IPRO FAQs

To make corrections, the entire file you uploaded containing the error must be deleted, and a replacement file including the corrected data is to be uploaded. We cannot correct individual cases. It is vital that you keep your previously uploaded files to help you in this process. We cannot send you your uploaded files.

Step 1. Request file deletion.

Step 2. Await confirmation of deletion.

Step 3. Upload the corrected file.

You can request case deletions for samples, pediatric cases, or adult cases.To do so, click on the "Request a Deletion" menu item under the appropriate data submission navigation menu drop down ('Adult', 'Pediatric', or 'Sampling').

You can also reach this page by clicking on the "Request a Submission File Deletion" link inside of the box at the bottom of the "Exception Reports" page. Please note that this link will take you to the 'Adult' cases file deletion request page. To request a deletion for other case types, please see above.

On this page just use the first drop down selection box to select the file you wish to delete and the second drop down box to verify your previously selected file. You must also include a reason for the request. Clicking on the 'Request a Deletion' button will generate a request for your file to removed from the system:

Metrics and exception reports can be accessed via the portal via the 'Reports' nav menu item:

Do I need to login to the website to get access to sepsis materials?The data dictionary, power points, webinars and more are available without login on the home pagescreen at https://ny.sepsis.ipro.org/.

I am the new coordinator for the sepsis project. How can I get a user name and password?Access to the Sepsis Data Portal is restricted to a main user from your site, who has been approved by your hospitals security/privacy officer. The main user (or administrator) may add additional users at his/her discretion based on hospital privacy practices.

I cannot remember my password to the Sepsis Protocol site?You can reset your password by going to https://ny.sepsis.ipro.org/, click reset password on the home page under support.

Can you tell me who the Health Commerce System (HCS) Account Holder at my site is? For information about your worksite Health Commerce System account, contact the Commerce Account Management Unit (CAMU) at Help Desk 1-866-529-1890 or [email protected].

IPRO staff cannot access your password, nor can we send it to you. If you lose access to your password you will need to create a new one. IPRO staff will never ask you for your password. To create a new password:

Visit https://ny.sepsis.ipro.org.

In the upper right hand corner click on the Forgot your password? link:

On that page you will be asked for theE-mail address you used when you signed up.

After completing your request you will receive an E-mail containing a link that you need to click on to reset your password:

Once you click on that link you will be brought to a page to reset your password requiring the same criteria as registration:

Q: Where do I find DropZone?

A: The sepsis clinical portal and DropZone are NOT the same location. Your DropZone account can be found at: https://mail.ipro.org/enduser/IPRO/en/login.html?v=5501. This link will bring you to the login screen.

Q: How do I add a new user to DropZone?

A: In order to change a primary user or add a back-up user to DropZone (not the clinical portal), the current primary user must send an email to [email protected]. Please include the new user's information (name, email address, and PFI(s) impacted). The facility's privacy officer must be ccd on that email.

In the event that a facility does not have a current primary DropZone user, the privacy officer must send this email on the behalf of the requesting user. When the request is received, the user will receive a system-generated email ("Invitation to the hospital folder") with a link to create a password for DropZone, and the user will then be able to set up an account. The user will also be notified via the helpdesk ticket that this email was sent. Check the spam folder if the email doesnt appear in the inbox.

Q: Is my clinical portal user automatically the same as the DropZone user?

A: No. The clinical portal and DropZone are two separate entities. The clinical portal allows unlimited users, while DropZone only allows a single primary and a single secondary user who must be registered through IPRO. Someone may be a portal user to upload clinical data but may not have access to the DropZone site to upload medical records. If you are unsure who the users are, please send a help desk ticket to sepsis- [email protected]. Also remember that when requesting user changes, specify whether it is for the clinical portal or DropZone and your hospital PFI. Your hospital's privacy officer must be ccd in the helpdesk ticket for the changes to occur.

Q: How can I find the shared Sepsis Project folder?

A: If you only report to IPRO for the Sepsis Project, then when you log in to DropZone, you are already in the shared Sepsis Project folder. You will know you are in the Sepsis Project folder because you can see your audit case list. Upload the complete medical records here for the appropriate cases, and make sure that the files are not password protected. If you report to IPRO for multiple projects, then when you log into DropZone, you will see a list of folders on the left-hand side with the names of each project for which you upload files. Click on the "Sepsis Project' folder, and again, you will know you are in the Sepsis Project folder because you can see your audit case list. Upload the complete medical records here for the appropriate cases, and make sure that the files are not password protected.

Q: What are the instructions for uploading your electronic (scanned) medical records for the Sepsis Data Audit?

A: The instructions are as follows:

Place all of your electronic files of your medical records in a single location.

Log into DropZone https://mail.ipro.org/enduser using the same username (your email address) and password that you previously created. There are only TWO DropZone users per hospital: one primary user and one back-up user. As a reminder, DropZone is the same site where you uploaded your response to the NYSDOH Data Integrity Report.

Once login is successful, you will either already be in the shared folder or you will open that folder (entitled SepsisProject). Review the How can I find the shared Sepsis Project folder? question and answer for clarification, if needed.

The user will now be able to upload files to this folder by clicking on the upload button, located by the right side of the screen.

An Upload Files message box will appear, and you will click the Add button at the top left, as shown below (this allows you to select the location of your files from your computer). Select the file(s) from your file location and click Open. The files will be populated in the window of the message box. After selecting all of your files and when you see those files listed in the box, click Upload (at the bottom right of the message box). All of your files will now be uploaded and listed in your DropZone folder. If successful, you will have then completed submitting your records. Hospitals may upload a single record or multiple records at a time. Please submit your records as soon as possible but before the deadline.

*Be sure to use the proper naming convention for medical records. If records cannot be submitted using DropZone, a copy of the medical record may be faxed to (516) 403-5966. Medical records cannot be mailed or emailed. Each requested medical record must be uploaded or faxed to IPRO by the deadline.

Q: What is the naming convention for medical records?

A: Each record should be identified by PFI (Permanent Facility Identifier), UPI (Unique Personal Identifier), and due date, all to be formatted in the following manner:

9999_SMTHEE1234_03142016.

Q: What is the naming convention for medical records in multiple volumes?

A: In general, the naming convention for all medical record files is PFI_UPI_DueDate. For example:

9999_SMTHEE1234_03142016

In the event that you need to upload the medical records for one patient in multiple volumes, please add numerical or alphabetical notations to the end of the naming convention. For example:

9999_SMTHEE1234_03142016(A)

9999_SMTHEE1234_03142016(B)

Q: I uploaded files into DropZone, and now they aren't here. Why can't I see them?

A: When files are uploaded into DropZone, we remove them from the DropZone server. If you successfully uploaded your files into DropZone and no longer see them there within 24-48 hours, it is because we already removed them from the server. You may submit a helpdesk ticket to [email protected] if you need confirmation of the receipt of your records.

Primary Users may add additional Users in the application interface:

Go to https://ny.sepsis.ipro.org/

Login as a Primary user:

Click on Secondary Users in the top navigation:

Click on the 'Add a New User' link:

Fill out the Secondary user's information:

Barring any errors, you should see a confirmation message and the new Secondary user now listed:This new secondary user willreceive an email at the address they provided during registration with an activation link.

Data Element Name: Insurance Number states blanks are not allowed. Please submit blank ("") for Insurance Number ifData Element Name: Payer = "A" (i.e. Self-Pay) or no insurance number is known. Insurance Number is required if element Payer is Medicare ("C"), Medicaid ("D"), Commercial Insurance ("F"), or Blue Cross ("G").

This will be reflected in version 1.21 of the dictionary, and is considered official for submission of Q2 2014 cases (data submission beginning August 1, 2014).

Go to http://ny.aims.ipro.org/accounts/aims_registration

Enter your email address, password, first name, and last name. Your password must have a length of at least 6.

Select one or more hospitals you will be submitting a policy for.

Click the Submit button.

To submit zero cases for a given reporting period for a hospital, start by logging in:

Once you have logged in, on the right hand side you will see a list of hospitals that you report for, and if any hospital have zero case you will see a the link to take you to attest that you are submitting zero cases:

Once you click on the link you will need to confirm that you are submitting zero cases by click on the the "Attest" button:

After you have successfully attested, you will see a confirmation screen and on the right hand side your hospital that has zero cases will be in green:

You can also click on the 'Attest zero cases for another quarter' link to attest zero cases for a quarter other than the current one:

Clicking that link will bring you to a confirmation page where you can select applicable previous quarters; applicable quarters will have no cases uploaded for them in the portal.

