2012 Core Measures. Acute Myocardial Infarction (AMI)

Transcription

1 2012 Core Measures Acute Myocardial Infarction (AMI) Aspirin at Arrival Aspirin Prescribed at Discharge Angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD). LVSD defined as an ejection fraction of less than 40% or a narrative description consistent with moderate or severe systolic dysfunction. Adult Smoking Cessation Advice/Counseling* Beta-Blocker Prescribed at Discharge Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival Primary PCI Received Within 90 Minutes of Hospital Arrival Statin Prescribed at Discharge. LDL-c cholesterol less than 100 mg/dl within first 24 hours of hospital arrival or within 30 days prior to hospital arrival would exempt the patient from the statin core measure treatment. Aspirin received within 24 hours before or after hospital arrival; or reason documented for not administering at arrival. Aspirin prescribed at discharge; or reason documented for not prescribing at discharge. ACEI or ARB prescribed at discharge, or reason documented in patient chart for not prescribing at discharge. AMI patients with a history of smoking cigarettes (smoked anytime during the year prior to hospital arrival) must be given smoking cessation advice or counseling during hospital stay. Beta-blocker prescribed at discharge; or reason documented for not prescribing beta-blocker at discharge. When fibrinolytic therapy is primary reperfusion therapy, an AMI patient with ST segment elevation or left bundle branch block (LBBB) must receive such therapy within 30 minutes or less of hospital arrival. Reason for delay must be documented. AMI patient with ST segment elevation or left bundle branch block (LBBB) must receive primary percutaneous coronary intervention (PCI) within 90 minutes or less of hospital arrival. Reason for delay must be documented. Statin prescribed at Discharge or reason documented for not prescribing statin at discharge. *Denotes Non-Accountability Measure, now being regulated as a global issue outside of the Core Measure environment.

2 Community-Acquired Pneumonia (CAP) Blood Cultures Performed Within 24 Hours Prior to or 24 Hours After Hospital Arrival for Patients Who Were Transferred or Admitted to the ICU Within 24 Hours of Hospital Arrival. Blood Cultures Performed in the Emergency Department Prior to Initial Antibiotic Received in Hospital Initial Antibiotic Selection for CAP in Immunocompetent Patient Initial Antibiotic Selection for CAP in Immunocompetent ICU Patient Initial Antibiotic Selection for CAP Immunocompetent Non ICU Patient Pneumonia patients whose initial emergency department blood culture specimen was collected prior to first hospital dose of antibiotics. Must receive an initial antibiotic regimen within the first 24 hours of arrival or the day prior to arrival and/or during this hospital stay. -

3 Heart Failure Discharge Instructions* Evaluation of LVS Function* Angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD). LVSD defined as an ejection fraction of less than 40% or a narrative description consistent with moderate or severe systolic dysfunction. Adult Smoking Cessation Advice/Counseling* Heart failure patients or their caregivers should be provided with written discharge instructions or educational materials at discharge or during the hospital stay addressing all of the following: Activity level Diet/fluid intake Follow-up with physician/apn/pn after discharge Discharge medications Weight monitoring What to do if heart failure symptoms worsen after discharge There must be documentation of at least one of the following: left ventricular systolic function (LVSF) assessment at anytime prior to arrival or during this hospitalization; a plan for LVSF assessment after discharge; or a reason documented by a physician/apn/pa for not assessing LVSF ACEI or ARB prescribed at discharge, or reason documented in patient chart for not prescribing at discharge. Heart failure patients with a history of smoking cigarettes (smoked anytime during the year prior to hospital arrival) must be given smoking cessation advice or counseling during hospital stay. *Denotes Non-Accountability Measure, now being regulated as a global issue outside of the Core Measure environment.

