Transcript CAA Provider Update on PQRS

CAA Provider Update on PQRS Reporting
Topics covered
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CMS Physician Quality Reporting System (PQRS)
Anesthesia Quality Institute (AQI) Qualified Clinical Data
Registry (QCDR)
Data Capture Instructions
Quality Measures (PQRS & Anesthesia Specific)
Reporting
Quality Measure Details
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Update on PQRS Reporting
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CMS Physician Quality Reporting System
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Quality measures updated annually
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In 2015 lack of reporting = financial penalties
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Applicable to all MDs, DOs & CRNAs
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New paperwork
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CAA will use the AQI QCDR
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The only anesthesia Qualified Clinical Data Registry
for reporting measures to CMS
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Includes anesthesia specific measures (CPOM*)
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Includes clinical outcomes (e.g. reintubation rate) vs
process measures (e.g. admin of abx)
*developed by the ASA Committee on Performance Outcome Measurements (CPOM)
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Data Capture and Entry
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Paper based collection (until AIMS are updated/installed)
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2 forms
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Non-cardiac (no beta blocker or central line measures)
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Cardiac (includes beta blockers & central line measures)
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Optical Mark Recognition (OMR) form “bubble sheet”
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Forms completed at facility, sent to RESULT and scanned.
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CAA PQRS Forms
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Instructions
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One form/patient should be completed
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For identification, include:
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Date of Service and Patient Name OR
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Date of Service and Patient Sticker
Answer all applicable measures
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Fill in circle (no check marks)
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No extraneous marks
Return forms to RESULT
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CAA QCDR/PQRS Measures
Type Focus
Description
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AQI All
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AQI All
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AQI All
Prevention of PONV: Combination Therapy (Adults)
Post-Anesthetic Transfer of Care Measure: Use of Checklist or Protocol for Transfer of Care
from Procedure Room to a PACU
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care
from Procedure Room to ICU
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AQI All
Composite Anesthesia Safety (Adverse Events)
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AQI All
Immediate Perioperative Cardiac Arrest Rate
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7
AQI All
AQI All
Immediate Perioperative Mortality Rate
PACU Reintubation Rate
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AQI All
Short-term Pain Management
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AQI N/A
Composite Patient Experience (Survey Vitals)
10 AQI Cardiac
Procedural Safety for Central Line Placement
11 PQRS Cardiac
Preop Admin of Beta Blockers to Patients with Isolated CABG Surgery
12 PQRS Cardiac
PQRS/
13 SCIP All
14 SCIP All
MSBT for placing a Central Venous Catheter
Perioperative Temperature Management
Antibiotic Administration one Hour Prior to Surgical Incision (not one of the 9 for PQRS)
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Details on Measures
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Measure Specifications are
included on subsequent slides
and the CAA website.
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For More info:
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Contact Michelle Lilly, 594-1390
[email protected]
or https://www.aqihq.org/PQRSOverview.aspx
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Quality Measure Details
PACU Reintubation Rate
Numerator
The number of patients re-intubated with an ETT or new surgical airway. Any such patient who was extubated and then
re-intubated before leaving the PACU.
Denominator
All patients receiving GETA who are extubated prior to PACU discharge
Exclusions
N/A
Rationale
Early reintubation of surgical patients is strongly associated with subsequent serious adverse outcomes, prolonged ICU
and hospital stay, and increased costs of care. Assessment of this metric under a unified definition will be an important
tool for benchmarking the performance of surgical facilities, anesthesia departments, and individual practitioners.
Type
Intermediate Outcome
Domain
Communication and Care Coordination
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Quality Measure Details
Short-term Pain Management
Numerator
The number of lucid patients with an initial pain score 7/10 or higher
Denominator
All patients age 10 and greater admitted to PACU who can be assessed for pain
Exclusions
Chronic pain patients taking narcotics prior to surgery, patients with major psychiatric disorders, patients who do not
speak English (or Spanish)
Rationale
Alleviation of pain is a core responsibility of the anesthesia provider, and adequate postoperative pain control is an
important component of patient satisfaction with anesthesia and surgery. A large body of literature exists to support
evidence-based practice in this area. Significant variability in outcomes exists at the practice, facility and individual
provider level. Capture of this metric under a common definition will greatly enhance anesthesia quality management
and lead directly to improvements in patient outcome.
