Inpatient and Outpatient Quality Measures (Core Measures) Education Program

1. Inpatient and Outpatient Quality Measures(Core Measures) Education Program Developed by The Stellaris Core Measure Workgroup

2. Goals • Provide Physician and Nursing staff with an overview of the National Inpatient and Outpatient Quality Measures (Core Measures) • Physician and Nursing staff will have an increased awareness of the evidence based practice that underlies the core measures • Physician and Nursing staff will have a better understanding of the documentation requirements related to Core Measures

3. Core measures is a National Quality Initiative Mandated by the Center for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC) to monitor specific hospital clinical processes and how well hospitals provide recommended care Evidence based best practice All major payers moving toward using Core Measure results to benchmark & for contract negotiations Basis for Medicare Pay for Performance/Value Based Purchasing As of 2013, also the basis for Physician reimbursement

4. Core measures is a National Quality Initiative • Rigorous “inclusion” and “exclusion” criteria & guidelines for “acceptable” documentation • Results undergo random validation studies • Penalties for failing validation • The Quality Management Department tracks and reports data in order to achieve the goal of high quality care. • Data published on CMS public website: • http://www.hospitalcompare.hhs.gov

5. Core Measures • Hospital Inpatient • Acute Myocardial Infarction (AMI) • Heart Failure (HF) • Pneumonia (PN) • Surgical Care Improvement Project (SCIP) • Emergency Department (ED) Throughput Measure-Admitted Patients • Global Immunization • Hospital Out-patient (HOP) • Emergency Department (ED) Throughput Measures -Discharged Patients • Surgery • AMI/Chest Pain

6. Acute MI Indicators • Aspirin (ASA) within 24 hours before or after arrival • ASA prescribed at discharge • Angiotensin Converting Enzyme Inhibitor (ACEI)/Angiotensin II Receptor Blocker (ARB) at discharge for LV systolic dysfunction (LVSD) • Fibrinolytic within 30 minutes of arrival • Percutaneous Coronary Intervention (PCI) within 90 minutes of arrival • Beta Blocker prescribed at discharge • Statin prescribed at discharge

9. Heart Failure Indicators • Discharge Instructions documented • Diet, activity, weight management, what to do if symptoms worsen, medications, physician follow up appointment • Evaluation of Left Ventricular Systolic (LVS) Function • ACEI or ARB for Left Ventricular Systolic Dysfunction (LVSD)

11. Pneumonia Indicators • Blood culture in ED prior to antibiotic • Blood cultures < 24 hours prior to or 24 hours after arrival for patients transferred or admitted to ICU • Antibiotics selection ICU/non-ICU

13. Pneumonia Antibiotic Consensus Recommendations Non-ICU Patient • β-lactam (IV or IM) + Macrolide (IV or PO) OR • Antipneumococcal Quinolone monotherapy (IV or PO) OR • β-lactam (IV or IM) + Doxycycline (IV or PO) OR • Tigecycline monotherapy (IV) Antibiotic Selection List β -lactam=Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam, Ertapenem, Ceftaroline Macrolide=Erythromycin, Clarithromycin, Azithromycin Antipneumococcal Quinolones=Levofloxacin, Moxifloxacin, Gemifloxacin Doxycycline Tigecycline Please note: the above requirements are incorporated into the Pneumonia Order Sets

14. Pneumonia Antibiotic Consensus Recommendations Non-ICU Patient with Pseudomonal Risk These antibiotics are acceptable for Non-ICU patients with Pseudomonal Risk ONLY: • Antipneumococcal/Antipseudomonal β -lactam (IV) + Antipseudomonal Quinolone (IV or PO) OR • Antipneumococcal/Antipseudomonal β -lactam (IV) + Aminoglycoside (IV) + either Antipneumococcal Quinolone (IV or PO) Or Macrolide (IV or PO) These antibiotics are acceptable for Non-ICU patients with β -lactam allergy and Pseudomonal Risk ONLY: • Aztreonam (IV or IM) + Antipneumococcal Quinolone (IV or PO) + Aminoglycoside (IV) OR • Aztreonam(IV or IM) + Levofloxacin1 (IV or PO) Antibiotic Selection List • Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin • Antipneumococcal/Antipseudomonal β -lactam = Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam, Doripenem • Aminoglycoside = Gentamicin, Tobramycin, Amikacin • Antipneumococcal Quinolone = Levofloxacin, Moxifloxacin, Gemifloxacin • Macrolide = Erythromycin, Clarithromycin, Azithromycin Please note: the above requirements are incorporated into the Pneumonia Order Sets

