Franciscan Quality Indicators

Transcription

Franciscan
Quality
Indicators
A guide to Centers for Medicare & Medicaid Services/
The Joint Commission quality measures including
Value Based Purchasing
Version 5.0 (Revised January, 2013)
How to Use This Booklet
Please review this booklet and keep it as a reference for providing care to patients who are being
treated for the conditions indicated. The booklet summarizes important sections from the CMS
Specifications Manual and other FHS-specific information.
The Centers for Medicare & Medicaid Services (CMS), along with public and private health care
stakeholders, are working to streamline and standardize hospital quality and safety performance
and reporting. This trend presents a valuable opportunity for Franciscan hospitals to refocus our
efforts to provide the best quality, best practices and best care to our patients. Quality of care
typically is determined through a set of uniform, national hospital quality measures which focus
on a limited number of high-volume inpatient conditions. The standard measures are described
inside this booklet.
CMS has introduced “value-based purchasing” (VBP) to encourage hospitals to follow these national
standards by linking reimbursement to quality performance. In this booklet, you will see the VBP
symbol next to quality measures that are currently included in the CMS value-based purchasing
program. More measures are expected to be added in the near future.
Excellent performance in these measures has been shown to produce the greatest impact on
quality improvement.
Quality indicators are reassessed and revised frequently; visit www.FHShealth.org/QCE/CMSspecs.asp for the latest information.
Table of Contents:
Medical Quality Indicators Overview
Emergency Department Quality Indicators
Hospital-Acquired Conditions (HACs) Hospital Consumer Assessment of Healthcare Providers and System (HCAHPS) Survey Pneumonia Antibiotic Recommendations for Non-ICU/PCU Patients and ICU/PCU Patients
Surgical Care Improvement Project (SCIP) Quality Indicators
Surgical Care Improvement Project – Inpatient Preoperative Antibiotic Prophylaxis Guidelines
Surgical Care Improvement Project – Outpatient Preoperative Antibiotic Prophylaxis Guidelines
Surgical Care Improvement Project – Venous Thromboembolism (VTE) Prophylaxis Options for Surgery
Education Form: Inpatient Acute Myocardial Infarction (AMI)
Education Form: Inpatient Heart Failure (HF)
Education Form: Left Ventricular Systolic Function (LVSF) Assessment Inclusion Table 1.2
Education Form: Immunizations
Education Form: Inpatient Surgical Care Improvement Project (SCIP)
Education Form: Inpatient Venous Thromboembolism (VTE) Education Form: Stroke
1-2
3
4
5-7
8
9
10
11-12
13-14
15-16
17-18
19
20
21-23
24-25
26-27
Franciscan Medical Quality Indicators
CMS/The Joint Commission
Medical Quality Indicators Overview
(CMS Specifications Manual 4.2b—Discharges between 1-1-13 and 12-31-13)
ACUTE MYOCARDIAL
INFARCTION
•
•
•
•
•
•
•
•
AMI-1 Aspirin at arrival*
AMI-2 Aspirin prescribed at discharge*
AMI-3 ACEI or ARB at discharge for left ventricular systolic dysfunction (EF < 40%)*
AMI-5 Beta-blocker at discharge
AMI-8a PCI within 90 minutes of hospital arrival VBP
AMI-10 Statin prescribed at discharge* VBP
AMI 30-day risk standardized readmission measure (Medicare patients)
AMI 30-day risk standardized mortality rate (Medicare patients) VBP
HEART FAILURE
•
•
•
•
•
HF-1 Discharge instructions include instructions regarding activity, diet, follow-up care, medications, symptoms worsening, and weight monitoring VBP
HF-2 Left ventricular function assessment
HF-3 ACEI or ARB at discharge for left ventricular systolic dysfunction (EF < 40%)*
Heart failure 30-day risk standardized readmission measure (Medicare patients)
Heart failure 30-day risk standardized mortality rate (Medicare patients) VBP
PNEUMONIA
•
•
•
•
•
•
•
PN-3a Blood cultures for patients admitted or transferred to ICU within 24 hours
of arrival
PN-3b Blood cultures performed prior to initial antibiotic when blood culture collected in the emergency department VBP
PN-6 Initial antibiotic selection–overall VBP
PN-6a Initial antibiotic selection for immunocompetent ICU patients
PN-6b Initial antibiotic selection for immunocompetent non-ICU patients
Pneumonia 30-day risk standardized readmission measure (Medicare patients)
Pneumonia 30-day risk standardized mortality rate (Medicare patients) VBP
IMMUNIZATIONS
• IMM-1 Pneumococcal Immunization
• IMM-2 Influenza Immunization
Quality indicators are reassessed and revised on a continual basis.
For the most current information, please visit the CMS
QualityNet Specifications Manual website: www.FHShealth.org/QCE/CMSspecs.asp
* If contraindicated, document reasoning/condition.
