Core Measures 2014

1. Core Measures2014 Revised 11/30/13

2. Core Measures: What’s That? “BEST PRACTICE” Evidence based measures that improve patient outcomes!

3. IF MEASURES ARE PROVEN TO WORK… WHY NOT UTILIZE THEM?

4. Core Measures at Lake Health • Acute Myocardial Infarction • Heart Failure • Pneumonia • Surgical Care Improvement Project (SCIP) • Stroke • Immunization-Influenza and Pneumococcal (IMM) • Venous Thromboembolism(VTE)

5. Expectations for Compliance 100%

6. AMI Data Elements • Percutaneous Coronary Intervention within 90 minutes of arrival for STEMI • Aspirin given within 24 hours before or after hospital arrival or physician documented reason for not prescribing (Aggrenox is not sufficient-does not contain enough aspirin) • LDL drawn within 24 hours of arrival or within 30 days prior to arrival • Aspirin prescribed at discharge or reason documented by physician if contraindicated (Aggrenox is not sufficient-does not contain enough aspirin) • ACE or ARB prescribed at discharge for Ejection Fraction < 40% or reason documented by physician if contraindicated • Beta-blocker prescribed at discharge or reason documented by physician if contraindicated • Statin prescribed at discharge or reason documented by physician if contraindicated

7. Making a difference at Lake Health! By changing our process and following Core Measures guidelines we have saved hearts and lives! (Time=Muscle)

8. HEART FAILURE Data Elements • Left Ventricular Function Assessment • ACE or ARB prescribed at discharge for Ejection Fraction < 40% or reason documented if contraindicated • Smoking cessation education • Written Discharge instructions must include: activity, diet, worsening symptoms, weight monitoring, follow up appointments , and fluid intake. • Medication reconciliation- Discharge medication list given to patient must match all discharge medications listed on discharge medication reconciliation orders, discharging physician and consult(s) orders and progress notes that address discharge medications

9. Smoking Cessation Education to ALL patients that have smoked in past year. Don’t forget the SNF transfers (document it on the yellow transfer form) ENOUGH SAID!

10. S.C.I.P.Surgical Care Improvement Project

11. SCIP Data Elements • Antibiotics started within 1 hour prior to surgical incision.(Vancomycin and Fluoroquinolones=2 hours) • Appropriate antibiotic selection based on surgical procedure • Prophylactic antibiotics should be discontinued within 24 hours of anesthesia end time (48 hours for CABG patients) • Reason for continuing antibiotics > 24 hours after anesthesia end time (48 hours for CABG patients) must have a physician documented infection • Appropriate hair removal. • Normal patient temperature (36.0 C or greater) within 30 minutes prior to or 15 minutes after anesthesia end time • When patient has beta blocker listed as a home medication, they must receive beta blocker during the following timeframes: • Day before surgery/day of surgery AND post op day 1/post op day 2 • Date, time, and sign when given or document contraindication • VTE (DVT) prophylaxis must be applied/administered within 24 hours prior to anesthesia start time or 24 hours after anesthesia end-time. Remember to document pharmacological and/or mechanical prophylaxis • Foley discontinued by post-op day 2 or obtain physician order for specific reason to continue foley. Date, time, and sign order • Cardiac Surgery patients require Controlled Postoperative Blood Glucose levels less than or equal to 180 within 18 to 24 hours after anesthesia end time

12. STROKE Data Elements • Thrombolytic therapy (tPA) started within 3 hours of symptom onset or physician documented reason why patient did not meet criteria for tPA. • Swallow screen prior to oral intake, including oral meds • Anti-thrombotic (includes anticoagulants and/or antiplatelets) given by Hospital Day 2 (Aspirin, Coumadin, Lovenox, Plavix, Pradaxa, Xarelto) • LDL drawn within 48 hours of arrival or within 30 days prior to admission • VTE prophylaxis should be administered/applied day of or day after hospital admission (Pharmacological and SCDS) • PT/OT/Speech consults or physician documented reason for not consulting • Discharge on statin if LDL > 100 or physician documented contraindication • Discharge on anti-thrombotic or physician documented contraindication • Discharge on anticoagulation therapy for patients with Afib or physician documentation contraindication • Written Discharge Medication list given to patient must match all discharge medications listed on DC Medication Reconciliation Orders, physician and consult(s) orders, and progress notes that address medications • Stroke Education- Print 2 copies from Soarian. Patient receives one copy. Copy signed by the patient placed in the chart. • Educate daily and include: when to call EMS, follow up, discharge medications, risk factors, warning signs/symptoms.