15. Pneumonia Antibiotic Consensus Recommendations ICU Patient • Macrolide (IV) + either β -lactam (IV) Or Antipneumococcal/Antipseudomonal β -lactam (IV) OR • Antipseudomonal Quinolone (IV) + either β -lactam (IV) OR Antipneumococcal/ Antipseudomonal β -lactam (IV) OR • Antipneumococcal Quinolone (IV) + either β -lactam (IV) OR Antipneumococcal/ Antipseudomonal β -lactam (IV) OR • Antipneumococcal/Antipseudomonal β -lactam (IV) + Aminoglycoside (IV) + either Antipneumococcal Quinolone (IV) OR Macrolide (IV) If the patient has Francisella tularensis or Yersinia pestis risk as determined by Another Source of Infection the following is another acceptable regimen: • Doxycycline (IV) + either β -lactam (IV) OR Antipneumococcal/Antipseudomonal β -lactam (IV) Antibiotic Selection List β -lactam = Ceftriaxone, Cefotaxime, Ampicillin/Sulbactam Antipneumococcal/Antipseudomonal β -lactam = Cefepime, Imipenem, Meropenem, Piperacillin/Tazobactam, Doripenem Macrolide = Erythromycin, Azithromycin Antipneumococcal Quinolones = Levofloxacin, Moxifloxacin Antipseudomonal Quinolone = Ciprofloxacin, Levofloxacin Aminoglycoside = Gentamicin, Tobramycin, Amikacin Please Note; The above requirements have been incorporated into the Pneumonia Order Sets

16. SCIP Indicators • Antibiotic within 1 hour of surgical incision • Prophylactic antibiotic selection • Antibiotic discontinued within 24 hours of anesthesia end time • Appropriate hair removal • Urinary catheter removed by Postoperative Day #1 or #2 • Perioperative temperature management • Venous thrombo-embolism (VTE) prophylaxis ordered & administered within 24 hours of anesthesia end time • Beta Blocker given in the perioperative period if on Beta blocker prior to arrival

20. Recommended VTE Prophylaxis Please Note; The above requirements have been incorporated into the Surgical Order Sets

21. Global Immunization • Pneumococcal Immunization • Patients age 65 and older • Patients age 6-64 years with high risk conditions • Influenza Immunization • Patients 6 months and older

24. Emergency Department Throughput for Admitted Patients 7/31/2014 • Median Time from ED Arrival to ED Departure for Admitted ED Patients • Admit Decision Time to ED Departure for Admitted Patients 24

26. Emergency Department Throughput for Discharged Patients • Median Time from ED Arrival to ED Departure • Door to Diagnostic Evaluation by MD/NP/PA • Left Without Being Seen • Median Time to Pain Management for Long Bone Fracture (patients >= 2 years of age) • Head CT scan results for Stroke (acute ischemic or hemorrhagic) interpreted within 45 minutes of Arrival 7/31/2014 26

28. Hospital Outpatient Surgery (HOP Surgery) Indicators • Timing of Antibiotic Prophylaxis • Antibiotic Selection

30. Hospital Outpatient AMI/Chest Pain(HOP AMI/Chest Pain) • Median Time to Fibrinolysis-patients with ST elevation MI (STEMI) or left bundle branch block (LBBB) • Fibrinolytic Therapy Received Within 30 Minutes • Median Time to Transfer to Another Facility for Acute Coronary Intervention • Aspirin at Arrival • Median Time to ECG

33. 7/31/2014 33