Selecting one of these cases and clicking the 'Attest' button will attest zero cases for the selected quarter.

If you are trying to find a facility to start a case for and no results are being found, you have the ability to add a facility. Attached is the documentation for adding a facility into the CCST system.

Attached below is a PDF guide on how to create a new case for CCST.

Case inclusion

Q: There are times when CMS reporting criteria is not met for a severe sepsis or septic shock case. Are we to report these cases to the NYSDOH portal?

A: Yes. 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, even if they do not meet CMS reporting requirements.

Q: CMS has excluded transfers in from acute care facilities. Is NYS also excluding these cases? If not, will we be able to report on treatment provided at the transferring hospital?

A:The Department is still requiring to report transfer cases (i.e., any admission with severe sepsis or septic shock must be reported). For a few select adherence variables, treatment prior to arrival at your facility may be reported in your data capture. You must follow CMS specifications INCLUDING the requirement to have the medical record documentation in YOUR medical record to support data reporting. Examples are provided in the initial pages of the NYSDOH Data Dictionary v4.1.

Q: If we have a case that does not meet CMS reporting requirements but does meet NYSDOH reporting requirements, what do we use for severe sepsis presentation time or septic shock presentation time? The patient has severe sepsis but has fallen out of CMS reporting.

A: All cases of severe sepsis or septic shock are to be reported to the NYSDOH portal even if they fall out of CMS reporting requirements. In these instances, there will still be clinical documentation that confirms severe sepsis or septic shock. The datetime associated with this clinical confirmation should be reported as the start time.

Q: If a patient is not actually diagnosed for severe sepsis or septic shock, but there is documentation for sepsis, and when abstracting for CMS case meet criteria for severe sepsis, does this case get submitted to NYS?

A: The criteria for reporting cases to the NYSDOH will remain the same as in prior Department reporting. Hospitals are NOT to be using the CMS method of selecting cases and adding DOH data elements to those cases. Only cases of severe sepsis and septic shock are to be reported. Cases of sepsis that do not progress to severe sepsis or septic shock are not to be reported to the NYSDOH.

Q: The CMS-SEP- 1 guidelines for the element severe sepsis present state that viral infections and fungal infections are not acceptable sources of infection. If a viral or fungal source is the only documented source of infection, should these cases be reported?

A: If severe sepsis or shock was part of the patient's final diagnosis (beyond the bacterial vs. viral/fungal infection) then this case would need to be reported to the NYSDOH. All cases of severe sepsis or septic shock are to be reported regardless of the source of infection.

Q: Will those cases from viral or fungal infections be in our denominator?

A: If the clinicians at your facility determined that a patient had severe sepsis or septic shock with only viral/fungal infection source, it would still be in the denominator. The denominator is all severe sepsis/septic shock patients - not all patients with severe sepsis or septic shock except viral/fungal infection sources. That is a filter that CMS chose to apply for infections. However, the NYSDOH did not. So if a clinician determined that a patient has severe sepsis or septic shock and the only source of infection was viral or fungal, it would need to be reported.

Measures

Q: What are the measures now with the revised data dictionary? What is time zero (or start time)?

A: The revision to the measures is currently under development. It is likely that the data will continue to be presented with more than one time zero for the quarterly hospital reports.

Q: Sep-1 is an "all or none" measure. Will the DOH also report this way?

A: The Department will continue to report out individual measures within the bundle to assist hospitals in quality improvement efforts.

Q: CMS requires a repeat lactate within 6 hours if the lactate is > 2. Has the DOH aligned with that or are they still using >4 for the repeat lactate requirement?

A: The Department has not yet released measure details. Therefore, if you repeated your lactate, be sure to report the data in the data collection portal.

Fluids

Q: If there is NO initial hypotension, lactate level is NOT >= 4 mmol/L, and NO documentation of septic shock, would the fluid administration data element be left blank? And if left blank, would the 10 fluid assessment data elements also be left blank?

A: The Adult Crystalloid Fluid Administration data element must be answered (for adult cases). For this data element, if none of the 3 CMS criteria are present (initial hypotension, lactate >= 4mmol/L, or documentation of septic shock), then you would choose option 3 as the answer. The data element must be answered (unless the patient was excluded from the protocol), so option 3 is the most appropriate. Also by choosing option 3, you will not need to answer the fluid assessment data elements.

Q: We provided crystalloid fluids for a patient who did not meet the requirement for fluids (i.e., the patient did not have elevated lactate, hypotension, or septic shock). What is the correct data response? Idon'twant to have to assess fluid responsiveness when fluids were not required.

A: The correct response for the NYSDOH data collection is option 3 = (No) Crystalloid fluids were not initiated prior to, at the time of, or after the presentation of Initial Hypotension, Initial Lactate Level Result >=4 mmol/L, or Documentation of Septic Shock, or unable to determine whether or not they were administered. Though you did provide fluids, you did not provide them for the conditions described. Fluid responsiveness data elements would not be required to be completed for option 3 data values.

Q: How is the Fluid Challenge Performed data element answered if there is no septic shock and therefore no time of septic shock presentation? Since we do not have septic shock what would the time frame be?

A: If a fluid challenge was not performed, then option "2 = (No) " would be chosen. This is 1 of 10 fluid assessment data elements that must be answered if Adult Crystalloid Fluid Administration was answered with option "1 = (Yes) ..." If there was no presentation of septic shock, the time window would default to that which begins with completion of fluids and ends 6 hours after severe sepsis presentation.

Q: If a patient has severe sepsis and receives the correct amount of fluids but does not meet the criteria for septic shock -- what would be the appropriate answer for Crystalloid Fluid Administration? And if the answer is yes and septic shock present is no, would we be required to fill out the fluid assessment data elements?

A: From what you describe in your example scenario, a patient was deemed as having severe sepsis with initial hypotension and thus received the sufficient amount of crystalloid fluids. If so, then you would answer "Yes" for that fluid data element, and the fluid assessment data elements would still need to be answered (yes/no) as being completed or not. These will be required if fluids are reported as given - not just for those with septic shock.

Q: CMS has the one hour post 30 ml/kg bolus as the time period for the assessment for persistent hypotension. Is the DOH planning on hypotension assessment in the one hour post completion of the bolus and not the entire 6 hour window?

A: The assessment of persistent hypotension will be according to CMS specifications.

Q: Since the completion date/time for fluids is no longer required, will the abstractor follow the same guidelines for SEP 1 to determine fluid completion time in order to identify persistent hypotension?

A: The abstraction/reporting of the fluid administration data element will all be according to CMS specifications.

Q: In order to meet the CMS focused exam data element ALL 5 elements under the focused CMS exam have to be documented OR 2 or more elements from hemodynamic monitoring (which includes passive leg raise and bedside echo). Would DOH consider separating them out?

A: The abstraction/reporting of the various fluid assessment data elements will all be according to CMS specifications. Pleases refer to the CMS notes and guidelines. It is possible to provide reporting for each focused exam in quarterly reports, if this is valuable to the provider community.

Timing

Q: How will you handle patients who have all of the sepsis treatments initiated prior to"official" admission? Prior to this, all of the data elements fell out unless date/time was arrival to hospital. Won't that happen with this new guideline?

A: For a few select adherence variables, treatment prior to arrival at your facility may be reported in your data capture. You must follow CMS specifications INCLUDING the requirement to have the medical record documentation in YOUR medical record to support data reporting. Examples are provided in the initial pages of the NYSDOH Data Dictionary v4.1.

Q: With CMS, the date and time of presentation of severe sepsis is based on documentation of severe sepsis or meeting the three criteria, will this apply to DOH determination of presentation of severe sepsis as well?

A: The abstraction/reporting of the severe sepsis presentation data element will all be according to CMS specifications. Please refer to the CMS notes and guidelines.

Please also see above FAQ:

If we have a case that does not meet CMS reporting requirements but does meet NYSDOH reporting requirements, what do we use for severe sepsis presentation time or septic shock presentation time? The patient has severe sepsis but has fallen out of CMS reporting.

All cases of severe sepsis or septic shock are to be reported to the NYSDOH portal even if they fall out of CMS reporting requirements. In these instances, there will still be clinical documentation that confirms severe sepsis or septic shock. The datetime associated with this clinical confirmation should be reported as the start time.