Clinical Effectiveness Department
Version 5.0, Revised: 1-2013
1
Medical Quality Indicators Overview (page 2)
Inpatient Venous
Thromboembolis (VTE)
•
•
•
•
•
•
VTE-1 Venous Thromboembolism Prophylaxis
VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis
VTE-3 Venous Thromboembolism Patients with Anticoagulation Overlap Therapy
VTE-4 Venous Thromboembolism Patients Receiving Unfractionated Heparin with Dosages / Platelet Count Monitoring by Protocol or Nomogram
VTE-5 Venous Thromboembolism Warfarin Therapy Discharge Instructions
VTE-6 Hospital Acquired Potentially-Preventable Venous Thromboembolism
STROKE
•
•
•
•
•
•
•
STK-1 Venous Thromboembolism (VTE) Prophylaxis
STK-2 Discharged on Antithrombotic Therapy
STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter
STK-4 Thrombolytic Therapy
STK-5 Antithrombotic Therapy by End of Hospital Day 2
STK-6 Discharged on Statin Medication
STK-10 Assessed for Rehabilitation
* If contraindicated, document reasoning/condition.
2
EMERGENCY DEPARTMENT QUALITY INDICATORS
Inpatient ED
• ED-1 Median time from ED arrival to ED departure for admitted patients
• ED-2 Admit decision time to ED departure time for admitted patients
Outpatient ED
(Hospital OQR Specifications Manual 6.0b—Discharges between 1-1-13 and 12-31-13)
•
•
•
•
•
•
•
•
•
•
OP-1 Median time to fibrinolysis
OP-2 Fibrinolytic therapy received within 30 minutes of ED arrival
OP-3 Median time to transfer to another facility for acute coronary intervention
OP-4 Aspirin at arrival
OP-5 Median time to ECG
OP-18 Median time from ED arrival to ED departure for discharged ED patients
OP-20 Door to diagnostic evaluation by a qualified medical personnel
OP-21 Median time to pain management for long bone fracture
OP-22 Left without being seen
OP-23 Head CT or MRI scan results for acute ischemic stroke or hemorrhagic stroke patients who received head CT or MRI scan interpretation within 45 minutes of ED arrival
3
Hospital-Acquired Conditions (HACs) and Present
on Admission (POA) Indicator Reporting
For discharges occurring on or after October 1, 2008, Inpatient Prospective Payment System (IPPS) hospitals will not
receive additional payment for cases when one of the selected complicating conditions is acquired during
hospitalization (i.e., was not present on admission).
Present on Admission (POA) is defined as present at the time the order for inpatient admission occurs—conditions that
develop during an outpatient encounter, including ED, observation or outpatient surgery, are considered POA.
If at discharge, there is a selected complicating condition that was not identified as POA, it is considered a
hospital-acquired condition.
The healthcare provider who is legally accountable for the patient must document POA before discharge.
The importance of consistent, complete documentation in the medical record cannot be overemphasized.
Hospital-Acquired Conditions (HACs)*
•
•
•
•
•
•
•
•
•
Deep Vein Thrombosis and Pulmonary Embolism following Certain Orthopedic Procedures
• Total Knee Replacement
• Hip Replacement
Foreign Object Retained After Surgery
Air Embolism
Blood Incompatibility
Pressure Ulcer Stages III & IV
Falls and Trauma
• Fracture
• Dislocation
• Intracranial Injury
• Crushing Injury
• Burn
• Electric Shock
Catheter-Associated Urinary Tract Infection (CAUTI)
Vascular Catheter-Associated Infection
Iatrogenic Pneumothorax with Venous Catheterization
•
•
•
•
•
Manifestations of Poor Glycemic Control
• Diabetic Ketoacidosis
• Nonketotic Hyperosmolar Coma
• Hypoglycemic Coma
• Secondary Diabetes with Ketoacidosis
• Secondary Diabetes with Hyperosmolarity
Surgical Site Infection, Mediastinitis, following Coronary Artery Bypass Graft (CABG)
Surgical Site Infection following Cardiac Implantable Electronic Device (CIED)
Surgical Site Infection following Certain Orthopedic Procedures
• Spine
• Neck
• Shoulder
• Elbow
Surgical Site Infection following Bariatric Surgery
for Obesity
• Laparoscopic Gastric Bypass
• Gastroenterostomy
• Laparopscopic Gastric Restrictive Surgery
*As specified as statue, CMS may revise the list of conditions
from time to time, as long as it contains at least two conditions
4
HCAHPS (“H-caps”)
Hospital Consumer Assessment of Healthcare Providers and Systems
The HCAHPS survey is a standardized national survey implemented by CMS. The survey contains 40 questions that
encompass 8 major composites measuring a patient’s perception of care received during his or her inpatient stay and
the understanding of care needed after discharged from the hospital. The survey asks about the aspects of the patient
experience that, based on research, are directly connected with health outcomes. The survey administered by phone
to a random sample of adult, discharged patients who had been treated for a range of medical conditions, including
maternity services. The 8 composite scores are currently included in the CMS value-based purchasing (VBP) program.
The inpatient survey sets a high bar for responses, with only the highest or “top box” responses counting in the VBP
scoring algorithm. The “top box” score is the best score on the scale (i.e., always, yes, 9 or 10, definitely yes). For example,
the top box composite score for “Doctor Communication” measures the percentage of patients who answered their
doctor was always courteous and respectful, listened carefully, and explained things in a way that was understood.
The survey is designed to produce comparable data to allow for objective and meaningful comparisons among hospitals
and to create incentives for hospitals to improve quality of care. The aim is to consistently score top-box rating in each
major composite.
AIDET is an evidence-based practice shown to improve patient perception of care when used appropriately with
every patient every time. AIDET means Acknowledging the patient and loved ones with eye contact and a smile,
Introducing yourself and your colleagues, providing information about the Duration of wait times and procedures,
providing Explanations why and Thanking patients and family members at the end of each encounter.
