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    Core Measures-CME 101 Core Measures-CME 101 Presentation Transcript

    • 06/11/13 1Inpatient and OutpatientQuality Measures(Core Measures)Education ProgramDeveloped by The Stellaris Core Measure Workgroup
    • GoalsProvide Physician and Nursing staff with an overviewof the National Inpatient and Outpatient QualityMeasures (Core Measures)Physician and Nursing staff will have an increasedawareness of the evidence based practice thatunderlies the core measuresPhysician and Nursing staff will have a betterunderstanding of the documentation requirementsrelated to Core Measures
    • 06/11/13 3Core measures is a National QualityInitiativeMandated by the Center for Medicare & Medicaid Services(CMS) and The Joint Commission (TJC) to monitor specifichospital clinical processes and how well hospitals providerecommended careEvidence based best practiceAll major payers moving toward using Core Measureresults to benchmark & for contract negotiationsBasis for Medicare Pay for Performance/Value BasedPurchasingAs of 2013, also the basis for Physician reimbursement
    • 06/11/13 4Core measures is a National QualityInitiativeRigorous “inclusion” and “exclusion” criteria & guidelinesfor “acceptable” documentationResults undergo random validation studiesPenalties for failing validationThe Quality Management Department tracks and reportsdata in order to achieve the goal of high quality care.Data published on CMS public website:http://www.hospitalcompare.hhs.gov
    • 06/11/13 5Core MeasuresHospital InpatientAcute Myocardial Infarction (AMI)Heart Failure (HF)Pneumonia (PN)Surgical Care Improvement Project (SCIP)Emergency Department (ED) Throughput Measure-AdmittedPatientsGlobal ImmunizationHospital Out-patient (HOP)Emergency Department (ED) Throughput Measures -DischargedPatientsSurgeryAMI/Chest Pain
    • 06/11/13 6Acute MI IndicatorsAspirin (ASA) within 24 hours before or afterarrivalASA prescribed at dischargeAngiotensin Converting Enzyme Inhibitor(ACEI)/Angiotensin II Receptor Blocker (ARB) atdischarge for LV systolic dysfunction (LVSD)Fibrinolytic within 30 minutes of arrivalPercutaneous Coronary Intervention (PCI)within 90 minutes of arrivalBeta Blocker prescribed at dischargeStatin prescribed at discharge
    • Acute MIIndicator Documentation RequirementsASA within 24 hrs beforeor after arrivalASA at discharge•Must have documentation for WHY no ASA, unless there isdocumentation of allergy, or patient currently on CoumadinACEI/ARB at discharge, ifLVSDReasons for not prescribing either an ACEI or ARB at discharge:• ACEI allergy AND ARB allergy• Moderate or severe aortic stenosis• Other explicit reason must be documented for notprescribing BOTH(If there is documented hyperkalemia, angioedema, renal arterystenosis, hypotension, or worsening renal disease, hold for onesufficient to justify hold for the other)Beta Blocker at discharge If not given, must document explicit reason• Beta-blocker allergy (allergy to one specific medication NOTexplicit contraindication for the entire class)• Second or third-degree heart block on ECG on arrival orduring hospital stay and does not have a pacemaker• Explicit “hold parameters” met• Other reasons explicitly documented
    • Acute MIIndicator Documentation RequirementsFibrinolytic within 30minutes of arrival•System reasons for delay are NOT acceptable.•There must be MD/PA/NP documentation that there was“hold”, “delay”, or “wait” in initiating Lytic/PCI AND this wasnot system related.If there’s a delay…. Acceptable documented reasons:•“Hold lytics. Will do CAT scan to r/o bleed” or•“Consent delay, patient deciding about treatment andwaiting to speak to husband before giving consent fortreatment.”Not acceptable documentation:•Equipment issue (IV pump malfunction)•Staff related - “Not enough staff due to blizzard"PCI within 90 minutes ofarrivalStatin prescribed atdischarge, if LDL > 100•Documentation results of LDL assessment within 24 hrs ofarrival•Allergy or specific other reason explicit for not prescribing mustbe documented.