Q: The Antibiotic Administration data element allows a window of 24 hours prior to or 3 hours following the severe sepsis presentation. However, for the Antibiotic Administration Selection data element, the responses only refer to a time window of 3 hours following and does not mention 24 hours prior to. Does this mean that even if an antibiotic was given within that 24 hour window before severe sepsis presentation, wecan'tsay Yes to antibiotic selection?

A: The abstraction/reporting of the severe sepsis presentation data element will all be according to CMS specifications. Please refer to the CMS notes and guidelines.

Q: For Vasopressor Administration, the DOH data dictionary states that this data element must be completed unless the patient was excluded. The time window given by CMS relates to septic shock presentation time. If a patient does not progress to septic shock, our data abstractorsdon'thave a window with which to complete this element. Therefore, if the patient does not have septic shock, can we leave this field blank?

A: No, the Vasopressor Administration data element cannot be left blank (unless the patient was excluded from the sepsis protocol). If the patient did not progress to septic shock, the time window would default to 6 hours after severe sepsis presentation.

Miscellaneous

Q: Will the DOH align with CMS regarding Lactic acid level and platelet levels as this often causes confusion?

A: The Department will still require that the actual value of the initial lactate be reported, as described in the NYSDOH Data Dictionary v4.1. The platelet data element will remain a severity adjustment variable, and it will require a response as to whether the platelet count at the time presentation of severe sepsis was <150,000 cell/mm3.

Q: Please clarify the point about contaminated blood culture collections as not meeting the requirement as reportable. Clinicians may not know about contamination until days after treatment initiates.

A: Failed attempts or contaminated specimens are not allowed to be reported as"collected" for cases reported to the NYSDOH. This is not meant to affect clinician care - this only applies to the reporting of the quarterly data for the NYSDOH.

Q: If there was no delay in collecting a blood culture, how do I answer the Blood Culture Collection Acceptable Delay? According to the data dictionary, we are required to answer this if Blood Culture Collection = 1.

A: If there was no delay in the collection of a blood culture, then an "acceptable delay" did not occur. If an "acceptable delay" never occurred, then there would naturally be no documentation of any "acceptable delay". Therefore, the option stating "No - there is no documentation supporting an acceptable delay in the collection of a blood culture" would be the appropriate selection if a delay never occurred for a blood culture collection.

Q: Why are there no pediatric recommendations regarding use of vasopressors or persistent hypotension?

A:Recommendations now are to start vasopressors if no response to 3 or more boluses of fluids by 1 hour of presentation.

Q: The Department is very interested in continuing to expand upon pediatric measures as clinically relevant and determined by the medical literature. Re: LIP/MD documentation -- does this mean this documentation does not have to be LIP/MD and the abstractor can assess by any documentation?

A: All instructions regarding acceptable documentation for CMS SEP-1 variables will need to be followed as specified by CMS. For other NYSDOH data elements, please follow the usual abstraction processes as noted in the Data Dictionary v4.1.

Q: If protocol was not initiated for a reason (i.e., an excluded case), does a MD or other LIP have to document this?

A: Yes. If a patient met acceptable exclusion criteria, then documentation of that reason by a physician, advanced practice nurse, or physician assistant will need to be present in the medical records. Hospital sepsis management policies were developed consistent with the initial NYSDOH regulations.

Q: Will policies updated to reflect the CMS SEP-1 and revised NYS DOH variables have to be reviewed and approved by NYS DOH?

A: Yes. Any sepsis protocol with significant changes must be submitted for review at https://ny.sepsis.ipro.org.

Q: Do I need to login to the website to get access to sepsis materials?

A: The latest Data Dictionary, PowerPoint presentations, webinars, and more are available without login on the New York Sepsis Data Collection home page at https://ny.sepsis.ipro.org.

Q: I am the new coordinator for the sepsis project. How can I get a user name and password?

A: Access to the Sepsis Data Collection Portal is restricted to a main user from your site, who has been approved by your hospitals security/privacy officer. The main user (or administrator) may add additional users at his/her discretion based on your hospitals privacy practices.

Q: What if Ican'tremember my password to the Sepsis Data Collection site?

A: You can reset your password by going to https://ny.sepsis.ipro.org. On the home page, look along the right side for the Technical Support section and click Reset your password.

Q: If my facilitys sepsis protocol has changed, does it need to be resubmitted?

A: Yes, protocols that have changed should be resubmitted for approval. At any time, your hospital may submit a new adult and/or pediatric sepsis protocol after revision of a current one. Please submit a help desk ticket to let us know that you wish to upload a revised protocol and briefly outline the key differences and reasons for the change. Then follow the instructions for uploading a new protocol, found at:

https://ipro.zendesk.com/hc/en-us/articles/203040444-Uploading-new-protocols-to-the-Sepsis-Data-Collection-Portal

Q: Should all Article 28 hospitals report severe sepsis and septic shock patients?

A: Yes. As per Department regulation, Article 28 hospitals are required to report data for severe sepsis and septic shock patients.

Q: Does the DOH mandate that we report through their data collection site?

A: Yes. The Department requires that this data must be reported via their designated data collection portal.

Q: What do we submit if we do not have cases for a quarter? Are we required to upload a blank file to indicate that we have met reporting requirements?

A: The Sepsis Data Portal website has a section to attest to reporting zero sepsis cases for your hospital for the reporting period. The link for attesting to zero cases is shown below:

https://ipro.zendesk.com/hc/en-us/articles/202898440-Submitting-zero-cases

Q: Within a hospital, who should be responsible for collecting the required data?

A: That decision is left to each hospital. However, in conversation with your colleagues, we have found that many hospitals are working with staff across several departments to collect data (e.g., infection prevention, information services, pharmacists, etc.). For example, the information services department may be able to pull administrative or electronic health record data to assist the clinical department(s) in their efforts to complete all of the required data elements. Other hospitals may be working to modify their healthcare data systems in order to capture all required data elements within their electronic health record.

Q: Will the abstraction tool require clinical judgment, or can it be completed by administrative staff?

A: There is no data collection tool. Data will be collected as a file to match formatting specified in the dictionary. Clinical judgment will certainly be required, although the data may be collected retrospectively, prospectively, or concurrently. Your IT/IS department may need to be involved in regards to extracting the data for transfer as a file. In the dictionary, you will see fields that are patient specific, so there are patient level requirements. It is anticipated that hospitals will find it easier to send all of the cases as a batch file rather than individually uploading each case. More information was provided during the webinar on April 29, 2014, which was recorded. A link to the recorded webinar is available at https://ny.sepsis.ipro.org. This and any other available materials are accessible to view and/or download without needing to login.

Q: For alphanumeric fields (e.g., 15), do we left pad with spaces, or do we simply submit upto 15 characters?

A: Submit up to 15 characters. There is no left padding.

Q: Will the Department provide a grid for chart abstraction? Will CSV files be accepted?

A: Data will not be collected using form or grid methods but will be accepted using more current data collection methodologies, such as NHSN data submission. Data will be accepted as a standard data file (e.g., a CSV file) which may be submitted as a batch of data or as a single case upload.

Q: Will hospitals be provided a snapshot of the data collection tool used to submit data for the sepsis initiative? Will we be submitting patient level results on every patient for each data element in the sepsis data dictionary or aggregate data?

A: There is no data collection tool, per se. Data will be collected as a file to match formatting specified in the data dictionary. Yes, the Department is collecting patient level data which is not to be aggregated by the hospital prior to submission.

Q: Will DOH/IPRO be creating a new report from our corrected data if we identified an error?

A: Data submissions are "frozen" at set times for report production of quarterly results. Therefore, prior quarterly data will not be recalculated. However, aggregated cumulative data (e.g., year to date, annual, etc.) will capture corrected data. It is important that corrected data be submitted as soon as possible since cumulative aggregate reporting will include these corrections.

*Please note that as of August 6, 2016, all reported data for discharges dated prior to January 1, 2016 (i.e., data for calendar years 2014 & 2015) were frozen. Therefore, corrections to the 2014 or 2015 data will not be accepted.

Q: How do I collect data? HANYS had a free tool but are now selling the sepsis tool. Are we required to purchase the HANYS data collection tool to submit hospital data?

