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Core Measure Components
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Core Measures • Goal: • The goal is for all Core Measure rates to be 100%. • Description: • This module will provide instructions for completing each Core Measure from patient Arrival to Discharge. • Objectives: • By completion of module, the employee will: • State key concepts relating to the Core Measure sets. • Utilize the corresponding checklist for each Core Measure set. • Identify and complete appropriate Measures for each • Core Measure set. • A score of 85% or better is required to pass the post test.
Background What are Core Measures? • Introduced in February 1997, The Joint Commission’s ORYX initiative integrates outcomes and other performance measurement data into the process. In 2002, accredited hospitals began collecting data on standardized or “Core” performance measures. In 2004, the Joint Commission and the Centers for Medicare and Medicaid Services began working together to align measures common to both organizations. These standardized common measures, called “Hospital Quality Measures” or “Core Measures” are integral to improving the quality of care provided to hospital patients and bringing value to stakeholders by focusing on the actual results of care. • Hospital Quality Measures and other Core Measure data are part of the priority focus process that is used by accrediting organizations to help focus on site survey activities. This data is also publicly reported on CMS websites. • The availability of measure performance results facilitates the consumer ability to make an informed choice about what hospital they want to use.
Participation • Why is Tulare Regional Medical Center participating in Core Measures? • It is a requirement of accrediting organizations to report on performance measurements. • Patients receive care that is evidence-based best standards of care. • Best Practice of care for patients • Shorter length of stay for hospital patients • Improved outcomes • Decreased health care costs • Provides information to the public on CMS website, “Hospital Compare” so the public can make informed choices regarding their health care. • Financial incentives: An increase or decrease in the amount of Medicare Reimbursement TRMC receives is based on our results. • Each diagnosis has a corresponding checklist to help remind what needs to be done to pass each measure. The checklists will also help to show what has already been completed. Be sure to initial when you complete a measure. The checklist should be placed in the front pouch of the patient chart.
Core Measures Reporting applies to all patients 18 & older and consists of: • Acute Myocardial Infarction (AMI) • Emergency Department Throughput • Heart Failure (HF) • Immunization – Influenza • Outpatient including: • Acute Myocardial Infarction • Emergency Department Throughput • Surgery • Stroke • Perinatal Care Mother and Baby • Pneumonia (PN) • Surgical Care Improvement Program (SCIP) • Stroke • Venous Thromboembolism (VTE or DVT)
AMI Core Measures “Arrival time” is the earliest documented time of patient contact in hospital. (Check all ER and Admit records for times and document the earliest one). AMI-1Aspirin on Arrival ASA 24 hrs prior to arrival or within 24 hrs after arrival or documentation of a contraindication if not given. • Look on ER nurse notes, ER physician notes/orders, ambulance report, and Home Medication Reconciliation for ASA taken before arrival. 2 Look on ER nurse notes for “medications” and eMARs for ASA given after arrival. • A contraindication to ASA might be (but not limited to) true ASA allergy, if the patient is bleeding (i.e. GI Bleed, nosebleed, coffee ground emesis, etc.) or if the patient is on Warfarin/Coumadin, or other reason documented by the physician. “Plavix is not a contraindication for ASA.” 4. If no ASA has been given and no contraindication is written, call the physician for an order and give ASA as soon as possible. If the physician does not want to order ASA, the reason why must be documented as a T/O on the Physicians Orders.
AMI-2 Aspirin Prescribed at Discharge ASA prescribed at discharge or a contraindication is written why not. 1. Look on DC medications on Home Medication Reconciliation, Physicians Orders and prescriptions for ASA. 2. Look on Physicians Orders and progress notes for a contraindication. (See contraindication to ASA on arrival) 3. If ASA is not ordered and no contraindication is written, call the physician for an order for ASA, document the order, or contraindication as a T/O on Physician Orders.