    • 06/11/13 9Heart Failure IndicatorsDischarge Instructions documentedo Diet, activity, weight management, what to do ifsymptoms worsen, medications, physicianfollow up appointmentEvaluation of Left Ventricular Systolic (LVS)FunctionACEI or ARB for Left Ventricular SystolicDysfunction (LVSD)
    • 06/11/13 10Heart FailureIndicator Documentation RequirementsDischarge Instructions (diet,activity, weight monitoring, what todo if symptoms worsen,medications, physician follow up)•Provided by Nursing and on MD Dischargeinstructions.•National emphasis as part of readmission reductionEvaluation of LVS Function •Even if an echo is not needed, some reference to pastecho or narrative description of LV function MUST bedocumented in current recordACEI or ARB for LVSD •If not prescribed, reason MUST be documentedappropriate data field•Contraindication to one not necessarilycontraindication for the other; both need to bereferenced
    • 06/11/13 11Pneumonia IndicatorsBlood culture in ED prior to antibioticBlood cultures < 24 hours prior to or 24hours after arrival for patients transferredor admitted to ICUAntibiotics selection ICU/non-ICU
    • 06/11/13 12PneumoniaIndicator Documentation RequirementsBlood cultures drawn priorto antibiotic•Use of pneumonia order sets by physicians•Documentation of blood draw time on blood culture setlabel•Blood culture must be drawn prior to administration ofantibioticBlood cultures < 24 hoursprior to or 24 hours afterarrival for patientstransferred or admitted toICU•Blood cultures must be ordered on patients transferred toor admitted to ICUAntibiotic selectionICU/non-ICU•See next slide “Guide for Antibiotic Selection forPneumonia” for physicians•Use of pneumonia order sets by physicians
    • Pneumonia Antibiotic Consensus RecommendationsNon-ICU Patientβ-lactam (IV or IM) + Macrolide (IV or PO)ORAntipneumococcal Quinolone monotherapy (IV or PO)ORβ -lactam (IV or IM) + Doxycycline (IV or PO)ORTigecycline monotherapy (IV)Antibiotic Selection Listβ -lactam = Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam, Ertapenem, CeftarolineMacrolide = Erythromycin, Clarithromycin, AzithromycinAntipneumococcal Quinolones = Levofloxacin, Moxifloxacin, GemifloxacinDoxycyclineTigecyclinePlease note: the above requirements are incorporated into the Pneumonia Order Sets
    • Pneumonia Antibiotic ConsensusRecommendationsNon-ICU Patient with Pseudomonal RiskThese antibiotics are acceptable for Non-ICU patients with Pseudomonal Risk ONLY: Antipneumococcal/Antipseudomonal β -lactam (IV) + Antipseudomonal Quinolone (IV orPO)OR Antipneumococcal/Antipseudomonal β -lactam (IV) + Aminoglycoside (IV) + eitherAntipneumococcal Quinolone (IV or PO) Or Macrolide (IV or PO)These antibiotics are acceptable for Non-ICU patients with β -lactam allergy and PseudomonalRisk ONLY: Aztreonam (IV or IM) + Antipneumococcal Quinolone (IV or PO) + Aminoglycoside (IV)OR Aztreonam (IV or IM) + Levofloxacin1 (IV or PO)Antibiotic Selection List Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin Antipneumococcal/Antipseudomonal β -lactam = Cefepime, Imipenem, Meropenem,Piperacillin/Tazobactam, Doripenem Aminoglycoside = Gentamicin, Tobramycin, Amikacin Antipneumococcal Quinolone = Levofloxacin, Moxifloxacin, Gemifloxacin Macrolide = Erythromycin, Clarithromycin, AzithromycinPlease note: the above requirements are incorporated into the Pneumonia Order Sets
    • Pneumonia Antibiotic Consensus RecommendationsICU Patient Macrolide (IV) + either β -lactam (IV) Or Antipneumococcal/Antipseudomonal β -lactam (IV)OR Antipseudomonal Quinolone (IV) + either β -lactam (IV) OR Antipneumococcal/Antipseudomonal β -lactam (IV)OR Antipneumococcal Quinolone (IV) + either β -lactam (IV) OR Antipneumococcal/Antipseudomonal β -lactam (IV)OR Antipneumococcal/Antipseudomonal β -lactam (IV) + Aminoglycoside (IV) + eitherAntipneumococcal Quinolone (IV) OR Macrolide (IV)If the patient has Francisella tularensis or Yersinia pestis risk as determined by Another Source ofInfection the following is another acceptable regimen: Doxycycline (IV) + either β -lactam (IV) OR Antipneumococcal/Antipseudomonal β-lactam (IV)Antibiotic Selection Listβ -lactam = Ceftriaxone, Cefotaxime, Ampicillin/SulbactamAntipneumococcal/Antipseudomonal β -lactam = Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam,DoripenemMacrolide = Erythromycin, AzithromycinAntipneumococcal Quinolones = Levofloxacin, MoxifloxacinAntipseudomonal Quinolone = Ciprofloxacin, LevofloxacinAminoglycoside = Gentamicin, Tobramycin, AmikacinPlease Note; The above requirements have been incorporated into the Pneumonia Order Sets