A: The NYSDOH accepts data as a flat file that aligns with the specifications in the data dictionary and the data template. These are free resources available to all hospitals and posted on the portal website. You may create your flat file in many ways. Some hospitals have their information technology departments pull the data elements that can be captured electronically and provide that file to hospital staff who then capture the remaining data elements via excel or some other program. Some hospitals have created screens to capture all of the data right in their EHR. Other hospitals have chosen to use a HANYS tool. The HANYS tool is not required nor is it a Department tool or endorsed by the Department. However, we are aware that HANYS has created this tool to assist hospitals in their data capture and they have designed the tool to meet reporting specifications.

Q: You use 'sepsis' at times. Is the intention 'severe sepsis and septic shock'?

A:Yes.

Q: What is the clinical source reference defining 'Severe sepsis/shock'?

A: There are many clinical sources that are widely available including the 'Surviving Sepsis Campaign' (see Dillinger, RP et al. Surviving Sepsis Campaign: International Guidelines for Management of Sever Sepsis and Septic Shock: 2012. Critical Care Medicine 2013; 41(2): 580- 637).

Q: Can the Department provide clinical guidance or advise on specific cases?

A: No. Hospitals should consult with their clinical staff for guidance on clinical determinations.

Q: Will the Department provide a list of broad spectrum antibiotics?

A: Hospitals should consult with their clinical staff for guidance on broad spectrum antibiotics.

Q: Are there any lists of medications that we need to refer to regarding Immune Modifying Medications?

A: Hospitals should consult with their clinical staff for guidance on lists of medications.

Log in to the site at http://hcv.aims.ipro.org/

Click on "Manage Policies" in the top navigation.

ON this page you can upload up to 3 policy documents. To upload a document select the Browse button under each Policy Document Number.

Once you have selected all of the documents you wish to upload. Click the Upload button.

2014 Births-Phase 1 Perinatal Care Provider Reporting Aggregate Results

From December 2015 through February 2016, 48 practices participated in the first phase of reporting for 2014 births in the Medicaid Perinatal Care Quality Improvement Project. New York State Medicaid members delivering infants in 2014 were attributed to the practice providing the majority of their prenatal care; practices were asked to review the medical records of a random patient sample supplied by the NYSDOH. A total of 879 reviews were submitted.

Analyses of aggregate data were conducted by IPRO on behalf of the NYSDOH Office of Quality and Patient Safety; the results are displayed in the slide presentation 2014 Births-Phase 1 Perinatal Care Provider Reporting Aggregate Results. The link below opens a copy of the slides presenting statewide data received from 2014 Births-Phase 1 reporting providers.

IPROdoes not offer abstraction tools for this program, only the upload and validation process.

NSLIJ abstractors should use https://kqmi.northshorelij.com/QMLOGIN/

Facilities must submit flat, delimited text files for validation. Header rows are requiredfor submission. If you choose to use Excel to enter your data, please see https://ipro.zendesk.com/hc/en-us/sections/200523960-File-Creation

Please note:

Data elements are to be delimited with semi-colon ;

All elements are to be enclosed with double quotes " " including numeric fields and blanks

Composite data elements are delimited with a colon :

One case per line

Example

"unique_personal_identifier";"patient_control_number";"date_of_birth";"gender";"race";"ethnicity";"payer";"insurance_number";"medical_record_number";"facility_identifier";"admission_datetime";"source_of_admission";"discharge_datetime";"discharge_status";"protocol_initiated";"protocol_initiated_place";"protocol_type";"excluded_from_protocol";"excluded_reason";"excluded_datetime";"excluded_explain";"earliest_datetime";"triage_datetime";"protocol_datetime";"vascular_or_interosseous_access_datetime";"left_ed_datetime";"destination_after_ed";"lactate_reported";"lactate_reported_datetime";"lactate_level";"lactate_level_unit";"lactate_reordered";"lactate_reordered_datetime";"blood_cultures_obtained";"blood_cultures_obtained_datetime";"blood_cultures_result";"blood_cultures_pathogen";"antibiotics_given";"antibiotics_start_datetime";"adult_fluids";"pediatric_fluids";"fluids_completed_datetime";"fluid_assessment";"hypotension";"vasopressors_given";"vasopressors_given_datetime";"cvp_measured";"cvp_measured_datetime";"scvo2_measured";"scvo2_measured_datetime";"platelet_count";"bandemia";"lower_respiratory_infection";"altered_mental_status";"septic_shock_diagnosis";"infection_etiology";"site_of_infection";"mechanical_ventilation";"mechanical_ventilation_datetime";"icu";"icu_admission_datetime";"icu_discharge_datetime";"chronic_respiratory_failure";"aids_hiv_disease";"metastatic_cancer";"lymphoma_leukemia_multiple_myeloma";"immune_modifying_medications";"congestive_heart_failure";"chronic_renal_failure";"chronic_liver_disease";"diabetes";"organ_transplant""TESTXX1234";"99999";"19700101";"M";"46";"5";"C";"1111";"2222";"0777";"2014-01-01 08:00";"4";"2014-01-02 13:00";"01";"1";"1";"1";"0";"";"";"";"2014-01-02 08:00";"2014-01-02 08:15";"2014-04-10 08:15";"2014-01-02 08:30";"2014-01-02 12:00";"2";"1";"2014-04-02 09:15";"8.0";"1";"0";"";"1";"2014-01-02 09:00";"1";"4";"1";"2014-01-02 09:00";"1";"9";"2014-04-02 11:00";"3:4";"0";"1";"2014-01-02 11:00";"0";"";"1";"2014-01-02 11:00";"1";"0";"0";"1";"1";"1";"4";"0";"";"1";"2014-01-02 12:00";"2014-01-02 13:00";"1";"0";"0";"0";"0";"1";"1";"1";"1";"1"

If my protocol has changed, does it need to be resubmitted?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.

Submit a helpdesk ticket to let us know that you wish to upload a revised protocol.

Q: What does 15 th Percentile based on statewide distribution mean?A: This represents the minimum value in order for that variable to pass validation, and its based on the statewide performance for each individual variable (e.g. Protocol Datetime, Blood Cultures Obtained, Bandemia, etc.). A variable then passes validation if the Percent Valid is equal to or greater than the 15 th Percentile value.Q: How can Fluids Completed Datetime be determined? Can we use the IV rate and the administration time to calculate this?A: The Fluids Completed Datetime is determined by several factors:

First, the weight of the patient (in kg) is located in the medical records. Using the required rate of 30ml/kg, the total fluid volume necessary for infusion is calculated (or the pediatric required volume is calculated).

Then, the clear documentation of start AND completion times for that amount of fluids is needed to answer that At least 30ml/kg crystalloid were given (or the pediatric required amount).

Using only the IV rate and administration time (i.e. start time) to guesstimate fluids completed is not appropriate.

If start times are documented for what would have been a sufficient number of fluid bags and if stop times are lacking for some or all, then the correct response would be "Volume of fluids given is unknown."

Documentation such as 2 liters of NS given or 3000ml administered are not considered appropriate documentation for fluids given. The start and completion times for those fluid bags are required.

