Core Measures ALQIO.Indd
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Complete and detailed information is available in the Specifi cations Manual located on QualityNet (www.QualityNet.org) under the Hospitals-Inpatient tab. AQAF 2 Perimeter Park South, Suite 200 West Birmingham, AL 35243 205-970-1600 or 800-760-4550 AMI, HF, PN & SCIP www.aqaf.com Core Measures Help Booklet This material was originally created by IQH, the Medicare Quality Improvement Organization for Mississippi, and distributed by AQAF, the Medicare Quality Improvement Organization for Ala- bama, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. Contents do not necessarily refl ect CMS policy. 10SOW-AL-C8-12-15 Page 1 Page 26 AMI Immunization - New (Beginning with January, 1 , 2012 discharges) Aspirin at Discharge: Pneumococcal Immunization (*PPV23) Prescribe at discharge or document reason for No aspirin at discharge. (Includes ALL patients discharged from acute care age 65 years and older AND ages 6 through 64 who are Documentation must clearly indicate aspirin is being prescribed at discharge. considered †high risk and who have a LOS less than or equal to 120 days) Excludes: Patients less than 6 years of age, who are pregnant or who received an organ transplant this Reasons: • Allergy hospitalization • Coumadin/warfarin or Pradaxa/dabigatran at discharge • Other explicitly documented reason by Phys/APN/PA/Pharmacist 1. Screen pts 65 and older and 6 – 64 years of age with a †high risk condition for vaccination status 2. *Vaccinate pt prior to discharge if: ‡Fibrinolytic Therapy: (Fibrinolysis/Reperfusion) a. Not previously vaccinated (Vaccines noted as “up-to-date” count. Do not use “UTD.” [If provided w/in 6hrs of hospital arrival & is primary reperfusion therapy] b. No documented allergy (document exact complication) Clear documentation is important: Applies to pts with ST-segment elevation/LBBB noted on ECG performed c. Not likely to be uneffective due to bone marrow transplant w/in the past 12 months closest to arrival. d. No radiation/chemotherapy currently being received as a scheduled dose, received Give w/in 30 min of hospital arrival or *document reason for the delay. during this stay or within 2 weeks prior to this stay Reasons: • Balloon pump; Cardiopulmonary arrest; Intubation e. No shingles (Zostavax) vaccination received w/in the past 4 weeks [Automatic - If occurred w/in 30 min after hosp arrival] f. Patient/caregiver does not refuse • Pt/Caregiver refusal [No further documentation needed] g. For patients 6 years of age or older: Did not receive a conjugate vaccine w/in the past the • Other reasons that include BOTH the notation of delay + underlying (non-system) reason previous 8 weeks ‡Table 4 †6-64 – High risk conditions include: diabetes, nephritic syndrome, ESRD, CHF, COPD, HIV or asplenia Primary PCI: (PCI/Reperfusion/Cath/Transfer to Cath Lab) [If performed w/in 24hrs of hospital arrival] - Clear documentation is important: Applies to pts with ST- †19-64 – Include the high risk condition of asthma in addition to the above segment elevation/LBBB noted on ECG performed closest to arrival. * For high-risk children 6-18 years of age may include either PCV13 or PPV23 as this population Perform w/in 90 min of hospital arrival or *document reason for delay. should receive PCV13 prior to PPV23 Reasons: • Balloon pump; Cardiopulmonary arrest; Intubation [Automatic - If occurred w/in 90 min after hosp arrival] Infl uenza Immunization • Pt/Caregiver refusal [No further documentation needed] (Includes ALL patients discharged from acute care age 6 months and older AND who have a LOS less than or • Other reasons that include BOTH the notation of delay + underlying (non-system) reason equal to 120 days.) *Only Phys/PA/APN documentation. Excludes: Patients less than 6 months of age or who received an organ transplant this hospitalization. ‡Statin (or HMG CoA reductase inhibitors) Prescribed at Discharge: Prescribe at discharge or document reason for No statin at discharge. *1. Screen pts 6 months and older during current fl u season (when vaccine is available - March) for vaccina- tion status. *Hospital is only responsible for collection during discharges Oct - March. Documentation must clearly indicate the medication (listed by name) is being prescribed at discharge. Reasons: • Allergy to or complication related to statins 2. Vaccinate pt prior to discharge if: • Other explicitly documented reason by Phys/APN/PA/Pharmacist, i.e., statins contrain- a. Not previously vaccinated this fl u season dicated due to: b. No documented allergy to infl uenza vaccine; anaphylactic latex allergy or • **Hepatic failure anaphylatic allergy to eggs (document exact complication) • **Myalgias c. Not likely to be uneffective due to bone marrow transplant w/in the past 6 months • **Rhabdomyolysis d. No documented Guillian-Barre’ syndrome w/in 6 weeks after previous infl uenza (**More common reasons. Must be