bf83a7acfb7b
   Meeting number: 178 733 0300
   Join by phone: 1-518-549-0500 Local
   Access code: 178 733 0300
4. Allscripts:
   December 15th, 9-10am
   Meeting link: https://meetny.webex.com/meetny/j.php?MTID=m4128f10f5df528752e2dac03730456e0
   Meeting number: 178 530 9611
   Join by phone: 1-518-549-0500 Local
   Access code: 178 530 9611
5. Meditech:
   December 17th, 2-3pm
   Meeting link: https://meetny.webex.com/meetny/j.php?MTID=m85061be81a87b0ac0efb7853a8f6f023
   Meeting number: 178 458 1650
   Join by phone: 1-518-549-0500 Local
   Access code: 178 458 1650

NYSDOH - Adult Sepsis and COVID-19 Data Dictionary, Digitalized Data Collection, D1.0 Released

NYSDOH Sepsis Care Improvement Initiative - Upcoming events & recorded webex link

2020 Reporting Update:
As a result of the ongoing public health emergency related to COVID-19, the New York State Department of Health (NYSDOH) has eliminated data submission requirements associated with the NYS Sepsis Care Improvement Initiative for all of CY 2020. Submission of data for 2020 will no longer be accepted in the portal using Data Dictionary version 7.1 for the Adult population or version 2.1 for Pediatric population. In addition, there will be no adult or pediatric audit for these quarters. This guidance applies to all hospitals, including sampling and non-sampling hospitals. Hospitals will instead be asked to direct their attention and efforts towards the updated reporting detailed below.

Updated Sepsis Reporting
The NYSDOH is in the process of transitioning to an automated abstraction process. A new data dictionary is currently under development and will be forthcoming. The new data dictionary will be posted on this page and shared by email with all NYS hospitals when it becomes available.

October 26, 2020 Update Webinar

The Department hosted a webinar on October 26, 2020 to provide an overview of the 2018 Sepsis Public Report and to detail anticipated reporting changes to the NYS Sepsis Care Improvement Initiative.
Please use the following link to view the recorded webinar (video begins at 11 minutes and 38 seconds): NYSDOH All Hospital Webinar (October 26, 2020).

Timeline for Transition to Updated Automated Abstraction
·        Data dictionary, definitions, and ICD-10 codes – October/November 2020
·        Build and test phase December 1st – February 28th, 2021
·        Hospitals start capturing cases from December 1st, 2020 – February 28th, 2021
·        Hospitals begin to report cases to DOH in March 2021

The NYSDOH will continue to closely monitor the evolving COVID-19 situation and will make changes to data submission timelines and/or requirements as needed. Thank you for your continued efforts and support during this time.

EHR Workgroups
NYSDOH will facilitate workgroups for hospitals using the same EHRs. Call and webinar information is posted below, anyone can join but we strongly encourage hospitals with any of these EHRs to participate. Individuals from hospitals with one of the below EHRs that are interested in helping lead discussions related to that EHR may email Sepsis.Clinical.Data@health.ny.gov<mailto:Sepsis.Clinical.Data@health.ny.gov> ahead of the meeting.

1.      Cerner Workgroup: November 9th, 10-11am
Meeting link: https://meetny.webex.com/meetny/j.php?MTID=md79022ac038f2d846833036204dcab10<http://r20.rs6.net/tn.jsp?f=001boqc0YrklxZ45Plsho7cd_M3IQnnXwXafsl_YMdtl0mMch21ymmDsei6MKr_MpTitaxb4DDTBMP2LlaQW5FgpaqxtsyLiaKT7SaPvvMFkpQIFmSgeX0Q6iKfO8yKPetveQMLYW9DSoFL4zoU4pt7SPTGeiyigkxTe-Ewpu-CYBzoEzlVGrFBQYkO3Z6kfziOCXos9boir7l6xlpFLxHXKIbwaIgn4RrP&c=CAIjaEFJGvGvj4zpZTn7AM48fFgqWU6wj8ORanDHWnxAI2Fi4E3nsA==&ch=HpLBsnLBJ6adhXKPGAilKaktqfPSiV5USetw4qJzqBOROtWHIV6HGw==>
Meeting number:171 011 3805
Join by phone: 1-518-549-0500 Local
Access code: 171 011 3805

2.      EPIC Workgroup: November 16th, 10-11am
Meeting link: https://meetny.webex.com/meetny/j.php?MTID=m1bb1d29a77a48ac2fb68bcb9314c9c08<http://r20.rs6.net/tn.jsp?f=001boqc0YrklxZ45Plsho7cd_M3IQnnXwXafsl_YMdtl0mMch21ymmDsei6MKr_MpTiHQYq1teo0oBne5aXwJFJfdx33Aui8RZDLnRs8_1z7Q9wCHqeT5N5-eR5pKd76sW2xX4k-O1pdPwTVXmGfiewL1_Rjh2m8pH8JFgxP2joXrY7Br2vhWuHAyJ-8jyntz5BS2g_QxZ1IIOWNeWQaZhtQ-e3NVB6dcdW&c=CAIjaEFJGvGvj4zpZTn7AM48fFgqWU6wj8ORanDHWnxAI2Fi4E3nsA==&ch=HpLBsnLBJ6adhXKPGAilKaktqfPSiV5USetw4qJzqBOROtWHIV6HGw==>
Meeting number: 171 708 1891
Join by phone: 1-518-549-0500 Local
Access code: 171 708 1891

3.      Allscripts: November 17th, 10-11am
Meeting link: https://meetny.webex.com/meetny/j.php?MTID=m28c3086bd9a44bd14cce52c8bae9e287<http://r20.rs6.net/tn.jsp?f=001boqc0YrklxZ45Plsho7cd_M3IQnnXwXafsl_YMdtl0mMch21ymmDsei6MKr_MpTie_8uAIsxOU4s7nBzOsVJK7Qd2IJWRkDFYtcP_2qUJdxLM7jgZKFwmJsIgFLFkyn7cI8T2KFATCrxGWppBEK9aXVnZm4IpLG_NaFyXmPQsWirIwckXbEWNR_QUO0OJjZrQlfkSyEL5_USBe0SKhDjfwTF8s8Odq-w&c=CAIjaEFJGvGvj4zpZTn7AM48fFgqWU6wj8ORanDHWnxAI2Fi4E3nsA==&ch=HpLBsnLBJ6adhXKPGAilKaktqfPSiV5USetw4qJzqBOROtWHIV6HGw==>
Meeting number: 171 443 1644
Join by phone: 1-518-549-0500 Local
Access code: 171 443 1644

4.      Meditech: November 20th, 10-11am
Meeting link: https://meetny.webex.com/meetny/j.php?MTID=m75245d0d27c7f642b8cdf931e30f5713<http://r20.rs6.net/tn.jsp?f=001boqc0YrklxZ45Plsho7cd_M3IQnnXwXafsl_YMdtl0mMch21ymmDsei6MKr_MpTinWzJwZThLufitIt5NDIfOhtY1dH0opc4KM4n6Y-WwKCbkroAmTV55kuCqCQUq2iyGXKEBpP6Is3_PmpA4I6VbEwXekRxr1y5gziChax3G3AzfoKA8C6dPtWD3jBp0ZZiVpaiKpFNZR-1L03jzEd6bpUDA8kKrVMh&c=CAIjaEFJGvGvj4zpZTn7AM48fFgqWU6wj8ORanDHWnxAI2Fi4E3nsA==&ch=HpLBsnLBJ6adhXKPGAilKaktqfPSiV5USetw4qJzqBOROtWHIV6HGw==>
Meeting number: 171 859 5522
Join by phone: 1-518-549-0500 Local
Access code: 171 859 5522

NYSDOH Sepsis Care Improvement Initiative October 26, 2020 Webinar and Q3 Reporting Update

NYSDOH Sepsis: 2020 Q1-Q2 Quarterly Reports

Dear Colleagues:

NYSDOH Sepsis 2019-2020 Exception Reports - Corrections requested by September 4, 2020

NYSDOH Sepsis Pediatric Audit Medical Records Request

NYSDOH Sepsis Care Initiative Announcement, July 1 2020

Dear Colleagues:
 
The Department continues to consider the implications and impact of COVID-19 on the provider community and hospitals. Therefore at this time, the reporting of sepsis cases to the NYSDOH sepsis portal remains optional. Deadlines have also been suspended for sepsis reporting for those hospitals that are continuing to report voluntarily. The decision to restart regular data submission and quality improvement activities related to the Sepsis initiative will be made after careful consideration of the impact of COVID on NY State, the hospitals, and the health care providers, and we will be closely monitoring all the relevant data.
 
If your hospital has the resources, and this would not interrupt other activities to abstract and sample for sepsis reporting, then you may continue to submit the cases voluntarily. With regard to eventual reporting of all sepsis cases, the Department will not require that hospitals back-report.
 
Many hospitals continue to report and submit questions to the helpdesk (https://ny.sepsis.ipro.org/support). The helpdesk remains open and responsive to your questions regarding individual case reporting and sampling, as well as all other sepsis reporting questions.
 