Q: Can you clarify Lactate Reported Datetime and Lactate Re-ordered Datetime?A: Lactate Reported Datetime This is the date and time that the lab result is reported for the first lactate level associated with the severe sepsis or septic shock episode. This is not when the sample is drawn, collected, sent to the lab, etc. Lactate Re-ordered Datetime This is the date and time that the second lactate is re-ordered.Q: How did the reviewers determine the validity of Protocol Datetime?A: Each hospital submitted a sepsis protocol for approval, and that approved protocol outlined how each facility would initiate their protocol. Based on what was said in the hospitals protocol, the reviewers then examined the medical records to see if a matching clear date and time of protocol initiation was be found in the documentation.Q: In the absence of clear documentation of sepsis protocol initiation, how do we determine a sepsis protocol start time?A: The protocol is reported as not initiated if thereisn'tclear documentation that aligns with your hospital protocol start time.Q: If I see elements of the protocol (lactate, antibiotics) being started but the sepsis protocol order set is not initiated, can I just use the date and time of one element as protocol initiation?A: The start of a protocol is designated within the individual hospitals sepsis protocol. In the absence of clear documentation that supports what the hospital's sepsis protocol states, then the protocol is reported as not initiated. However, the data for those individual patient care elements should still be reported.Q: I reviewed our audit results, and Ican'taddress any issue unless I know what the auditors found and why items were marked invalid. Can I get a list of what the auditors found? Can we discuss these findings?A: Individual case results will not be discussed, and auditor findings will not be provided. The purpose of these audits was to help facilities identify areas where data abstraction and reporting may need to be addressed.Q: We have items that were submitted and found in the audit to have failed. However, we can find in our EMR where those items are valid. Do we have to change anything if we disagree?A: If you find that your data is correct according to your records, you would not resubmit the data. Be sure when medical records are requested for audit that the complete medical record is submitted AND, is legible and documented well. If you have data to correct, you will need to request that the entire file which contains the case(s) is deleted and then resubmitted with corrections also resubmitting the correct cases. Please see FAQs on file correction if you are uncertain of the processQ: Can I use the intubation time for Mechanical Ventilation Datetime?A: Yes. The intubation datetime must be that which is specifically associated with the initiation of mechanical ventilation for the patient. Any type of mechanical ventilation (invasive or noninvasive) is acceptable, except CPAP or BIPAP that is used specifically for sleep apnea. An order date/time for mechanical ventilation is not acceptable.Q: What if the patient arrives in the ED and is already receiving and continues to receive ventilation support?A: The arrival date and time would be used for Mechanical Ventilation Datetime.Q: Does the route of administration matter for broad spectrum antibiotics?A: No. The Data Dictionary does not specify a required route of administration.Q: I can see clearly in the order history the dates and times for blood cultures, antibiotics, etc. However, these items were marked as invalid. Why is that?A: It is not the order datetimes that are to be reported.

For blood cultures, the datetime that the blood culture was drawn or collected is to be submitted. If cultures are ordered as a set, then the first datetime for blood culture collection is reported.

For broad spectrum antibiotics, the date and time that the antibiotic was administered is to be submitted and not the time that the order was verified. Please bear in mind that other words may be equivalent to administered, such as given, started, or performed.

The order history alone would not be sufficient to provide such data.

Q: From what I understand, the earliest and triage times were only to be filled out for patients with sepsis protocols initiated in the ED. Otherwise, these fields could be left blank. Thats what we did, but on our audit report, we have numerous invalids for earliest and triage. Why is that?A: As discussed in the WebEx presentation, the Earliest and Triage Datetimes could be left blank if no protocol was initiated in the ED. However, those fields were abstracted, and that would explain those invalids. As such, attention and resources should be directed at any other variables that did not perform well.Q: Is the triage time asking for when the triage is started or completed?A: The Triage Datetime is referring to the start or initiation of the triage assessment process in the ED.Q: We receive severe sepsis/septic shock patients as transfers from another facility. If the sepsis protocol was initiated at the other facility, we may not repeat elements of the protocol when clinically not necessary. This may result in adherence variables not being completed on our end. How do we handle this?A: The treatment that is provided at your facility is what you would report and not what was done at the other facility. For transfer patients, make sure to label those cases as such in the admission or discharge status and transfer status variables.Q: Will the audit results change our data for public reporting?A: No, the audit and validation process did not change what was reported by the hospitals. The results of the audit were to aid each facility in identifying areas for correction and improvement. It is up to each facility to take the audit results and assess how to address process improvements, if needed.Q: What section or portion of the medical records did the auditors examine in validating the variables?A: The entire medical record that was submitted by each hospital was reviewed during the audit.

Our hospital uses an EMR that collects both Date/Time of Death and Date/Time of Discharge. In some cases these do not match. Which time should we report for the Discharge Datetime variable?

Hospitals are directed to report the date/time of death if this is earlier than the administrative discharge date.

Are standing orders needed to be able to answer "yes" to initiation of protocol? If a standing order is the initiation of your protocol, then yes, the standing order would be needed.

What do you enter if the initial IV was started in the field for patients transported via ambulance? The protocol would start at the time the patient arrived at the Emergency Room.

What does "at the time of the sepsis protocol" refer to? The time frame "at the time of the sepsis protocol" refers to when the protocol is started.

If we have both the ED arrival time and the triage time, which should we use? Both time elements should be reported in the dictionary for their respective data element fields.

If an ED patient was not admitted, should the data be included? Yes, if the patient had severe sepsis or septic shock then the data is to be reported for this patient.

Specifically, what constitutes "initiation" of a protocol? First lactate, IV bolus? Hospitals determine what constitutes the initiation of their protocol.

Do we report the 1st lactate or, the 1st lactate >=4? The first lactate is to be reported.

If a lactate was reported in the ER several days prior to admission, do we report the ER lactate as the first lactate? The lactate to be reported is the first lactate associated with your sepsis protocol.

Do we include antibiotics given prior to the identification of severe sepsis?

See the Data Dictionary for the data element Antibiotics Given. Use the values to specify if you gave antibiotics prior to or post initiation of the sepsis protocol.

What do you enter if the protocol was not started in the ED? If the protocol was not started in the ED, then the data element Earliest Time and Triage Datetime will be blank. The data element Protocol Datetime will be completed by the hospital, as it is not limited to the ED.

What if normalization of BP, or other technologies, is used to evaluate response to fluid resuscitation? Is this considered clinical judgment? What is the timeframe for determining responsiveness? Yes, this is a clinical judgment. The timeframe for determining responsiveness may be detailed in the hospital protocol.

If vascular access is obtained in the ambulance, is the time reported as 'arrival to ED', similar to the protocol initiation time? The actual time of vascular access should be reported. The actual time of protocol initiation should be reported.

Why was the timeline for blood culture (data element 'Blood Cultures Obtained') set at 24 hours prior to protocol initiation and up to 48 hours post?

This was established to be consistent with current practice guidelines including CDC NHSN strategies for identifying when a positive blood culture is related to the specific infectious episode and Surviving Sepsis Campaign definitions.

Is the date/time of blood culture "obtained," the time blood cultures were drawn or the time when the result was obtained? Report the date/time when the blood cultures were drawn. Blood cultures should be obtained prior to antibiotic administration and within 3 hours of protocol initiation. Blood cultures can be reported for the period up to 24 hours prior to initiation of the protocol to 48 hours after initiation of the protocol.

One co-morbidity variable states "Indicate if the patient was admitted to the Intensive Care Unit (ICU)." Is this at any time during hospital stay or only at the time of admission? Indicate if the patient was admitted at any time during the stay and specify the date and time in the 'ICU Admission Datetime' data element.

How do we report multiple sepsis events during a single admission?

The first event of severe sepsis or septic shock is to be reported.

Will DOH/IPRO be providing clarification in the dictionary surrounding the timelines? For example, Lactate Reported Date/time is the date the first lactate level was reported by the lab, meaning the very first lactate versus the lactate at the time of the severe sepsis/ septic shock event? Can this apply to all adherence measures? Unless specified differently in the variable description (e.g., blood cultures) the reporting period relates to treatment events in the 3 and 6 hour bundle periods. All reported adherence measures are to be reported for the severe sepsis or septic shock episode.

For the timely crystalloid administration treatment variable, can you please clarify whether you are looking at patients who were administered 30 ml/kg of crystalloid within 3 hours or 6 hours of time of presentation? Typically 20-30 ml/kg is given during the 3 hour bundle for empiric fluid loading. Is DOH only measuring for the initial fluid resuscitation which usually occurs in the 3 hour bundle? If there are subsequent boluses given in the 6 hour bundle which exceeds the 30 ml/kg being measured, should the latest end time be entered instead? Please clarify. Timely crystalloid administration is reported as adult patients who were hypotensive or had an elevated lactate, severe sepsis or septic shock who were administered at least 30 ml/kg of crystalloid within 6 hours of protocol initiation.

Please clarify the exclusion of newborn/infant in the NICU who was not previously discharged from initial hospital stay. Go to https://ny.sepsis.ipro.org/ and on the left side of the screen under "documents" there is a protocol guide and the exclusions are listed on pages 7-8. It is not necessary to login to the site to download these materials.

Do we collect data on patients excluded from the protocol? Yes. If any of the adherence elements were applied the data would be collected. In addition, all demographic, co-morbidity, and severity variables would be reported.