AMI-3ACE-I or ARB for LVSD ACE-I or ARB prescribed at discharge for documented moderate/severe LVSD or EF <40% or documentation of a contraindication for not ordering. If the Ejection Fraction is <40%, or the physician documents “moderate or severe left ventricular systolic dysfunction (LVSD)”, an ACE-I or ARB should be prescribed at discharge or a contraindication written why not. 1. Look on DC medications, on Home Medication Reconciliation, Physicians Orders and prescriptions for ACE-I or ARB. 2. Look on Physicians Orders and progress notes for a contraindication. The contraindication should state the reason BOTHACE-I & ARB are contraindicated. 3. If there is a documented Ejection Fraction (see Echocardiogram) of 40% or greater, the ACE-I/ARB is not required and there is no need to call the physician for an order. 4. If the ejection fraction is <40% and there is no order or written contraindication for ACE-I or ARB, call the physician and document the order or a contraindication as T/O on Physician Orders.
AMI-3 ACE-I or ARB for LVSD continued… Reasons for not prescribing either an angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) at discharge could include: • ACE-I allergy and ARB allergy • Moderate or severe aortic stenosis • Other reasons documented by the physician or pharmacist for not prescribing an ACE-I and not prescribing an ARB at discharge. NOTE: Documentation of a reason for not prescribing one class (either ACE-I or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only: • Worsening Renal Function/Renal Disease/Dysfunction • Angioedema • Hyperkalemia • Hypotension • Renal Artery Stenosis .
AMI-5Beta-Blocker Prescribed at Discharge Beta-Blocker is prescribed at discharge or documentation of a contraindication for not ordering. 1. Look on DC medications on Home Medication Reconciliation, Physicians Orders and prescriptions for Beta-Blocker. 2. Look on Physicians Orders and progress notes for a contraindication. 3. If a Beta-Blocker is not ordered and no contraindication is written, call the physician and document the order, or contraindication as a T/O on Physician orders.
AMI-7 Median Time to Fibrinolytic Medication AMI-7aFibrinolytic TherapyReceived Within 30 Minutes of Hospital Arrival Time to fibrinolytic therapy is a strong predictor of outcome in patients with AMI. National guidelines recommended that fibrinolytic therapy be given within 30 minutes of hospital arrival in patients with ST- segment elevation or Left Bundle Branch Block (LBBB). Despite these recommendation, few eligible older patients receive timely fibrinolytic therapy. • When a patient presents to the ED with an AMI chest pain. • Triage immediately. • If bed available, take to bed immediately and start Chest Pain Control. • If no bed available, take to triage nurse to start Chest Pain Protocol. • Perform STAT EKG within 10 minutes of arrival and give to MD on duty when done. Do not put EKG on desk or hand to MD and check orders at a later time. If ST elevation (STEMI) or LBBB on EKG, inquire whether he/she is going to consider ordering TNK. • If TNK is ordered-administer STAT. Be sure to document time TNK was started.
AMI-10Statin Prescribed at Discharge Statin is prescribed at discharge or documentation of a contraindication for not ordering. Look on DC medications on Home Medication Reconciliation, Physicians Orders and prescriptions for a Statin. Look on Physicians Orders and progress notes for a contraindication. If a Statin is not ordered and no contraindication is written, call the physician and document the order, or contraindication as a T/O on Physician orders.
Inpatient ED Throughput ED-1aMedian Time from ED Arrival to ED Departure for Admitted ED Patients Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. • Determine Arrival Time: “Arrival time” is the earliest documented time of patient contact in the hospital. • Check all ER, admit and Registration records for times. • Accurately document the date and time the patient leaves the emergency department and is transferred to the floor.
Inpatient ED Throughput Continued… ED-2aAdmit Decision Time to ED Departure Time for Admitted Patients • Determine the earliest date and time the ED Physician/ PA saw the patient. • Ensure the Departure Date and Time are accurate and readable when the patient leaves the emergency department and is transferred to the floor.
HF (Heart Failure) HF-2May be completed any time after admit and prior to day of discharge. There are no TIMED arrival measures for HF. HF-2Left Ventricular Function Assessment LVF assessed during this admit or Documentation of previous assessment(no time limit) or LVF assessment scheduled for after patient discharge. Ejection Fraction% (document on checklist). Note: Any document that states an Ejection Fraction or other type of LVF assessment may be used to determine Left Ventricular Systolic Dysfunction (LVSD). For example: Cardiac echo, cardiac cath report, cardiac consult report, H & P, etc. all may have EF documented.