INPATIENT HCAHPS SURVEY QUESTIONS
*Top Box Score
Doctor
Communication
VBP
*4=Always,
3=Usually,
2=Sometimes,
1=Never
During this hospital stay, how often did doctors treat you with courtesy
and respect?
During this hospital stay, how often did doctors listen carefully to you?
During this hospital stay, how often did doctors explain things in a way you
could understand?
Nurse
Communication
VBP
During this hospital stay, how often did nurses treat you with courtesy
and respect?
During this hospital stay, how often did nurses listen carefully to you?
*4=Always,
3=Usually,
2=Sometimes,
1=Never
During this hospital stay, how often did nurses explain things in a way you
could understand?
5
HCAHPS (page 2)
*Top Box Score
Responsiveness
of staff
VBP
During this hospital stay, after you pressed the call button, how often did you
get help as soon as you wanted it?
*4=Always,
3=Usually,
2=Sometimes,
1=Never
Environment
VBP
During this hospital stay, how often were your room and bathroom kept clean?
Pain Management
VBP
During this hospital stay, how often was your pain well controlled?
Communication
about Medications
VBP
Before giving you any new medicine, how often did hospital staff tell you what
the medicine was for?
Discharge
instructions
VBP
During this hospital stay, did doctors, nurses or other hospital staff talk with you
about whether you would have the help you needed when you left the hospital?
Overall Rating of
Hospital
VBP
Using any number from 0 to 10, where 0 is the worst hospital possible and 10 is
the best hospital possible, what number would you use to rate this hospital?
During this hospital stay, how often did you get help in getting to the bathroom
or in using a bedpan as soon as you wanted?
During this hospital stay, how often was the area around your room quiet
at night?
*4=Always,
3=Usually,
2=Sometimes,
1=Never
*4=Always,
3=Usually,
2=Sometimes,
1=Never
During this hospital stay, how often did the hospital staff do everything they
could to help you with your pain?
Before giving you any new medicine, how often did hospital staff describe
possible side effects in a way you could understand?
*4=Always,
3=Usually,
2=Sometimes,
1=Never
*1=Yes,
2=No
During this hospital stay, did you get information in writing about what
symptoms or health problems to look out for after you left the hospital?
Would you recommend this hospital to your friends and family?
During this hospital stay, how often did the staff treat you as a whole person,
not just a medical condition?
*10=Best hospital
possible,
0=Worst hospital
possible
How often did the staff meet your expectations regarding your family's
involvement in your care?
6
HCAHPS (page 3)
*Top Box Score
New
A Hospitalist is a hospital-based doctor who cares for hospitalized patients
in the place of a patient’s personal healthcare provider. Did you receive care
from a Hospitalist?
Yes/No
Using any number from 0 to 10, where 0 is the worst possible care and
10 is the best possible care, what number would you use to rate the care
received from the hospitalist who treated you?
0-10
Thinking of your hospital stay, what one thing could the hospital have
done better?
Is there a specific person you would like to see complimented or thanked
for the care they provided?
NEW
Understanding
Care When
Discharged
During this hospital stay, staff took my preferences and those of my
family or caregiver into account in deciding what my health care
needs would be when I left.
1=Strongly agree
2=Disagree
3=Agree
4=Strongly agree
When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
1=Strongly agree
2=Disagree
3=Agree
4=Strongly agree
When I left the hospital, I clearly understood the purpose for taking each of my medications.
1=Strongly agree
2=Disagree
3=Agree
4=Strongly agree
5=I was not given
any medication
when I left the
hospital
7
PNEUMONIA ANTIBIOTIC RECOMMENDATIONS for
Non-ICU/PCU Patients and ICU/PCU Patients
Note: Pharmacy to adjust antibiotic dosing for renal function
Patient Type
Approved Antibiotics
NON-ICU/PCU PATIENT
• Doxycycline (PO or IV)
+
• Ceftriaxone (IV)
OR
• Azithromycin (PO or IV)
+
• Ceftriaxone (IV)
OR
• Levofloxacin (PO or IV)
ICU/PCU PATIENT
•
•
•
•
Ceftriaxone (IV)
+
Azithromycin (IV)
OR
Ceftriaxone (IV)
+
Levofloxacin (IV)
For documented B-lactam allergy:
• Aztreonam (IV)
+
• Levofloxacin (IV)
NON-ICU/PCU OR ICU/PCU PATIENT
WITH PSEUDOMONAL RISK
Clearly document pseudomonal risk in
the medical record. Pseudomonal risk is
defined as having multiple rounds of
antibiotics or corticosteroids with
documented structural lung disease (i.e.,
chronic bronchitis, COPD, emphysema).
