# Health Information Management Technology: an Applied Approach 4th Ed – AHIMA – Chapter 9

Average Daily Census
The total number of IPSDs for a week, month, and so on divided by the total number of days in the period of interest. The average number of inpatients treated during a given period of time.
Census
The census is the number of hospital inpatients present at any one time. It generally reports patient activity for a 24 hour reporting period.Included in the report is the # of inpatients admitted and discharged, and transferred from another unit (intra-hospital). Adults and children (A&C) are reported separately from newborns. Census is generally taken at midnight.
daily inpatient census
The result of the official count taken at midnight. Because patients admitted and discharged the same day may not be present at the census-taking time, the hospital must account for them separately. the daily inpatient census reflects the total number of patients TREATED during the 24 hour period.
ISPD – Inpatient Service Day
A unit of measure that reflects the services received by one inpatient during a 24 hour period.The number of IPSDs for a 24 hour period is equal to the daily inpatient census, that is one service day for each patient treated.
length of Stay LOS
has a defined unit of measurement, day, and a real zero point – zero days. Because it has a real zero point, we can state that an LOS of six days is twice as long as an LOS of three days.
Average Length of Stay ALOS
calculated from the total LOS/# of patients discharged. Average length of stay = Total length of stay for a given period/Total number of discharges, including deaths, for the same period.
Outpatient vs Inpatient
Hospital Inpatient – patient who is provided with room, board, and continuous general nursing service in an area of an acute care facility where patients generally stay overnight at a minimum.
Hospital Outpatient – A hospital patient who receives services in one or more of the hospital’s facilities when he or she is not currently an inpatient or home care patient; may be classified as either an emergency outpatient or clinic outpatient.
Proportion
is a particular type of ratio in which x is a portion of the whole (x+y). In a proportion, the numerator is always included in the denominator. x/(x+y) – ex: x = # of patients discharged alive, y = # of patients who died: x = 235, y = 22: 235/(235+22) = 237/257; reduce the fraction so that either x or y = 1: 235/257=0.91/1; the portion of patients discharged alive was 0.91
Rate
often used to measure events over a period of time; may be reported daily, weekly, monthly, or yearly. Allows for trend analysis and comparisons over time. Formula: x/y X10nth
In calculating the rate:
the numerator is always included in the denominator; also when calculating a facility based rate, the numerator is first multiplied by 100 and then divided by the denominator.
Ratio
In a ratio, the quantities being compared, such a patient discharge status (x=alive, y=dead), may be expressed so that x and y are completely independent of each other, or x may be included in y. Ratio-level data: used to report morbidity (illness), mortality (Death), and natality (birth) at local, state and national levels. Represents the number of times something happened relative to the number of times it could have happened. Formula: Ratio, proportion, rate = x/y X 10nth
Figuring ratios:
For example the outcome of patients discharged from community Hospital could be compared in one of two ways:
alive/dead or x/y – represents the number of patients discharged alive compared to number of patients who died.
alive/(alive+dead) or x/(x+y) – represents the number of patients discharged alive compared to all patients discharged
scales of measurement
nominal, ordinal, interval, or ratio
data collected
either continuous or discrete
Nominal-level data
all into groups or categories; measures data by name only (ex. third party payer, race, and sex) no order to its data collection
Ordinal-level data
does have some inherent order and higher numbers associated with higher values, the order is meaningful not the number itself. Ex: staging of a pressure ulcer has 4 stages with stage 4 being the most severe. The number 4 is the most severe type of pressure ulcer; however, we cannot measure the differences between the levels in exact numerical terms
Interval-level data
most important characteristic is that the intervals between successive values are equal: Ex: 1 degree between each temperature on thermometer but there is no true zero – so we cannot say that 40 degrees F is twice as warm as 20 degrees F
Ratio-level data
is the highest level of measurement. Has a defined unit of measure, a real zero point, and the intervals between successive values are equal. Only when a zero on a scale truly means the total absence of a property being assessed can that scale be described as ratio-level. Ex: age, height and LOS
Difference between ratio and interval scales
there is no true zero point on the interval scale
Discrete Data (Variables)
nominal or ordinal (name, gender, race, Likert scale, anything that is ordered). those that fall into catagories
Continuous Variables (Data)
either interval or ratio-level (some ratio level variables are discrete) Measurement can be subdivided into smaller values. ex: individual’s weight may be 120 or 121 or any weight between 120 and 121. Continuous variables include fractions. Addition, subtraction, multiplication, and division may be performed on continuous variables.