Thank you for all your continuous efforts to reduce the impact of COVID in NY State.

Best regards,
The sepsis team

NYSDOH Sepsis Care Improvement Initiative Announcement, effective March 13, 2020

NYSDOH Sepsis 2020 Pediatric Data Dictionary Typo Revision

Dear Colleagues:

It has come to our attention that there was a typographical error in the Pediatric Dictionary V2.0 (2020) . Specifically, the PALS criteria for ages 1 to <10 years of age should read SBP<70 + age x 2. This correction was made on Table 1: Age-specific Systolic Blood Pressure Values for Hypotension in the Septic Shock Present section of the data dictionary. The corrected formula is consistent with the cited literature in that table. The revision is available now here.

As a reminder, the NYSDOH has aligned with CMS dictionary releases and will therefore have two Adult and Pediatric data dictionaries for 2020. The next release will be for July 1 discharges to align with the CMS dictionary Q3-Q4, V5.8 . These revised DOH versions are expected to be released to the hospitals by mid to end of April of 2020.  

Should you have any questions you may submit a helpdesk ticket at https://ny.sepsis.ipro.org/support.

Best regards,
The Sepsis Team

NYSDOH Sepsis 2019 Exception Reports - Corrections due March 9, 2020

Dear Colleague,

NYSDOH Sepsis: 2020 Measure Specifications & Adult Dictionary Modification V7.1

NYSDOH Sepsis 2020 Adult and Pediatric Data Dictionaries and Primary User Survey Notification

NYSDOH Sepsis: 2019 Q3 Quarterly Reports

NYSDOH Sepsis Audit Medical Records Request-Due November 4, 2019

NYSDOH Sepsis: 2019 Q2 Quarterly Reports

NYSDOH Sepsis 2019 Exception Reports - Corrections due September 16, 2019

NYSDOH Sepsis ADULT Audit Reports: Data corrections due by August 30, 2019

• Be sure the workbook is in tableau packaged workbook type
• Right click the file and select "unpackage"
• Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
• Click the file of choice and it will open in excel

NYSDOH Sepsis Pediatric Audit Reports: Data corrections due by August 30, 2019

• Be sure the workbook is in tableau packaged workbook type
• Right click the file and select "unpackage"
• Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
• Click the file of choice and it will open in excel

• Be sure the workbook is in tableau packaged workbook type
• Right click the file and select "unpackage"
• Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
• Click the file of choice and it will open in excel

NYSDOH Sepsis 2019 Q1 Exception Reports - Corrections due June 10, 2019

• Quarterly data submission for discharges for 1/1/2019 through 3/31/2019 is due this Friday, May 31, 2019. Note that pediatric data submissions are uploaded following the pediatric data dictionary for 2019 discharges. Data dictionaries may be found at https://ny.sepsis.ipro.org/pages/data_dictionary_documentation.

• Two separate medical record requests were sent to complete the audit selection of 2018 discharges. The requests were uploaded to your hospital drop zone folders.
• April 29, 2019 a case list of medical records selected for audit for discharges spanning from 7/1/2018 to 9/30/2018 was uploaded with a due date of May 31, 2019.
• May 10, 2019 a case list of medical records selected for audit for discharges spanning from 10/1/2018 to 12/31/2018 was uploaded with a due date of June 10, 2019.
• The complete medical record, including Emergency Department and ICU records, and all demographics, laboratory orders and results, medications, progress notes, transfer information, admission and discharge documentation, must be provided for each requested admission. Please submit any questions regarding this request to the Sepsis Help Desk at https://ny.sepsis.ipro.org/support For more information, regarding drop zone users may refer to the FAQ’s located at: https://ipro.zendesk.com/hc/en-us/articles/217731607-Dropzone-FAQ

NYSDOH Sepsis Audit Medical Records Request-Due May 31, 2019

NYSDOH Sepsis Adult Audit Reports Released 4/12/2019

• Be sure the workbook is in tableau packaged workbook type
• Right click the file and select "unpackage"
• Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
• Click the file of choice and it will open in excel

NYSDOH Sepsis: 2019 Measure Specifications & Adult Dictionary Modification V6.3

NYSDOH Sepsis: Quarterly Rpts, sampling opt-in, portal downtime, & clarification

• The list of eligible hospitals is under documentation
• Power Point and Recorded event is under Webinars
• Opt in form is under the sampling section after log in.

• CMS specifications include the combination of infection, SIRs and organ dysfunction to identify severe sepsis, or, alternatively, clinician documentation of severe sepsis. The CMS specifications (notes for abstraction) stipulate that infections documented to be known viral, fungal or parasitic infections should not be used to establish the infection criterion for severe sepsis present. Infections/suspected infections of unknown etiology should be used to establish the infection criterion for severe sepsis present, and viral infections with suspected supra-infection should also be used to establish the infection criterion for severe sepsis present. If severe sepsis is met by clinician documentation only, and the documentation indicates that severe sepsis is due to a viral, fungal or parasitic infection, this documentation of severe sepsis should not be used.
• For cases with septic shock, CMS specifications indicate that if within 6 hours of septic shock clinical criteria met or clinician documentation of septic shock there isadditional explicit clinician documentation that septic shock is known to be due only to viral, fungal, or parasitic infection-septic shock “not present” should be chosen.

NYSDOH 2019 Revised Sepsis Adult Data Dictionary Format Issue

NYSDOH Sepsis 2018 Exception Reports

• A modification to Pregnancy Status with an additional value added; and
• Clarifying language regarding infection with sole source viral, parasitic, or fungal infection.

• Documented extubation time can be used for end of mechanical ventilation if not otherwise documented. This may be defined as successful extubation or completion time of the withdrawl of NIV support.
• The following existing abstraction points still apply:
• The datetime of the clinician’s order for mechanical ventilation extubation is not acceptable.
• If the patient is discharge or transferred with mechanical ventilation, use Discharge Datetime.
• If a patient was only intubated for surgery and was able to be extubated, then mechanical ventilation would not apply.

• The list of eligible hospitals is under documentation
• Power Point and Recorded event is under Webinars
• Opt in form is under the sampling section after log in.

NYSDOH Sepsis 2019 Adult Data Dictionary

• A validation sample request for discharges in 2018Q2 was distributed on 12/19/2018. In recognition of the holidays, additional time was granted for medical record submission. These records are due on or before 1/31/2019.
• The power point and recording from the 12/14/2018 web ex is posted to the website for download and review. As noted during the web ex, the Department is planning to schedule a webinar in February to review measure specifications and dictionaries for 2019 in addition to providing an opportunity for questions.
• Hospitals may submit questions at any time to https://ny.sepsis.ipro.org/support

2019 NYSDOH Pediatric Data Dictionary and WebEx Reminder

Reminder and NYSDOH 2019 Pediatric Data Dictionary Release

Dear Colleagues:

In 2019 the NYSDOH Sepsis Improvement Initiative will begin collecting pediatric sepsis data using a dedicated Pediatric Data Dictionary for Severe Sepsis or Shock (https://files.constantcontact.com/cc47eb8e001/521e3021-21c4-455b-9e74-ebf7937b0529.pdf). Through the efforts of your colleagues on the Pediatric Sepsis Advisory Committee and your hospital associations, we are pleased to release this dictionary which will be reviewed during a webinar on December 14, 2018 at 9am. Please register for the event at https://ipro.webex.com/ipro/onstage/g.php?MTID=e5acd6aede06b4251554b000a09eadd54. The event will be recorded and available for review within a couple of days post event. During the event we will review the purpose of the changes and go through various data elements in detail to ensure consistent reporting across the state. The full meeting agenda is listed below. We look forward to your participation during the event. You may download the new dictionary at https://ny.sepsis.ipro.org/ on or after December 13, 2018.

Webex Agenda 12/14/2018 at 9am

Pediatric Data Dictionary
Pediatric Intake System
Adult Update
Health System Data Requests
Sampling Reminder
Regulation Update

Additionally, the NYSDOH has granted an extension for the exception reports related to 2018Q3 to Friday 12/14/2018 to enable hospitals to correct their sepsis data prior to quarterly report generation.

Best regards,

The Sepsis Team

NYSDOH Sepsis Upcoming Web: 2019 Pediatric Data Dictionary and More

Announcement

Effective November 14, 2018, the Medical Staff - Sepsis Protocol regulations at 10 NYCRR Part 405.4 have been amended to no longer require hospitals to send protocols to the Department (via IPRO) each time they are updated by the hospital.  Importantly, hospitals are still required to maintain and update sepsis protocols based on newly emerging evidence-based standards, and the Department still retains the authority to request sepsis protocols at any time.  However, the Department will no longer require protocols to be approved prior to implementation.