•
•
•
•
Piperacillin/Tazobactam (IV)
+
Levofloxacin (IV)
OR
Meropenem (IV)
+
Levofloxacin (IV)
For documented B-lactam allergy:
• Aztreonam (IV)
+
• Levofloxacin (IV)
RISK SPECIFIC TREATMENTS
IF MRSA IS SUSPECTED:
IF ASPIRATION IS SUSPECTED:
IF PNEUMOCYSTIS PNEUMONIA IS
SUSPECTED IN AIDS PATIENT
ADD: Vancomycin (IV)
ADD: Clindamycin (IV)
ADD: Trimethoprim/
sulfamethoxazole (PO or IV)
Special Considerations
2nd dose per Pharmacy protocol
Not necessary if on Pipercillin/Tazbactam
IV per Pharmacy dosing
8
Franciscan Surgical Quality Indicators
SURGICAL CARE IMPROVEMENT PROJECT (SCIP)
Quality Indicators
Inpatient
•
•
•
•
•
•
•
•
•
INF-1 Prophylactic antibiotic received within one hour prior to surgical incision VBP
INF-2 Prophylactic antibiotic selection VBP
INF-3 Prophylactic antibiotics discontinued within 24 hours after surgery end time
(48 hours for cardiac surgery) VBP
INF-4 Cardiac surgery patients with controlled 6 a.m. postoperative serum glucose on Postop Day 1 and Postop Day 2 – (glucose < 200) VBP
INF-6 Appropriate hair removal
INF-9 Urinary catheter removed on Postop Day 1 or Postop Day 2 VBP
INF-10 Surgical patients with perioperative temperature management—forced air warming or temperature ≥ 96.8
CARD-2 Surgical patients on beta-blocker prior to arrival who received betablocker during the perioperative period (24 hours before surgery through
Postop Day 2 with day of surgery being Day Zero) VBP
VTE-2 Surgery patients who received appropriate venous thromboembolism
prophylaxis within 24 hours prior to surgery to 24 hours after surgery VBP
OUTPATIENT
(CMS Hospital OQR Specifications Manual 6.0—Discharges between 1-1-13 and 12-31-13)
• OP-6 Timing of antibiotic prophylaxis
• OP-7 Prophylactic antibiotic for surgical patients
For the most current information, please visit the CMS QualityNet Specifications
Manual website: www.FHShealth.org/QCE/CMSspecs.asp
9
SURGICAL CARE IMPROVEMENT PROJECT – INPATIENT
Preoperative Antibiotic Prophylaxis Guidelines
Surgery Type
CABG, Cardiac, Vascular
• Cefazolin
• Vancomycin*
Hip/Knee Arthroplasty
• Cefazolin
• Vancomycin*
If ß-lactam allergy:
• Clindamycin
• Vancomycin
• Clindamycin
• Vancomycin
Colon
• Cefoxitin—1st choice at FHS facilities
• Cefazolin + Metronidazole
If PCN or ß-lactam allergy:
• Metronidazole + Levofloxacin
• Metronidazole + Gentamicin
• Clindamycin + Gentamicin
Hysterectomy,
Hysterectomy + Colon**
• Cefazolin
• Cefoxitin
*Vancomycin should be used with caution. Only acceptable with specific
documentation of provider justification, such as MRSA colonization or infection,
increased MRSA rate related to facility or operation specific, chronic wound care
or dialysis, continuous inpatient stay >24 hours prior to procedure, transfer from
an inpatient hospitalization after a three-day stay, acute inpatient hospitalization
or LTC within last year, or valve surgery. This must be explicitly documented in
the medical record with the order.
**If Cefazolin used for hysterectomy prior to colon surgery, and redosing is
required, redose with Cefoxitin
For the most current information, please visit the CMS QualityNet
Specifications Manual website: www.FHShealth.org/QCE/CMSspecs.asp
10
Surgical Care Improvement Project – Outpatient
Preoperative Antibiotic Prophylaxis Guidelines
Surgery Type
Cardiac (Pacemakers
or AICDs), VASCULAR
• Cefazolin
• Vancomycin* (acceptable with
documented justification for use)
• Clindamycin
• Vancomycin
ORTHOPEDIC, PODIATRY
Transrectal
Prostate Biopsy
• Cefazolin
• Vancomycin (acceptable with
•
•
•
•
•
• Clindamycin
• Vancomycin
Cefazolin
Ciprofloxacin (may be oral abx.)
Cefoxitin
Gentamicin + Metronidazole
Gentamicin + Clindamycin
Penile Prosthesis
Insertion, Removal,
Revision
• Gentamicin + Cefazolin
• Gentamicin + Cefuroxime
• Gentamicin + Clindamycin
PEG Placement,
PEG Revision
•
•
•
•
Cefazolin
Cefoxitin
Cefazolin + Metronidazole
Vancomycin* (acceptable with
• Clindamycin ± Gentamicin
• Clindamycin ± Ciprofloxacin
• Vancomycin ± Ciprofloxacin
11
Surgical Care Improvement Project – Outpatient
preoperative Antibiotic prophyLaxis Options (Page 2)
Surgery Type
LaparoscopicallyAssisted Hysterectomy
and Vaginal
Hysterectomy
• Cefazolin
• Cefoxitin
Pubovaginal Sling
• Cefazolin
• Cefoxitin
Head and Neck
• Cefazolin
• Vancomycin* (acceptable with
• Clindamycin
Neurological
• Cefazolin
• Clindamycin
• Clindamycin
• Vancomycin
12
Surgical Care Improvement Project Venous
Thromboembolism (VTE) Prophylaxis Options for Surgery
Surgery Type
Recommended Prophylaxis Options*
Any of the following:
Intracranial
Neurosurgery
•
•
•
•
Intermittent pneumatic compression devices (IPC) with or without graduated compression stockings (GCS)
Low-dose unfractionated heparin (LDUH)
Low molecular weight heparin (LMWH)†
LDUH or LMWH† combined with IPC or GCS
General Surgery
•
•
•
•
Low molecular weight heparin (LMWH)
LDUH or LMWH combined with IPC or GCS
Factor Xa Inhibitor
Gynecologic Surgery
•
•
•
•
•
Factor Xa Inhibitor
Intermittent pneumatic compression devices (IPC)
LDUH or LMWH combined with IPC or GCS
Urologic Surgery
•
•
•
•
•
•
Factor Xa Inhibitor
Graduated compression stockings (GCS)
LDUH or LMWH or Factor Xa Inhibitor
combined with IPC or GCS
Any of the following with a
documented reason for not
administering pharmacological
prophylaxis**
•
•
* Patients who receive neuraxial anesthesia or have a documented reason for not administering
pharmacological prophylaxis may pass the performance measure if pharmacological or mechanical
prophylaxis is ordered and received anytime from hospital arrival to 24 hours after anesthesia
end time.