Identify if discrete or continuous:
1. zip code – discrete
2. blood pressure – continuous
3. Heart Failure Classification I, II, III, IV – discrete
4. Age – continuous
5. Ethnicity – discrete
6. Marital Status – discrete
7 Length of Stay – continuous
8. Discharge disposition (home, SNF, etc) – discrete
9. Weight – continuous
10. Level of Education – discrete
11. Race – discrete
12. Temperature in degrees Fahrenheit – continuous
13. Types of third-party payers – discrete
14. Gender – discrete
15. Height – Continuous
Data Collected
either facility based or population based
Sources of Facility based
Acute care facilities, long-term care facilities, and other types of healthcare organizations. AND Population – based statistics are gathered from cities, counties, states, or specific groups within the population, such as individuals affected by diabetes.
Death rate
For hospital rate: (# of deaths divided by # of discharges)multiplied by 100 = percentage of death or death rate
For community rate: (# of deaths X population [1k, 10k or 100k]) divided by community size
Calculating risk for contracting a disease
Risk rate = Number of cases occurring during a given time period/Total number of cases or population at risk during the same time period
Identify the following statement as a rate, a ratio, or a proportion
Identify the following statement as a rate, a ratio, or a proportion
At the annual state HIM meeting, 85 of the registrants were female and 35 were male. Therefore 0.71 percent of the registrants were female. = Proportion
Identify the following statement as a rate, a ratio, or a proportion
Of the 250 patients admitted in the last six months, 36 percent had Type II diabetes mellitus. = Rate
Hospital newborn Inpatient
A patient born in the hospital at the beginning of the current inpatient hospitalization – infants born on the way to the hospital or at home are considered hospital inpatients, not hospital newborn inpatients
Community Hospital reported the following statistics for adults and children at 12:01 am April 1: Census 150; Admissions 20; Discharges 15; 1 patient admitted and died the same day; 1 patient admitted and discharged alive the same day. Calculate the following for April 2:
a. Inpatient census
b. daily inpatient census
c. Inpatient service days
a. 155
b. 157
c. 157
Community Hospital reported the following statistics for their newborn unit at 12:01 am April 1: Census 14: Births 5; Discharges 3; 1 Newborn born and transferred to the state University Hospital. Calculate the following for April 2:
a. inpatient census
b. Daily inpatient census
a. 16
b. 17
Community Hospital reported the following statistics for their intensive care unit at 12:01 am April 1:Census 10; 1 patient admitted directly from the ESD; 1 patient transferred from surgery unit; 1 patient transferred from the Medicine unit; 1 patient transferred to the Medicine unit; 1 patient admitted and died the same day. Calculate the following for April 2:
a Inpatient census
b. Daily inpatient census
a. 12
b. 13
Inpatient bed occupancy rate
another indicator of the hospital’s financial position is also called the percentage of occupancy. It is the percentage of official beds occupied by hospital inpatients for a given period of time. The total number of inpatient service days is used in the numerator because it is equal to the daily inpatient census or the number of patients treated daily.The Occupancy rate compares the number of patients treated over a given period of time to the total number of beds available for the same period of time.
total number of Bed Count Days
The total number of inpatient times the total number of days in the period is called the total number of Bed Count Days
Formula for Inpatient bed occupancy rate
Inpatient bed occupancy rate =
Total # of inpatient service days for a given period/Total number of inpatient bed count days for the same period
Bed turnover Rate
is a measure in hospital utilization. Bed turnover rate = Total # of discharges, including deaths, for a given period/Average bed count for the same period
What is the inpatient bed occupancy rate for each of the following patient care units at Community Hospital for the month of June? Calculate to one decimal point
1. Inpatient Unit Serv Days bed ct Occ Rate
Medicine 580 36 53.7
Surgery 689 42 54.7
Pediatric 232 18 43.0
Psychiatry 889 35 84.7
Obstetrics 222 10 74.0
Newborn 222 15 49.3
2. Use the preceding info to determine the Occupancy Rate for Community Hospital – all Adults and Children (exclude newborns).
2,612 141 x30 = 4230 = 61.8
On July 1st, Community Hospital expanded the number of patient beds from 156 to 200. Use the following information to determine the Occupancy Rate for January to June; July to December; and the total for the year (non leap year) serv days bed count
Jan – June 15672 156
July – Dec 25876 200
January – June Occupancy Rate:
15672/28236 = 55.5
July – December Occupancy Rate:
25876/36800 = 70.3
Total for the year =
41,548/65,036 = 63.9
Calculate the total length of stay for the patient discharges and the average length of stay. (calculate 1 decimal point)
Total length of stay = 758
Number of patients discharged = 115
Average length of stay = 6.6
Hospital Death (Mortality) Rates
based on number of patients discharged, alive and dead, from the hospital. Newborns are counted as well.
