In The Know: Part II Specifications Manual Reminders

1. In The Know: Part IISpecifications Manual Reminders Version 2.6b and Version 2.6b (4th Qtr 2008—3rd Qtr 2009) April 2009

2. 4th Qtr 2008—1st Qtr 2009 DischargesSpecification Manual, Version 2.5b Significant Changes to Remember

3. Adult Smoking History (all topics)(Version 2.5b) • Content now specifically defines two of the four acceptable sources for documentation • Nursing Assessment Form • H&P • Excluded Data Sources identified • Documentation from a transferring facility or a previous admission

4. Clinical Trial (all topics)(Version 2.5b) • Documentation must support that the patient was enrolled in a clinical trial during this admission. (Prior to or during this EOC) • “Yes” requires allthree of these conditions: • Signed consent form for the clinical trial • Experimental study NOT observational study (e.g., registry) • Enrolling patients with the same condition as the measure set being studied

5. Clinical Trial (continued)(Version 2.5b) • Select “No” if • The signed consent form is for an observational study only. • It is not clear whether the study described in the signed patient consent form is experimental or observational. • It is not clear which study population the clinical trial is enrolling. Assumptions should not be made if it is not specified.

6. Clinical Trial (continued)(Version 2.5b) • THE ONLY ACCEPTABLE SOURCE: • Signed consent form for clinical trial

7. Heart Failure(Version 2.5b) • Discharge Instructions Address Medications: If there is documentation that the patient was discharged on insulin(s) of ANY kind, ANY reference to ANY type of insulin in the written discharge instructions is sufficient, for the purposes of the Discharge Instructions measure (HF-1). • E.g., D/C Summary notes patient discharged on “Humulin Insulin” and “Insulin 70/30” is listed on the discharge instruction sheet – Consider this a match.

8. PCI Date and PCI Time: New inclusion terms for non-primary PCIs: • Not immediate (No immediate indication to cath) • Not primary (Will schedule elective PCI) • Not urgent ( PCI not urgent at this time) Acute Myocardial Infarction(Version 2.5b)

9. Pneumonia(Version 2.5b) • Antibiotics: Only need to document those given during the first 24 hours after arrival for Pneumonia (used to be 36 hours) • Antibiotic Received: Limitations on using H&Ps are removed (i.e., not limited to those dictated day of admission or day prior) • Influenza Vaccination Status: Is now measured from October through March

10. SCIP(Version 2.5b) • Antibiotic Received: Limitations on using H&Ps have been removed (they are not limited to those dictated the day of admission or the day prior to admission) • Infection Prior to Anesthesia and Postoperative Infections: Lung infiltrates have been removed from the Inclusion Lists (common findings and only rarely reflect infectious causes)

11. SCIP (continued)(Version 2.5b) • Preoperative Hair Removal: Abstract only from data sources that document actual hair removal • Surgery End Time: • Priority order removed for Data Sources • Priority order added for Inclusion List (1st, 2nd, and 3rd priority levels)

12. SCIP (continued)(Version 2.5b) • Beta-Blocker Perioperative: When the patient arrived the day of surgery abstract “yes” if: • The patient took the beta-blocker at home that same day • The patient took the beta-blocker the night prior and the time is documented to show it was during the perioperative period • Beta-Blocker Perioperative: When the patient arrived > 1 day prior to surgery, abstract “yes” as long as a time shows it was taken during the perioperative period

13. 2nd Qtr 2009—3rd Qtr 2009 DischargesSpecifications Manual, Version 2.6b Significant Changes to Remember

14. “Using the Specifications Manual”Version 2.6b Clarification of “episodes of care” Must meet the following criteria: All “acute inpatient” episodes of care billed under the hospital’s acute CMS Certification Number (CCN) All payor sources

15. Data DictionaryVersion 2.6b As electronic data are available at all times during the hospitalization, it is acceptable to use this data for abstraction purposes. [It is critical that you include this information in validation record copies when requested!] It is no longer necessary to include a copy of the hospital’s policy on the “Use of Abbreviations.”

16. Conflicting InformationVersion 2.6b • When both inclusions and exclusions are documented, use the inclusion term…unless otherwise specified in the data element.

17. Episodes of Care (EOC)Version 2.6b • An EOC must meet the following criteria: • All “acute inpatient” episodes of care billed under the hospital’s acute CMS Certification Number (CCN) • All payor sources • Patients transferred from one acute care hospital to another acute care hospital that is within the same healthcare system and shares the same CMS Certification Number (CCN) should be abstracted as one episode of care.

18. Arrival Date & Arrival Time(all topics)Version 2.6b • Review the “Notes for Abstraction” for each data element as there is additional information clarifying how to abstract for patients coming from outpatient settings, direct admits, and observation status.

19. Comfort Measures Only(all topics) Version 2.6b New bullet providing additional abstraction guidance regarding CMO documentation dated prior to arrival or which refers to the pre-arrival time period. Inclusion List is all-inclusive and has two new inclusion terms: Brain death Organ harvest Exclusion bullets have been removed and replaced with, “All terms other than those on the Inclusions List.”

20. Acute Myocardial Infarction Version 2.6b First PCI Date and First PCI Time: Remove bullet regarding attempted, but not completed….. “Not needed in abstraction because inclusion in the PCI measures is determined by the billed ICD9CM procedure codes.”

21. AMI and Heart Failure Version 2.6b LVSD: Guideline wording revised to increase abstraction clarity and simplify the data element.

22. Heart Failure Version 2.6b • Discharge Instructions Address Activity • Discharge Instructions Address Diet • Discharge Instructions Address Follow-up • Discharge Instructions Address Symptoms Worsening • Data Element wording has been simplified to increase clarity and decrease abstraction burden.