For additional information on all changes to the regulation, please see the following link: https://regs.health.ny.gov/sites/default/files/pdf/recently_adopted_regulations/Medical%20Staff%20%E2%80%93%20Sepsis%20Protocols.pdf

NYSDOH Sepsis 2018Q1-Q2 Exception Reports

NYSDOH Tableau Sepsis Audit Report User's Guide

NYS hospitals, the NYSDOH, and IPRO are working together to make a difference for sepsis patients locally and globally

NYS hospitals, the NYSDOH, and IPRO are working together to make a difference for sepsis patients locally and globally. At the 2nd World Sepsis Congress (https://www.worldsepsiscongress.org) hosted by the Global Sepsis Alliance, two presentations highlighted the NYS Sepsis Initiative. Dr. Marcus Friedrich, Chief Medical Officer, NYSDOH and Dr. Christopher Seymour, Assistant Professor, University of Pittsburgh School of Medicine each gave presentations highlighting the impact of Rory's Regulation and hospital efforts to improve care for sepsis patients. A link to the recorded session, power points, and the World Sepsis Congress are available at https://ny.sepsis.ipro.org.

NYSDOH Sepsis Adult&Pediatric Audit Reports: Data corrections due by September 30, 2018

• Be sure the workbook is in tableau packaged workbook type
• Right click the file and select "unpackage"
• Two more files are created when you unpackage. One file is the performance averages. One file is the case-level audit results.
• Click the file of choice and it will open in excel

NYSDOH Sepsis Audit Medical Records Request-Due September 24, 2018

NYSDOH Sepsis Audit Report Survey

NYSDOH Sepsis Quarterly Reports 2018-Q1 (July 2018)

Dear Colleague,

On the June 20th sepsis audit webinar hosted by IPRO, we proposed a methodology for reporting severe sepsis presentation that would help us understand populations reported across hospitals and how differences, if any, might affect measurement. We have received feedback from many hospitals that reflect concerns about the impact on existing processes the implementation of stratified reporting of severe sepsis presentation (criteria met within 6 hours and within 6-24 hours) would have. Consequently, we will not be implementing this reporting change that was discussed on the June 20 sepsis audit webinar at this time. The Department will discuss this issue further with the Sepsis Advisory Group, and will revisit the issue with you after those discussions conclude.

The goal of the NY State Sepsis Care Improvement Initiative to improve sepsis care in the State. We apologize for any concern or confusion the presentation of this proposed reporting methodology caused, and very much appreciate your feedback.

Sincerely,

Jeanne Alicandro, MD MPH 
Medical Director
Office of Quality and Patient Safety
New York State Department of Health

Marcus Friedrich, MD, MBA, FACP
Chief Medical Officer
Office of Quality and Patient Safety
New York State Department of Health

Dear Colleagues,

The NYSDOH Sepsis Initiative Adult Audit Reports for Q1 & Q2 of 2017 are available and will be uploaded to drop zone by close of business Monday, 6/25/2018. You may login to drop zone at https://mail.ipro.org/enduser/IPRO/en/login.html?v=5501.

At this time we are releasing only the adult audit reports. We are working with the Department to review and finalize the pediatric audit results, and they will be released at a later date.

The recording and slides from NYSDOH WebEx of June 20, 2018 are posted to the portal (right side of screen under “webinars”). The Data Dictionary for Severe Sepsis and Septic Shock, V5.2 has also been posted (https://ny.sepsis.ipro.org/files/documents/5-2/dictionary.pdf ). As noted in the WebEx, this dictionary is in effect for 7/1/2018.

Thank you for your continued efforts to improve sepsis care. Please submit any questions you have to the helpdesk at https://ny.sepsis.ipro.org/support.

Best regards,
The Sepsis Team

Constant Contact

Dear Colleague, 

We are pleased to announce that we will be issuing sepsis notifications in the future through Constant Contact. This enhancement allows interested parties to manage their inclusion or exclusion for sepsis announcements. As a courtesy we have loaded your email automatically and therefore no action is required unless you wish to unsubscribe. You may also direct colleagues to subscribe as well using this link: https://visitor.r20.constantcontact.com/manage/optin?v=001tY_bKFFKcKxHMJQ5T58eaQQI5oyK6CBFlgEdDSGqPfLYJ5r7c0CNskxws06xMmB3ivmvHYNBKpEjDKES7L0p_DNV-fjrEiBK5DcZpyc3dJ0%3D

Note that you will receive the standard email address for this announcement and one from constant contact.

The NYSDOH Sepsis Exception Reports are in the sepsis portal and available for download (https://ny.sepsis.ipro.org/).

If you had case(s) submitted by your hospital(s) for 2017-2018 data submissions that were in error (for example, not unique patient records; included overlapping admission and discharge dates, etc), you will have a report for download on the portal. Please review all of the fields for the case(s) you delete and then upload the correct case(s). Data correction and resubmission is required on or before COB on June 12, 2018 to enable your next quarterly report to capture these changes. Cases identified as submitted with these errors will not be pulled into the quarterly reports without your corrective actions. Please note that discharges prior to 1/1/2017 are static therefore your report will only show discharges from January 1, 2017 forward.

A new category of cases were added to the exception report for 2017. These cases represent instances where clinical criteria seem to be indicative of septic shock (elevated lactate ≥ 4 mmol/L {with elevated lactate reason=2} and/or persistent hypotension) however, the case(s) was not submitted as “septic shock present”. Please review the case(s) to determine if data entry is accurate. Correct data entry as needed. Should you wish for additional details, please see the clarifying email sent on May 15, 2018 which remains posted on the portal (https://ny.sepsis.ipro.org).

Specific instructions for file correction and resubmission are on the sepsis website (https://ny.sepsis.ipro.org). You may log in to the portal, click "Data Submission", then "Corrections Reports" to find and download your exception/correction report. The report is available in PDF format posted within this section. Please submit a helpdesk ticket to https://ny.sepsis.ipro.org/support if you have questions. We have recently enhanced the helpdesk with the addition of a form which allows a helpdesk submitter to better direct their question through issue categorization.

Thank you for helping to ensure that your data and reports are as accurate as possible.

Best regards,
The Sepsis Team

NYSDOH Important Sepsis Updates

Dear Colleagues,

The following announcement includes two important updates:

1. Clarification and call for correction of exception report cases for 2017 and
2. Release of FAQs from the February 2018 Abstractor Meeting.

Clarification and call for correction of exception report cases: We have been in communication with Mathematica regarding the specifications they maintain for CMS SEP 1 to ensure complete clarity regarding the septic shock present variable. During the review of hospital submitted data, we have noted in many NYS Sepsis submitted cases that although clinical septic shock criteria have been entered, data entry indicates that septic shock was not present. Specifically, hospitals report an elevated lactate (> 4 mmol) and/or persistent hypotension yet hospitals are not reporting a "yes" to septic shock present. The below information provides further clarity.

It is important to note that the CMS dictionary in Notes for Abstraction, clarifies that "Presence of Septic Shock" may be identified based upon clinical criteria or physician/APN/PA documentation of Septic Shock. This is the guidance hospitals should refer to when abstracting data, as per CMS. In order to establish the presence of Septic Shock by clinical criteria, one of following two criteria (a or b) must be met.

1. Severe Sepsis Present AND Persistent Hypotension in the hour after the conclusion of the target ordered volume of Crystalloid Fluid Administration, (regardless of when the crystalloid fluids were completed) as evidenced by two consecutive documented recordings of: systolic blood pressure (SBP) <90, or mean arterial pressure <65, or a decrease in systolic blood pressure by >40 mmHg. Physician/APN/PA documentation must be present in the medical record indicating a >40 mmHg decrease in SBP has occurred and is related to infection, Severe Sepsis or Septic Shock and no other causes.
2. Severe Sepsis Present AND Tissue hypoperfusion as evidenced by Initial Lactate Level Result >=4 mmol/L. In conclusion, the CMS SEP1 data dictionary for septic shock present states if the Physician/APN/PA document the presence of septic shock, OR Severe sepsis is present AND initial lactate level was ≥ four, OR Severe sepsis was present AND persistent hypotension was present, then value"1"(yes), should be selected for the Septic Shock Present variable.

Below are links which provide additional clarification:
https://www.qualityreportingcenter.com/event/sep-1-early-management-bundle-severe-sepsis-septic-shock-v5-3a-measure-updates/
https://www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2FQnetTier2&cid=1141662756099

Next Steps:

1. Download your updated exception report for CY2017 data which was uploaded on 4/27/2018.
2. Request a file deletion to remove the incorrect cases from the portal (instructions for finding your file and requesting file deletion are here).
3. Upload your corrected data prior to May 30, 2018.

Release of FAQs from the February 2018 Abstractor Meeting:

The responses to the questions asked during the sepsis data abstractor meetings held in February 2018 have been posted to the portal.

We thank you for your participation during these events and look forward to continuing to work together to clarify issues as they arise. Should you have any questions, please submit a helpdesk ticket so that we may assist.

Thank you,

The Sepsis Team

NYSDOH Sepsis Quarterly Reports Uploaded

Dear Colleague,

Hospital-specific Sepsis Data Reports through 2017Q4 are available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org/.    If you have both adult and pediatric data, you will have two reports available for download.  The reports are accessible to your hospitals designated portal user(s).  He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital.    Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.