Gross Death rate
the proportion of all hospital discharges that ended in death. It is the basic indicator of mortality in a healthcare facility. Calculated by dividing the total number of deaths occurring in a given time period by the total number of discharges, including death, for the same time period. (ans x 100)
Net death rate
an adjusted death rate, calculated with the assumption that certain deaths should not count against the hospital and does not include patients who die within 48 hours of admission. The reason for excluding them is that 48 hours is not enough time to positively affect patient outcome. To calculate: Net death rate = Total # of inpatients deaths (including NBs) misus deaths < 48 hours for a given time period/ Total number of discharges, (including A&C and NB deaths) minus deaths <48 hours for the same period. (ans x 100)
Newborn Death rate
include only infants born alive in the hospital. The newborn must have been delivered alive. A stillborn infant is not included in either the newborn death rate or the gross or net death rate. Newborn death rate = Total # of NB deaths for a given period/Total number of NB discharges (including deaths) for the same period. (ans X 100)
Fetal death rate
death of a stillborn baby – death prior to the fetus’s complete expulsion or extraction from the mother in a hospital facility, regardless of the length of the pregnancy. Stillborns are neither admitted or discharged from the hospital. A fetal death occurs when the fetus fails to breathe or show any other evidence of life, such as a heartbeat, a pulsation of the umbilical cord, or a movement of the voluntary muscles. To calculate the fetal death rate: divide the Total # of intermediate and late fetal deaths for a given period by the total number of live births plus total number of intermediate and late fetal deaths for the same period. (ans x 100)
Maternal death rate (hospital based)
death of any woman from any cause related to, or aggravated by pregnancy or its management, regardless of the duration or site of the pregnancy. Maternal deaths that result from accidental or incidental causes are not included in the maternal death rate. To calculate: Maternal death rate = Total # of direct maternal deaths for a given period/Total # of maternal (OB) discharges, including deaths , for the same period. (ans x 100)
Hospital inpatient autopsy
an examination of the body of a patient who died while being treated in the hospital. A pathologist or some other physician on the medical staff performs this type of autopsy in the facility.
Hospital Autopsy
is an examination of the body of an individual who at some time in the past had been a hospital patient and was not a hospital inpatient at the time of death.
Gross autopsy rate
the proportion or percentage of deaths that are followed by the performance of autopsy. Gross autopsy rate = Total inpatient autopsies for a given period/Total # of inpatient deaths for the same period. (ans x 100)
Net autopsy rates
If the body of a patient who has died are not available for autopsy, ex: coroner or medical examiner may claim a body for legal reasons. In these situations, the hospital calculates a net autopsy rate.Unavailable bodies are excluded from the denominator. Net autopsy rate = Total # of autopsies on inpatient deaths for a period/Total # of inpatient deaths minus unautopsied coroners’ or medical examiners’ cases for the same period. (ans x 100)
Hospital Autopsy rate
This is an adjusted rate that includes autopsies on anyone who may have at one time been a hospital patient. Includes: bodies of inpatients, except those removed by the coroner. When the hospital pathologist or other designated physician acts as an agent in the performance of an autopsy on an inpatient, the death and the autopsy are included in the percentage. Bodies of other hospital patients, including ambulatory care patients, hospital home care patients, and former hospital patients who died elsewhere, but whose bodies have been made available for autopsy to be performed by the hospital pathologist or other designated physician. Hospital autopsy rate = Total # of hospital autopsies for a given period/Total # of deaths of hospital patients whose bodies were available for autopsy for the same period. (ans x 100)
“available for hospital autopsy involves several conditions, including:
-The autopsy must be performed by the hospital pathologist or a designated physician on the body of a patient treated at some time at the hospital.
-The report of the autopsy must be filed in the patient’s health record and in the hospital laboratory or pathology department.
-The tissue specimens must be maintained in the hospital laboratory.
Newborn autopsy rate
Autopsy rates usually include autopsies performed on newborn infants unless a separate rate is requested. Newborn autopsy rate = Total # of autopsies on NB deaths for a given time period/Total # of NB deaths for the same period. (ans x 100)
Fetal autopsy rate
are important for the clinician to determine the cause of the fetal loss and to the parents to determine if they need genetic counseling or other types of prenatal care in the future. Completed on stillborns classified as either intermediate or late fetal deaths . Fetal autopsy rate = Total # of autopsies on intermediate and late fetal deaths for a given period/Total # of intermediate and late fetal deaths for the same period. (ans x 100)
Nosocomial (hospital acquired) infections
The Joint Commission requires hospitals to follow written guidelines for reporting all types of infections. Calculations may be for the entire hospital or for a specific unit. Examples: respiratory, gastrointestinal, surgical wound, skin, urinary tract, septicemias, and infections related to intravascular catheters. Hospital Acquired infection rate = Total # of hospital acquired infections for a given period/ Total # of discharges, including deaths, for the same period. (ans x 100)
Postoperative infection rate
is the proportion or percentage of infections in clean surgical cases out of the total number of surgical operations performed. A clean surgical case is one in which no infection existed prior to surgery.