23. Pneumonia and SCIP Version 2.6b • Antibiotic Name, Date, Time, and Route • Abstract antibiotics from narrative charting ONLY if there is no other documentation that reflects an antibiotic was given. • Do not collect antibiotics documented on the operative report as this does not reflect actual administration. 23

24. Pneumonia Version 2.6b • Antibiotic Name, Date, Time, and Route Multi-page/sided forms • The signature, initials or date from one side CAN be applied to all documentation on that form. • If no signature or initials on any side/page of the form, you cannot abstract that antibiotic. • If no date on any side/page of the form, use UTD for that information. 24

25. Pneumonia Version 2.6b • Multi-page/sided forms • The CDAC abstractors must follow the same guidelines! • When preparing your records for validation, if you have these forms and the date is on at least one side or page of a set, you are allowed to hand-write the date on the other pages of the set! Warning! 25

26. Pneumonia Version 2.6b • Blood Culture Collected, Date, and Time • Use documentation that demonstrates actual collection of the blood culture. • If multiple times of collection are documented, abstract the earliest (initial) time, providing documentation demonstrates collection. • No longer limits abstraction to documentation of “drawn, collected, or obtained” times. 26

27. Pneumonia Version 2.6b • Chest X-Ray • If the inclusion term is prefaced with wording such as “no significant” or “no definite,” select 4 (UTD). Do NOT use Appendix H, Table 2.6! • Priority order for sources • The Inclusion List is all inclusive! If you don’t see those words/phrases (or minor variations of them), you cannot abstract as “1”! Remember… 27

28. Pneumonia Version 2.6b • Pneumonia Diagnosis: ED/Direct Admit • When the ED form completed by the ED physician does not include pneumonia as final diagnosis, but… • The hospitalist, attending, or consultant does document a diagnosis of pneumonia (whether patient is still in ED or not), • Select “3” (no pneumonia diagnosis). 28

29. Pneumonia Version 2.6b • Pneumonia Diagnosis: ED/Direct Admit • If an ED patient or direct admit final diagnosis includes “aspiration pneumonia,” select “3” (no pneumonia diagnosis). 29

30. Pneumonia Version 2.6b • Pseudomonas Risk • “Asthma” has been added to the Exclusion List • Pulse Oximetry Done • Retired (no longer measured) 30

31. SCIP Version 2.6b • Beta-Blocker Current Medication • Now “prior to arrival,” not “prior to admission.” (also applies to Beta-Blocker During Pregnancy) • If the patient stopped taking a beta-blocker prior to arrival but was started on it in the hospital prior to surgery, select “No.” 31

32. SCIP Version 2.6b • Beta-Blocker Current Medication • If a beta-blocker is listed as a “home” or “current” medication… • But the physician does not continue it after arrival…….select “Yes.” • And is continued after arrival, but stopped prior to surgery……. select “Yes.” 32

33. SCIP Version 2.6b • Infection Prior to Anesthesia and • Postoperative Infections • Addition to the Inclusion List: “Purulence/pus” • Addition to the Exclusion List: “Bacteria in urine (Bacteriuria)” 33

34. SCIP Version 2.6b • Infection Prior to Anesthesia is only used to exclude cases from the SCIP-Inf measures. • If the physician knew or suspected that an infection might be present prior to surgery, this might have influenced the prophylactic antibiotic choices. Do not mistake the clinical definition of Infection Prior to Anesthesia with the abstraction definition! Remember… 34

35. SCIP Version 2.6b • Laparoscope • Select “Yes” if • Only incisions made were those to insert the laparoscopic equipment • If drains are inserted and there are no other incisions except those to insert the laparoscopic equipment. • Select “No” if • An additional incision, a hand insertion, or an extension of the laparoscopic insertion sites is made. 35

36. SCIP Version 2.8 • Oral Antibiotics • “Prior to incision” is now “more than 24 hours prior to incision.” • Added: “Oral antibiotics may be given less than 24 hours prior to incision, but this data element is only concerned with those given GREATER than 24 hours prior to incision.” 36

37. SCIP Version 2.6b • Reason for Not Administering Beta-Blocker - Perioperative • Previously titled “Contraindications to…” • Focus changed from contraindications for “prescribing” beta-blockers to reasons for not “administering” beta-blockers. 37

38. SCIP Version 2.6b • VTE Prophylaxis • Now only collect through 24 hours after Surgery End Time. (used to be 48 hours) • Reason for Not Administering VTE Prophylaxis • Added: Blood or blood products administered intraoperatively and documented on the anesthesia record or operative report should be considered an order for transfusion—select Value “2.” 38

39. SCIP Version 2.6b • Reason for Not Administering VTE Prophylaxis • Added: Reinfusion of blood products collected with blood recovery systems should not be considered for this element. • Added: For patients on continuous IV heparin therapy within 24 hours before or after surgery, select Value “3.” • “Patient Refusal” added to the Inclusion List, reasons for not administering mechanical prophylaxis. 39

40. Pneumonia and SCIP Any Version… Abstraction Tip… • Antibiotic Name, Date, Time, and Route • Do I abstract this antibiotic or not??? • If you have UTD for any data element, abstract that “dose” with UTD in the missing info field. • When in doubt, abstract it! • During validation, you will NOT be penalized for additional “doses.” You WILL be penalized if you do not abstract one “dose” that the CDAC abstracted! 40

41. Over 1 million drug-related injuries occur every year in health care settings. The Institute of Medicine estimates that at least a quarter of these injuries are preventable. To find out how to prevent medication errors, go tohttp://www.hsag.com/ca_drugsafety/. www.hsag.com This material was prepared by Health Services Advisory Group Inc., the Medicare Quality Improvement Organization for California, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication No. CA-9SOW-6.1-042109-02 41