The 2016 Sepsis Public Report is now publicly available at the links below:

https://www.health.ny.gov/press/reports/index.htm
https://www.health.ny.gov/press/reports/docs/2016_sepsis_care_improvement_initiative.pdf

As a reminder, to access your quarterly report(s), log into the sepsis data portal. Once you are logged in, click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support.  If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name.  You will then be provided with the contact name within your hospital.


Thank you for your attention to the report(s) and your continued efforts at improving sepsis care.   Should you have any questions please submit a helpdesk ticket to: Sepsis Help Desk at sepsis-ny@support.ipro.us.

The 2016 Sepsis Public Report

The 2016 Sepsis Public Report is now publicly available at the links below:

https://www.health.ny.gov/press/reports/index.htm
https://www.health.ny.gov/press/reports/docs/2016_sepsis_care_improvement_initiative.pdf

NYSDOH Sepsis Pre-release hospital public data reports for CY2016

Dear Colleague,

We are pleased to inform you that your  public-release preview Hospital-specific Sepsis Data Reports are available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org/.    If you have both adult and pediatric data, you will then have two reports available for download.  The New York State Department of Health will be releasing the full 2016 New York State Report on Sepsis Care Improvement Initiative in the coming week.

This report describes outcomes for patients with severe sepsis/septic shock being treated in hospitals across New York during 2016.  It represents considerable efforts by New York State hospitals and clinicians, over the past years, to measure and improve care for individuals with this common, complex, and lethal, condition.   The results are presented for use of protocols, adherence to key interventions within those protocols within specific recommended time frames and risk adjusted mortality rates (adults) for your hospital.  Public reporting of hospital performance is one dimension of New York's overall initiative to focus quality and safety improvement efforts on the identification and care of patients with sepsis in New York.

The reports are accessible to your hospitals designated portal user(s).  He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital.    Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.

Report Access Details:
To access your report(s), start by logging into the sepsis data portal. Once you are logged in, click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support.  If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name.  You will then be provided with the contact name within your hospital.

Thank you for your attention to the report(s) and your continued efforts at improving sepsis care.

Best regards,
The Sepsis Team

NYSDOH Data Dictionary Version 5.1 Release, Webex

Dear Colleagues,

We are pleased to release the updated NYSDOH Sepsis Data Dictionary Version 5.1, effective for discharges from January 1, 2018. One of the more significant changes evidenced in this release is the alignment with CMS SEP-1, Version 5.4. Though the CMS SEP-1 V5.4 Dictionary is effective for discharges beginning July 1, 2018, the Department has elected for early adoption for New York State data collection, given the significant reduction of data collection burden for fluid assessment data elements. The CMS SEP-1 Dictionary v. 5.4 also provides clarification for several elements that address some of the concerns we heard from abstractors in face to face to meetings. Please pay attention to all of the changes throughout the dictionary as you abstract discharge data for 2018.

We are working to program the portal to accept these changes as quickly as possible and appreciate your patience. There will be an announcement when the portal can begin accepting 2018 discharges.

As a reminder, the Department is holding a Sepsis Webex on February 15, 2018 at 10am, EST which will review the 2016 public report data; data dictionary and measure specification changes for 2018; and the 2017 audit. Register for this event here. For those unable to attend, the meeting will be recorded and posted to the portal site within a few days of the event.

Thank you for your continued efforts to improve sepsis care. Please submit any questions you have to the helpdesk at sepsis-ny@support.ipro.us.

Best regards,

The Sepsis Team

New Sepsis Materials, Upcoming Event

Dear Colleague,

We are pleased to share several important materials and an upcoming event for the NYSDOH Sepsis Initiative.

Hospital-specific Sepsis Data Reports through 2017Q3 are available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org/. If you have both adult and pediatric data, you will have two reports available for download. The reports are accessible to your hospitals designated portal user(s). He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital. Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.

NYSDOH Measure Specification Documentations are attached to this email and available on the portal for both 2015/2016 and 2017. These documents continue to increase transparency and provide details needed to fully understand the data elements and values used in measure calculations. The measure specifications for 2018 will be shared as soon as they are complete.

NYSDOH Sepsis Webex on February 15, 2018 at 10am, EST will review the 2016 public report data; data dictionary and measure specification changes for 2018; and the 2017 audit. Register for this event at 
https://ipro.webex.com/ipro/onstage/g.php?MTID=ef7e20a91400b18ea9e7c1842749a2f56. For those unable to attend, the meeting will be recorded and posted to the portal site within a few days of the event.

As a reminder, to access your quarterly report(s), log into the sepsis data portal. Once you are logged in, click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support. If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name. You will then be provided with the contact name within your hospital.

Thank you for your attention to the report(s) and your continued efforts at improving sepsis care.

Best regards,

The Sepsis Team

Data Dictionary 5.0

Dear Colleague,

The NYSDOH is pleased to provide hospitals with an updated Data Dictionary for Severe Sepsis or Septic Shock. This version 5.0 is effective for discharges beginning with January 1, 2018 and forward. The dictionary contains significant changes which include additional clarifications and details to assist in data collection; greater alignment with CMS SEP-1 specifications where possible; and, the incorporation of answers provided in prior FAQs and helpdesk tickets. In fact, the prior FAQs are removed from the portal as their relevance to current data collection is captured within the data dictionary at this time. It is hoped that this reduces confusion. Overall the changes were the result of significant input from hospital data abstractors, your hospital associations, the Sepsis Advisory Group and pediatric sub-committee, and your efforts in submitting clarifying questions to the helpdesk. Thank you for your input to ensure data accuracy and integrity.

Please note that there are significant changes in the dictionary which will require programming to the data portal. Until these changes are programmed into the portal, the portal will not accept 2018 cases. However, data is due two months after the conclusion of a quarter; therefore, discharges beginning January 1, 2018 are not due in the portal until the deadline of May 31, 2018. We will be working to allow cases into the portal within the next 4-6 weeks to allow ample time for data submission.

Within the next several weeks we will be releasing quarterly reports for Q1, Q2, and Q3 of 2017 along with a Measure Specification document which details the data elements used for measure calculations. This document continues transparency efforts in data collection and measure calculations. Along with the release of these reports in the coming weeks, we will schedule a webinar to review the Data Dictionary, the Measure Specifications, and the released Quarterly Hospital Reports.

Thank you for your patience and your continued investment in this important initiative.

Best regards,

The Sepsis Team

Upcoming Webinar

Dear Colleagues,

Hospitals that submitted more than 400 cases to the sepsis clinical database during the last full year of data collection are eligible to apply for sampling. The large-volume hospitals that opt-in for sampling as part of the sepsis quality improvement initiative will submit a total of 400 cases for calendar year 2018. Your facility has been identified as a large-volume hospital that is eligible for sampling. As such, we'd like to invite you to join us for a 1 hour webinar on Friday, January 19, 2018 from 10:00 am - 11:00 am to learn more details about the opportunity to submit a sample for calendar year 2018.

There are many personnel who work for multiple hospitals therefore we have attached a PDF list of eligible hospitals along with their PFI to assist in identifying which of your facilities are eligible for sampling.

This webinar will provide information about the sepsis sampling plan, the process that will be followed for those hospitals that opt to participate in sampling for 2018, and will include a live demonstration of the IPRO portal that hospitals will use to submit those cases from which NYS DOH personnel will select a sample. The presentation will last about 40 minutes and will be followed by a 20 minute question and answer period.

Please register for the event at:  https://ipro.webex.com/ipro/onstage/g.php?MTID=ea6fe564796377214d251bbfc50ad8c65

NYSDOH Sepsis Exception Reports: Important Update

Dear Colleagues:

Recently we disseminated sepsis exception reports with a new category of potential data entry concerns. This category represents cases with clinical criteria indicative of septic shock (severe sepsis plus lactate >=4 and/or persistent hypotension) yet the hospital did not report the patient with "septic shock present" or a datetime. Several hospitals provided helpful insight into how these data are abstracted. Please be advised that the Department is in communication with CMS to discuss how hospitals are interpreting the data definitions and the measure algorithm to ensure that data definitions are clear and that DOH is aligned with CMS. CMS is reviewing the issue and has indicated that they will provide a comprehensive response by next week.

We have asked that you consider the accuracy of the data entry for your cases; however, given this ongoing discussion with CMS you might wish to refrain from amending data for this category until the discussion concludes. This would ensure consistency in your data entry and common interpretation and understanding of reported data fields.

Thank you for your efforts and insights. We will communicate with you as soon as possible when we hear from CMS.

Best regards,

The sepsis team

Latest Exception Reports

Dear Colleague,

The NYSDOH Sepsis Exception Reports were loaded to the sepsis portal today (https://ny.sepsis.ipro.org).

