1. Cardiology Wards
Introduction to 7 south

2. Cardiology Wards Medical Director 7 South – Bart Cox, MD
Unit Director 7 South – Melissa Johnson, RN, MSN
Pharmacist – Tiffany Montoya, PharmD, PhC
Chief Resident – Mark Garcia, MD

3. Presentation Goals and Objectives
Interdisciplinary approach
Improve communication between Residents, Nurses, Pharmacists, Social Workers, Discharge Managers, Techs
Improve outcome measures, education, and patient care
Identify areas needing improvement and areas of success
Discuss Core Measures and HF Performance Indicators
Increase resident’s knowledge of 7 south
Projects, On going research, New devices
Changes in protocols
Identify and address issues
Medication Reconciliation Tutorial

4. Inpatient Cardiology
Goals and Objectives

5. Inpatient Cardiology Wards - Orientation
Read the University Cardiology Rotation Handout
in the packet
Be familiar with packet material
New Call schedule
Must comply with duty hours (28hr rule)
Clinic schedules
Residents need to be familiar with all patients on service
Recommend creating a master schedule and posting it in the workroom

6. Orientation Packet
University cardiology rotation goals and expectations
Discharge summary template
H and P template
Nuts and bolts for orders
Call schedule sample
Common phone numbers
Common medications and dosage
Orientation PowerPoint

7. Performance Measures Core Measures and why it is this important to you
Heart Failure Performance Indicators

8. Core measures and Public Reporting
Centers for Medicare and Medicaid (CMS)
The Joint Commission (TJC)
And several others teamed up to create the:
Hospital Quality Alliance (HQA)
Used Evidence Based Medicine and developed “Core Measures”
Public Reporting of Core Measure compliance
Is this hospital providing care proven to improve mortality, morbidity, re-hospitalizations, etc.?

9. Core measures and Public Reporting
TJC (hospital accreditation people) and CMS (payment people)
Receives accreditation survey from United Hospital Center (UHC)
CMS provides payments to hospitals based upon the Annual Payment Update (APU)
Reductions in payment for noncompliance
Other payer's: public and third party use info and compare hospitals
The Joint Commission (TJC)
Hospital accreditation based upon core measures, efforts to improve problem areas, and continuous submission of data

10. Core measures and Public Reporting
Provide transparency to the public
Holds health care organizations accountable for performance
Provides patients with a high standard of care and interventions known to improve outcomes

11. UNMH Core Measures AMI Aspirin on arrival
Aspirin prescribed at discharge
ACEI or ARB for LV systolic dysfunction
Beta Blocker prescribed at discharge
PCI within 90 minutes of arrival
Statin at discharge
Fibronolytic therapy with 30 minutes of arrival
Smoking Cessation HF
Discharge Instruction (6 elements)
Evaluation of LVS function
ACEI/ARB for LVSD
Smoking Cessation

12. UNMH Core Measures - Below Target
Covers January 2011 to December 2011
Core
Measures
Apr 2011 – March 2012
Observed%
Oct – Dec 2011 (Q4)
Observed %
Jan – March 2012 (Q1)
April – June 2012
2012(Q2)
Observed %
Target
(Per UHC)
% HF-3 ACEI or ARB for LVSD 96 97 90
100 95
% AMI-3: ACEi or ARB for LVSD
% HF-1: Discharge Instructions 88 81 87 92 94

13. UNMH Core Measures - Below Target

14. Areas needing IMPROVEMENT and areas of success
Medications
Discharge
Documentation
Ward Specific

15. Areas of improvement: Medications
ACEi/ARB - Documentation of intolerance/contraindication
ACEi/ARB for AMI with LV dysfunction and HF patients with LV dysfunction
Document ACEi (or ARB) held for:
Worsening renal function, angioedema, hyperkalemia, hypotension, or renal artery stenosis
If ACEi allergy, then must state ARB contraindication (allergy not a class effect)
Aldosterone Antagonist
Appropriate documentation
Appropriate indications
Medication Reconciliation
Must be done on admissions, transfers, and discharges
Discharge instructions must match discharge summary