Type
Intermediate Outcome
Domain
Person and Caregiver-Centered Experience and Outcomes
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Quality Measure Details
Immediate Perioperative Cardiac Arrest Rate
Numerator
Number of patients experiencing an unanticipated cardiac arrest
Denominator
All scheduled procedures receiving anesthesia
Exclusions
Cases with planned cardiac arrest: deep hypothermia, electrophysiology cases, cardiac bypass cases
Rationale
Cardiac arrest in the perioperative period is an unintended serious adverse event, associated with immediate mortality
of about 50%. Arrest can occur as the result of sudden physiologic disruption due to surgery or medications (e.g.
anaphylaxis, air embolus) or as the cumulative result of progressive deterioration (e.g. bleeding, heart failure).
Prevention of cardiac arrest is a core goal of anesthesia providers, with high face validity as a discriminator of the
quality of anesthesia care.
Type
Intermediate Outcome
Domain
Patient Safety
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Quality Measure Details
Immediate Perioperative Mortality Rate
Numerator
The Number of patients who die in OR / PACU prior to discharge
Denominator
All scheduled procedures receiving anesthesia
Exclusions
Organ donors
Rationale
Type
Domain
Mortality is the outcome of ultimate interest to patients and providers. Albeit very rare in the perioperative period,
death in the OR or PACU is a sentinel event in any anesthesia department, as the majority of such occurrences can be
traced directly to anesthetic management issues. Capturing this data in a uniform fashion will allow assessment of
variability across practices and facilities, as well as identification of the rare outlier at the individual physician level.
Outcome
Patient Safety
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Quality Measure Details
Prevention of PONV – Combination Therapy
Numerator
Denominator
Patients who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of
different classes preoperatively or intraoperatively.
Definition: The recommended first- and second-line classes of pharmacologic anti-emetics for PONV prophylaxis in
patients at moderate to severe risk of PONV include (but are not limited to): • 5-hydroxytryptamine (5-HT3) receptor
antagonists (e.g., ondansetron, dolasetron, granisetron and tropisetron) • steroids (e.g., dexamethasone) •
phenothiazine (e.g., promethazine, prochlorperazine) • phenylethylamine (e.g., ephedrine) • butyrophenones (e.g.,
droperidol, haloperidol) • antihistamine (e.g., dimenhydrinate, diphenhydramine)
All patients aged 18 years and older who receive an inhalational general anesthetic and have three or more risk factors
for PONV
Definition:
Risk factors for PONV are:
(1) female gender,
(2) history of PONV or a history of motion sickness,
(3) non-smoker, and
(4) intended administration of opioids for post-operative analgesia*
*This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU)
or post-operative period, or opioids given in the PACU, or opioids given after discharge from the PACU.
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Quality Measure Details
Prevention of PONV – Combination Therapy (Continued)
Exclusions
Rationale
Denominator Exception: Documentation of medical reason(s) for not administering pharmacologic prophylaxis (eg,
intolerance or other)
Postoperative nausea and vomiting (PONV) is an important patient-centered outcome of anesthesia care. PONV is
highly dis-satisfying to patients, although rarely life-threatening. A large body of scientific literature has defined risk
factors for PONV, demonstrated effective prophylactic regimes based on these risk factors, and demonstrated high
variability in this outcome across individual centers and providers. Further, a number of papers have shown that
performance can be assessed at the level of individual providers -- the outcome is common enough that sufficient
power exists to assess variability and improvement at this level.
Type
Process
Domain
Person and Caregiver-Centered Experience and Outcomes
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Quality Measure Details
Composite Patient Experience
Numerator
All patients surveyed.
Denominator
All adult patients who can complete an AQI approved survey. (Survey Vitals)
Exclusions
Non verbal patients, patients with major psychiatric disorders, patients who cannot be surveyed due to language
barriers.
Rationale
Patient-centered outcomes are important discriminators of the quality of anesthesia practice, and every anesthesia
department and provider should have access to relevant data collected by the facility, as a means of guiding quality
improvement initiatives.