If you had case(s) submitted by your hospital(s) for 2017 data submissions that were in error (for example, not unique patient records; included overlapping admission and discharge dates, etc), you will have a report for download on the portal. Please review all of the fields for the case(s) you delete and then upload the correct case(s). Data correction and resubmission is required on or before COB on December 7, 2017 to enable your next quarterly report to capture these changes. Cases identified as submitted with these errors will not be pulled into the quarterly reports without your corrective actions. Please note that discharges prior to 1/1/2017 are static therefore your report will only show discharges from January 1, 2017 forward.

A new category of cases have been added to the exception report. These cases represent instances where clinical criteria are indicative of septic shock (elevated lactate ≥ 4 mmol/L and/or persistent hypotension) however, the case(s) was not submitted as "septic shock present". Please review the case(s) to determine if data entry is accurate. Correct data entry as needed. We are not removing these cases from your quarterly report but are suggesting that there may be error in data entry.

Specific instructions for file correction and resubmission are on the sepsis website (https://ny.sepsis.ipro.org). You may log in to the portal, click "Data Submission", then "Corrections Reports" to find and download your exception/correction report. The report is available in PDF format posted within this section. Please submit a helpdesk ticket to sepsis-ny@support.ipro.us if you have questions.

Thank you for helping to ensure that your data and reports are as accurate as possible.

Best regards,

The Sepsis Team

NYSDOH Sepsis-Corrected Quarterly Reports and NYSDOH Survey

Dear Colleague,

We are contacting you for two reasons: a correction to the recently released sepsis quarterly reports and, to disseminate a survey to collect contact information for the Department.

Quarterly Reports:

We regret to inform you that the reports that were loaded to the Sepsis Clinical Data Portal on August 31, 2017 contained a minor programming error which did not appropriately handle all of your data. Specifically, data for quarter one of 2017 has been corrected in several places in the report.

There was a minor impact of this error in the aggregate; however, individual hospitals may be more significantly impacted. We are releasing corrected reports for all providers, which ensure that your hospital has an accurate report. The incorrect reports have been removed from the portal and the corrected reports were uploaded today. Please be sure to discard the incorrect report, if already downloaded, and use the report ending with yesterday’s date (i.e., file name ending in 20170907).

Thank you for your understanding. We apologize for the inconvenience caused by this error.

Survey: Survey Link: https://redcap.ipro.org/surveys/?s=CTYLX94JAH

We are compiling a list of hospital contacts to facilitate sepsis communications between the NYS Department of Health (DOH) and hospitals participating in the Sepsis Initiative. We are asking hospitals to identify a primary point of contact for sepsis communications, ideally your identified sepsis coordinator, to ensure that important DOH information reaches the appropriate staff. While this identified contact person will receive all important DOH sepsis communications, we will continue to send notices to all drop zone and portal users as appropriate.

The NYS DOH is convening two meetings to provide a forum for feedback and discussion among hospitals regarding the data collection process. We are asking for your assistance with identifying staff at your facility responsible for abstracting data and data entry, e.g. medical record abstractors and coders, who would be appropriate for attendance at a meeting to discuss the data collection process and opportunities for improvement. The primary point of contact for the hospital might be the best person to submit the survey for the hospital.

Please complete this survey by Monday, September 11, 2017. Should you have any questions about this request, please submit a helpdesk ticket to sepsis-ny@support.ipro.us.

Best regards,
The Sepsis Team

NYSDOH Sepsis Hospital Quarterly Reports Released

Dear Colleague,

We are pleased to inform you that your Hospital-specific Sepsis Data Reports are available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org. If you have both adult and pediatric data, you will then have two reports available for download. These reports reflect the changes to the Data Dictionary effective 1/1/2017. Measures have been modified for 2017 to incorporate these changes. Attached to this email, you will find a document created by the Department that will assist in understanding how the measures have been revised, along with implications for trending and comparisons.

The reports are accessible to your hospitals designated portal user(s). He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital. Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.

Data Dictionary:
Please note that the changes to the NYSDOH sepsis data dictionary were NOT meant to change the denominator of cases reported to the NYSDOH data portal. The NYSDOH aligned on select data elements. Hospitals should identify severe sepsis and septic shock cases for reporting to the Department as they have done so for all reporting periods: reporting all cases of severe sepsis or septic shock regardless of how they are identified.

Report Access Details:
To access your report(s), start by logging into the sepsis data portal. Once you are logged in, click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support. If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name. You will then be provided with the contact name within your hospital.

Thank you for your attention to the report(s) and your continued efforts at improving sepsis care. Please submit follow-up questions as needed to the helpdesk at sepsis-ny@support.ipro.us

Have a wonderful holiday weekend!

Best regards,
The Sepsis Team

Announcement:

Sepsis audit process and results; opportunity for data correction; timeline for upcoming public release of sepsis risk adjusted mortality rate; and Webex invitation.

Dear Colleague,

As you are aware, effective May 1, 2013 NYSDOH Title 10 New York Codes Rules and Regulations (NYCRR) Sections 405.2 and 405.4 were amended to require that hospitals have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock. In addition, subdivision 7 (ii) states that “Hospitals shall submit data specified by the Department to permit the Department to develop risk-adjusted severe sepsis and septic shock mortality rates in consultation with appropriate national, hospital and expert stakeholders.”

The Department is again working with a team of risk adjustment experts including hospital physicians, ICU physicians, and statistical and modeling experts. These experts use your sepsis data to adjust your mortality rate based upon many factors, some of which include demographics and comorbidities. It is therefore critical that the data submitted by your hospital and used for public reporting and risk adjusted mortality rates be as accurate as possible. Before the model is finalized, to help ensure the accuracy of reported data, the Department of Health authenticates the integrity of the data through a data validation audit. The Department selected samples of cases from each hospital for medical record review (i.e., data validation). The information provided in these sampled medical records was compared to the data dictionary elements submitted by your hospital. The purpose of the feedback report is to provide information to assist your hospital in improving the accuracy of your data prior to public data release, which is scheduled for Fall 2017.

Before the risk adjustment model is finalized and as a final validation step prior to public data release, hospitals are afforded a one-time opportunity to review and correct discrepancies between reported data and data abstracted during audit. The risk adjustment model and publically reported data will include calendar year 2016 discharges. Your hospital data validation report will be uploaded to DropZone (https://mail.ipro.org/enduser/IPRO) and available for download by June 30, 2017 by your hospital’s DropZone authorized user. If you are uncertain on who the DropZone user is for your hospital, please submit a helpdesk ticket (email sepsis-ny@support.ipro.us) specifying your hospital PFI and request the contact information for your user.

This audit report presents the performance of specific data elements during the audit of your hospital’s submitted data. The visualizations depict the proportion of agreement between your hospital’s reported data and the auditor’s review of the medical records and the relational position of that performance against the state’s aggregate performance. In addition, an aggregate proportion of agreements of the data element categories are presented to highlight the validation rates by variable groups. Examples of invalid data might be the submission of a fluid datetime that aligns in the chart with the fluid start time and not the fluid completion time; failure to find that a protocol was started when viewing the medical record for which a protocol datetime was reported; medication datetimes not aligning between the reported data and the medical record. These are just a few instances for which the data would be designated as invalid. This report is provided to assist your hospital in the data review and abstraction efforts. To that end, case level data has been provided in an accompanying spreadsheet for all cases with ANY discrepancy that were included in the audit of 2016 cases. We are intentionally providing much greater detail than in previous reporting to assist in your correction efforts. Please keep in mind however that we cannot review individual cases with hospitals. We understand that some hospitals may disagree with the audit findings, but the Department will not be able to discuss individual case results. The data used in this audit were those that had been submitted by each hospital at the time the sample was drawn. It is possible that you may have already corrected some of the data elements for which results are reflected in this report.

Again, please note that this information is provided to assist your hospital in improving overall accuracy in data submission. Results should be interpreted in light of patterns of errors found in the data, rather than solely looking to individual case results. Therefore, when reviewing this report and your data for instances for which the data could not be validated, you may want to extrapolate and apply the findings to cases that were not selected for audit during all reporting periods. Accurate and clear documentation in the medical record is a key factor when determining data validity. Public data release will include discharges spanning 1/1/2016 through 12/31/2016, and therefore you will want to focus your corrective efforts on these discharges as a priority.

Please carefully and thoroughly review the data provided in this report and take the necessary actions to correct your data if needed, prior to July 31, 2017. As of July 31, 2017, all data for calendar year 2016 will be closed, and no additional data changes will be permitted. After July 31, 2017, hospitals may only revise data for discharges from January 1, 2017 onward.

Again, you must correct cases with discharge dates through December 31, 2016, prior to the close of business on July 31, 2017. The data must be completed and closed to allow sufficient time to finalize the risk adjustment model prior to the release of your risk adjusted mortality rate and the performance measures in the fall of 2017, as mandated by statute.