13. Pneumonia • Initiate Patient Care Guidelines if there is a delay in seeing the ED physician • Select and begin Core Measure Pneumonia checklist from your Soarian worklist • Utilize CPOE Adult Pneumonia Orders- ED • Document antibiotic administration date and time • Blood Cultures as ordered and document time drawn-Must be collected on ICU admissions or transfers within 24 hours of arrival • Appropriate antibiotic selection (use Pneumonia order set to determine if proper selection) • Pneumonia: Patient to ICU • ED physician will date, time, and sign order to admit to ICU using Soarian • Nurse obtains blood culturesprior to giving antibiotics and documents time drawn Pneumonia: Patient to Medical Surgical Unit • Start antibiotics (no blood cultures need to be done unless the physician orders them) • If blood cultures are ordered on a Medical Surgical patient in the ED prior to the admission order, they must be collected prior to antibiotic administration • If patient transfers to the ICU within 24 hours of hospital arrival, then obtain order and collect blood cultures within 24 hours of hospital arrival

14. Influenza/Pneumococcal Screening • Influenza screening should be completed on all patients 6 months and older from September 1 through April 30. Influenza screening should be done with each hospital visit during this time period. • Pneumococcal screening should be completed on all patients, all year long, and screened with each hospital visit. • Administer immunization as indicated or document contraindication

15. Venous Thromboembolism(VTE) • Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected • VTE Prophylaxis should be applied/administered Day of or Day after hospital arrival and/or Day of or Day after ICU transfer • Acceptable VTE Therapy -Low dose unfractionated heparin (LDUH), Low molecular weight heparin (LMWH), Pneumatic Compression Devices, Graduated compression stockings, Factor Xa Inhibitor, Warfarin, Venous Foot Pumps, Oral Factor Xa Inhibitor • Complete DVT-VTE Risk Score on admission assessment for all patients. If score equal to 2 or more, apply appropriate mechanical VTE prophylaxis • If mechanical prophylaxis contraindicated, print DVT/VTE Prophylaxis orders, call physician, obtain order and administer pharmacologicagent • Must have physician documentation of a reason for not giving both mechanical and pharmacologic prophylaxis to prevent outlier • Overlap Therapy-Patients with confirmed VTE diagnosis should receive 5 days of overlap therapy (parenteral anticoagulation and warfarin) and should have an INR ≥ 2 to be discharged on Coumadin alone • Patients who receive < than 5 days of overlap therapy, should be discharged on both medications(Coumadin and parenteral agent) or have a physician documented Reason for Discontinuation of Parenteral Therapy • Patients who receive < than 5 days of overlap therapy, but have a therapeutic INR must still have documentation of reason for discontinuation of parenteral therapy. Example “Lovenox discontinued due to INR=2.5” • Discharge on Coumadin teaching-Written discharge instructions should address compliance issues, dietary advice, follow up monitoring, and potential for adverse drug reactions/interactions. On Discharge Instructions-nurse should select “yes” for discharge Coumadin and Coumadin care note. Provide copy of care note to patient. Provide education to all patients discharged on Coumadin

16. CORE Measure Medications • ACE/ARB at discharge= CHF and AMI core measures • Appropriate Antibiotics Selection= SCIP & Pneumonia • tPA= Stroke patient’s symptom onset within 3 hours • Aspirin on arrival and at discharge= AMI core measure • Beta Blocker at discharge= AMI core measures • Pre-operative and Post-operative Beta Blocker= SCIP • Statin at discharge= AMI and Stroke core measures • Antithrombotic by Day 2 and at discharge= Stroke core measures • Anticoagulation at discharge= Stroke patient with AFIB • Medication Reconciliation at discharge= CHF and Stroke patient

17. Key Points • Check for pharmacologic and/or mechanical DVT prophylaxis. Chart mechanical prophylaxis under patient care intervention(SCD’s). Do not chart machine not availableor up ad lib • For pharmacological prophylaxis, complete SCIP checklist and/or Stroke checklist. If VTE not ordered, contact the physician, and obtain an order for VTE or an order for contraindication • Complete DVT-VTE Risk Score on admission assessment for allpatients. If score equal to 2 or more, apply appropriate mechanical VTE prophylaxis • Check for core measure labs/tests. Use your core measure checklist to assist you. • Foley must be discontinued by POD 2. Document reason why foley is not discontinued as a physician order. Use Foley order set. • Core Measure checklists- documentation only in checklist is not sufficient. After contacting physician, make sure to write as a physician order. • Disease specific education is required for your patient!!! • Provide Written Discharge Instruction for CHF, Stroke and Coumadin teaching

18. Disease Specific Certification Stroke • Use of Stroke Order Set • Post-TPA Neurological checks every 15 minutes x 2hours, every 30 minutes x 6 hours, then every 1 hour x 24 hours • Post-TPA VS every 15 minutes x 2hours, every 30 minutes x 6 hours, then every 1 hour x 24 hours • Nurse to perform and document NIH stroke Scale • Repeat NIH stroke scale with any change in patient condition and document • Daily Education on new medications given Heart Failure • Use of CHF Order Set and progress note • Documented Daily Weights and I and O’s • Appropriate Care Plan for Diagnosis • NYHA classification and Left Ventricular Systolic Function documented • EP consult or palliative care consult if appropriate • Order for heart failure clinical referral • Education-60 minutes spent for heart failure education • Daily Education on new mediations given • 7 day post hospitalization appointment

19. You are the patient advocate!!! Follow core measures and make a difference in your patient’s outcomes!!!

20. Questions?