Type
Composite
Domain
Person and Caregiver-Centered Experience and Outcomes
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This metric is captured automatically.
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Quality Measure Details
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for
Direct Transfer of Care from Procedure Room to ICU
Numerator
Patients who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia
practitioner to the responsible ICU practitioner.
Denominator
All patients, regardless of age, who receive an anesthetic and are admitted to an ICU directly from the anesthetizing location
Exclusions
None
Rationale
Hand-offs of care are a vulnerable moment for patient safety, but required in any 24/7 healthcare system. Anesthesia providers
routinely transfer critically ill patients from the OR to the ICU, and are responsible for transmitting knowledge about patient
history, a summary of intraoperative events, and future plans for hemodynamic and pain management to the ICU team. Evidence
demonstrates that this process can be facilitated by use of a checklist that motivates completion of all key components of the
transfer, and this is an emerging best practice in anesthesia care.
Type
Process
Domain
Communication and Care Coordination
Transfer Protocol
The key handoff elements that must be included in the transfer of care protocol or checklist include:
1. Identification of patient
2. Identification of responsible practitioner (primary service)
3. Discussion of pertinent medical history
4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)
5. Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation
level and paralytic management and intravenous fluids/blood products and urine output during the procedure
6. Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance),
complications, need for laboratory or ECG and medication administration
7. Opportunity for questions and acknowledgement of understanding of report from the receiving ICU team
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Quality Measure Details
Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Transfer of
Care from Procedure Room to PACU
Numerator
All age patients transferred directly from the procedure room to PACU for post-procedure care for whom a checklist
or protocol which includes the key transfer of care elements is utilized.
Denominator
All age patients who are cared for by an anesthesia practitioner and are transferred directly from the procedure room
to the PACU upon completion of the anesthetic.
Exclusions
Patients who are not admitted directly to the PACU.
Rationale
Type
Hand-offs of care are a vulnerable moment for patient safety, but required in any 24/7 healthcare system. Anesthesia
providers routinely transfer patients from the OR to the PACU, and are responsible for transmitting knowledge about
patient history, a summary of intraoperative events, and future plans for hemodynamic and pain management to the
new care team. Evidence demonstrates that this process can be facilitated by use of a checklist that motivates
completion of all key components of the transfer, and this is an emerging best practice in anesthesia care.
Process
Domain
Communication and Care Coordination
Transfer protocol
The key transfer of care protocol or handoff tool/checklist handoff elements that must be included in the transition of
care include:
1. Identification of patient
2. Identification of responsible practitioner (PACU nurse or advanced practitioner)
3. Discussion of pertinent medical history
4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)
5. Intraoperative anesthetic management and issues/concerns.
6. Expectations/Plans for the early post-procedure period.
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7. Opportunity for questions and acknowledgement of understanding of report from the receiving PACU team
Quality Measure Details
Composite Anesthesia Safety
Numerator
All patients who have the planned procedure, and who do not have a major complication of anesthesia
Denominator
All scheduled procedures receiving anesthesia.
Exclusions
None
Rationale
Serious adverse events are rare in anesthesia care, but can be assessed for performance improvement purposes as a
composite of mortality, major organ system injury, and unintended events (e.g. anaphylaxis, cardiac arrest) that carry a
high risk. Completion of a scheduled surgery or procedure WITHOUT complication is the fundamental goal of both
patients and anesthesia providers, suggesting that this metric is at the core of assessment for the specialties involved.
Type
Outcome
Domain
Effective Clinical Care
Additional:
Complete Adverse Event Sheet or Web portal entry on CAA website
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Measures Specifics
Perioperative Temperature Management
Numerator
Patients for whom either:
• Active warming was used intraoperatively for the purpose of maintaining normothermia OR
• At least one body temperature equal to or greater than 36 degrees Centigrade (or 96.8 degrees Fahrenheit)
was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time
Denominator
All patients, regardless of age, undergoing surgical or therapeutic procedures under general or neuraxial anesthesia of
60 minutes duration or longer, except patients undergoing cardiopulmonary bypass
Exclusions
None
Rationale
Anesthetic-induced impairment of thermoregulatory control is the primary cause of perioperative hypothermia. Even
mild hypothermia (1-2°C below normal) has been associated in randomized trials with a number of adverse
consequences, including: increased susceptibility to infection, impaired coagulation and increased transfusion
requirements, cardiovascular stress and cardiac complications, post-anesthetic shivering and thermal discomfort.