HF (Heart Failure) Continued… • Look for an order for cardiac echo (echocardiogram, cardiac echo doppler) during this admit. If not ordered on admit, look in transcription for an echo, write DO NOT REMOVE, the date and your initials on the report, put it in the chart and document in progress notes “Copy of previous echo put in chart, EF% (Be sure to date, time, & sign your entry). • 2. If there is no previous echo and no echo has been ordered on admit, notify the physician and obtain on order for an echo. If the physician has a contraindication (example: No echo due to advanced age and family wishes) for echo, document the reason as a T/O on the Physician Orders. • Physician may also document “echo will be scheduled as an outpatient after discharge” (this will meet the requirement). If the LVF is not assessed, the reason why is documented by a physician. • 4 For any echo found, document Ejection Fraction % on HF Checklist. The Ejection Fraction will determine if the patient needs an ACE-I or ARB while hospitalized and at discharge.
HF-3 ACE-I or ARB for LVSD • ACE-I or ARB prescribed at discharge for documented moderate/ severe LVSD or EF a contraindication written why not ordering (same contraindications as with AMI). • If the Ejection Fraction is <40%, or the physician documents “moderate to severe left ventricular systolic dysfunction (LVSD)”, an ACE-I or ARB should be prescribed at discharge or a contraindication written why not. • Look on DC medications, on Home Medication Reconciliation, Physicians Orders and prescriptions for ACE-I or ARB. • Look on Physicians Orders and progress notes for a contraindication. The contraindication should state the reason BOTH ACE-I & ARB are contraindicated. • If there is a documented Ejection Fraction (see Echocardiogram) of 40% or greater, the ACE-I /ARB is not required and there is no need to call the physician for an order.
Immunizations Influenza Vaccine Status All applicable patients must be offered the Influenza vaccine. To determine if the patient needs this vaccination, complete the Adult Pneumococcal & Influenza Vaccination Screen (found in Physician Orders #199 on the Intranet site). If it is determined after completion of the screen that the patient needs the vaccine, put the screen in the Physician Orders for signature. If no vaccines are needed, write N/A in the physician signature space and put the screen in Physicians Orders (no signature is needed). Do not put the vaccination screen in front pocket!!!
IMM-2: Influenza Vaccination Prior to discharge, if it is determined the patient needs either or both vaccines, obtain consent, administer vaccines and document on the consent form. Excluded Patient Populations: • Less than 6 months of age • Expire prior to hospital discharge • Organ transplant during the current hospitalization • Vaccination was indicated, but supply had not been received by the hospital due to problems with vaccine production or distribution • Length of stay greater than 120 days • Transferred or discharged to another acute care hospital • Leave Against Medical Advice (AMA)
Immunization Physician Order Set
Outpatient Measures
Outpatient Acute Myocardial Infarction and Chest Pain Measures OP-1 through OP-5 “Arrival Time” is the earliest documented time (military time) the patient arrived at the outpatient or emergency department. OP-1 Median Time to Fibrinolysis data collection only. Time in minutes to fibrinolytic therapy after arrival.
OP-2Fibrinolytic Therapy Received Within 30 • Minutes of ED Arrival • Time to fibrinolytic therapy is a strong predictor of outcome in patients with AMI. • National guidelines recommend that fibrinolytic therapy be given within 30 minutes of hospital arrival in patients with ST- segment elevation or Left Bundle Branch Block (LBBB). Despite these recommendation, few eligible older patients receive timely fibrinolytic therapy. • When a patient presents to the ED with an AMI chest pain: • a. Triage immediately. • b. If bed available, take to bed immediately and start Chest Pain Control. • c. If no bed available, take to triage nurse to start Chest Pain Protocol. • d. Perform STAT ECG (EKG) within 10 minutes of arrival and give to MD on duty when done. Do not put EKG on desk or hand to MD and check orders a later time. If ST elevation (STEMI) of LBBB on EKG, inquire whether he/she is going to consider ordering TNK. • e. If TNK is ordered-administer STAT. Be sure to document time TNK was started.