16. Areas of improvement: Discharge
Written discharge instructions and/or educational material must be given to patient or care giver at discharge and address the following
Activity Level
Diet
Discharge Medications (med rec)
Follow-up Appointments
Weight Monitoring
What to do if symptoms worsen

17. Areas of improvement: Discharge
Discharge instructions
Recent decline in HF dc instructions (mostly due to med rec)
Don’t delete instruction sections
Matching lists in dc summary and discharge instructions
Sign depart process then discharge order (last two things)
Discharge follow-up in 7 days by any provider
Weekend scheduling
Medication Errors
Medication reconciliation at admission, transfer, and discharge decreases error rates

18. Areas of improvement: Depression Screening
PHQ9 and documentation of results
Starting to screen depression in AMI and HF patients
Residents need to document scores in dc summary
If >10 then discuss treatment options with patient
Treat – sertraline, defer to PCP must have f/u call to PCP, or inpatient psych consultation
If patient has SI/HI or + on question #9 – needs physician assessment and possible psychiatry consultation if provider feels necessary
Patients will need outpatient follow up instructions in dc summary

19. Areas of improvement: Documentation
H & P Documentation
Recent decline in complete documentation on H and Ps:
Family History:
Not okay to state “non-contributory”
It is okay to use that phrase during oral presentations
Review of Systems:
Must document 10 systems – 2 items each
Cannot say “otherwise negative” or “12 point ROS completed and negative”

20. Areas of improvement: Ward Specific
Potential hour violations with new call schedule
Be aware of clinic and post call days
Create a master schedule and post in work room
Let fellow know >1 hour prior to suspected hour violation to handoff duties
Hand washing: Physicians on 7 south 33% (poor)
Residents need to be familiar with all Cardiology patients

21. Areas of success Aspirin on arrival Aspirin on discharge
Smoking Cessation
Statin on discharge
LV function evaluation in heart failure
Communication – Showing Patients Respect
Cardiac Rehab referral

22. Upcoming Events and Ongoing Research
Ultrafiltration (Aquapheresis™) started August 2012
Educational DVDs
Pulmonary hypertension continuous infusion

23. Cardiology admissions
Residents will be given a handout on “high risk features”
Will need to call fellow if meeting this criteria
Residents will need to use powerplans for all:
Heart Failure admissions (Adult Heart Failure)
Do not uncheck Cardiac Rehab
Acute Myocardial Infarcts (Adult Acute Coronary Syndrome)
All admissions from 7 am – 8:30 pm will be discussed with cardiology fellow
All heart failure admitted to cardiology, unless multiple diagnosis, heme/onc receiving therapy
All transfers are attending to attending

24. Cardiology admissions
All blocking, refusals, “turfing” to other services will require:
Discussion with fellow or attending prior to refusal
Documentation that fellow/attending was in agreement
Consult note will have name of fellow/attending
Consult note on all refusals

25. Cardiology admissions
Family Medicine
Give Family Medicine service first option of admission
All STEMIs go to cardiology
PCP and primary cardiologist
Please forward H and P and DC summaries to PCP and Cardiologist

26. Cardiology discharges
Use the standardized DC summary template:
Cath reports, PHQ9 score and discussion, medication contraindications, discharge weight, follow up, reason for medication changes, etc.
EMR (=cardiacdischargesummary) if typing
Resident not responsible for scheduling PCP appointment
All CAD and HF patients will be referred to cardiac rehab
Make sure it is ordered prior to discharge (on HF powerplan)
Do not “uncheck” the cardiac rehab order
Assure appropriate medications and matching dc instructions to dc summary upon discharge
When in doubt ask.

27. Medication Reconciliation
Tiffany Montoya, PHARMD, PHC
Medication Reconciliation made easy (and correct)
Evaluations will be based on compliance
Will be tracking residents performance of med rec
If unable to be at orientation:
Will need to schedule meeting within one week with Tiffany
Mid-point evaluation