On October 23rd, 2014, we updated our
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Core MeasuresCore measures are evidence based practice standards thathave been researched and shown to improve patientoutcomesCenter for Medicare and Medicaid Services (CMS)established the core measures in 2000Reporting core measures is a CMS requirement forreimbursementThe scores obtained on the quality measures are reportedquarterly to CMS The data is then reported publicly on Hospital CompareThis can be considered a public report card on how allhospitals perform in regard to quality
Core MeasuresAt WCMC we currently report on and/or monitor: • Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Pneumonia (PN) • Surgical Care Improvement Project (SCIP) • VTE protocols • StrokeEach clinical focus has a team composed of a physician, managers,administrative staff, staff nurses, and case managers that collectdata and review processes to improve WCMC’s performancePatients admitted with one of the clinical focuses will have anidentifiable red chart
Core Measures (continued)The red chart will have thepublicly reported measures thatMUST be addressed listed on alaminated sheet located on theinside front coverIt is EVERYONE’S responsibilityto make sure these measuresare met according to thepatient’s diagnosis
Core Measures - AMIAMI patients will have:• ACE/ARB on discharge for LVSD (EF < 40%)• PCI within 90 minutes of arrival (STEMI or LBBB, or MI with any mention of location if described as acute or evolving)• Smoking Cessation• Beta-Blocker AND Statin at discharge• ASA on arrival AND at dischargeAny medication contraindication must be documented in themedical record and it must also be documented that it is thereason for not prescribing the drug
Core Measures - HFHF or CHF patients will have:• LV function assessment or Discharge on these documentation of EF in chart patients is a three part• ACE/ARB for LVSD (EF < 40%) at process: discharge (1) Nursing Discharge• Smoking Cessation Summary must match• Written discharge instructions to the (2)MD’s medication address ALL of the following; reconciliation and that • Medications must match (3)the MD’s • Diet Discharge summary • Activity • F/U with MD • Weight monitoring • Worsening symptoms
Core Measures - PneumoniaPneumonia patients will have:• First antibiotic RECEIVED within 6 hours of arrival (time is from first time of any documentation on chart)• Smoking cessation advice/counseling• Ordered blood cultures must be collected in the ED prior to initial antibiotic – no exceptions• Blood cultures within 24 hours (prior to or after) arrival on patients transferred or admitted to the ICU• Appropriate antibiotic selection
Core Measures - SCIPSCIP or Surgical Care Improvement Project patients will have:• Appropriate antibiotic selection• Antibiotics within 1 hour of incision time• Antibiotics discontinued within 24 hours after anesthesia end time• Patients on beta-blockers prior to arrival will have beta blocker given within 24 hours of incision (must have documentation of last dose given to comply with measure)• Appropriate hair removal – surgical clippers
Core Measures – SCIP (cont) Temperature management documentation (> 96.8 F 30 minutes prior through 15 minutes after anesthesia end time) Urinary catheters MUST be removed by post-op day 2 or documented reason why not VTE Prophylaxis (pharmacological and/or mechanical) ordered anytime from hospital arrival to 24 hours after anesthesia end time VTE prophylaxis received within 24 hours after anesthesia end time
Core Measures - VTEVTE or Venous Thromboembolism measures the number ofpatients who receive VTE prophylaxis or have documentation ofwhy no prophylaxis was givenVTE patients with anticoagulation overlap – This measureassesses the number of patients diagnosed with confirmed VTEthat receive both Lovenox and warfarin for 5 days and until theINR > 2.o before the Lovenox is discontinued. Both criteria haveto be met. The overlap for 5 days and INR > 2.0.For example, if the INR is less than 2.0 then the Lovenox iscontinued longer than the 5 days until the INR of 2.0 is met. If theINR is 2.0 and the overlap has only occurred for 3 days, theLovenox is continued for the full 5 days.
Core Measures – VTE (cont) VTE Discharge instructions – This measure assesses the number of patients diagnosed with confirmed VTE that are discharged to home, home health, court/law enforcement or home on hospice care on warfarin with written discharge instructions that address all four criteria: Compliance issues, dietary advice, follow-up monitoring, and information about the potential for adverse drug reactions Incidence of potentially preventable VTE – This measure assesses the number of patients diagnosed with confirmed VTE prophylaxis during hospitalization (not present on admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date
Core Measures – VTE (cont)Discharge instructions on Coumadin is imperative whether a homemed or a new med• Click the box under educational needs for patients discharged on Coumadin, review Coumadin education packet with patient.• Address F/U monitoring including name and number of MD/office• Date for next PT/INR blood drawPatients must be discharged on BOTH Lovenox and Warfarin unlessBOTH criteria are met;• Has had 5 days of Lovenox• INR greater than 2
Core Measures - StrokeStroke patients will have;• Received VTE prophylaxis or have documentation why none was given the day of or the day after hospital admission• Stroke patients will have SCD’s instead of the anti-embolic stockings• Antithrombic therapy and Statin at discharge• Anticoagulation therapy for A-Fib/Flutter at discharge• Assessed for Rehab during stay
Core Measures – Stroke (cont)The following will be addressed• Follow up appointment (not as needed - document specifics Dr. Spock in 1 week, or date and time)• Discharge Medications (be sure they are clearly identified)• Discharge instructions; check the stroke box under educational needs and provide the required education elements reviewing with patient • Activation of the emergency medical system (EMS) • Risk factors for stroke • Warning signs and symptoms of a stroke