Introduction to Core Measures Preferred Nurse Staffing

Core Measures Who is information reported to? JCAHO CMS National Patient Safety Foundation

Inpatient Core Measure Groups Acute Myocardial Infarction (AMI) Congestive Heart Failure (HF) Pneumonia (PN) Surgical Care Improvement Project (SCIP)

AMI Measures AMI 1 Aspirin w/in 24 hours of arrival* The early use of aspirin in patients with acute myocardial infarction results in a significant reduction in adverse events and subsequent mortality AMI-2 Aspirin at discharge.* Studies have demonstrated that aspirin can reduce this risk by 20% Leading cause of death in the US Primary disease category for hospital patient discharges 900,000 people in US are diagnosed each year Of these cases approximately 225, 000 result in death Aspirin causes platelets to become less sticky and disrupts clot formation

AMI Measures AMI-3 ACEI or ARB for LVSD* ACEI therapy reduces mortality and morbidity in patients with left ventricular systolic dysfunction (LVSD/EF less than 40%) after AMI

AMI- 4 Smoking Cessation Counseling AMI Measures AMI- 4 Smoking Cessation Counseling Smoking cessation reduces mortality and morbidity in all populations. Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit

Aspirin on arrival/within 24 hours of presentation AMI Measures AMI-6 Aspirin on arrival/within 24 hours of presentation Beta Blocker on arrival/within 24 hours of presentation Beta Blockers are cardiac meds used to help regulate the heart rate and prevent arrhythmias

AMI-5 Beta Blocker at discharge* AMI Measures AMI-5 Beta Blocker at discharge* Beta blockers prescribed for patients who have suffered an acute myocardial infarction can reduce mortality and morbidity. Studies have demonstrated that the use of beta blockers is associated with about a 20% risk reduction

AMI Measures AMI-7 Median time to fibrinolysis AMI-7a Thrombolytic Agent received within 30 minutes of arrival Time to fibrinolytic therapy is a strong predictor of outcome in patients with an acute myocardial infarction. Consider that nearly 2 lives per 1000 patients are lost per hour of delay Thrombolysis w/in 30 minutes – time element

AMI-8a PCI received within 90 minutes of patient arrival AMI Measures AMI-8 Median time to PCI AMI-8a PCI received within 90 minutes of patient arrival The early use of primary angioplasty in patients with acute myocardial infarction who present with ST-segment elevation or LBBB results in a significant reduction in mortality and morbidity The earlier primary coronary intervention is provided, the greater its effect PCI within 90 minutes-cardiac intervention-time element

Heart Failure Measures HF –1 Discharge Instructions Written instructions or educational material must address all of the following and must be specific to heart failure: Activity level Diet A written list of discharge medications Follow-up appointment Weight monitoring What to do if heart failure symptoms worsen 5 Million adults in US have CHF 500k to 900k new cases are diagnosed every year More Medicare dollars are spent for the diagnosis and treatment of HF than for any other diagnosis CHF is leading hospital adm dx >65age Discharge Instructions: Educating pts with heart failure is critical Non-compliance is a major cause of hospital readmission Must address all 6 elements in the patient’s record to count

Heart Failure Measures HF-2 LVF assessment* Appropriate selection of medications to reduce morbidity and mortality in heart failure requires the identification of patients with impaired left ventricular systolic function (Ejection fraction less than 40%) Assessment of Left Ventricular performance (ECHO) is critical to the diagnosis and management of heart failure EF </= 40%

Heart Failure Measures HF-3 ACEI or ARB for LVSD* ACEI therapy reduces mortality and morbidity in patients with heart failure and left ventricular systolic dysfunction These cardiac medications decrease the workload of the heart and help to alleviate symptoms

Heart Failure Measures HF-4 Smoking Cessation/counseling Smoking cessation reduces mortality and morbidity in all populations Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit

Community Acquired Pneumonia Pneumonia Measures Community Acquired Pneumonia PN-1 Retired PN-2 Pneumococcal vaccination* Pneumococcal vaccination is indicated for persons 65 years of age and older, because it is up to 75% effective in preventing pneumococcal bacteremia and meningitis Community Acquired Pneumonia is the 6th most common cause of death Annually: 2-3 million cases CAP result in 10 million MD visits, 500K hospitalizations and 45,000 deaths 90% of deaths from PN are in pts 65 and older Organisms have become more resistant to penicillin from overuse/therefore harder to tx

