Transcript Core Measures - Lake Health System Emergency Services

Core
Measures
2014
Revised 11/30/13
Core Measures: What’s
That?
“BEST
PRACTICE”
Evidence based
measures
that improve
patient
outcomes!
IF MEASURES ARE
PROVEN TO
WORK…
WHY NOT UTILIZE
THEM?
Core Measures at
Lake Health
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Acute Myocardial Infarction
Heart Failure
Pneumonia
Surgical Care Improvement
Project (SCIP)
• Stroke
• Immunization-Influenza and
Pneumococcal (IMM)
• Venous
Thromboembolism(VTE)
Expectations for
Compliance
100%
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
Making a difference
at
Lake Health!
By changing our
process and
following
Core Measures
guidelines
we have saved
hearts and lives!
(Time=Muscle)
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
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!
S.C.I.P.
Surgical Care
Improvement
Project
SCIP
Data Elements
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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
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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
STROKE Data Elements
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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)
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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)
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PT/OT/Speech consults or physician documented reason for not consulting
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Discharge on statin if LDL > 100 or physician documented contraindication
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Discharge on anti-thrombotic or physician documented contraindication
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Discharge on anticoagulation therapy for patients with Afib or physician
documentation contraindication
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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
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Stroke Education- Print 2 copies from Soarian. Patient receives one copy.
Copy signed by the patient placed in the chart.
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Educate daily and include: when to call EMS, follow up, discharge
medications, risk factors, warning signs/symptoms.
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 drawnMust 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 cultures prior 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
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
Venous
Thromboembolism(VTE)
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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 pharmacologic agent
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
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
Key Points
• Check for pharmacologic and/or mechanical DVT
prophylaxis. Chart mechanical prophylaxis under
patient care intervention(SCD’s). Do not chart
machine not available or 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 all patients. 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
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
You are the patient
advocate!!!
Follow core measures and
make a
difference in your patient’s
outcomes!!!
Questions?