** For example, documented high risk of bleeding, active bleeding, thrombocytopenia, patient
on continous IV heparin therapy or patient refusal.
† Current guidelines recommend postoperative low molecular weight heparin for Intracranial
Neurosurgery.
13
SURGICAL CARE IMPROVEMENT PROJECT VTE PROPHYLAXIS OPTIONS
FOR SURGERY (Page 2)
Surgery Type
Recommended Prophylaxis Options*
Any of the following:
Any of the following with a
documented reason for not
administering pharmacological
prophylaxis**
Elective Hip
Replacement: Total,
Partial and Revisions
• Low molecular weight heparin (LMWH)
•Warfarin
• Factor Xa Inhibitor
• Oral Xa Inhibitor
• Intermittent pneumatic compression devices (IPC)
• Venous foot pump (VFP)
Hip Fracture Surgery
• Low-dose unfractionated heparin (LDUH)
•Warfarin
•
•
•
Elective Knee
Replacement: Total
and Revisions
•Warfarin
• Oral Xa Inhibitor
Venous foot pump (VFP)
* Patients who receive neuraxial anesthesia or have a documented reason for not administering pharmacological prophylaxis may pass the
performance measure if pharmacological or mechanical prophylaxis is ordered and received anytime from hospital arrival to 24 hours after anesthesia
end time.
** For example, documented high risk of bleeding, active bleeding, thrombocytopenia, patient on continous IV heparin therapy or patient refusal.
† The U.S. Food and Drug Administration has approved Xarelto (rivaroxaban) to reduce the risk of blood clots, deep vein thrombosis (DVT)
and pulmonary embolism (PE) following knee or hip replacement surgery ONLY.
For the most current information, please visit the CMS QualityNet
Specifications Manual website: www.FHShealth.org/QCE/CMSspecs.asp
14
E d u c at i o n F o r m
INPATIENT ACUTE MYOCARDIAL INFARCTION (AMI)
Acute Myocardial
Infarction (AMI)
QUALITY INDICATORS
Explanation and/or contraindications must be documented
in the medical record
Aspirin at Arrival—
Or documented as taken/
given within 24 hours
before or after arrival
Reasons for not administering include:
• Aspirin allergy
• Coumadin/warfarin or Pradaxa/dabigatran as pre-arrival medication
• Other reasons explicitly documented by Physician/APN/PA or Pharmacist
ACEI or ARB at
Discharge for LVSD—
(LVSD defined as EF< 40%
or narrative description of
moderate or severe systolic
dysfunction)
Reasons for not prescribing include:
• Documented allergy to both ACEI and ARB
• Moderate or severe aortic stenosis
• Physician/APN/PA or Pharmacist documentation of BOTH a reason for not
prescribing ACEI at discharge AND a reason for not prescribing an ARB at discharge. Note: Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only: angioedema, hyperkalemia,
hypotension, renal artery stenosis, worsening renal function/renal disease/dysfunction.
• Reason documented by Physician/APN/PA or Pharmacist for not prescribing an ARB at discharge AND an ACEI allergy
• Reason documented by Physician/APN/PA or Pharmacist for not prescribing an ACEI at discharge AND an ARB allergy
Note: Reasons for no ACEIs and reasons for no ARBs must be explicitly documented (e.g.,
"K+5.5—No ACEI") or clearly implied (e.g., “severe hypotension with ACEIs in past, “
“Hx ACEI-induced cough,” “ARBs contraindicated.”)
15
INPATIENT ACUTE MYOCARDIAL INFARCTION (AMI) (page 2)
ACUTE MYOCARDIAL
INFARCTION (AMI)
Aspirin Prescribed
at Discharge
• Aspirin allergy
• Coumadin/warfarin or Pradaxa/dabigatran prescribed at discharge
Beta-Blocker
Prescribed at
Discharge
• Beta-blocker allergy
• 2nd or 3rd degree heart block (without pacemaker) on ECG on arrival or during
hospital stay
• Other reasons documented by Physician/APN/PA/Pharmacist—must be explicit
(e.g.–”COPD-No BBs”) or clearly implied (e.g.–”BBs contraindicated”)
PCI within 90 minutes
of hospital arrival
System reasons for delay are not acceptable such as equipment or staff unavailability.