The Department is providing a WebEx event on July 5, 2017 at 2pm, EST to assist you in understanding and interpreting the report. Please register for the event at:

https://ipro.webex.com/ipro/onstage/g.php?MTID=e305f95d9f4ca4cc16bee38610af5ef38

To assist in your understanding of the process and timeline leading to the public release of sepsis data, please refer to the timeline listed below:

Brief timeline overview:

June 30, 2017 Audit feedback reports received by hospitals

June 30 – July 31, 2017 Hospital opportunity for data correction for all discharges between 1/1/2016 to 12/31/2016

August – September 2017 Data analysis and risk adjustment model generation for CY 2016 data

September - October 2017 Risk adjustment model refinement (calendar year 2016 model)

Fall 2017 Public release of risk adjustment model and performance measures (CY2016)

We look forward to speaking with you during the WebEx event on July 5 at 2pm.

Best regards,

The Sepsis Team

NYSDOH Sepsis FAQs and Upcoming Webinar

Dear Colleague,

We are pleased to release the attached Frequently Asked Questions to assist with data collection related to the Data Dictionary for Severe Sepsis or Septic Shock, Version 4.1 effective for discharges from January 1, 2017 onward.  We have attempted to address the concerns brought forth through the helpdesk, your hospital associations, and from other feedback that we received.  

As noted in the document, we want to thank the hospital staff including nurses, physicians, coders, abstractors, physician assistants, administrators, and assistants for your hard work in making the New York State Sepsis initiative truly special by improving care for our patients.

We introduced the alignment with CMS SEP-1 and the NYSDOH sepsis initiative to reduce the burden for abstraction.  While we realize that this initially can cause some confusion, we want to emphasize that at the end we expect less work for hospitals and the abstractors.  The purpose of this document is to clarify the confusion to the greatest extent possible. 

To further assist in ensuring consistency in data collection and interpretation, the Department is holding a webinar on May 12, 2017 at 10:30am, EST.  The event will be recorded for those unable to participate. 

To register for the online event:

1. Go to https://ipro.webex.com/ipro/onstage/g.php?MTID=ecf4434c458119b299c4482f079723cb5
2. Click 'Register'
3. On the registration form, enter your information and then click Submit.

The reporting deadline for the data which aligns with this dictionary has been extended to ensure that there is ample time to review the FAQs, attend the webinar, and make changes if needed in your data submission.  The reporting deadline for discharges between 1/1/2017 and 3/31/2017 is now June 30, 2017.   Please be sure all cases have been submitted by this date.  If you do not have cases within this reporting period, you must attest to zero cases. 

Thank you for your efforts to date.  We look forward to continuing to work together towards improving care. 

Best regards,

The Sepsis Team

Governor Cuomo Announces Reforms Spurred Consistent Decline in Sepsis Mortality Rates

Governor Andrew M. Cuomo today announced that New York has achieved a consistent reduction in sepsis mortality rates as a result of the groundbreaking Rory's Regulations. Named for the late Rory Staunton and first championed by Governor Cuomo in 2013, these regulations established first-in-the-nation protocols for hospitals to improve identification and treatment of sepsis.

To read more click here

NYSDOH Hospital-specific sepsis data reports

We are pleased to inform you that your Hospital-specific Sepsis Data Reports are available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org/.    If you have both adult and pediatric data, you will then have two reports available for download.

The reports are accessible to your hospitals designated portal user(s).  He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital.    Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.

Data Dictionary:
Please note that the changes to the NYSDOH sepsis data dictionary were NOT meant to change the denominator of cases reported to the NYSDOH data portal.   The NYSDOH aligned on select data elements.  Hospitals should identify severe sepsis and septic shock cases for reporting to the Department as they have done so for all reporting periods:  reporting all cases of severe sepsis or septic shock regardless of how they are identified.  The Department will be monitoring volume closely during the upcoming data submissions to ensure that there is no change in volume (particularly as a result of misinterpretation).  Hospitals will still identify their pool of cases for NYSDOH and then collect the data as required by our dictionary.    You may submit any follow-up questions to the helpdesk.

Report Access Details:
To access your report(s), start by logging into the sepsis data portal. Once you are logged in, click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support.  If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name.  You will then be provided with the contact name within your hospital.

Thank you for your attention to the report(s) and your continued efforts at improving sepsis care.

Best regards,
The Sepsis Team

Dear Colleague,

It has come to our attention that there were a few variables that were inadvertently left out of latest data dictionary release.  Attached is Version 4.1 which captures these changes.  Also note the critical clarification regarding the cases to be submitted to the NYSDOH portal.   

Critical clarification:

• To be clear: NYSDOH is ONLY aligning with select CMS SEP-1 data elements. The denominator for the NYSDOH data submission still requires reporting ALL cases of severe sepsis or septic shock INCLUDING cases identified through coding AND/OR other avenues (e.g., concurrent case identification; retrospective review; and so forth). Hospitals are NOT to be using the CMS method of selecting cases and adding DOH data elements to those cases. This would be an incorrect interpretation of the 2017 modification; the NYSDOH requires reporting ALL severe sepsis and septic shock cases regardless of how they are identified.

The following fluid assessment data elements were not included in Version 4.0 in error. The same expectations apply to these as were applied for the fluid assessment data elements outlined in the 4.0 version. These variables are CMS SEP-1 data elements, and therefore data collection will follow CMS SEP-1 specifications. They are required for data collection beginning with discharges on or after January 1, 2017.

• Central venous oxygen measurement
• Central venous oxygen measurement datetime
• Central venous pressure measurement
• Central venous pressure measurement datetime
• Fluid challenge performed
• Fluid challenge performed datetime

Thank you for your continued efforts at improving patient care.  As always, please continue to submit questions to the helpdesk as clarifications questions arise.

We wish you all a wonderful holiday season.

Best regards,

The sepsis team

Dear Colleague,

The NYSDOH is pleased to provide hospitals with an updated Data Dictionary for Severe Sepsis or Septic Shock.  This version 4.0 is effective for discharges beginning with January 1, 2017 and forward.  The dictionary contains significant changes which include additional clarifications and details to assist in data collection; alignment with CMS SEP-1 specifications where possible; and, the incorporation of answers provided in prior FAQs and helpdesk tickets.  These changes were the result of significant input from your hospital associations, the Sepsis Advisory Group and pediatric sub-committee, and your efforts in submitting clarifying questions to the helpdesk.  Thank you for your efforts to ensure data accuracy and integrity. 

As noted in prior communications, the NYSDOH in collaboration with IPRO and your hospital associations is holding a webinar on Tuesday, December 13 at 10:30am, EST.  The Sepsis Webinar will discuss the content and the release of sepsis public data and will review the new data dictionary in detail.  You must register for the event!  Event details are as follows: 

Date and Time:                      

Tuesday, December 13, 2016 10:30 am, ESTRegister for the event at: https://ipro.webex.com/ipro/onstage/g.php?MTID=eacefba0616b7ec6d77ce8f5315bc3be0

Please make every effort to attend this important webinar. The event will be recorded and posted to https://ny.sepsis.ipro.org/ for those unable to attend the live event.

Best regards,

The Sepsis Team

Announcement:

The audit is intended to validate hospital data that is used for measures and the risk adjustment model.  Since these data will be publically reported in the Fall, the hospitals want to be sure to have complete and accurate data.  The audit reports were disseminated to assist in this effort.  For THIS audit, the DOH will NOT change your data to align with what was abstracted during audit.  Hospitals want to use this data to look into “invalid” data to see if there are corrections they need to make to their data.  The hospitals will need to request the deletion of a record they want to correct and then reload corrected data.  If they do not have changes (for example, they find they inadvertently did not send a full record requested at audit) then the hospital should not make changes to their data.  They may want to change medical record copying and submission processes for future audit requests then (in this example).

Sepsis Audit FAQ's

Please click here to got ot the Sepsis Audit FAQ.

Announcement:  Sepsis audit process and results; opportunity for data correction; timeline for upcoming public release of sepsis risk adjusted mortality rate; and, Webex invitation.

Dear Colleague,

As you are aware, effective May 1, 2013 NYSDOH Title 10 New York Codes Rules and Regulations (NYCRR) Sections 405.2 and 405.4 were amended to require that hospitals have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock.  In addition, subdivision 7 (ii) states that “Hospitals shall submit data specified by the Department to permit the Department to develop risk-adjusted severe sepsis and septic shock mortality rates in consultation with appropriate national, hospital and expert stakeholders.” 

The Department is working with a team of risk adjustment experts including hospital physicians, ICU physicians, and statistical and modeling experts.  These experts use your sepsis data to adjust your mortality rate based upon many factors, some of which include demographics and co-morbidities. It is therefore critical that the data submitted by your hospital and used for public reporting and risk adjusted mortality rates be as accurate as possible.  Before the model is finalized, to help ensure the accuracy of reported data, the Department of Health authenticates the integrity of the data through a data validation audit.  The Department selected samples of cases from each hospital for medical record review (i.e., data validation).  The information provided in these sampled medical records was compared to the data dictionary elements submitted by your hospital. The purpose of the feedback report is to provide information to assist your hospital in improving the accuracy of your data prior to public data release which is scheduled for Fall 2016.