OP-3Median Time to Transfer to Another Facility for Acute Coronary Intervention Time (in minutes) from Emergency Department arrival to transfer to another facility for acute coronary intervention (primary angioplasty, etc.). The earlier primary coronary intervention is provided, the more effective it is. Documentation must include a specifically defined reason for transfer such as PCI, “Coronary Angioplasty”, or “for Cardiac Catheterization”. Patients transferred for primary PCI rarely meet recommended guidelines for door-to-balloon time. Current recommendations support a door-to-balloon time of 90 minutes or less.
OP-4Aspirin at Arrival ED acute myocardial infarction or chest pain patients (with Probable Cardiac Chest Pain) without ASA contraindications who received ASA within 24 hours before ED arrival or prior to transfer. 1. If patient has not had ASA prior to arrival, no ASA has been given and no contraindication is documented, ask the physician for an order and give ASA as soon as possible. 2. A contraindication to ASA might be (but not limited to) the patient is bleeding i.e. GI bleed, bloody stools, coffee ground emesis, etc., or if the patient is on Warfarin/Coumadin, has ASA allergy, or other reason documented by the physician. Note: Plavix is not a contraindication to ASA.
OP-5 Median Time to EKG (ECG) • Time (in minutes) from emergency department arrival to EKG/ECG (performed in the ED prior to transfer) for AMI or Chest Pain patients. • Guidelines recommend patients [resenting with chest discomfort or symptoms suggestive of ST-segment elevation have a 12-lead EKG (ECG) performed within a target of 10 minutes of emergency department arrival.
OP-6 Timing of Antibiotic Prophylaxis(The antibiotic also must be the correct antibiotic.) • A pre-op antibiotic must be administered within 1 hour prior to the surgical incision if the patient is not already getting antibiotics for an infection prior to surgery. • (If the patient is already on antibiotics prior to surgery, a pre-op does not need to be given within 1 hour to surgical incision.) • If no pre-op antibiotic has been ordered, call the physician for an order and document on Physician Orders. • 2. Do Notgive the pre-op on the unit. It will be administered in the OR department. • OP-7 Prophylactic antibiotic selection for surgical patients • Surgical patients who received prophylactic antibiotics consistent with current guidelines • (specific to each type of surgery). • 1. When you obtain an order for pre-op prophylactic antibiotic, make sure it is on the list of recommended prophylactic antibiotics. See Prophylactic Antibiotics Regimen for Surgery list.
Outpatient ED Throughput OP-18Median Time from ED Arrival to ED Departure for Discharge ED Patients Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. • Determine Arrival Date and Time: “Arrival time” is the earliest documented time of patient contact in the hospital. • Check all ER, admit and Registration records for times. • Accurately document the date and time the patient leaves the emergency department and is discharged.
Outpatient ED Throughput Continued… OP-20Door to Diagnostic Evaluation by a Qualified Medical Personnel Ensure the earliest date and time the ED Physician/ PA saw the patient is documented and readable.
OP-21Median Time to Pain Management for Long Bone Fracture Median time from emergency department arrival to time of initial oral or parenteral pain medication administration for emergency department patients with a principal diagnosis of long bone fracture (LBF). Rationale: Pain management in patients with long bone fractures is undertreated in emergency departments. Emergency department pain management has room for improvement. Patients with bone fractures continue to lack administration of pain medication as part of treatment regimens. When performance measures are implemented for pain management of these patients administration and treatment rates for pain improve. Ensure all patients with a long bone fracture receive pain medications as part of their treatment. 2. If pain medications are contraindicated, be sure the physician/PA has documented this in the record. 3. If no pain medication has been given and no contraindication is written, contact the physician for an order and give as soon as possible. If the physician does not want to order pain medications, the reason why must be documented.