Reasons for delay include:
• Cardiopulmonary arrest
• Initial family or patient refusal
• Mechanical circulatory assist device insertion
• Intubation
• Other patient centered reason explicitly documented by physician
Statin prescribed
at discharge
• Statin medication allergy
• Other reasons documented by Physician/APN/PA or Pharmacist (e.g.–”Chronic liver failure–Statins contraindicated”)
• Hepatic Failure
• Hepatitis
• Myalgias
• Patient/family refusal
• Rabdomyolysis
16
INPATIENT HEART FAILURE (HF)
Heart Failure (HF)
QUALITY INDICATORS
LVF Assessment
Documentation of left ventricular systolic function assessment prior to arrival, during
hospitalization, planned for after discharge or reason documented by Physician/APN/PA
for not assessing. See table 1.2 for complete list of inclusions.
Nephrology patients coming in with pulmonary edema of cardiogenic origin will end up
in the heart failure population. Please make sure LVF assessment is documented on
these patients or explicitly document why LVF is not being assessed (e.g., ”ESRD. Will not
measure EF.”)
ACEI or ARB at
Discharge for LVSD—
(LVSD defined as EF< 40%
or narrative description
of moderate or severe
systolic dysfunction)
• Documented allergy to both ACEI and ARB
• Moderate or severe aortic stenosis
• Physician/APN/PA or Pharmacist documentation of BOTH a reason for not prescribing ACEI at discharge AND a reason for not prescribing an ARB at discharge.
Note: Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only: angioedema, hyperkalemia,
hypotension, renal artery stenosis, worsening renal function/renal disease/dysfunction.
• Reason documented by Physician/APN/PA or Pharmacist for not prescribing an ARB at discharge AND an ACEI allergy
• Reason documented by Physician/APN/PA or Pharmacist for not prescribing an ACEI at discharge AND an ARB allergy
Note: Reasons for no ACEIs and reasons for no ARBs must be explicitly documented (e.g.,
“K+5.5—No ACEI”) or clearly implied (e.g., “severe hypotension with ACEIs in past, “
“Hx ACEI-induced cough,” “ARBs contraindicated.”)
*LVSF assessment is a measure or left ventricular contractility and may be
described either quantitatively or qualitatively (e.g., “left ventricular EF=30%” or
“moderate left ventricular systolic dysfunction”).
17
INPATIENT HEART FAILURE (HF) (page 2)
Heart Failure (HF)
QUALITY INDICATORS
Complete Discharge
Instructions
All six elements must be covered:
• Diet
• Activity
• Discharge medications (medications list on provider discharge summary, discharge medication reconciliation form, and nursing discharge instruction list must match)
• Follow-up appointment—cannot state “follow-up as needed.” Needs provider name and date & time of appt if available.
•What to do if symptoms worsen specific to heart failure
•Weight monitoring
18
Left Ventricular Systolic Function (LVSF)
Assessment Inclusion Table 1.2
Echocardiogram
(echo)
• Cardiac ultrasound
• Transesophageal echocardiogram (TEE)
• Transthoracic echocardiogram (TTE)
Cardiac
Catheterization
(cath) with Left
Ventriculogram
(LV gram)
• Cardiac cath with mention of LVSF
• Cardiac/coronary angiogram with LV gram
• Cardiac/coronary angiogram with mention of LVSF
• Cardiac/coronary arteriogram with LV gram
• Cardiac/coronary arteriogram with mention of LVSF
• Left heart cath with mention of LVSF
• Left ventriculogram (LV gram)
Other LVSF Assessment
Tests
• Cardiac MRI with mention of LVSF
• CT scan of chest with mention of LVSF
• Multiple gated acquisition scan (MUGA) or other cardiac imaging testing described as gated or blood pool
• Other nuclear test (e.g., SPECT, PET) with mention of LVSF
Left Ventricular
Systolic Function
(LVSF)
• Akinesis described as left ventricular
• Diastolic dysfunction, failure, function or impairment
• Dysfunction described as biventricular, left ventricular (LVD, LVSD), systolic or
ventricular
• Dyskinesis described as left ventricular
• Ejection fraction (EF, LVEF)
• Endstage cardiomyopathy
• Failure described as biventricular, left ventricular, systolic or ventricular
• Function described as biventricular, left ventricular (LVF), systolic or ventricular
• Hypokinesis described as left ventricular
19
Immunizations
Immunization
QUALITY INDICATORS
Pneumococcal
Vaccination—must be
assessed and administered
when applicable to all
patients ≥ 65 years old and
ages 5-64 with high risk
conditions (i.e., Diabetes,
Nephrotic Syndrome,
ESRD, CHF, COPD, HIV,
Asthma, Aspienia)
• Pneumococcal vaccine was received in the past and this is documented in the
medical record for the present episode of care
• Documentation of patient or caregiver's refusal of pneumococcal vaccine
• Documented allergy/sensitivity to pneumococcal vaccine (reaction must
be documented)
• Documented bone marrow transplant within the past 12 months
• Documentation that patient is currently receiving scheduled course of chemotherapy or radiation during this hospitalization or less than 2 weeks prior
• Documentation that patient received shingles vaccine (Zostavax) within last 4 weeks
• Patients 5-18 years of age who received a conjugate vaccine within the previous 8 weeks
Influenza
Vaccination—
must be assessed and
administered when
applicable to all patients
6 months of age and older,
regardless of diagnosis,
hospitalized (discharged)
during the months of
September through March
• Influenza vaccine was received in the past (during this flu season) and is documented in the medical record for the present episode of care
• Documentation of patient or caregiver's refusal of influenza vaccine
• Documented allergy/sensitivity to influenza vaccine (reaction must be documented)
• Documented anaphylactic egg allergy
• Documented anaphylactic latex allergy
• Documented bone marrow transplant within the past 6 months
• Documented history of Guillian-Barré syndrome within 6 weeks after a previous
influenza vaccination
20
INPATIENT SURGICAL CARE IMPROVEMENT PROJECT (SCIP)
Surgical Care
Improvement Project
(SCIP) QUALITY
INDICATORS
Appropriate VTE
(Venous
Thromboembolism)
Prophylaxis received
Patient must receive appropriate VTE prophylaxis according to current recommendations.