Whether the benefits of avoiding hypothermia in patients undergoing cardiopulmonary bypass (CPB) outweigh
potential harm is uncertain, because known complications of CPB include cerebral injury, which may be mitigated by
mild hypothermia. Therefore, patients undergoing CPB are excluded from the denominator population for this
measure. Several methods to maintain normothermia are available to the anesthesiologist in the perioperative period;
various studies have demonstrated the superior efficacy of over-the-body active warming (eg, forced air, warm-water
garments, and resistive heating blankets).
Type
Process
Domain
N/A
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Quality Measure Details
Antibiotic Administration One Hour Prior to Surgical Incision
Numerator
Number of surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours
if receiving vancomycin, or a fluoroquinolone.)
Denominator
All surgical patients with no evidence of prior infection.
Exclusions
Patients less than 18 years of age
Rationale
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels at the time of skin incision.
Studies performed in the 1960’s and 1970’s demonstrated that a common reason for failure of prophylaxis was delay of
antibiotic administration until after the operation. In a study of 2,847 surgery patients at LDS Hospital in Salt Lake City,
it was found that the lowest incidence of post-operative infection was associated with antibiotic administration during
the one hour prior to surgery. The risk of infection increased progressively with greater time intervals between
administration and skin incision. This relationship was observed whether antibiotics preceded or followed skin incision
(Classen 1993).
Type
Domain
Process
N/A
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Quality Measure Details
Preop Admin of Beta Blockers in Patients with Isolated
CABG Surgery
Numerator
Denominator
Isolated CABG surgeries for patients aged 18 years and older
Exclusions
None
Rationale
Postoperative atrial fibrillation (POAF) is a common complication following cardiac surgery, occurring in 25-40% of
patients (Crystal, 2004, Burgess, 2006). POAF has been associated with increased rates of post-operative morbidity and
mortality and consequently, increased costs (Mariscalco, 2008, Crystal, 2004, Bramer, 2010). Prophylactic
administration of beta-blockers have been shown to reduce the risk of POAF and mortality following isolated coronary
artery bypass graft surgery (Connolly, 2003, Mariscalco, 2008, Ferguson, 2002). Khan’s meta-analysis of RCTs
found that "Preoperative BB initiation resulted in 52% reduction in the incidence of AF as compared to controls,
however these results were not statistically significant”. ElBardissi (2012) showed a 19.5% increase in preoperative use
of beta-blockers from 2000-2009.
Type
Process
Domain
N/A
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Quality Measure Details
Composite Procedural Safety for Central Line Placement
Numerator
The number of patients with documented arterial injury (from the medical record or PSI code) or pneumothorax
requiring thoracostomy placement (CPT 32035, 32036,32551)
Denominator
All patients receiving central line placement for a planned surgical procedure
Exclusions
Emergencies
Rationale
Placement of central venous catheters is common for anesthesia providers, but may be associated with serious
adverse events. Arterial injury and pneumothorax each require additional treatment that adds to the cost and
discomfort of care. Recent scientific literature has documented that the risk for these complications can be reduced
through evidence-based practice, including the use of ultrasound localization of the central vein. This measure will
allow for documentation of variability in occurrence of this outcome, and will empower quality improvement efforts.
Type
Intermediate Outcome
Domain
Patient Safety
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Quality Measure Details
MSBT for placing a Central Venous Catheter
Numerator
Patients for whom central venous catheter (CVC) was inserted with all elements of maximal sterile barrier technique,
hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
Denominator
All patients, regardless of age, who undergo CVC insertion
Exclusions
None
Rationale
Catheter-related bloodstream infection is a costly complication of central venous catheter insertion, but may be
avoided with routine use of aseptic technique during catheter insertion. This measure is constructed to require that all
of the listed elements of aseptic technique are followed and documented.
Type
Domain
Process
N/A
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For more info:
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Questions:

Contact Michelle Lilly, Director of Quality Programs at
[email protected] or 594-1390
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