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Department of Health

Information for a Healthy New York

Welcome to the NY State Sepsis Data Collection Portal

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Life of a Sepsis Case

Discharge Reporting   |   Data Submission   |   Sample   |   Measures   |   Quarterly Report   |   Data Audit   |   Public Report & RAMR

Overview & Case Reporting

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 make this additional data reporting more user friendly, beginning in 2017, NYSDOH has aligned with select CMS SEP-1 data elements and measures. However, the denominator for the NYSDOH data submission still requires reporting ALL cases that meet criteria for severe sepsis or septic shock INCLUDING cases identified through coding AND/OR other avenues (e.g., concurrent case identification; retrospective review; and so forth).

The hospital is responsible for reporting all diagnosed cases of severe sepsis or septic shock, regardless of billing code designation. Cases diagnosed as sepsis but that do not meet criteria for severe sepsis or septic shock are not to be submitted.

Hospitals must report:

  • Patients in inpatient settings:
    • Includes psychiatric inpatient hospitals and units within hospitals but excludes ambulatory clinics
    • If an ED patient was not admitted, but the patient had severe sepsis or septic shock, then the data is to be reported for this patient
  • The first event of severe sepsis or septic shock for multiple sepsis events during a single admission
  • A single case for patients who are internal transfers from other units within the hospital. Report the full episode of patient care as a single record which depicts complete hospital patient care.

Please note this is not an exhaustive list of all reporting requirements. Refer to the Data Dictionaries for additional information.

Cases excluded from the protocol using an acceptable exclusion reason in the data dictionary must still be reported though the full data capture of all data elements is reduced. If the ED patient had severe sepsis or septic shock but was never admitted, the data would still need to be reported. Admissions to observation alone would also need to be reported.

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Announcements

NYSDOH Sepsis Audit Medical Records Request-Due June 10, 2019

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 be used for public reporting of hospital performance measures and for risk adjusted mortality rates, is both accurate and complete, the Department of Health continues to select samples of cases from each hospital for medical record review. The information provided in these sampled medical records is compared to the data dictionary elements submitted by your hospital. 
This audit covers discharge dates from 10/1/2018 through 12/31/2018. A list of cases selected for validation audit was uploaded to your hospital folder in Drop Zone on Friday, May 10, 2019. Be sure to use the correct medical record request case list (i.e., file ending in 20190510). We are accepting scanned medical records via your Drop Zone account. Your authorized Drop Zone users for your hospital will have access to this case list as well as the ability to upload the medical records. Instructions for medical record submission are detailed below. Each requested medical record must be uploaded to IPRO by 6/10/2019. We appreciate early uploads when convenient for hospitals. All medical record file names must be identified by PFI (Permanent Facility Identifier), UPI (Unique Personal Identifier) and due date deadline, in the following format: (PFI_UPI_DueDate) 9999_SMTHJE1234_06102019.
 
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
 
Some hospitals have expressed an interest in submitting a focused and targeted portion of the medical records that were selected for audit. If you are interested in submitting a targeted medical record in lieu of submitting the entire medical record, please submit a helpdesk ticket and provide your contact phone number so we can discuss this possibility. The targeted medical record would need to include all of the documentation to support the data provided for each data element entered by your hospital in the case data submission to the portal.
 
For more information, regarding drop zone users may refer to the FAQ’s located at:
Thank you for your continued efforts in providing excellent patient care and for your commitment to accuracy and completeness in your data submissions.
 
As previously noted, all sepsis announcements are issued through Constant Contact. This enhancement allows interested parties to manage their inclusion or exclusion for sepsis announcements. If there are colleagues who wish to receive these announcements, please direct him/her to subscribe here.
 
Reminder:
The 2017 Sepsis Public Report is now live. Please see the link below
 
 
Best regards,
 
The sepsis team
 
Posted on: 05/13/2019

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

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 be used for public reporting of hospital performance measures and for risk adjusted mortality rates, is both accurate and complete, the Department of Health continues to select samples of cases from each hospital for medical record review. The information provided in these sampled medical records is compared to the data dictionary elements submitted by your hospital. 
This audit covers discharge dates from 7/1/2018 through 9/30/2018. A list of cases selected for validation audit will be uploaded to your hospital folder in Drop Zone byclose of business today. Be sure to use the correct medical record request case list (i.e., file ending in 20190429). We are accepting scanned medical records via your Drop Zone account. Your authorized Drop Zone users for your hospital will have access to this case list as well as the ability to upload the medical records. Instructions for medical record submission are detailed below. Each requested medical record must be uploaded to IPRO by 5/31/2019We appreciate early uploads when convenient for hospitals. All medical record file names must be identified by PFI (Permanent Facility Identifier), UPI (Unique Personal Identifier) and due date deadline, in the following format: 
 
(PFI_UPI_DueDate)9999_SMTHJE1234_05312019
 
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
 
Some hospitals have expressed an interest in submitting a focused and targeted portion of the medical records that were selected for audit. If you are interested in submitting a targeted medical record in lieu of submitting the entire medical record, please submit a helpdesk ticket and provide your contact phone number so we can discuss this possibility. The targeted medical record would need to include all of the documentation to support the data provided for each data element entered by your hospital in the case data submission to the portal.
 
For more information, regarding drop zone users may refer to the FAQ’s located at:
Thank you for your continued efforts in providing excellent patient care and for your commitment to accuracy and completeness in your data submissions.
 
As previously noted, all sepsis announcements are issued through Constant Contact. This enhancement allows interested parties to manage their inclusion or exclusion for sepsis announcements. If there are colleagues who wish to receive these announcements, please direct him/her to subscribe at: https://visitor.r20.constantcontact.com/manage/optin?v=001tY_bKFFKcKxHMJQ5T58eaQQI5oyK6CBFlgEdDSGqPfLYJ5r7c0CNskxws06xMmB3ivmvHYNBKpEjDKES7L0p_DNV-fjrEiBK5DcZpyc3dJ0%3D
 
The 2017 Sepsis Public Report is now live. Please see the link below:
 
 
Best regards,
The Sepsis Team
 
Posted on: 04/30/2019

NYSDOH Sepsis Adult Audit Reports Released 4/12/2019

Dear Colleagues,
 
The NYSDOH Sepsis Initiative Adult Audit Reports for Quarter 1, 2018 are available and have been uploaded to the sepsis portal under the "metrics" tab today Friday, 4/12/2019.  Note that the reports are not in drop zone where they were posted in the past but are in the portal (where you recently received quarterly reports). These reports contain case level PHI therefore it is important to follow hospital security protocol regarding distribution, sharing, and storing your file.
 
We will hold a WebEx in the coming weeks to review high level results and will send a date and time announcement when finalized. There was a past webinar to review the format and functionality of the tableau reports which was recorded at the time of the event on June 20, 2018. The recording and slides from NYSDOH WebEx of June 20, 2018 are posted to https://ny.sepsis.ipro.org/pages/knowledge_base (under “webinars”). When viewing this recording, please disregard the reference to the Data Dictionary discussion as this refers to a different year of collection but the tableau functionality and format remains the same. There is also a Tableau Users Guide posted.
 
We hope hospitals are able to take full advantage of the case level drill down functionality within tableau but understand that some hospitals prefer to view the data in excel. To extract an excel version from tableau, see slides 36-37 from the presentation or follow these steps:
  • 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
If you cannot unpackage and need assistance, please submit a helpdesk ticket and we will be happy to assist and send your hospital data in excel via drop zone.
 
Also note that you may need to update your free version of tableau to enable best viewing of the reports.
 
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
 
Posted on: 04/15/2019

For all previous announcements, click here.