    • 06/11/13 16SCIP IndicatorsAntibiotic within 1 hour of surgical incisionProphylactic antibiotic selectionAntibiotic discontinued within 24 hours of anesthesia endtimeAppropriate hair removalUrinary catheter removed by Postoperative Day #1 or #2Perioperative temperature managementVenous thrombo-embolism (VTE) prophylaxis ordered &administered within 24 hours of anesthesia end timeBeta Blocker given in the perioperative period if on Betablocker prior to arrival
    • 06/11/13 17SCIPIndicator Documentation RequirementsPre-op antibioticadministration within 1 hourof incision (2 hr windowallowed for Vancomycin &Levaquin)•Date/time/route of antibiotic administration MUST beclearly documented in the appropriate data field•Be mindful of delays in surgeryAntibiotic selection •MDs must use prophylactic antibiotic order sets•Document clarification of appropriate antibiotic selectionfor patients with beta- lactam allergy using prophylaxisorder setAntibiotic discontinued w/in24 hours of anesthesia endtime•MDs must use prophylactic antibiotic order sets•MD order reflecting continuation of antibiotics must havedocumentation of current or suspected infection.•The date/time/route of antibiotic administration MUSTclearly documented in the appropriate data fieldAppropriate hair removal •No hair removal, hair removal with clippers or depilatoryis considered appropriate. Shaving is consideredinappropriate
    • SCIPIndicator Documentation RequirementsUrinary Catheter removed byPostoperative Day (POD) #1 or#2•Placement and discontinuance of catheter MUST be clearlydocumented in the appropriate data field•MD order required to maintain catheter beyond POD#2, ifclinically indicated•Reason for continuance of catheter must be documented by MDPeri -op temperaturemanagement•Use of Bair hugger MUST be clearly documented in theappropriate data field•First temperature documented in PACU must be <15 minutesVTE ordered & given w/in 24hours anesthesia end time•MDs must use order sets•Date/time/route of VTE administration MUST be clearlydocumented by Nursing in the appropriate data fieldBeta Blocker givenperioperatively, if on BetaBlocker prior to arrival•Last dose, date and time of Beta Blocker must becommunicated to medical team and documented in theappropriate data field•Perioperative period defined as the day prior to surgery throughpostoperative Day#2 with day of surgery being Day Zero•If postoperative length of stay is ≥ 2 days, Beta Blocker should beadministered the day prior to or day of surgery AND onpostoperative Day#1 or Day#2 unless reason for not administeringis documented in the appropriate data field
    • Recommended Prophylactic Antibiotic Regimen Selection for SurgerySurgical Procedure Approved AntibioticsCABG, OtherCardiac orVascularCefazolin, Cefuroxime or Vancomycin 1If β-lactam allergy: Vancomycin2or ClindamycinHip/KneeArthroplastyCefazolin, Cefuroxime or Vancomycin 1If β-lactam allergy: Vancomycin2or ClindamycinColon Cefotetan, Cefoxitin, Ampicillin/Sulbactam or Ertapenem 3OR Cefazolin or Cefuroxime + MetronidazoleIf β-lactam allergy:Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin +AztreonamOR Metronidazole + Aminoglycoside OR Metronidazole + QuinoloneHysterectomy Cefotetan, Cefazolin, Cefoxitin, Cefuroxime, OR Ampicillin/SulbactamIf β-lactam allergy:Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin +Aztreonam OR Metronidazole + Aminoglycoside OR Metronidazole + QuinoloneHysterectomywith an OtherProcedure Codeof Colon SurgeryCefotetan, Cefazolin, Cefoxitin, Cefuroxime, OR Ampicillin/Sulbactam OR Ertapenem 3If β-lactam allergy:Clindamycin + Aminoglycoside OR Clindamycin + Quinolone OR Clindamycin +Aztreonam OR Metronidazole + Aminoglycoside OR Metronidazole + QuinolonePlease Note: The above requirements have been incorporated into the Surgical Order SetsSpecial Considerations:1Vancomycin is acceptable with a physician/APN/PA/pharmacist documented justification for its use.2For cardiac, orthopedic, and vascular surgery, if the patient is allergic to beta-lactam antibiotics, Vancomycin or Clindamycin are acceptable substitutes.3A single dose of Ertapenem is recommended for colon procedures.
