Your Medicare QIO* Answers Your Questions The SCIP Card-2 Beta-Blocker Measure

1. Your Medicare QIO* Answers Your QuestionsThe SCIP Card-2 Beta-Blocker Measure Susan Hiyama, RN, MSN, CPHQ Health Services Advisory Group of California, Inc. Henrietta Hight, RN, BA, BSN FMQAI, Inc. *QIO = Quality Improvement Organization. This Presentation is brought to you by the QIOs of California, Arizona, and Florida

2. Sponsoring Organizations • Health Services Advisory Group, Inc. • Medicare Quality Improvement Organization for Arizona since 1979. • Health Services Advisory Group of California, Inc. • Medicare Quality Improvement Organization for California since 2008 • FMQAI, Inc. • Medicare Quality Improvement Organization for Florida since 1993. 2

3. Q1: What is SCIP? www.medqic.org/scip 3

4. Surgical Care Improvement ProjectNational Goal • To reduce preventable surgical morbidity and mortality by 25% by 2010. 4

5. SIP/SCIP National Expert Panel/Steering Committee • American College of Surgeons • American Hospital Association • Agency for Healthcare Research and Quality • American Association of Critical Care Nurses • American College of Chest Physicians • American College of Obstetricians & Gynecologists • American Geriatrics Society • American Academy of Orthopedic Surgeons • American Society of Anesthesiologists • American Society of Health System Pharmacists • Association of Professionals in Infection Control and Epidemiology • Association of PeriOperative Registered Nurses • Centers for Disease Control and Prevention • Centers for Medicare & Medicaid Services • Department of Veteran’s Affairs • Institute for Healthcare Improvement • The Joint Commission • Society for Critical Care Medicine • Society of Colon and Rectal Surgeons • Surgical Infection Society • Society for Healthcare Epidemiology of America • Society of Thoracic Surgeons • The Medical Letter • Sanford Guide 5

6. Surgical Care Improvement Project (SCIP) Preventable Complication Measures Surgical infection prevention Cardiovascular complication prevention Venous thromboembolism prevention 6

7. Surgical Care Improvement Project 7 *NQF endorsed

8. Q2: What is the Card-2 Measure? 8

9. The SCIP Card-2 Measure Description: Surgery patients on a beta- blocker prior to arrival who received a beta- blocker during the perioperative period. [The information on this and the following slides is adapted from the Specifications Manual for National Hospital Inpatient Quality Measures, version 3.0b. You can always find the most up-to-date information about quality measures in the Specifications Manual, which can be found by going to www.qualitynet.org, clicking on the “Hospitals-Inpatient” tab, then clicking on the Specifications Manual option.] 9

10. Q3: Can you help us understand why Card-2 is such a high-priority topic? 10

11. Card-2 Measure as a Priority • The American College of Cardiology and American Heart Association recommend continuation of beta-blocker therapy in the perioperative window. • Accumulating evidence suggests that titration to maintain tight heart rate control should be the goal. • Adverse cardiac events occur in 2%–5% of patients undergoing noncardiac surgery, and in almost 34% of patients undergoing vascular surgery. • Current studies suggest that appropriately administered beta-blockers reduce perioperative ischemia, especially in patients considered to be at risk. 11

12. Q4: My patient’s home medications include antihypertensive and cardiac medications, as well as a beta-blocker. Why the concern for beta- blockers specifically? 12

13. Card-2 Rationale • Beta-blockers are agents that block beta-adrenergic receptors. • Their actions include: • Decrease in the rate and force of heart contractions. • Reduction of blood pressure. • Other anti-hypertensives focus on the muscle of blood vessels rather than cardiac muscle. 13

14. Q5: What exactly is required to meet the Card-2 beta- blocker measure? 14

15. Measure Requirements • Patients on home beta-blocker therapy must receive a beta-blocker during the perioperative period. • If the patient does not receive a beta- blocker within the perioperative period, clear documentation of contraindications must be noted in the medical record. 15

16. Measure Requirements – Beta-Blocker Documentation Beta-blocker documentation should: • Be provided in the operating room by the anesthesiologist on the anesthesia record – include the beta-blocker name, date, time, and route of administration. Or • Be provided in the PACU (Post-Anesthesia Care Unit/Recovery Room) by the nurse or anesthesiologist on the PACU record – include the beta-blocker name, date, time, and route of administration. 16

17. Q6: How do I know if a patient takes a beta-blocker as a home medication? 17

18. Home Medication – Beta-Blocker Check any and all History & Physical documentation (medicine, surgery, anesthesia): • There may be contradictory entries, so verify. • Check Medication Reconciliation records completed at admission. • Ask the patient what medications are taken at home and when they were last taken ― document the patient’s response. 18

19. Home Medication – Beta-Blocker • Check the list in the CMS Specifications Manual, Appendix C, Table  1.3. • Manual revisions come out every 6 months for discharges starting with April 1st and October 1st discharges. Compare the patient’s home medication list to the CMS source: 19

20. Q7: What is the “perioperative period” in which a patient should receive a beta- blocker? How are the start- and end-times determined? 20