Regarding fluids, when a patient has renal failure or heart failure and we cannot give 30 ml/kg what do we do? In institutions not following invasive protocol we cannot perform 6 hour bundle - does this reflect as non-compliance? Several 'Clinical Contraindications' are present in the data dictionary related to IV or IO fluids. If the patient meets one of these criteria that exclude his/her from being treated according to your institution's severe sepsis/septic shock protocol, you should still record data for any components of the protocol they may have received. In addition, all demographic, co- morbidity, and severity variables would be reported. These patients will be included in all outcome measures. The Department has not yet determined whether they will or will not be included in adherence measures.

If patient has a DNR, is the case excluded? Do we need to submit any data on the case?

If the patient has advanced directives or a DNR in place prior to (or at) the development of severe sepsis or septic shock that preclude one or more elements of the protocol then the protocol is not reported. All demographic, severity, and co-morbidity data elements are still required to be reported for the patient.

Regarding clinical contraindications and protocol exclusions:

Does the chart have to have a written statement that the "the patient has end stage renal disease or congestive heart failure and is excluded from the sepsis protocol?"

If the patient is a known hemodialysis patient, would they then be excluded based on history?

If the chart shows that the patient is in decompensated heart failure, could I exclude this patient? Of course, I would still enter all interventions and results that were done during the course.

If it is a written statement that is required, could it be documented in the discharge summary or does it need to be during the window?

Several 'Clinical Contraindications' are present in the data dictionary. If the patient meets one of these criteria and there was clear documentation in the record at the time of treatment for severe sepsis/septic shock that they were excluded from your institution's protocol as a result of this contraindication, you should document that contraindication in this section. However any other protocol interventions that were applied should be documented in appropriate sections and all demographic, co-morbidity, and severity variables would be reported.

If a patient meets criteria for more than one exclusion i.e., 'Interventions clinically contraindicated' and 'Patient has advanced directives in place that precluded one or more elements of the protocol', which exclusion should be reported. The Data Dictionary (Version 1.41) has been modified to permit reporting more than a single exclusion.

Aminor change has been madeto the Sepsis Data Dictionary 1.41 as a result of hospital feedback and a need for clarification. The data element Hypotension has beenmodified to capture reporting when a patient does not have hypotension.

The change is as follows:

(v 1.41) Hypotension Code 2= No hypotension or elevated lactate

now reads

(v 1.42) Hypotension Code 2 = No hypotension

This change will not require a change to thedata template. The template has been renumbered to 1.42, but no changes have been made to the file. Users may continue to use template 1.41 if so desired.

This change is effective for discharges on or after January 1, 2015.

Version 1.41 is no longer listed as official documentation, but can be retrieved fromhttp://ny.sepsis.ipro.org/files/documents/1-41/dictionary.pdf

Cases excluded from the sepsis protocol due to a clinical contraindication report the reason for exclusion using one or more of the 'Excluded Explain' values listed in the Data Dictionary. Based on feedback from providers and advice from Sepsis Advisory Committee experts, the descriptors for code value "1" has changed.

v1.2 definition: 1 = IV or IO fluids (acute, decompensated congestive heart failure)

v1.21 definition: 1 = IV or IO fluids (acute, decompensated congestive heart failure, pulmonary edema and LVAD)

This will be reflected in version 1.21 of the dictionary, and is considered official for submission of Q2 2014 cases (data submission beginning August 1, 2014).

Log in to http://hcv.aims.ipro.org/

Click on "Secondary Users" in the top navigation.

Click on "Add a New User".

Enter the secondary users's email address, first name, and last name then click on the Submit button.

PFI is a Permanent Facility Identifier administered by the NYS Department of Health.

You can find your PFI by locating your facility on http://hospitals.nyhealth.gov/ - your PFI is listed on the "Overview" tab.

To confirm a PFI, simply add it to this URL http://hpo.ipro.org/browse_view.php?pfi= and double check the facility that loads.

Example:http://hpo.ipro.org/browse_view.php?pfi=0001

You can also find a NYS PFI listing here:

http://www.health.ny.gov/statistics/sparcs/reports/compliance/alpha_facilities.htm

Element Source of Admission modified to include codes "A" and "D"

A=Transfer from a Rural Primary Care Hospital. The patient was admitted to this facility as a transfer from a Rural Primary Care Hospital (RPCH) where he or she was an inpatient.

"D=Transfer from One Distinct Unit of the Hospital to another Distinct Unit of the Same Hospital Resulting in a Separate Claim to the Payer. Inpatient: The patient was admitted to this facility as a transfer from hospital inpatient within this facility resulting in a separate claim to the payer.

This will be reflected in version 1.21 of the dictionary, and is considered official for submission of Q2 2014 cases (data submission beginning August 1, 2014).

What ICD-9/DRG codes are to be included to identify patients? Is this primary discharge diagnosis or any diagnosis? The Department is not specifying which codes would be included. Any patient diagnosed with severe sepsis or septic shock discharged within the reporting quarter should be reported regardless of coding/DRG assignment.

Determining the difference between severe sepsis and septic shock in pediatric patients is not always possible. Pediatric patients should be categorized as having septic shock when you are unable to differentiate between the two.

What is the expectation for the receiving hospital for reporting on patients transferred with sepsis 'present on admission', from both another ED or as a direct inpatient hospital transfer? Both the transferring and receiving hospitals are responsible for collecting and reporting the variables, including demographics, adherence, severity adjustment and co-morbidity variables. Data from both institutions will eventually be linked for outcomes and adherence measures reporting. It is understood that the hospital may not have data on all elements but is expected to report on the data that is available for each hospital.

Can lactate be reported in mEq/L units? No, data will be reported using one of the specified units in the data dictionary.

Do we need to report out of state transfers? Yes. Instructions on reporting out of state transfers are contained within the data dictionary.

What source of admission is Assisted Living?

Non-Health Facility Point of Origin

When DOH states "all cases are to be reported on", are they referring to all cases coded on discharge as sepsis/severe sepsis OR cases with an admission working diagnosis of sepsis? The hospital is responsible for reporting all diagnosed cases of severe sepsis or septic shock.

For the bandemia data element within the severity adjustment variables, can you please confirm why the bandemia is 5% and provide reference to the relevant literature for our hospital? The bandemia element is one component of the Mortality in Emergency Department Sepsis (MEDS) score and has been used in various studies for the creation of risk adjusted mortality associated with sepsis. Shapiro NI, et al. Mortality in Emergency Department Sepsis (MEDS) score: a prospectively derived and validated clinical prediction rule. Critical Care Medicine 2003; 31(3): 670-675.

Why are we collecting data on obvious answers such as low platelets associated with sepsis? Several data elements are captured to determine severity adjustment values.

What if the protocol was never ordered but elements were addressed i.e., fluids, antibiotics but not lactate? Would I answer No for the protocol and enter the variables? Correct, you would enter "NO" for the protocol and would report data elements which were addressed.

Does their need to be clinical documentationsupporting why the protocol was not initiated? Yes.

If protocol was started in the ED and following day, patient was made comfort care, do we answer "patient excluded from the protocol"? No. Exclusion criteria need to be in place at the time the protocol would have been initiated.

Is Altered Mental Status the 1st assessment or after the protocol initiated? The variable reports a difference in mental status at time the protocol is initiated, as compared to the patient's baseline.

In reference to the "Site of Infection" variable, if there are more than one suspected or diagnosed sites of infection, should code 7 be selected?

No, the most likely source of infection should be chosen. If the site of infection cannot be determined then choose 7=Unknown.

Does mechanical ventilation include NPPV or only invasive mechanical ventilation? What if patient arrives on a vent or has a history of mechanical ventilation? Include all types of assisted ventilation except CPAP or BiPAP for sleep apnea.

If the patient is from a nursing home, is the severe sepsis/septic shock categorized as "hospital acquired" consistent with pneumonia measures? If a patient arrives at a hospital with severe sepsis or septic shock then the condition was not hospital acquired.

How do we report steroids as dosage/type can vary for acute or chronic conditions? Clinical judgment should be used.

Is Hepatitis B or C without liver failure included in the liver co-morbidities? What about acute vs. chronic liver failure? Chronic liver disease as a co-morbidity is detailed in the data element 'Chronic Liver Disease'.

If a severe sepsis diagnoses was made intra-op, how do we submit this? The severe sepsis or septic shock protocol should still be initiated and all variables reported. Any specific concerns can be addressed through Help Desk support.