    • Please Note; The above requirements have been incorporated into the Surgical Order Sets
    • Global ImmunizationPneumococcal ImmunizationPatients age 65 and olderPatients age 6-64 years with high riskconditionsInfluenza ImmunizationPatients 6 months and older
    • Global ImmunizationIndicator Documentation RequirementsPneumococcalVaccination•Includes:Inpatients age 65 & older;Inpatients age 6 to 64 with a High Risk Diagnosis(High Risk Diagnosis - Diabetes, Nephrotic syndrome,ESRD, CHF, COPD, HIV or Asplenia)Inpatients age 19-64 years with Asthma•Contraindications:Hypersensitivity to components of the vaccineBone marrow transplant within the past 12 monthsReceived chemo or radio therapy during this hospitalization orwithin 2 weeks priorReceived Shingles vaccine within 4 weeks prior to arrivalPt 6 yrs of age who received a conjugate vaccine within theprevious 8 weeks•Screening questions in the RN admission and dischargeassessments must be completed•Patients have the option of declining the vaccine
    • Global ImmunizationIndicator Documentation RequirementsInfluenza Vaccination •Includes inpatients age 6 months and older•Contraindications:-Hypersensitivity to eggs or other components of thevaccine-Bone marrow transplant within the past 6 months-History of Guillain-Barre’ Syndrome within 6 weeksafter a previous influenza vaccination-Anaphylactic latex allergy•Screening questions in the RN admission and dischargeassessments must be completed•Patients have the option of declining the vaccine
    • 06/11/13 24Emergency Department Throughput forAdmitted Patients• Median Time from ED Arrival to EDDeparture for Admitted ED Patients• Admit Decision Time to ED Departure forAdmitted Patients
    • ED Throughput – Admitted PatientsIndicator Documentation RequirementsMedian Time from EDArrival to EDDeparture forAdmitted ED Patients•Arrival time MUST be clearly documented in theappropriate data field•Departure time from ED MUST be clearly documentedin the appropriate data fieldAdmit Decision Timeto ED Departure forAdmitted Patients•Decision to admit can be the bed request time oradmission order
    • 06/11/13 26Emergency Department Throughput forDischarged PatientsMedian Time from ED Arrival to ED DepartureDoor to Diagnostic Evaluation by MD/NP/PALeft Without Being SeenMedian Time to Pain Management for Long BoneFracture (patients >= 2 years of age)Head CT scan results for Stroke (acute ischemic orhemorrhagic) interpreted within 45 minutes ofArrival
    • ED Throughput – Discharged PatientsIndicator Documentation RequirementsMedian time arrival to EDdeparture•Arrival time and time left ED MUST be clearly documented in theappropriate data fieldMedian time door todiagnostic evaluation byMD/APN/PA•Arrival time and time seen by physician, advanced practice nurse orphysicians assistant (MD/APN/PA) MUST be clearly documented inthe appropriate data fieldLeft Without Being Seen Includes patients who leave the ED without being evaluated by aphysician/advance practice nurse/physician’s assistantMedian time to pain mgt forlong bone fractureIncludes patients >= 2 years of ageHead CT scan results forStroke interpreted within 45minutes of arrivalIncludes pts > 18 years of age with acute ischemic or hemorrhagicstroke
    • 06/11/13 28Hospital Outpatient Surgery (HOPSurgery) IndicatorsTiming of Antibiotic ProphylaxisAntibiotic Selection