Difference between a surgical procedure and a surgical operation
-surgical procedure is any single, separate, systematic process on or within the body that can be complete in itself. A physician, dentist, or some other licensed practitioner performs a surgical procedure, with or without instruments to: Restore disunited or deficient parts; Remove diseased or injured tissues; Extract foreign matter; Assist in obstetrical delivery; and Aid in diagnosis.
-Surgical operation involves one or more surgical procedures that are performed on one patient at one time using one approach to achieve a common purpose.
Postoperative infection rate – calculation
Postoperative infection rate = # of infections in clean surgical cases for a given period/Total # of surgical operations for the same period. (ans x 100) Consultation rate = Total # of patients receiving consultations for a given period/Total # of discharges and deaths for the same period.
Case mix
is a method of grouping patients according to a predefined set of characteristics. Medicare Severity diagnosis-related groups (MS-DRGs) are often used to determine case mix in hospitals.
Case-mix index (CMI)
is the average relative weight of all cases treated at a given facility or by a given physician which reflects the resource intensity or clinical severity of a specific group in relation to the other groups in the classification system. CMI is a measure of the resources used in treating the patients in each hospital or group of hospitals. May be calculated for all patients discharged, discharges by payer, or the discharges by particular physicians. CMI calculated: multiply the number of cases for each MS-DRG by the relative weight of the MS-DRG, summing the result (687.8310 and dividing by the total number of cases (484). By convention the CMI is calculated to five decimal points and rounded to four.
Uses for CMI
indicate the average reimbursement for the hospital. Is a measure of the severity of illness of Medicare patients.
Excellent source of information for benchmarking purposes
Healthcare Cost Utilization Project database (HCUPnet) available online
Hospital ambulatory care:
All hospital directed preventive, therapeutic, and rehabilitative services provided by physicians and their surrogates to patients who are not hospital inpatients
Outpatient
A patient who receives ambulatory care services in a hospital-based clinic or department.
Hospital outpatient
A hospital patient who receives services in one or more of a hospital’s facilities when he or she is not currently an inpatient or a home care patient
Emergency patient
A patient who is admitted to the emergency department of a hospital for diagnosis and treatment of a condition that requires immediate medical, dental, or allied health services in order to sustain life or to prevent critical consequences
Clinic outpatient
A patient who is admitted to a clinical service of a clinic or hospital for diagnosis or treatment on an ambulatory basis
Referred outpatient
An outpatient who is provided special diagnostic or therapeutic services by a hospital on an ambulatory basis but whose medical care remains the responsibility of the referring physician
Outpatient visit
A patient’s visit to one or more units or facilities located in the ambulatory services area (clinic or physician’s office) of an acute care hospital in which an overnight stay does not occur
Encounter
The professional, direct personal contact between a patient and a physician or other person who is authorized by state licensure law and, if applicable, by medical staff bylaws to order or furnish healthcare services for the diagnosis or treatment of the patient; face-to-face contact between a patient and a provider who has primary responsibility for assessing and treating the condition of the patient at a given contact and exercise.
Occasion of service
A specified, identifiable service involved in the care of a patient that is not an encounter (for example, a lab test ordered during an encounter)
Ambulatory surgery center or ambulatory surgical center (ASC)
Under Medicare, an outpatient surgical facility that has its own national identifier, is a separate entity with respect to its licensure, accreditation, governance, professional supervision, administrative functions, clinical services, recordkeeping, and financial and accounting systems; has as its sole purpose the provision of services in connection with surgical procedures that do not require inpatient hospitalization; and meets the conditions and requirements set forth in the Medicare Conditions of Participation. May also be referred to as: short-stay surgery, one-day surgery, same-day surgery, or come and go surgery services.
Vital Statistics
data collected and reported on a community, regional, and national basis levels. Collection and analysis of data related to the crucial events in life: birth, death, marriage, divorce, fetal death, and induced terminations of pregnancy. Statistics are used to identify trends.
Epidemiology
study of factors that influence the health status of a population
National Vital Statistics System (NVSS)
responsible for maintaining the official vital statistics of the U.S. These statistics are provided to the federal government by state operated registration systems. NVSS housed in the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC)