Inpatient Instrument Update

Inpatient Instrument Update Quarter 1 FY2011 WVMI Confidential and Proprietary

Objectives • The purpose of this presentation is to call your attention to changes in the 1Q11 inpatient instruments • The most salient changes will be noted here and it is important that you review all highlighted areas of the instruments • The same changes in terminology as mentioned in the CGPI/HBPC presentation apply to the inpatient instruments/exit reports as well WVMI Confidential and Proprietary

Questions! • Please write down your questions as you proceed through this presentation and then email them to aullum@wvmi.org • As mentioned in the CGPI presentation we will be scheduling some conference calls to present the answers to your questions. • Dates and times of conference calls to be announced shortly WVMI Confidential and Proprietary

Some Common Changes • The Skin Integrity module has been deleted and is no longer attached to inpatient instruments • Ptorigin: this question has been deleted from the inpatient instruments (ACS, IHF, PN, SC, VTE) • Ptorigin was replaced by a new question transin2 in ACS and PN WVMI Confidential and Proprietary

Transin2 • Was the patient received as a transfer from inpatient, outpatient or emergency/observation department of another hospital OR from an ambulatory surgery center? • 1. Patient received as a transfer from an inpatient department of another hospital • If the medical record reflects only that the patient was received as a transfer from another hospital and the abstractor is unable to determine if the patient was in an inpatient or an outpatient department, select value “1.” • 2. Patient received as a transfer from an outpatient department of another hospital (excludes emergency/observation departments) WVMI Confidential and Proprietary

Transin2 • 3. Patient received as a transfer from the emergency/observation department of another hospital • If a patient is transferred in from the emergency department or observation unit of ANY outside hospital, select value “3”, regardless of whether the two hospitals are close in proximity, part of the same hospital system, have a shared medical record or provider number, etc. • 4. Patient received as a transfer from an ambulatory surgery center • 99. None of the above or unable to determine from medical record documentation. • Exclusion Statement : Transfer from an inpatient, outpatient, or emergency/observation department of another hospital OR ambulatory surgery center partially excludes the case from the Joint Commission AMI National Hospital Quality Measures. Smoking counseling, pneumococcal vaccination, and influenza vaccination remain applicable measures. WVMI Confidential and Proprietary

Emergency Department Question Changes • The definition/decision rules for some of the ED questions (ACS, IHF and PN) have some wording changes • Q: Enter the earliest documented time of the decision to admit the patient • For purposes of this data element “decision to admit time” is the time the physician/APN/PA communicatesthe decision to admit the patient from the Emergency Department to the hospital as an inpatient • Do not include any documentation from external sources (e.g., ambulance record, clinic note) obtained prior to arrival (also applies to decision to admit date) • Do not use admit order time for the Decision to Admit Time unless documentation clearly indicates this is the time the provider communicated the decision. If the documentation does not clearly indicate this was the time of the decision, enter 99:99 WVMI Confidential and Proprietary

Comfort Measures Only • Changes involve the definition/decision rules which have been reformatted for better understanding • A clarification was added: • A negative comfort measures only notation associated with a day/date may be acceptable (e.g. On Day 0, the physician documents, “The patient is not a hospice candidate.” On Day 3, the physician orders a hospice consult. Select “2.”) WVMI Confidential and Proprietary

ACS WVMI Confidential and Proprietary

ACS Validation Module • Changes common to other instruments as previously noted • New question 20 (tranvaed) • Was the patient received from the emergency department of another VAMC? • ED of another VAMC includes both ED and observation bed/unit stays at that hospital WVMI Confidential and Proprietary

History and Assessment Module • Two new medications were added to the definition/decision rules for questions 54 and 96 (priorx, lipidmed). Both are lipid lowering medications • Pitavastatin (Livalo) • Fenofibric acid (Fibricor) • The troponin bioassay question was deleted WVMI Confidential and Proprietary

ACS Discharge Module • There are some definition/decision rule changes/additions in the Discharge module • Please read all the highlighted areas, including: • ACEI and ARBs may be described as RAS (renin-angiotensin system) or RAAS (renin-angiotensin-aldosterone system) blockers/inhibitors. WVMI Confidential and Proprietary

Discharge Module Rule Changes/Additions • There is an additional rule about contradictory documentation of discharge medications (ACE, ARB, ASA, BB, etc) • Consider documentation of a “hold” on an [ARB, ACE, ASA, etc] after discharge as contradictory ONLY if the timeframe on the hold is not defined (e.g., “Hold losartan” does not have a timeframe). WVMI Confidential and Proprietary

New option • Question 9 (platagdc) has a new answer option • 5. other • If you see the platelet aggregation inhibitor prasugrel (Effient) prescribed, use option 5 WVMI Confidential and Proprietary

Lipid Lowering Medications • There are now new questions about lipid lowering medications prescribed on discharge • There are separate questions for statin medications and non-statin lipid lowering medications WVMI Confidential and Proprietary

Question 17 (statatdc) • Was a statin medication prescribed at discharge? • Review all documentation of discharge medications to determine if a statin medication was prescribed at discharge • Refer to JC Appendix C, Table 8.1 or a drug handbook for a complete list of statin drugs WVMI Confidential and Proprietary

Enter the statin medication • In question 18 you will enter the statin medication prescribed at discharge • If the patient is taking a combination medication, select the statin component of the medication • e.g.simvastatin/ezetimibe; select simvastatin WVMI Confidential and Proprietary

If no statin medication was prescribed at discharge • Answer question 19, reason for not prescribing a statin medication • Follow the definition/decision rules to determine if documentation is acceptable as a reason for not prescribing a statin medication at discharge WVMI Confidential and Proprietary

Question 20 (nonstadc) • Was a non-statin lipid lowering medication prescribed at discharge? • Review all documentation of discharge medications to determine if a non-statin lipid lowering medication was prescribed at discharge • Please refer to a drug handbook for a complete list of non-statin lipid lowering medications • Note that the fibrates and omega-fatty acids classifications (that were deleted from CGPI questions) remain in ACS WVMI Confidential and Proprietary

Which non-statin was prescribed? • If a non-statin lipid lowering medication was prescribed at discharge, indicate the medication in question 21 (lipdmed) • Use option 14 for a medication not specifically listed WVMI Confidential and Proprietary

If a non-statin lipid lowering med was not prescribed…. • Answer question 22, reason for not prescribing a non-statin medication • Follow the definition/decision rules to determine if documentation is acceptable as a reason for not prescribing a non-statin lipid lowering medication at discharge WVMI Confidential and Proprietary

Other ACS Modules • Please review the highlighted changes to the definition/decision rules in • ACS on Initial Presentation • ACS after Admission • Continuing Inpatient Care and Assessment • There are no changes to • Revascularization module • Transfer from a Community Hospital WVMI Confidential and Proprietary

ACS Scoring Changes • The date parameter for inclusion was changed to >=10/1/10 • Ihi9, statin prescribed at discharge was added • Other changes were a result of deletion of the patient origin question and addition of transin2 • The exit report guide will reflect the changes WVMI Confidential and Proprietary

Pneumonia WVMI Confidential and Proprietary

Pneumonia Validation Module • In addition to the general inpatient instrument changes noted at the beginning of this presentation please note some minor wording changes to the rules for • adm24icu (question 18) • pndxed (question 25) • pndxadm (question 26) WVMI Confidential and Proprietary

Pneumonia Acute Care Module • There is a revision to the definition of compromising condition in question 4 of the acute care module • Compromising condition = The patient has a clinical condition that could cause an impaired immune system or is on a therapy that puts them at a higher risk for infection. The only acceptable compromising conditions are the conditions listed. WVMI Confidential and Proprietary

Other changes to compcond • Select 1 if there is documentation that the patient is currently undergoing systemic chemotherapy or radiation therapy or received chemotherapy or radiation therapy within the last 3 months prior to hospitalization • Additional conditions where no timeframe is necessary • Any “Immunodeficiency Syndrome” • Congenital or hereditary Immunodeficiency • For conditions within the past 3 months, if there is no timeframe documented in the medical record to indicate the condition has been present within the last 3 months (e.g., ‘history of’, etc.), do not select “1” WVMI Confidential and Proprietary

Pseudomonal Risk • Question 6 has been changed from “indicate all that apply” format to answers of only yes or no • You will still look for the same 3 conditions • Structural lung disease And documented history of repeated antibiotics or chronic systemic corticosteroid use • Bronchiectasis documented as a possible consideration by a clinician at the time of admission • Clinician or pharmacist documented pseudomonal risk WVMI Confidential and Proprietary

Pseudomonal Risk • If there is documentation of any of the three bulleted conditions, you will answer yes • With the change in format of this question, it is important that you remember to look for all of the relevant conditions • The definition/decision rules have been revised to provide additional guidance in selecting these conditions. WVMI Confidential and Proprietary

Drug Resistant Pneumococcus • Question 7 has also been changed from the “indicate all that apply” format to yes/no • Select yes if any of the listed conditions are documented in the record as per guidance in the definition/decision rules • Patients 65 and over • ICU Patients – within 24 hours of arrival • Alcoholism—any mention in chart • Systemic antibiotic therapy in the last 3 months (prior to arrival) • Medical co-morbidities • Exposed to child in daycare • Injection drug user—only illicit drugs WVMI Confidential and Proprietary

Medication Questions • The definition/decision rules for question 16 (abrecvd) have some changes regarding acceptable documentation of antibiotics received within 24 hours prior to arrival or the day prior to arrival • Example: “Patient started on antibiotics two days ago.” Not acceptable • Example: “Patient has been maintained on Rocephin for the last 5 days.” Acceptable • Example: An arrival time is documented as 1400 and the antibiotic is documented as given at 1352 on the same date. The dose cannot be abstracted as given during the hospital stay and should be used to abstract Antibiotic Received as Value 1 or 2 as applicable. WVMI Confidential and Proprietary

Antibiotic Table • Please review the definition/decision rules for question 17 • Mainly, the revisions are clarifications to existing rules regarding • misspelled or missing antibiotic names • antibiotic administration information • antibiotic administration documented by someone other than the person giving the dose WVMI Confidential and Proprietary

Pneumococcal Vaccination Status • There are some wording changes to question 21 (vaxstat) • Answer option 4 now includes patients receiving chemotherapy or radiation less than 2 weeks prior to arrival • Documentation of refusal of pneumococcal vaccination may be by the patient or caregiver • The caregiver is defined as the patient’s family or any other person (e.g., home health, VNA provider, prison official or other law enforcement personnel) who is responsible for the care of the patient when the patient is unable to make this decision on his/her own. WVMI Confidential and Proprietary

Influenza Vaccination • Same change regarding refusal by a caregiver as in vaxstat • A change to option 4 • a prior history of Guillian-Barre syndrome within 6 weeks after a previous influenza vaccination (as a reason for not giving influenza vaccination) • The previous instructions regarding acceptance of the H1N1 vaccine were deleted as they no longer apply in the current flu season WVMI Confidential and Proprietary

Pneumonia Scoring Changes • Changes include: • The date parameter for inclusion was changed to >=10/1/10 • CAP 13: risk of pseudomonas options are no longer included • CAP 14: Changes to drug regimens • CAP 18: patients transferred in from another ED are not excluded • All changes will be noted in the exit report guide WVMI Confidential and Proprietary

Inpatient Heart Failure WVMI Confidential and Proprietary

Common Changes as previously noted….. Ptorigin question was deleted Changes to Emergency Department questions Changes to Comfort Measures only rules WVMI Confidential and Proprietary