4 Surgical Care Improvement Project (SCIP) Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Prophylactic Antibiotic Selection for Surgical Patients Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time Cardiac Surgery Patients With Controlled 6AM Postoperative Blood Glucose (200 or less serum glucose) Surgery Patients with Appropriate Hair Removal Urinary catheter removed on Postoperative Day 1 (POD1) or Postoperative Day 2 (POD2) with day of surgery being day zero Surgery Patients with Perioperative Temperature Management Surgery Patients on Beta-Blocker Therapy Prior to Arrival Who Received a Beta- Blocker During the Perioperative Period Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Documented prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). Documented reason by physician/apn/pa for extending duration of the antibiotic administration past 24 hours after Anesthesia End Time (including extensions for specific treatments) Documented patient s blood glucose level on Postoperative Days 1 and 2, both closest to 6AM. Indicate in the documentation what method of hair removal was performed prior to the principal procedure. Documentation that the urinary catheter was removed on POD 0 through POD 2 with the Anesthesia End Date being POD 0. Or documented reason for not removing the urinary catheter postoperatively. Documentation in the medical record for active warming used intraoperatively OR at least one body temperature equal to or greater than 96.8 o F/36 o C within the 30 minutes immediately prior to or the 15 minutes immediately after Anesthesia End Time. Document that patient was on a daily beta-blocker therapy prior to arrival. Document that beta-blocker was received during the perioperative period; or reason for not administering a beta-blocker during the perioperative period. Document by physician/apn/pa or pharmacist in the medical record of a reason for not administering pharmacological and/or mechanical VTE prophylaxis.

5 Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery Document patient was on a continuous oral anticoagulation therapy prior to admission. Document type and that the ordered VTE prophylaxis was received within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time.

6 Stroke Venous Thromboembolism (VTE) Prophylaxis Discharged on Antithrombotic Therapy Anticoagulation Therapy for Atrial Fibrillation/Flutter Thrombolytic Therapy Antithrombotic Therapy By End of Hospital Day 2 Discharged on Statin Medication Stroke Education Assessed for Rehabilitation Ischemic and hemorrhagic stroke patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission. Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. Acute ischemic stroke patients who arrive at this hospital within 2 hours of time last known well and for whom IV t-pa was initiated at this hospital within 3 hours of time last known well. Ischemic stroke patients administered antithrombotic therapy by the end of hospital day 2. Ischemic stroke patients with LDL greater than or equal to 100 mg/dl, or LDL not measured, or who were on a lipidlowering medication prior to hospital arrival are prescribed statin medication at hospital discharge. Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke. Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services.

7 Immunizations Pneumococcal Immunization (PPV23) Overall Rate Pneumococcal Immunization (PPV23) Age 65 and Older Pneumococcal Immunization (PPV23) High Risk Populations (Age 6 through 64 years) Influenza Immunization This prevention measure addresses acute care hospitalized inpatients 65 years of age and older AND inpatients aged between 6 and 64 years who are considered high risk and were screened for receipt of 23-valent pneumococcal polysaccharide vaccine (PPV23) and were vaccinated prior to discharge if indicated. The numerator captures two activities; screening and the intervention of vaccine administration when indicated. As a result, patients who had documented contraindications to PPV23, patients who were offered and declined PPV23 and patients who received PPV23 anytime in the past are captured as numerator events. This prevention measure addresses acute care hospitalized inpatients age 6 months and older who were screened for seasonal influenza immunization status and were vaccinated prior to discharge if indicated. The numerator captures two activities: screening and the intervention of vaccine administration when indicated. As a result, patients who had documented contraindications to the vaccine, patients who were offered and declined the vaccine and patients who received the vaccine during the current year s influenza season but prior to the current hospitalization are captured as numerator events.

8 ED Departure for Admitted ED Patients- Overall Rate Departure for Admitted ED Patients- Reporting Measure Departure for Admitted ED Patients- Observation Patients Departure for Admitted ED Patients- Psychiatric/Mental Health Patients Admit Decision Time to ED Departure Time for Admitted Patients Overall Rate Admit Decision Time to ED Departure Time for Admitted Patients Reporting Measure Admit Decision Time to ED Departure Time for Admitted Patients Psychiatric/Mental Health Patients Departure for Admitted ED Patients. Admit Decision Time to ED Departure Time for Admitted Patients