    • 06/11/13 29Hospital Outpatient SurgeryIndicator Documentation RequirementsTiming of Antibiotic Prophylaxis(2 hour window allowed for Vancomycin &Levaquin)•Requirement of one hour timing applies toALL procedural areas•MDs must use prophylactic antibiotic ordersets•Date/time/route of antibiotic administrationMUST be clearly documented in the appropriatedata fieldAntibiotic Selection •MDs must use prophylactic antibiotic order sets•Document clarification of appropriate antibioticselection for patients with beta- lactam allergy•Date/time/route of antibiotic administrationMUST be clearly documented in the appropriatedata field
    • 06/11/13 30Hospital Outpatient AMI/Chest Pain(HOP AMI/Chest Pain)Median Time to Fibrinolysis-patients with STelevation MI (STEMI) or left bundle branch block(LBBB)Fibrinolytic Therapy Received Within 30 MinutesMedian Time to Transfer to Another Facility forAcute Coronary InterventionAspirin at ArrivalMedian Time to ECG
    • 06/11/13 31Hospital Outpatient AMI/Chest PainIndicator Documentation RequirementsMedian Time to Fibrinolysis (STEMI orLBBB)•Time of arrival MUST be clearly documented in theappropriate data field•Medication administration time MUST be clearlydocumented in the appropriate data fieldFibrinolytic Therapy Received Within 30Minutes•System reasons for delay are NOT acceptable•There must be MD/PA/NP documentation that therewas “hold”, “delay”, or “wait” in initiating Lytic/PCI ANDthis was not system relatedMedian Time to Transfer to AnotherFacility for Acute Coronary Intervention•Time of arrival and transfer MUST be clearlydocumented in the appropriate data field•Patient disposition MUST be clearly documented in theappropriate data fieldAspirin at Arrival •Should be considered even if clinicalpresentation is atypical•If Aspirin not given, the reason must be documentedMedian Time to ECG •ECG to be completed within 10 minutes of arrival•Must document accurate arrival time•Date/time of ECG MUST be clearly documented in theappropriate data field
    • 06/11/13 32Core MeasureOverviewIndicatorsAcute MI ASA w/in 24 hrs ofarrivalASA at discharge ACE/ARB atdischarge, ifLVSDFibrinolytic within30 min of arrivalPCI within 90minutes of arrivalBeta Blocker atdischargeStatin prescribed at discharge, ifLDL>100Heart FailureD/C Instructions Evaluation of LVsystolic functionACEI/ARB for LVsystolicdysfunctionPneumoniaBlood Cultureprior to AntibioticAdministrationBlood Culture <24 hrs prior to or 24hrs after arrival for pts transferred oradmitted to ICUAntibioticSelection ICU/non-ICUSurgical CareImprovementProgram (SCIP)Antibiotic givenwithin one hour ofincision timeProphylacticAntibioticselectionAntibiotic d/cw/in 24 hrs ofanesthesia endtimeAppropriate HairRemovalRemoval of FoleyCatheter Post-opDay #1 or #2Peri-op TempManagementVTE ordered &given w/in 24 hrsof anesthesia endtimeBeta Blocker inPeri-op periodPneumococcalVaccinePts age 65 & older are screened forvaccine and receive, if indicatedPts age 6-64 years with high riskcondition-screened for vaccine andreceive, if indicated
    • 06/11/13 33Core MeasureOverviewInfluenzaVaccinePatients 6 months & older-screened for & receive vaccine in season if indicatedED Throughput-AdmittedPatientsED Arrival Time to ED Departure forAdmitted PatientsAdmit Decision Time to ED Departurefor admitted ptsED Throughput –DischargedPatientsED Arrival time to ED Departure Time Door toDiagnosticEvaluation byMD/NP/PALeft Without BeingSeenTime to Pain MedicationAdministration for Long Bone FractureHead CT scan results for Stroke (acuteischemic or hemorrhagic) interpretedwithin 45 minutes of arrivalHospitalOutpatientSurgeryAntibioticSelectionTiming of Antibiotic ProphylaxisHospitalOutpatientAMI/CPMedian Time toFibrinolysisFibrinolytictherapy within 30minutesMean time toEKGASA at arrivalMedian time to transfer for Acute Coronary Intervention