Pneumonia Measures PN-3a Blood cultures performed w/in 24 hours prior to or after arrival to the ICU PN-3b- Blood cultures preformed in the ED before the initial antibiotic Published treatment guidelines recommend the collection of blood cultures for all inpatients with severe pneumonia to optimize therapy

PN-4 Smoking Cessation/counseling Pneumonia Measures PN-4 Smoking Cessation/counseling Smoking cessation reduces mortality and morbidity in all populations. Patients who receive even brief smoking-cessation advice from their care providers are more likely to quit

Pneumonia Measures PN-5a – 8 hours PN-5b Initial antibiotic received within 4 hours of arrival PN-5c - 6 hours … clinical evidence of an association between timely inpatient administration of antibiotics and improved outcome among pneumonia patients Start best antibiotic within 6 hours of hospital arrival – reduce mortality by 15-30%

Pneumonia Measures PN-6 Initial antibiotic selection for CAP PN 6a ICU patient PN 6b Non- ICU patient If pt NON-ICU treat for strep, Hflu, klebsiella, atypicals (legionella, mycoplasma, clamydia) If pt is ICU – treat more aggressively for Legionella and possibly pseudomonas

Pneumonia Measures PN-7 Pneumonia patients age ≥ 50 y.o., hospitalized during October, November, December, January, February or March who were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated. Influenza vaccination is indicated for people age 50 years and older, because it is highly effective in preventing influenza-related pneumonia, hospitalization, and death. Vaccine coverage in the United States is suboptimal. Screening and vaccination of inpatients is recommended, but hospitalization is an underutilized opportunity to provide vaccination to adults.

Surgical Care Improvement Project SCIP- Inf 1 Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision The risk of infection increases progressively with greater time intervals between administration and skin incision. Currently for the month of October, 100% compliance rate

SCIP Measures SCIP-Inf 2- Appropriate antibiotic selection SCIP-Inf 3: Prophylactic antibiotic discontinued within 24 hours after surgery SCIP-Inf 6: Appropriate hair removal SCIP-Inf 7: Perioperative normothermia among colorectal surgical patients Surgical patients who received prophylactic antibiotics consistent with current guidelines (specific to each type of surgical procedure). A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-effective, and has a spectrum of action that covers most of the probable intraoperative contaminants for the operation. First or second-generation cephalosporins satisfy these criteria for most operations, Complete lists available, broken down by procedure Short duration of antibiotics is effective in preventing post op infections Longer duration of antibiotics is more likely to cause development of drug resistant bacteria Studies show that shaving causes multiple skin abrasions that later may become infected. Normothermia within 15 minutes of PACU arrival 96.8 – 100.4 is considered normothermia research has correlated impaired wound healing, adverse cardiac events, altered drug metabolism, bleeding disorders and increased rates of post op infection.

SCIP Measures SCIP-Card-2 Surgery Patients on Beta Blocker Therapy prior to admission who received a Beta Blocker during the perioperative period. Recent study: POISE

SCIP Pre-Op Document appropriate hair removal-do not use the word shave or razor in the record Document any DVT prevention measures applied at this point (TED’s/SCD’s) Antibiotic start w/in 60 min of incision (120min for Vancomycin) Beta Blocker received & documented during peri-operative period if indicated (Medication Reconciliation)

SCIP Measures SCIP-VTE-1 Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered SCIP-VTE-2 Surgery Patients Who Received Appropriate VTE Prophylaxis Within 24 Hours Prior to Surgery to 24 Hours After Surgery 30 million + surgeries performed annually VTE is one of the most common postop complications Prophylaxis is the most effective strategy to reduce morbidity and mortality Often underused Check for VTE prophylaxis orders OR physician documentation of contraindication

What can you do to help? Be a part of this successful process Do not underestimate your impact on patient outcomes Teach – provide education to your patients as you provide their care Documentation – use the proper forms and order sets Talk to your peers and co-workers/make core measures part of your daily vocabulary Man or woman is not an island: daily chart review to ensure timely delivery of quality care. Tools available on each unit to serve as triggers to implement appropriate care measures. If you have suggestions to improve the process…see members of the quality team