Weight • There is a wording change to question 28 • Enter the patient’s first weight measured after acute care arrival • We are no longer collecting height in IHF WVMI Confidential and Proprietary

LVSF Assessment As in CGPI and ACS there are wording changes to the definition/decision rules regarding acceptable documentation of LVSF assessment. Please review these changes carefully and answer questions accurately WVMI Confidential and Proprietary

Vaccine Questions The pneumococcal pneumonia and influenza immunization questions have been deleted from the IHF instrument A new “common” module for immunizations will be discussed later WVMI Confidential and Proprietary

Discharge Medications The same definition/decision rule changes seen in ACS are in the IHF discharge medication question, including the question about insulin on discharge WVMI Confidential and Proprietary

IHF Discharge Instructions • There are no real changes, but the definition/decision rules have been tweaked for clarification • Please review the changes including the change to the rules of question 84 (discharge medication instructions) • If there is documentation of a plan to start/restart a medication after discharge or a hold on a medication for a defined timeframe (e.g. “Start Plavix as outpatient”, “Hold furosemide for 2 days”) and the medication is NOT listed as a discharge medication elsewhere, the medication on hold is not required to be in the discharge instructions. • If the medication IS listed as a discharge medication elsewhere, the medication is required to be in the discharge instructions. WVMI Confidential and Proprietary

Following completion of the IHF module Cases flagged for CGPI will continue through validation questions and subsequent questions as applicable Reminder: When a record appears on the HF pull list for the first time in the fiscal year, the full CGPI data collection will be performed. Each record will be subject to the comprehensive CGPI abstraction only once per year. WVMI Confidential and Proprietary

IHF Scoring Changes • The date parameter for inclusion was changed to >=10/1/10 • Chi21 (pneumococcal screening and/or immunization) was deleted • Chi23 (influenza immunization) was deleted • A new indicator (dmi1) Discharged on insulin with diabetes education documented was added to the Pilot exit report • Details of scoring will be in the exit report guide WVMI Confidential and Proprietary

VTE WVMI Confidential and Proprietary

Common Changes Ptorigin question deleted Changes to ED questions Changes to CMO rules WVMI Confidential and Proprietary

Question 21 vtesurg • A timeframe has been added to this question • Was a surgical procedure performed using general or neuraxial anesthesia the day of or the day after hospital admission? • Guidance has been added to the definition/decision rules regarding general and neuraxial anesthesia • We are now collecting only the surgery end date following this question WVMI Confidential and Proprietary

Wording change to question 24…. Enter the date the initial VTE prophylaxis was administered after hospital admission. WVMI Confidential and Proprietary

Question 25: reasons for no VTE prophylaxis • There are some important additions to the rules for this question: • For patients on continuous IV heparin therapy the day of or day after hospital admission, select “Yes.” • For patients on warfarin therapy prior to admission, but placed on hold due to “high INR”, select “Yes.” • Both the pharmacological and mechanical approaches must be assessed to answer “Yes” to this data element. For example, if there is physician documentation of “bleeding, no pharmacologic prophylaxis needed”, there must also be documentation of a reason why no mechanical prophylaxis was administered to select “Yes.” If either type of prophylaxis was administered, then no reason is required. WVMI Confidential and Proprietary

Question 29 icusurg • Was a surgical procedure performed using general or neuraxial anesthesia the day of or the day after ICU admission? • Follow definition/decision rule guidelines for determining whether the patient was given general or neuraxial anesthesia • If a procedure was done, you will enter the anesthesia start date in question 30 • If an anesthesia start date is not documented use surrounding documentation to determine the date anesthesia started. • Example: The anesthesia end date is 10-02-20XX, the anesthesia start time is 2330 and the anesthesia end time is 0045. The anesthesia start date should be abstracted as 10-01-20XX because it is obvious that the date would change if the anesthesia ended after midnight. WVMI Confidential and Proprietary

Inpatient Instrument Update