Outpatient ED Throughput Continued… OP-22Left Without Being Seen Percent of patients who leave the Emergency Department (ED) without being evaluated by a physician/advance practice nurse/physician’s assistant. No action is necessary on this indicator. It is solely for tracking volume numbers.
OP-23 Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Description: Emergency Department Acute Ischemic Stroke or Hemorrhagic Stroke patients who arrive at the ED within 2 hours of the onset of symptoms who have a head CT or MRI scan performed during the stay and having a time from ED arrival to interpretation of the Head CT or MRI scan within 45 minutes of arrival. Decreasing radiology turnaround times will enhance decision making capabilities for patients with TIA or Acute Ischemic Stroke. Because of the therapeutic time window for treatment possibilities, timely completion and results of the CT or MRI scan are imperative and will directly impact the quality of care a patient receives. • Ensure all possible stroke diagnosis patients receive a head CT or MRI. • Determine and Document the date and time the patient was “Last Known Well”. • Double check to make sure the CT or MRI results are received within 45 minutes of patient arrival.
PCM – 01 Elective Delivery Patients with elective vaginal deliveries or elective cesarean sections at ≥37 and <39 weeks of gestation completed. For almost 3 decades, the American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have had a standard requiring 39 completed weeks gestation prior to an ELECTIVE delivery, either vaginal or operative (ACOF 1996). Most of these elective deliveries are for convenience, and result in significant short term neonatal morbidity (neonatal intensive care unit admission rates of 13-21%). When admitting a mother for an elective delivery be sure to double check the final gestational age. If the gestational age is <39 weeks, ensure the physician documents the diagnosis for the early delivery.
PCM – 02a Cesarean Section Description: Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section. Rationale: The removal of any pressure to not perform a cesarean birth has led to a skyrocketing of hospital, state and national cesarean section (CS) rates. A recent study showed if labor was forced when the cervix was not ready the outcomes were poorer. • For potential 1st time cesarean section mothers double check to ensure documentation supports the reasoning for the cesarean section.
PCM – 03 Antenatal Steroids Description:Patients at risk of preterm delivery at ≥24 and <32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns. Rationale:The National Institutes of Health 1994 recommendation is to give a full course of corticosteroids to all pregnant women between 24 weeks and 34 weeks of gestation who are at risk of preterm delivery. Repeated corticosteroid courses should not be used routinely, because clinical trials show decreased brain size, decreased birth weight, and adrenal insufficiency in newborns exposed to repeated doses. Treatment should consist of two doses of 12 mg of betamethasone given intramuscularly 24 hours apart or four doses of 6 mg dexamethasone given intramuscularly every 12 hours. A full course of antenatal corticosteroids should be administered to women with premature rupture of membranes (PROM) before 32 weeks of gestation to reduce the risks of respiratory distress syndrome, prenatal mortality, and other morbidities. • Determine if the patient is in the patient population (≥24 and <32 gestation with PROM). • Confirm a physician order is present for the above and follow accordingly.
PCB – 04 Health Care – Associated Blood Stream Infection in Newborns Health care-associated bacteremia is a significant problem for infants admitted into neonatal intensive care units (NICUs) and other hospital units. This is especially true for very low birth weight infants who are at high risk for these infections due to their immature immune systems and need for invasive monitoring and supportive care. • If the newborn has a diagnosis of Septicemia or Bacteremia, be sure the physician has documented this. • Ensure Birth Weight is present.
PCB – 05 Exclusive Breast Milk Feeding PCB – 05aExclusive Breast Milk Feeding Considering Mother’s Choice The measure is reported as an overall rate which includes all newborns exclusively fed breast milk during the entire hospitalization, and a second rate, a subset of the first, which includes only those newborns exclusively fed breast milk during the entire hospitalization excluding those whose mothers chose not to breast feed. • Is the mother exclusively breast feeding or not? Be sure to educate every mother on the benefits/risks and document. • If the newborn is not exclusively breast fed, be sure to document if this is due to the mother’s decision or a contraindicated condition documented by the physician. • If necessary, contact the Lactation Consultant for assistance.