linked to no statins prescribed.) vaccination ‡Table 5 e. Patient/caregiver does not refuse Excludes: Patients with an LDL < 100 mg/dL [either direct or calculated] w/in 24hrs after hospital arrival or 30 days prior to hospital arrival and not discharged on a statin. Special Note: Comfort Measures Only excludes cases from all measures except lytic and PCI. Page 25 Page 2 ED Throughput - New (Beginning with January, 1 , 2012 discharges) AMI Beginning with January 2012, the following measures were retired or suspended. Median Time from ED Arrival to ED Departure for Admitted ED Patients: (Includes ALL patients discharged from acute care AND with a LOS less than or equal to 120 days) There are several reasons measures are retired: 1. Measure performance among hospitals is so high and unvarying that meaningful distinctions and Excludes: Patients who are not *ED patients improvements in performance can no longer be made; 2. Performance or improvement on a measure does not result in better patient outcomes; Document in the ED Record the date and time when the patient physically left the ED. (Don’t use disposittion 3. A measure does not align with current clinical guidelines or practice; date/time, the time the discharge order was written, or the report called time.) Emphasis is placed on captur- 4. There is the availability of a more broadly applicable measure for the topic; ing the latest time the patient was receiving care in the ED, under ED services or awaiting transport. 5. There is the availability of a measure that is more proximal in time to desired patient outcomes for the particular topic; 6. There is the availability of a measure that is more strongly associated with desired patient outcomes for the Admit Decision Time to ED Departure Time for Admitted Patients: particular topic; and (Includes ALL patients discharged from acute care AND with a LOS less than or equal to 120 days) 7. Collection or public reporting of a measure leads to negative unintended consequences other than patient harm. Excludes: Patients who are not *ED patients The one retired measure, Adult Smoking Cessation Advice/Counseling, is considered “topped out,” indicating that Document in the ED Record the date and time the decision was made to admit the patient to the hospital as nationally, it has met and maintained a very high performance level, with little or no room for improvement. Also, an inpatient. (The admit or disposition order date/time may be used). Emphasis is placed on when the screening should apply to ALL patients, not just those with AMI. No data will be collected or reported on this AMI measure. (earliest) decision was communicated. The suspended measures are those which CMS is considering retiring; however, due to public concern over Document in the ED Record the date and time when the patient physically left the ED. (Don’t use disposittion possible declination of adherence, data collection and submission may be continued and any data submitted will be date/time, the time the discharge order was written, or the report called time.) Emphasis is placed on captur- publically reported on Hospital Compare. ing the latest time the patient was receiving care in the ED, under ED services or awaiting transport. Because these measures are still considered “best practices” and indicators of high quality, they will * ED Patient is defi ned as any patient receiving care or services in the Emergency Department. continue to be a part of this Core Measures Help Booklet. Special Notes for **Observation Patients Aspirin at Arrival: [Suspended] Under ED Services: Use the time patients depart from observation services. Give w/in 24hrs before or after arrival or document reason for No aspirin on arrival. • If admitted to an observation unit of the ED, use the time they departed the observation unit. • If placed into observation services but remains in the ED or ED unit, use the time they departed the ED or Note regarding 24 hrs prior to arrival: For patients received as transfers, documentation must be clear that ASA ED unit for the fl oor/surgery, etc.; not the time they are placed into observation. was received within 24 hours of arrival or was a current medication at the transferring facility. Reasons: • Allergy Outside the services of the ED: Use the time of departure from the ED. • Pre-arrival Coumadin/warfarin or Pradaxa/dabigatran • If patient is placed into observation but remains in the ED or ED unit, use the time they departed the ED • Other explicitly documented reason by Phys/PA/APN/Pharmacist or ED unit for the fl oor/surgery, etc.; not the time they are placed into observation. ** Observation Services: Services furnished by a hospital on the hospital’s premises, including use of a bed and periodic monitoring by a hospital’s nursing or other staff, which are reasonable and necessary to evaluate an outpatient’s condition or determine the need for possible admission to the hospital as an inpatient.