See VTE Prophylaxis Options for Surgery for listing of current recommendations by
surgery type.
Most surgeries require a pharmacologic prophylaxis agent such as low molecular weight
heparin (LMWH) or low-dose unfractionated heparin (LDUH) unless there are documented
reasons for not administering pharmacologic prophylaxis. Orders to hold prophylaxis
without a documented reason or contraindication does not meet the compliance
requirement for this indicator.
Reasons for not administering pharmacologic prophylaxis include:
• Active bleeding (GI bleeding, cerebral hemorrhage, retroperitoneal bleeding)
• Documented bleeding risk
• GI bleed
• Risk of bleeding
• Hemorrhage
• Patients on continuous IV heparin therapy within 24 hours before or after surgery
• Thrombocytopenia
• Patient refusal
If a patient has contraindications to pharmacologic prophylaxis, the patient is eligible
for mechanical prophylaxis devices unless there are documented reasons for not
administering mechanical devices.
Reasons for not administering mechanical prophylaxis include:
• Bilateral amputee
• Bilateral lower extremity trauma
• Patients on continuous IV heparin therapy within 24 hours before or after surgery
• Patient refusal
21
INPATIENT SURGICAL CARE IMPROVEMENT PROJECT (SCIP) (page 2)
SURGICAL CARE
IMPROVEMENT PROJECT
(SCIP)
Prophylactic
Antibiotics
Discontinued within
24 Hours after
anesthesia End Time
(48 Hours for CABG/
Cardiac Surgeries)
Antibiotics must be discontinued within 24 hours of the anesthesia end time as
documented on the anesthesia record (if anesthesia end time is not documented on
the anesthesia record use the “To PACU” time).
If antibiotics are continued beyond 24 hours (48 hours for cardiac/CABG cases) there must
be explicit documentation stating why the antibiotic is still needed. Must document
“possible infection” or “suspected infection” or an actual infection. Documentation of
symptoms such as fever or increased WBC is not sufficient documentation to abstract a
postoperative infection that warrants continuation of prophylactic antibiotics.
Types of infections that are acceptable for continuation of antibiotics (must be documented):
• Necrotic/ischemic/infarcted bowel
• Abscess
• Necrosis
• Acute abdomen
• Osteomyelitis
• Aspiration pneumonia
• Other documented infection
• Bloodstream infection
• Penetrating abdominal trauma
• Bone infection
• Perforation of bowel
• Cellulitis
• Purulence/pus
• Crohn's disease
• Pneumonia or other lung infection
• Endometritis
• Sepsis
• Fecal contamination
• Surgical site or wound infection
• Free air in abdomen
• Ulcerative colitis
• Gangrene
• Urinary tract infection (UTI)
• H. pylori
Not acceptable for continuation of antibiotics:
• Avascular necrosis
• Fungal infections
• Bacteria in urine (Bacteriuria) • History of MRSA
• “carditis” (such as pericarditis) • History of MRSA
without mention of infection • History of infection
• Colonized MRSA
• Viral infections
22
INPATIENT SURGICAL CARE IMPROVEMENT PROJECT (SCIP) (page 3)
SURGICAL CARE
IMPROVEMENT PROJECT
(SCIP)
SURGERY PATIENTS ON
BETA-BLOCKER THERAPY
PRIOR TO ARRIVAL
WHO RECEIVED A
BETA-BLOCKER DURING
THE PERIOPERATIVE
PERIOD
The perioperative period for the SCIP cardiac measures is defined as 24 hours prior to
surgical incision through POD 2.
If a beta-blocker is listed as a home or current medication, it must be continued during
the perioperative period unless there is explicit documentation stating reason for not
administering (e.g., heart rate less than 50 bpm or other reason documented by
Physician/APN/PA or Pharmacist). "Hold PO meds" or "NPO-hold meds" are not acceptable
reasons for not administering beta-blockers postoperatively.
If it is documented that the patient took a beta-blocker prior to arrival, there must be
a date and a time to indicate when the last dose of the beta-blocker was taken.
23
INPATIENT VENOUS THROMBOEMBOLISM (VTE)
VTE QUALITY
INDICATORS
VTE RISK ASSESSMENT
AND APPROPRIATE
PROPHYLAXIs Begun
Applies to:
• Medical and surgical patients upon hospital admission
• ALL patients upon admission / transfer to ICU
Key Points:
• Documentation must be completed within 1 day of admission, surgery, or transfer to ICU
• Both pharmacologic and mechanical prophylaxis must be addressed. If one type of
prophylaxis is contraindicated (with reason documented), the other type of prophylaxis must be used unless a contraindication is explicitly documented as well. (e.g. ‘Active GI bleeding- LMWH contraindicated’. The patient would still require mechanical prophylaxis.)
Reasons for not administering any pharmacologic or mechanical prophylaxis:
• Patient at low risk for VTE
• Explicit documentation that patient doesn’t need VTE prophylaxis
• Patient / Family refusal
ONLY Acceptable Oral Factor Xa Inhibitor Indications:
• History of hip replacement surgery (not fracture)
• History of knee replacement surgery
• History of/current finding of Atrial Fibrillation or Atrial Flutter (except when terminated
within 8 weeks following CABG)
• Past/current history of treatment for VTE
ANTICOAGULATION
OVERLAP THERAPy
Key Points:
• If warfarin prescribed during hospitalization or at discharge, parenteral anticoagulation (IV, SQ) AND warfarin must be administered on the same calendar day or documented reason why not
• Must be on overlap therapy for at least 5 days, until INR ≥ 2, before parenteral therapy is discontinued. If less than 5 days since overlap therapy begun, or INR < 2, patient must be discharged on both medications.
Reasons for not administering overlap therapy:
• Surgical procedure
• Bleeding complications
24
INPATIENT VENOUS THROMBOEMBOLISM (VTE) (page 2)
VTE QUALITY
INDICATORS
ANTICOAGULATION
OVERLAP THERAPy
(cont.)
Reasons for discontinuation of parenteral therapy:
• Bleeding risk
• ‘High’ INR value, supratherapeutic
• Severe anemia
• Active bleeding
• Not a candidate for long-term anticoagulation
• Previously on warfarin
• Received blood during this timeframe
• Scheduled for surgery
• Thrombocytopenia
• Patient/Caregiver refusal
COMPLETE WARFARIN
THERAPY DISCHARGE
INSTRUCTIONS
All four elements must be addressed within the medical record:
• Compliance issues
• Importance of taking warfarin as instructed
• Importance of monitoring warfarin with scheduled PT/INR blood draws
• Dietary Advice
• A ‘consistent amount’ of foods with Vitamin K rather than avoidance should
be advised
• Avoid major changes in dietary habits, or notify health professional before
changing habits
• Follow-up Monitoring
• Information about plans to monitor warfarin post-discharge (i.e. ‘Follow-up with Coumadin clinic in 1 week’)
• Potential for Adverse Drug Reactions and Interactions
• Diet and medications can affect the PT/INR level
• Do not take or discontinue any medication or over-the-counter medication except on the advice of the Physician or Pharmacist
•Warfarin increases the risk of bleeding
25
STROKE
STROKE Quality
Indicators
VTE Prophylaxis given
the day of or the day
after hospital admission (ischemic and
hemorrhagic)
•
•
•
Reasons for not administering must be explicitly documented such as “Active GI bleed – LMWH contraindicated”
Documentation that patient is ambulating without mention of VTE prophylaxis is
insufficient
Stroke patients require a documented reason for not administering another form of prophylaxis when graduated compression stockings are the ONLY form of VTE
prophylaxis administered
Antithrombotic
therapy prescribed at
hospital discharge
– anticoagulant and
antiplatelet drugs
(Ischemic)
•
•
•
All discharge medication documentation available in the chart will be taken into account unless the documentation is contradictory
If documentation is contradictory, it will be considered “unable to determine” which will result in a variance
The antithrombotic must be listed by name and not by medication class
Anticoagulation
Therapy for Atrial
Fibrillation/Flutter
prescribed at hospital
discharge
(Ischemic)
•
•
Thrombolytic Therapy
for acute ischemic
stroke patients who
arrive within 2 hours
of time last know well
and IV tPA initiated
within 3 hours
•
•
Reasons for not initiating IV thrombolytic therapy must be explicitly documented by a Physician/APN/PA or Pharmacist
Nursing may document patient/family refusal, NIHSS score of zero or initiation of IV thrombolytic at a transferring hospital
26
Stroke (page 2)
STROKE Quality
Indicators
Antithrombotic
Therapy by End of
Hospital Day 2
(Ischemic)
•
•
Reason for not administering antithrombotic therapy must be dated/timed prior to end of hospital day 2 and explicitly documented by a Physician/APN/PA or Pharmacist
Nursing may document patient/family refusal but it must be documented in the
timeframe of arrival to end of hospital day 2
Discharged on Statin
Medication
(Ischemic)
•
•
•
The statin must be listed by name and not by medication class
Stroke Education
(Ischemic and
hemorrhagic)
Documentation that the patient or caregiver was given educational materials during the
hospital stay addressing all of the following:
• Activation of emergency medical system
• Follow up after discharge (must be specific with provider name and appointment)
• Medications prescribed at discharge (Home Medication List must match with Discharge MedRec and Discharge Summary)
• Risk factors for stroke
•Warning signs and symptoms of stroke
Assessed for
Rehabilitation services
(Ischemic and
hemorrhagic)
•
•
Assessment for rehabilitation services must be completed by a qualified provider
(excluding nursing)
Documentation must be stated in the context of rehabilitation services such as “Patient returned to prior level of function, rehabilitation not indicated at this time” or “Symptoms resolved – no rehab needed”
27

Franciscan Quality Indicators

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