21. Card-2 Perioperative Timeframe • For this measure, the perioperative period is defined as 24 hours prior to surgical incision through discharge from the post-anesthesia care/recovery room (PACU). • If a patient goes directly from the OR to the ICU or any area other than the PACU, the time frame ends upon leaving the OR.    • Start- and end-times are located on the anesthesia record, OR record, and/or surgery record. 21

22. Q8: What are the contra-indications to receiving a beta-blocker, and how are contraindications documented? 22

23. Beta-Blocker Contraindication Documentation―Physician • The physician must clearly and legibly document in the medical record specific reasons why the patient did not receive the medication; or • The physician’s order or other documentation should contain hold parameters such as heart rate or blood pressure. • The beta-blocker may be held if the heart rate is below 50 (49 or below). • The blood pressure parameters are at the discretion of the physician. If a beta-blocker is not ordered within this time frame: 23

24. Beta-Blocker Contraindication Documentation―Nursing If a beta-blocker is not administered within this time frame: • The nurse “holding” the medication must document the BP and HR measurements as the reason for the hold. • This is best documented alongside the notation indicating the held beta-blocker dose. • If the patient is allergic to the ordered beta-blocker, the nurse must notify the ordering physician and request an order for a substitute beta-blocker. 24

25. Beta-Blocker Contraindication Documentation NOTE: NPO status is not a contraindication to the patient receiving a beta-blocker medication. • Many surgeons and anesthesiologists will allow pills to be taken with a sip of water. • The medication may be given IV.   25

26. SCIP Beta-Blocker While NPO Reminder Poster • This reminder poster is available at several Web sites: • http://www.hsag.com/azhospitals/scip/resources.aspx • http://www.hsag.com/cahospitals/scip/resources.aspx • http://www.fmqai.com/library/attachment-library/ID-55%20FMQAI_SCIP-NPOv2.pdf • https://www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolTemplate&cid=1228751144401&parentName=Category 26

27. Q9: How have other hospitals found success with the Card-2 measure? 27

28. Card-2 Measure Implementation Educate staff on the benefits to the patient of continued beta-blocker therapy. Provide staff education on the beta-blocker measure as it pertains to morbidity, cost, and care measures. Post beta-blocker reminder signs  in very visible areas around the pre-op area, OR, PACU, physician call-rooms and nurses stations. Provide clear documentation of home beta-blocker therapy Computer decision support systems Protocols, preprinted orders Periodic audit and feedback 28

29. Card-2 Measure Implementation • Provide patients with very specific pre-op instructions regarding their medications – “NPO except for meds” may not be understood by patients. • Institute a policy that “hold parameters” must be included in every beta-blocker order. • Set a nursing standard that states that BP/HR must be documented on the Medication Administration Record when a beta-blocker dose is held. • Include beta-blocker questions on the pre-op surgical checklist. • Include beta-blocker questions in pre-op “Time Out.” 29

30. Card-2 Measure Implementation • Create and educate a dedicated in-hospital team, and provide them with necessary tools to implement the beta-blocker quality measure: • Hospitalist/surgeon/anesthesiologist as chairperson(s) on the SCIP team • Pharmacists and nurses as key team members • Foster an integrated patient management approach 30

31. Role of the SCIP Physician Champion – Card 2 • Has the ability to influence others’ attitudes and behaviors • Serves as an informal leader and competent role model • Supports change and innovation • Communicates the case for change to others • Stands up for ideas that he or she supports • Cardiology Department Leader • Anesthesiologist 31

32. Card-2 Measure Implementation • Utilize all available quality improvement resources and tools (QIO, MedQIC, TJC, IHI, AHRQ, etc.) • Stay aware of the current measures and updates. • Support activities that raise awareness and implementation of pending measures. • Partner with other organizations in efforts to improve quality. • Post monthly or quarterly core measure results. • Discuss measure fallouts and corrective action plans. • Recognize the efforts of all to succeed. 32

33. The Take-Home Messages • Preventing surgical cardiovascular complications is the goal of SCIP Card 2. • Patients on beta-blocker therapy prior to admission should receive a beta-blocker within the perioperative time frame. • Clear documentation of the beta-blocker dose received or beta-blocker contraindications are required. • Everyone involved in the patient’s care, from pre-operative planning through discharge from the PACU, can help meet this SCIP measure. • Having a strong SCIP team and a strong SCIP physician champion will foster success. 33

34. The Take-Home Messages For additional SCIP resources, including the supporting documents for this Webinar, go to: Arizona = http://www.hsag.com/azhospitals/scip/resources.aspx California = http://www.hsag.com/cahospitals/scip/resources.aspx Florida = http://www.fmqai.com/PatientSafety-SCIP-Tools.aspx 34

35. 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 to (Florida) http://www.fmqai.com/PatientSafety-FMSI.aspx,(Arizona) http://www.hsag.com/azproviders/drugsafety.aspx, or (California) http://www.hsag.com/caproviders/drugsafety.aspx. www.hsag.com www.fmqai.com This material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California; Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona; and FMQAI, Inc., the Medicare Quality improvement Organization for Florida, 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 Nos. CA-9SOW-6.2.3-122109-01, AZ-9SOW-6.2.3-122109-01, FL2009F62ST1611497 35