Transfer Facility can be identified by

New York State PFI

Federal ID

State Code (for transfers from other parts of the United States not including New York State)

Country Code (for transfers from international sources)

Wherever possible submit the transfer facility PFI. A list of New York State Permanent Facility Identifiers can be found at:

- https://www.health.ny.gov/statistics/sparcs/reports/compliance/pfi_facilities.htm

(In your Web browser, use CTRL+F to search the page)

If the transfer facility is not listed, it may be a federal entity, in which case please see:

- https://docs.google.com/a/ipro.us/spreadsheets/d/1yqRmyhOsNdDa4anxgug2jRqUXwhaK0x32G9-A8ItDH0/edit#gid=0

If the transferring facility is not in New York State please submit the two digit FIPS State Numeric Code(see table below)to represent the transfer facility state. This is ONLY to be used when patients are transferred in/out of state therefore the code for New York will not be accepted for data submission.

If the transfer facility is not listed on anyof these sources, and is an acute care hospital, please submit a ticket with the full name and state of the transferring acute care facility.

If the transfer facility is located outsidethe United States and is an acute care hospitalrefer to https://en.wikipedia.org/wiki/ISO_3166-1#Officially_assigned_code_elements for the ISO alpha-2 code and submit the two letter country code.

Name

FIPS State Numeric Code

Alabama

01

Alaska

02

Arizona

04

Arkansas

05

California

06

Colorado

08

Connecticut

09

Delaware

10

District of Columbia

11

Florida

12

Georgia

13

Hawaii

15

Idaho

16

Illinois

17

Indiana

18

Iowa

19

Kansas

20

Kentucky

21

Louisiana

22

Maine

23

Maryland

24

Massachusetts

25

Michigan

26

Minnesota

27

Mississippi

28

Missouri

29

Montana

30

Nebraska

31

Nevada

32

New Hampshire

33

New Jersey

34

New Mexico

35

New York

UNACCEPTED

North Carolina

37

North Dakota

38

Ohio

39

Oklahoma

40

Oregon

41

Pennsylvania

42

Rhode Island

44

South Carolina

45

South Dakota

46

Tennessee

47

Texas

48

Utah

49

Vermont

50

Virginia

51

Washington

53

West Virginia

54

Wisconsin

55

Wyoming

56

If a hospital chooses the multiple race code (MR = multi-racial), are they also to select the appropriate codes for each race in that same field or simply leave it as MR? For example, should it be MR:01:41?

The file can contain any permutation of the listed codes. In this case, "MR", "MR:01:41", or "01:41" would all be accepted by the portal.

Instructions for uploading your electronic (scanned) medical record for the Sepsis Data Audit

Place all of your electronic files of your medical records in a single location.

Log into Drop Zone https://mail.ipro.org/enduser/ using the same username (your email address) and password that you created previously. There are only TWO Drop Zone users per hospital: a primary user and one back-up hospital user. As a reminder, Drop Zone is the same site where you uploaded your response to the NYSDOH Data Integrity Report.

Once login is successful you will open the shared folder (entitled SepsisProject).

User will now be able to upload files to this folder, by clicking on the upload button on the right side of the screen.

The following box opens and you will click the Add botton in the top left of the box as shown below (which allows you to select the location of your files from your computer). Select the file(s) from your file location and click open. The files will be populated in the window. When you see all of your files listed in the box, click upload (within the bottom of that same box as shown below). All of your files will now be shown/listed in your Drop Zone folder and you will then have completed submitting your records.

Hospitals may upload a single record or multiple records at a time. Please submit your records as soon as possible but before the deadline.

Be sure to follow file naming convention:

Each record should be identified by PFI (Permanent Facility Identifier), UPI (Unique Personal Identifier) and due date deadline, in the following format: 9999_SMTHEE_09102015.If records cannot be submitted by Drop Zone, a copy of the medical record may be faxed to (516) 403-5966. Medical records cannot be emailed or mailed. Each requested medical record must be uploaded or faxed to IPRO by 9/17/2015.

Once you have logged in as a registered user, you will have the option to upload cases using the supportedfile format.

You are free to upload as many files as you need, however, each file must contain unique cases. Any file you upload that contains a case already reported for your account will be rejected in its entirety. You will need to remove that case and resubmit the file.

If you choose to upload for multiple facilities, you may find it helpfulto separate the cases into facility-specific files, however, you are also free to combine them or group them in any manner that best serves your organisation.

You may upload cases throughout the submission period. There is no limit to the number of files or number of cases.

We urge you to retain all files submitted. We do not keep your files, they are destroyed as soon as they are validated. The data is stored separately. We cannot send your files back to you.

Once the portal is open, a servicewill be available to request deletion of inaccurate data.

Once logged in, click on 'Data Submission', followed by 'Submit File' found on the top navigation bar.

The current measurement period is automatically selected. If you are submitting data using a previous dictionary/template, please select the correct measurement period for uploading from the drop down box shown.

Hit the 'Browse' button to open up a file select dialog. Select the .csv or .txt file containing one or more rows of sepsis data and click 'OK'.

The name of the file you selected should appear next to the 'Browse' button. Click the 'Upload' button to upload the file.

Should all Article 28 hospitals, psychiatric facilities and clinics report patients? All hospitals should report patients in inpatient settings. This includes psychiatric inpatient hospitals and units within hospitals but excludes ambulatory clinics.

What variables will be used for risk adjustment and co-morbidity (e.g., age, race, etc)? We will be using a number of demographic variables, in addition to the severity and co- morbidity variables as defined in the dictionary. The risk adjustment model will be shared at a later date.

For alphanumeric fields (e.g., 15) do we pad with spaces or simply submit UP to 15 characters?

Submit up to 15 characters. There is no left padding.

Will the Department provide a grid for chart abstraction? Will CSV files be accepted? Data will not be collected using form or grid methods but will be accepted using more current data collection methodologies such as NHSN data submission. Data will be accepted as a standard data file (e.g., a CSV file) which may be submitted as a batch of data or as a single case upload.

Will hospitals be provided a snapshot of the data collection tool used to submit data for the sepsis initiative? Will we be submitting patient level results on every patient for each data element in the sepsis date dictionary or aggregate data? There is no data collection tool; per se. Data will be collected as a file to match formatting specified in the data dictionary. Yes, the Department is collecting patient level data which is not aggregated by the hospital prior to submission.

Within a hospital, who should be responsible for collecting the required data? That decision is left to each hospital however, in conversation with your colleagues; we have found that many hospitals are working with staff across several departments to collect data (e.g., infection prevention, information services, pharmacists, etc). For example, the information services department may be able to pull administrative or electronic health record data to assist the clinical department(s) in their efforts to complete all of the required data elements. Other hospitals may be working to alter health data systems to capture all required data elements within their electronic health record.

What if the patient name is too short? What are the specific date requirements? How long is the field for a particular data element? Each data element is specified in detail in the data dictionary. Within the dictionary, you will find examples for more complicated situations such as a short patient name, missing social security numbers, actual variable sizes and types. The dictionary will be the definitive source for data specification. Please consult https://ny.sepsis.ipro.org/ to ensure you have the most current version of the data dictionary.

What do we submit if we do not have cases for a quarter? Are we required to upload a blank file to indicate that we have met reporting requirements? The Sepsis Data Portal website has a section to attest to reporting zero sepsis cases for your hospital for the reporting period.

Does the DOH mandate that we report through their data collection site? Yes, as per Department regulation, Article 28 hospitals will be required to submit data for their severe sepsis and septic shock patients. This data must be reported via the Department designated data collection portal.

Will the abstraction tool require clinical judgment or can it be completed by administrative staff? There is no data collection tool. Data will be collected as a file to match formatting specified in the dictionary. There will certainly be clinical judgment required, although the data may be collected retrospectively, prospectively, or concurrently. Your IT/IS department may need to be involved in regards to extracting the data for transfer as a file. In the dictionary, you will see fields that are patient specific so there are patient level requirements. It is anticipated that hospitals will find it easier to send all of the cases as a batch file rather than individually uploading each case. More information was provided during the webinar on April 29, 2014, which was recorded. A link to the recorded webinar is available at https://ny.sepsis.ipro.org/. It is not necessary to login to download and/or view materials.

When will we receive data/reports back? Will we be able to produce reports summarizing adherence rates and outcomes? It is expected that data will be provided to hospitals on a quarterly basis, post data analysis. The risk-adjusted mortality and process measure results will take longer to produce.

