Data: Submission, Dictionary, and Exceptions

Data dictionary

The DATA DICTIONARY FOR SEVERE SEPSIS OR SEPTIC SHOCK, released by Office of Quality and Patient Safety, NYSDOH is a catalog of detailed information about the required data which must be submitted to the Department as per NYSDOH Title 10 New York Codes Rules and Regulations (NYCRR) Sections 405.2 and 405.4. The Dictionary provides specifications such as names, format, meaning, relationships to other data, and structure. Each dictionary(s) aligns with a particular discharge timeframe therefore the dictionary version and specification must be noted prior to data collection and submission.

Data must follow the formatting and structure as defined in the dictionary using the data dictionary template provided for each dictionary. For instruction on uploading cases please click here. High volume hospitals are eligible for sampling . Please click the link to read more about sampling.

What are Exceptions?

"Exceptions" are high level data discrepancies that indicate there was an obvious error in data submission. After your submitted data is received in the sepsis portal at the conclusion of a reporting quarter, each of the cases will be checked for exceptions. Specifically, when any two or more of your cases/records are overlapped by PCN (with different MRN), MRN (with different UPI) or the time interval between admission and discharge, they will be identified and categorized in the exception reports. Exception reports will be disseminated within a week of the close of the reporting period. The exception report is not intended to capture the accuracy of all data elements, only logical mistakes which can be found in simple data scans. An email notice will be sent to all hospitals that have elected to receive sepsis notices when exception reports are released.

What do I do?

Exception reports can be downloaded from https://ny.sepsis.ipro.org/. Facilities are expected to correct their data by requesting a file deletion and re-uploading the corrected data by the due date specified in the exception reports. Hospitals are provided threebusiness days to correct these errors. If these exceptions are not corrected by the due date, these exception cases will be removed from the dataset. In other words, the data for these discrepant cases will not be included in your hospital quarterly report.

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Sample & Weighting

NYS DOH began accepting a sample of adult sepsis cases from high volume hospitals beginning with the January 2017 discharges. A high volume hospital is one that submitted greater than 400 eligible adult sepsis cases to the sepsis clinical database in a prior calendar year (CY). Those hospitals that are eligible for sampling and opt-in will be required to submit select data elements for ALL eligible cases to enable sample selection. The hospital will then be provided with a random sample of cases for reporting, and ultimately will submit data for a total of 400 cases for the reporting CY. Statistical analyses show that 400 cases per hospital are sufficient to estimate hospital-level risk-adjusted mortality rates. Sampling is not applicable to pediatric cases.

Hospitals that elect to sample will have their reported data weighted to appropriately reflect upon statewide performance.

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Measures: Process & Outcome

Measures collected for the NYS Sepsis Improvement Initiative consist of process and outcome measures (i.e, risk adjusted mortality rates).

Process measure details are provided in the measure specifications, which are available for each year of sepsis data collection. Measures Specifications contains the algorithm/calculation used in deriving the rates for measures/bundles in quarterly hospital reports. For different calendar years, different specification documents are listed; therefore, you will want to review the measure specifications for the discharge timeframe under review.

Measures Specifications beginning in 2017 have been fairly closely aligned with CMS. For all measures, the variables and their associated reported values from the Data Dictionary are used. Please note that different measures may have different exclusions/denominators. Not all cases are included in all measures/bundles. For measures initial lactate administration, blood culture collection and antibiotics administration, the denominators are the same: cases not excluded within 3-hour of Severe Sepsis/Septic Shock. These three measures together are the 3-hour bundle.

For measures repeat lactate administration, crystalloid fluid administration, vasopressor administration and fluid assessment, the exclusions/denominators are different, since not all of these measures are applicable to all cases. Details are presented in the Measures Specifications. These measures, in combination with the 3-hour bundle, comprise the composite bundle.

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Quarterly Hospital Report

New York State Severe Sepsis-Septic Shock Data Reports are generated each quarter for each hospital with sepsis cases submitted to the sepsis portal. Adult and pediatric cases are captured in separate reports for each facility.

Reports:

• Are generated quarterly to align with case submission reporting deadlines.
• Capture data submitted to the sepsis portal by the due date of data corrections after exception reports are released.
• Provide measure performance for the hospital and the state that align with the measure specifications for that discharge year.

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Data Audit: Process & Purpose

Data is audited to ensure that the quarterly and annual process measures and the risk-adjusted mortality rates are accurate. In brief, the audit compares the NYSDOH portal submitted hospital data to the patient medical record to determine that the data is accurate. The auditors use the appropriate NYSDOH Data Dictionary, webex materials, helpdesk responses and the relevant CMS Data Dictionary to perform the audit.

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Public Report & Risk-adjusted Mortality

Each annual report presents hospital-reported process measure and outcome data for all adult and pediatric patients with a diagnosis of severe sepsis or septic shock seen at the facility from the second quarter (Q2) of 2014 through the final quarter of the report discharge timeframe. Adult patients are defined as those age 18 years or older, and pediatric patients are those age younger than 18 years. Data in this report are presented through the calendar year of the report to align with risk-adjusted mortality data, which are available for that particular calendar year. Risk adjustment takes into consideration the different mix of characteristics and comorbid conditions, including sepsis severity, of patients cared for within each hospital and permits comparison of hospital performance.

Beginning in 2014, each acute care hospital in New York that provides care to patients with sepsis was required by amendment of Title 10 of the New York State Codes, Rules and Regulations (Sections 405.2 and 405.4)

• To develop and implement evidence-informed sepsis protocols, which describe their approach to both early recognition and treatment of sepsis patients.
• To report data to the Department that is used to calculate each hospital’s performance on key measures of early treatment and protocol use.
• To submit sufficient clinical information for each patient with sepsis to allow the Department to develop a methodology to evaluate ‘risk adjusted’ mortality rates for each hospital.

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Each year, the New York State Department of Health publishes a report of updated data from the New York State Sepsis Care Improvement Initiative. The reports contain results for hospitals' use of sepsis protocols to identify and treat adults and children with sepsis, hospitals' adherence to time-dependent key interventions to treat sepsis, and risk adjusted mortality rates (for adults) for each reporting hospital in New York State (NYS): https://www.health.ny.gov/diseases/conditions/sepsis/#rpts.