Before the risk adjustment model is finalized, and as a final validation step prior to public data release, hospitals are afforded a one-time opportunity to review and correct discrepancies between reported data and, data abstracted during audit.  The risk adjustment model and publically reported data will include calendar year 2015 discharges.  Your hospital data validation report will be uploaded to Drop Zone (https://mail.ipro.org/enduser/IPRO) and available for download by June 22, 2016 by your hospital drop zone authorized user.  If you are uncertain on who the drop zone user is for your hospital, please submit a helpdesk ticket (email sepsis-ny@support.ipro.us) specifying your hospital PFI and request the contact information for your user.

The audit report represents areas where your performance was considered an outlier in data accuracy.  Importantly, “outlier” status was defined as at least one standard deviation from the mean.  This allows for the greatest amount of data feedback to providers to assist in your data correction efforts.  It is important to understand that the Department and IPRO will NOT be supporting discussion or appeals of individual cases to either support or refute audit findings.  This effort provides an additional opportunity (beyond each quarter’s feedback reports) for hospitals to correct data, if reported incorrectly, prior to closing the data set which will be used for public reporting.  Importantly, the data submitted to the clinical data portal at the time of the audit sample selection was the data that was validated.  Therefore, you may have already corrected or changed your data.  Data errors may range from typographical errors; to misunderstanding regarding reporting start or completion time for a data element; to simply finding the data reported cannot be found in the medical record.  Your report will specify what data element(s) was found to be invalid and will provide the medical record information to enable you to identify the case. 

Again, please note that this information is provided to assist your hospital in improving overall accuracy in data submission.  Results should be interpreted in light of patterns of errors found in the data, rather than solely looking to individual case results. Therefore, when reviewing this report and your data for instances for which the data could not be validated, you may want to extrapolate and apply the findings to cases that were not selected for audit during all reporting periods.  Accurate and clear documentation in the medical record is a key factor when determining data validity.  Public data release will include discharged spanning 1/1/2015 through 12/31/2015 therefore you will want to focus your corrective efforts on these discharges as a priority.

Please carefully and thoroughly review the data provided in this report and take the necessary actions to correct your data if needed, prior to July 31, 2016.  As of July 31, 2016 all data from project inception through discharge dates up to and including December 31, 2015 will be closed and no additional data changes will be permitted. After July 31, 2016, hospitals may only revise data for discharges from January 1, 2016 onward. 

Again, you must correct cases with discharge dates through December 31, 2015 prior to close of business on July 31, 2016. The data must be completed and closed to allow sufficient time to finalize the risk adjustment model prior to the release of your risk adjusted mortality rate and the performance measures in the Fall of 2016, as mandated by statute. 

The Department is providing a WebEx event on June 28, 2016 at 1pm, EST to assist you in understanding and interpreting the report.  Please register for the event at :https://ipro.webex.com/ipro/onstage/g.php?MTID=e66bda79ba100528f171ebb2e1d30eb6b

To assist in your understanding of the process and timeline leading to the public release of sepsis data, please refer to the timeline listed below. 

Brief timeline overview:

We look forward to speaking with you on June 28 at 1pm during the webex event.

Best regards,

The Sepsis Team

Dear Colleague,

As a follow-up to the recently released data dictionary (version 3.0), we want to clarify that we understand that there may be rare instances for which a patient does not enter your hospital through the ED or Triage. In these instances, hospitals may leave those fields blank, but only in those instances. We do not expect a high volume of cases to be reported without ED or Triage datetimes.

Reminder:

Data correction based upon your exception report is due tomorrow. Please be sure to get these corrections in so that your hospital report accurately reflects your data. Note that only hospitals with an exception report were notified so if you did not receive an email, you did not have a report.

Best regards,
The Sepsis Team

Dear Colleague,

We are pleased to inform you that your Hospital-specific Sepsis Data Reports are available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org. If you have both adult and pediatric data, you will then have two reports available for download.

The reports are accessible to your hospitals designated portal user(s). He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital. Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.

Report Access Details:
To access your report(s), start by logging into the sepsis data portal. Once you are logged in, click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support. If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name. You will then be provided with the contact name within your hospital.

Thank you for your attention to the report(s) and your continued efforts at improving sepsis care.

Best regards,
The Sepsis Team

Hospital Feedback Incorporated into Reports

Dear Colleague,

Recently, sepsis hospital reports were released to provide updated quarterly data for your hospital.  Upon receipt of these most recent reports, hospitals requested a modification to the reports to provide greater ease in data comparison of hospital to state performance.  The Department appreciates your responsiveness to these reports and is pleased to provide the requested modification.

The adult reports, which were uploaded on November 14, 2015 are meant to completely replace prior reports.  These reports provide:

-trend tables with state percents trended across all quarters of the table(s);
-the removal of visual percents from the charts, which prevented clear view of pictorial trends; and,
-complete data as of November 13, 2015 which captures hospital entered data changes and updates through this date.

These same updates will be applied to the Pediatric Reports, which will be uploaded on Tuesday, November 17.

Please be sure to use these most recent reports, as they do capture your most current data for these reported quarters.  Also note the NYSDOH report training held on November 4 was recorded and is available, along with the slides at https://ny.sepsis.ipro.org/ .  You do not need to be logged in to the site to access these training materials.

Questions may be submitted to the helpdesk at sepsis-ny@support.ipro.us

Best regards,
The Sepsis Team

Announcement: Conference Call Materials

• NYSDOH Sepsis Report Training Webinar (November 4th, 2015)
  Recorded WebEx
• Sepsis Report Training (November 4th, 2015)
  PowerPoint Presentation

Dear Colleague,

We regret to inform you that the ADULT reports that were loaded to the Sepsis Clinical Data Portal on October 28, 2015 contained a minor programming error which did not appropriately handle all of your exclusion cases.  Specifically there was a modification in this data report release which looks at the exclusion datetime and time of death to determine if a case should be in the denominator for the three and six hour measures and bundles independently.  For example, patient expiring after 3 hours but before 6 hours would be in the 3 hour measures but not in the 6 hour measures.  This represents a change from prior reports.

On a statewide basis, there were relatively few cases impacted by this change however, individual hospitals with a large number of exclusions would be more significantly impacted.  We are releasing corrected reports for all providers, which ensures that your hospital (with either one or many exclusions) has an accurate report.  The incorrect reports have been removed from the portal and the corrected reports were uploaded today.  Please be sure to discard the incorrect report and use the report ending with today's date (i.e., file name ending in 20151030).  The pediatric reports were not affected by this change.

Also remember to register for the upcoming Report Webinar to be held on November 4, 2015 at 11am.  Register by clicking the following link:
https://iproevents.webex.com/iproevents/onstage/g.php?MTID=eb1e392fdc4777f5d8631a9ccae22a549

Thank you for your understanding.  We apologize for the inconvenience caused by this error.

Best regards,
The Sepsis Team

Dear Colleague,

We are pleased to inform you that your ADULT Hospital-specific Sepsis Data Report is available for download on the New York Sepsis Data Collection Portal at https://ny.sepsis.ipro.org/. If you submitted pediatric cases, your PEDIATRIC Hospital-specific Sepsis Data Report will be available for download on Thursday by 2pm. If you have both adult and pediatric data, you will then have two reports available for download.

The reports are accessible to your hospitals designated portal user(s). He/she may download the report(s) and disseminate the report internally as deemed appropriate at your hospital. Please note that although case level detail is not provided in the report, the aggregated data is still considered confidential information and therefore should be disseminated with care.

This comprehensive report contains trended data and statewide comparison data. The Department is providing a one-hour training to assist hospitals in fully understanding all of the data provided in the report(s). The webinar which will be held on November 4, 2015 at 11am will cover reports in detail including numerator, denominator, and inclusion criteria. During this training, there will not be sufficient time to address questions outside of the reports therefore hospitals should continue to direct other sepsis project questions to the helpdesk at sepsis-ny@support.ipro.us.

To register for the online event:

1. Go to
   https://iproevents.webex.com/iproevents/onstage/g.php?MTID=eb1e392fdc4777f5d8631a9ccae22a549
2. Click Register.
3. On the registration form, enter your information and then click Submit.

Report Access Details:

To access your report(s), start by logging into the sepsis data portal. Once you are logged in click on the "Metrics" link in the top navigation. On that page you will see a list of metric reports that have been made available for you to download. If you did not submit data, a metric report is not available for you to download and you will receive a message stating that you have no metric reports available to download.

If you have forgotten your password to access the sepsis data portal, please click on the link "Reset your password" in the right hand navigation under technical support. If you require access to the sepsis data portal for your hospital, you will need to contact the primary user for your hospital as they have the ability to add users for their hospital. If you do not know who your primary contact is, please submit a ticket to our support desk with the full name of the hospital you are requesting access for along with the PFI number of your hospital as well as your full name. You will then be provided with the contact name within your hospital.

Thank you for your attention to the report(s) and your continued efforts at improving sepsis care. We look forward to addressing your report questions on November 4.

Best regards,

The Sepsis Team

Sepsis: Hospital Exception Reports, Updated Data Dictionary and updates

Data Dictionary for Severe Sepsis or Septic Shock, V2.0:

The Data Dictionary for Severe Sepsis or Septic Shock has been updated to include a change to the data element Excluded Reason, as well as the addition of sub-heading for two variables. Please review the change log on page 87 of the dictionary to be sure you understand the change in detail. For your convenience, the dictionary is attached and is also posted on the sepsis website at https://ny.sepsis.ipro.org/ . There ARE changes to the data codes and values. The change is effective for discharges on or after October 1, 2015.

Hospital-specific Exception Report:

There were cases submitted by several hospital(s) that were either not unique patient records or included overlapping admission and discharge dates. As a result of hospital ability to modified previous data submissions, we have run the exception report for all data submitted to date. If your hospital has cases which have problematic data, an exception report was uploaded to the data portal today. This report lists the cases in error. Data correction and resubmission is required on or before September 30, 2015 to enable quarterly report production in October. Specific instructions for file correction and resubmission are on the sepsis website (https://ny.sepsis.ipro.org/ ). You may log in to the portal, click "Data Submission", then "Corrections Reports" to find and download your exception/correction report. The report is available in PDF format posted within this section.

Data Validation Efforts:

The due date for the submission of records for the data audit was yesterday, September 17, 2015. Please be sure you have met your requirement and have uploaded all of the medical records requested from your hospital.

Quarterly Data Submission Requirement:

As you are aware, hospitals are required to comply with timely quarterly submission of all severe sepsis or septic shock cases. At this time, hospitals have submitted five quarters of data. Unfortunately, there are providers who are not meeting the deadline provided by the Department for data submission. CEOs of non-compliant hospitals will be receiving notification from the Department of Health regarding their non-compliance with this regulation.

Sepsis Protocols:

If you want to submit a revised protocol based upon review of performance data, please do so and please explain what the differences are and why you have changed the protocol. Protocols that have not changed do not need to be resubmitted.

A few reminders:

• Hospitals are to continue to correct cases as needed within the sepsis data portal.
• The next due date for quarterly data is November 30, 2015. Please plan accordingly and report early. You may submit cases in batches or as single cases. Cases can be submitted in batches by the week, month, quarter.

A clarification:

There are two methods in which you communicate with the Department for the Sepsis Project.

• Clinical Data Portal (https://ny.sepsis.ipro.org/ ) {Site for the submission of quarterly cases}
• Hospitals submit data on all severe sepsis and septic shock cases following the Data Dictionary for Severe Sepsis or Septic Shock. Data is due quarterly and all information including the dictionary, data templates, FAQs, recorded webinars, and more are at this site. If you have staff turn-over and/or assign new staff to the effort, you should direct your staff to this site to retrieve both the most current information AND historical project information. You do NOT need to log in to review the materials. You DO need to log in to submit or download reports. There is a primary hospital user and this hospital user assigns secondary users. There is no limit to the number of secondary users but hospitals must remember this site contains your hospital files and protected information. If you change primary users, you must copy your hospital privacy officer in your helpdesk ticket requesting this change.
• Drop Zone {Site for the submission of medical records and other materials related to data validation/audit activities}
• Hospital primary users ONLY received an email invitation to this site and their hospital folder. The Department provided each hospital with Case List of records selected for audit on this site. Upon log in, the user is directed to the folder where the file is located. Hospitals were to download the list and upload the medical records.
• The hospital primary user is permitted to assign a single back-up user to this site. You may request this back up user, if you have not already done this, through the helpdesk. Your hospital privacy officer MUST be copied on the request. You may also email support directly which also creates a helpdesk ticket.

You may consider the Clinical Data Portal as the site for all data submission and reports for clinical cases directly submitted by hospitals. Drop Zone is utilized for all Data Integrity and Data Audit activities, including medical record submission.

Annonucement: Sepsis Data Audit

Dear Colleague:

Effective May 1, 2013 NYSDOH Title 10 New York Codes Rules and Regulations (NYCRR) Sections 405.2 and 405.4 were amended to require that hospitals have in place evidence-based protocols for the early recognition and treatment of patients with severe sepsis and septic shock. Consistent with these regulations, subdivision 7 (i, ii) specified that “medical staff shall be responsible for the collection, use, and reporting of quality measures related to the recognition and treatment of severe sepsis for purposes of internal quality improvement and hospital reporting to the Department."

To help ensure that reported data, which will ultimately be used for public reporting of hospital performance, is both accurate and complete, the Department of Health is using a variety of methods to authenticate the integrity of the data and the reports. As a first step, hospitals were given Data Integrity Reports which analyzed the severe sepsis and septic shock cases reported through the data submission portal to SPARCS. In this second step, the Department has selected a sample of cases from each hospital for medical record review. The information provided in these sampled medical records will be compared to the data dictionary elements submitted by your hospital. Areas of focus may include validation of: correct case inclusion (i.e., ensuring severe sepsis/septic shock case identification); performance; and, date and time validation for protocol and performance.

The Department is working with a team of risk adjustment experts who will use your sepsis data to adjust your mortality rate based upon many factors, some of which include demographics and co-morbidities. It is therefore critical that data validation include an audit of your patient demographics and clinical conditions, including patient severity and co-morbidity(s). The data audit will also look at other important aspects of care such as the appropriate use of exclusions, data elements used to create the measures, and discharge disposition.

This initial audit covers discharge dates from 4/1/2014 through 9/30/2014. A list of cases selected for validation audit has been uploaded to your hospital folder in Drop Zone. In response to hospital requests for electronic acceptance of medical records, we are accepting scanned medical records via your Drop Zone account. Instructions for medical record submission are detailed below. Each requested medical record must be uploaded to IPRO by 9/17/2015. All medical record file names should be identified by PFI (Permanent Facility Identifier), UPI (Unique Personal Identifier) and due date deadline, in the following format: 9999_SMTHEE_09102015.

The complete medical record, including Emergency Department and ICU records, and all demographics, laboratory orders and results, medications, progress notes, transfer information, admission and discharge documentation, must be provided for each requested admission. Please submit any questions regarding this request to the Sepsis Help Desk at sepsis-ny@support.ipro.us. For instructions on uploading your electronic (scanned) medical record for the Sepsis Data Audit, please click here.

Thank you for your continued efforts in providing excellent patient care and for your commitment to accuracy and completeness in your data submissions.

Announcement: Survey

For hospitals who wish to see the questions in advance, a copy of the survey is provided here. After review, be sure to click the survey link and provide your response for your hospital. Please remember that the Department is looking for a single survey from each hospital, even if you are part of a hospital system.

Announcement: Data Integrity Report

The Department will use a variety of methods to authenticate the integrity of the data and to support hospitals in their data reporting efforts. Data Integrity Reports were created which analyze the severe sepsis and septic shock cases reported through the data submission portal compared to SPARCS. Each facility has four reports of findings based on the comparison of your SPARCS data submission with the severe sepsis/septic shock clinical data set. A description of each report as well as instructions for access to the reports is available at https://ny.sepsis.ipro.org/data_integrity_reports. The Data Integrity Report response from hospitals will be due by June 30, 2015. In follow-up to the reports, it is our expectation that hospitals will take two important steps as needed:

1. submit to the Department any new cases they discover that were not previously submitted (or remove cases that were submitted that should not have been); and,
2. review their own process of case identification, diagnostic coding and submission in light of these findings along with making any adjustments needed in order to provide complete and accurate data in accordance with Department requirements for the Severe Sepsis/Septic Shock clinical data as well as for SPARCS.

Sepsis Template 1.41 Updated (2015-02-04)

The dictionary file for collection period 1.41 has been modified to clarify element Hypotension (https://ipro.zendesk.com/hc/en-us/articles/203834284) . No changes are needed to the template file, but the available files are now numbered 1.42. For historical purposes the 1.41 dictionary may be retrieved from here

Sepsis Template 1.4 Updated (2014-12-16)

The template file for collection period 1.4 has been modified to exclude Vascular Access datetime. If you have already downloaded the template file prior to Dec 16, 2014, please re-download from https://ny.sepsis.ipro.org/files/documents/1-4/template.txt

Announcement: Resubmissions / Corrected Data

Self-auditing users who have found errors wish to resubmit data for Measurement Period Jul 01 - Sep 30, 2014 may do so by:

• requesting a deletion of previous data
• re-uploading a corrected submission file

Please note: data submissions must be sent using the correct submission template, which are available from the documentation page. Corrected files received prior to Dec 31 will be incorporated into the next hospital-specific reports (previous reports will not be modified).

Registration

Registration can be performed at any time. Registration can take up to one week to approve, so please be sure to register in advance of the current data submission deadline to ensure access to your account. Click here to register a new account. If you facility is not available to select, your facility already has a Primary User and you will need to contact that person for access to your facility account.

Help and Documentation

Our Help Center contains useful articles on Registration, File Creation, File Submission, and Data Dictionary data elements. You may also send us your questions regarding any of these topics using our Support Request form.

Please note, questions regarding the use of the HANYS or KQMI tools must be sent to their pertinent support channels for assistance, we cannot support these third-party tools directly.