Will DOH/IPRO be creating a new report from our corrected data if we identified an error?

Data submissions are 'frozen' at set times for report production of quarterly results. Therefore, prior quarterly data will not be recalculated however; aggregated cumulative data (e.g., year to date, annual, etc) will capture corrected data. It is important that corrected data be submitted as soon as possible since cumulative aggregate reporting will include these corrected data.

Is the raw mortality score eventually going to be weighted?

Decisions on analysis of mortality are still in process however a risk-adjusted mortality is planned.

If a patient was treated for severe sepsis in an acute care facility and then discharged from the acute care facility and admitted to a hospice bed in the same facility (which is a contracted service, a new encounter with a different account number), is it necessary to reenter the same patient into the database for this second encounter when no elements of the protocol (no IV, no antibiotic, no blood draws as per advance directives) are being implemented? The full care for the severe sepsis or septic shock episode, regardless of the hospital unit for which the patient may have presented during the stay, should be reported. For example, if the severe sepsis was identified and treatment begun in the psychiatric unit of your hospital then you also want to report the care provided in that unit in addition to the continued care in a different unit of the same hospital. The case should not be reported again. Transfer status will be reported as 1=Not a Transfer-Patient was neither admitted as a transfer nor, discharged as a transfer to/from a different acute care hospital.

Where can I obtain a list of all hospitals' PFI numbers?

A link to determine PFI's is available on the data portal web site under 'Help Center and Documentation'; it is listed in the data dictionary; and list at: http://www.health.ny.gov/statistics/sparcs/reports/compliance/alpha_facilities.htm

If a patient is moved from one area of the hospital to another i.e., from the Emergency Department to the ICU should this be reported as a Transfer? No. This patient is not considered a transfer. Only if the patient is moved between different hospitals, with discharge and admission at each location, and separate billing from each location, is the case considered a transfer.

If a patient is moved from one area of the hospital to another within the same hospital system i.e., from the Psychiatric Unit to an inpatient medical floor should the case be reported twice. No. Only cases transferred between hospitals should be reported separately by each separate hospital. Cases transferred between units or floors of the same hospital should be reported as a single case(s) with the full hospital care reported in its entirety.

If a protocol is initiated in the ER by the ICU team prior to transfer, do we report "Protocol Initiated Place' as the ER or the ICU? You should report 'Protocol initiated in the emergency room'. The protocol initiated place is the physical location of the patient when the protocol was initiated.

End user technical support is available 8am thru 4pm EST.

To request a new primary contact, you must first login to the Sepsis Data Portal, then click on the Users menu item on the top navigation menu bar.

On the users page, there is an option in the bottom of the users list labelled Request a New Primary Contact

Click on this option and you will be presented with a form as below:

Select the new primary contact from the dropdown list, and enter the email address of the privacy officer for your facility. Once completed, you may submit the form for us to process. If the primary officer is a new user not in the dropdown list, you must first add him/her as new user from the Users page.

The latest SHA256 hashed certificates are used by the Sepsis Data Collection Portal for the encryption of all data being transferred from a site visitorto the server.The following Webbrowsers supportSHA256 certificates (but please see the note below):

Internet Explorer 7+ with Windows XP SP3+ (Please note IE browsers depends on the Operating System)

Safari with Mac OS X 10.5+

Firefox 1.5+

Netscape 7.1+

Mozilla 1.4+

Opera 9.0+

Konqueror 3.5.6+

Mozilla based browsers 3.8+

Chrome 26+

Note for Mac and Windows XP users: While Macs running Mac OS X 10.5+ support the newer SHA256 hashing algorithm, Chrome and Safari users may experience difficulty verifyingthe root certificate. If you are a Mac OS X 10.5+ user having trouble with the site certificate and receiving a security error, we recommend using the latest Firefox browser forMac OS. Windows XP users using Internet Explorer 7/8 may experience similar issues and if so, we recommend usingMozilla Firefox or Google Chrome.

Opening a CSV file in a spreadsheet application may place all fields in the first cell of the application. If you choose to populate the text file in Microsoft Excel or a similar application, you will need to follow that applications' text file import process.

Here are some links that may help, please understand that your particular instructions will vary depending on your operating system, your spreadsheet application and the version thereof.

MS Excel 2003: http://office.microsoft.com/en-us/excel-help/import-or-export-text-files-HP001130599.aspx

MS Excel 2007: http://office.microsoft.com/en-us/excel-help/import-or-export-text-txt-or-csv-files-HP010099725.aspx

MS Excel 2010: http://office.microsoft.com/en-us/excel-help/import-or-export-text-txt-or-csv-files-HP010342598.aspx

MS Access 2003: http://office.microsoft.com/en-us/access-help/import-or-link-data-and-objects-HP005187610.aspx

MS Access 2007: http://office.microsoft.com/en-us/access-help/import-or-link-to-data-in-a-text-file-HA001232227.aspx

MS Access 2013: http://office.microsoft.com/en-us/access-help/import-data-into-an-access-database-HA102840199.aspx

Apache OpenOffice: https://wiki.openoffice.org/wiki/Documentation/FAQ/Calc/Files/How_do_I_open_a_tab-delimited_file_in_OpenOffice.org_Spreadsheet%3F_What_if_I_have_a_different_type_of_delimiter%3F

Libre Office: https://help.libreoffice.org/Calc/Importing_and_Exporting_Text_Files

For submission, the only acceptable file is a text/csv file, semi-colon delimited, double-quoted on all fields. Please ensure that the spreadsheet software you use can export your data to such a file.

To aid in the data submission and review process, IPRO suggests the naming convention below. The Clinical Data Portal will accept any valid file, however, the use of naming conventions will aid in correcting errors or in the resubmission of valid files.

For single facility submissions

sdc_id_yyyy-mm-dd_version.csv or sdc_id_yyyy-mm-dd_version.txt

WHERE

sdc = project identifier (do not change), id= four digit permanent facility identifier (PFI), or six digit Pellucid ID, yyyy-mm-dd = date of file creation (not date of file submission to Clinical Data Portal), and version = single digit 0-9 version of the file (default to "0", increment if versioned on the same day).

examples

sdc_0123_2014-08-16_0.csv sdc_0123_2014-12-21_0.csv sdc_0123_2014-12-21_1.csv

For multiple/group facility submissions

sdc_groupid_yyyy-mm-dd_version.csv or sdc_groupid_yyyy-mm-dd_version.txt

WHERE

sdc = project identifier (do not change), groupid= Clinical Data Portal groupidentifier (available from within the portal), yyyy-mm-dd = date of file creation (not date of file submission to Clinical Data Portal), and version = single digit 0-9 version of the file (default to "0", increment if versioned on the same day).

examples

sdc_42_2014-08-16_0.csv sdc_42_2014-12-21_0.csv sdc_42_2014-12-21_1.csv

Your Group ID can be found under "My Hospitals".

All users are given a Group ID, even if data is being submitted for only one hospital.

If you plan on using Micorosft Excel to populate your data, you will need to carefully save the file as a delimited file with certain options.

If you do not know how to do this, it is usually very helpful to consult with your data or technical support staff that have experience performing this function.

As there are many versions of spreadsheet software we cannot support any one version individually, but in general the instruction found at http://www.howtogeek.com/howto/21456/export-or-save-excel-files-with-pipe-or-other-delimiters-instead-of-commas/ should give you an understanding of the method to save the file in the specified format.

See also: http://knowledgebase.chartio.com/knowledgebase/exporting-csv-files-with-double-quotes-from-excel

The Clinical Data Portal only registers the Primary User.A Primary User may represent one or more data reporting facilities. Primary Users may add additional Users in the application interface.

To register, visit https://ny.sepsis.ipro.org

Primary Users must be eligible to handle PHI for their facility or group.

To register you must provide:

A valid E-mail address (this will serve as your username)

A 16 character password

Your legal name

The facility or facilities for which you have the legal right to transactPHI

After registering, a validation E-mail will be sent to the address used to register. This E-mail must be received for the account to be validated.

Go to https://ny.sepsis.ipro.org/

Click on Registration in the top navigation:

Fill out the registration form:

At the bottom of the registration form you must search for/select the hospitals that you are going to be collecting sepsis data for and click Submit:

Once you fill out the registration form you will receive a confirmation message:

After you have created your account you will receive an email to confirm your email address, you must provide a valid email address in order to confirm your account of approval: