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Core Measures Quick Guide

Core Measures
Acute Myocardial Infarction
Heart Failure
Pneumonia and Antibiotic Recommendations
Venous Thromboembolism (VTE)
Stroke
Perinatal Care
Children’s Asthma Care
Surgical Care Improvement Program (SCIP)

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Acute Myocardial Infarction

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
  1. PCI within 90 minutes of arrival time
Document reason for PCI delay.
  1. Aspirin on arrival
Order ASA on arrival or document contraindication in all patients. Document if pre-hospital ASA was taken at home earlier that day or given by EMS.
  1. Aspirin at discharge
Order ASA at discharge or document contraindication.
  1. Statin prescribed at discharge
Order LDL test within 24 hours of arrival
  1. ACEI or ARB at discharge
Document LVSF < 40% or narrative of moderate to severe LV systolic dysfunction.
  1. Beta Blocker at discharge
If any recommended medications are not prescribed, document the reason/rationale.Document all discharge medications and give the complete discharge medication list to the patient with the written discharge instructions.

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Heart Failure

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
Written Discharge Instructions must address all of the following:

  • Activity recommendations
  • Dietary restrictions
  • Follow up appointments
  • Prescribed medication regimen
  • Weight monitoring, and
  • Symptoms worsening
Use the Discharge Instruction Record, document all discharge medications as listed in the EMR. Give acomplete discharge medication list to the patient with the written discharge instructions.
Left ventricular systolic function assessed. Document the LVSF on every encounter, even if from a prior encounter; planned for after discharge, or document a reason for not assessing the LVSF.
ACEI or ARB prescribed at discharge for LVSF < 40%. If neither ACEI nor ARB is prescribed, document the specific reason, addressing both the ACEI and the ARB.

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Pneumonia

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
For pts. admitted or transferred to ICU within 24 hours, blood cultures must have been drawn within 24 hours of arrival or within 24 hours before ICU transfer. Write the actual time that blood cultures are collected on the actual specimen label.
ED blood cultures must be drawn before any antibiotics are administered. Place order for blood culture prior to placement of antibiotic order. Document blood culture draw time in the EMR before the prescribed antibiotic is scanned.
Initial antibiotics administered within first 24 hours must meet CMS guidelines for ICU and non-ICU pneumonia patients.

 

Pneumonia Antibiotic Recommendations

NON-ICU patients 1. Ceftriaxone (IV or IM) + doxycycline IV/PO preferred, or 2. Antipneumococcal quinolone monotherapy IV/PO such as Moxifloxacin IV or PO if severe B-lactam allergy preferred, or 3. B-lactam IV/IM + macrolide IV/PO or 4. Tigecycline monotherapy (IV)***********************B-lactam (IV or IM) = ceftriaxone, cefotaxime, ertapenem, ampicillin/sulbactam, ceftaroline, ampicillin Macrolide (IV or PO) = erythromycin, clarithromycin, azithromycin Antipneumococcal quinolone (IV or PO) = levofloxacin, moxifloxacin, gemifloxacinNON-ICU Patient with Pseudomonal Risk 1. Piperacillin/tazobactam IV + doxycycline IV/PO +/- tobramycin IV preferred, or 2. Antipneumococcal/antipseudomonal B-lactam (IV) + Antipseudomonal quinolone IV/PO, or 3. Antipneumococcal/antipseudomonal B-lactam (IV) + Aminoglycoside IV + either antipneumococcal quinolone (IV/PO) or Macrolide (IV/PO)NON ICU patient with Pseudomonal Risk AND

  1. B-Lactam Allergy:

Aztreonam IV + Moxifloxacin IV/PO +/- Tobramycin IV or

Aztreonam IV/IM + antipneumococcal quinolone IV/PO + aminoglycoside IV

  1. Renal Insufficiency Aztreonam (IV or IM) + levofloxacin or moxifloxacin (IV/PO)

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Antipseudomonal quinolone (IV or PO) = ciprofloxacin, levofloxacin Antipneumococcal/antipseudomonal B-lactam (IV) = cefepime, imipenem, meropenem, piperacillin/tazobactam, doripenem Aminoglycoside (IV)= gentamicin, tobramycin, amikacin Antipneumococcal quinolone (IV or PO) = levofloxacin, moxifloxacin, gemifloxacin Macrolide (IV or PO) = erythromycin, clarithromycin, azithromycin

ICU patients

  1. Ceftriaxone (IV) + azithromycin (IV) preferred, [Macrolide (IV) + either B-lactam (IV) or antipneumococcal/antipseud. B-lactam (IV)] or 2. [Antipseudomonal quinolone (IV) + either B-lactam(IV) or antipneumococcal/ antipseudomonal B-lactam (IV)] or 3. [Antipneumococcal quinolone (IV) +either B-lactam (IV) or antipneumococcal/ antipseudomonal B-lactam (IV)] or 4. [Antipneumococcal /antipseudomonal B-lactam (IV) + aminoglycoside (IV) + either antipneumococcal quinolone (IV) or macrolide (IV)] or 5. If the patient has sickle cell disease, Ceftriaxone (IV) + moxifloxacin (IV) preferred.

If the patient has Francisella tularensis or Yersinia pestis as possible source of infection the following is acceptable:

Doxycycline IV + either B-Lactam (IV) or antipneumococcal/antipseudomonal B-lactam (IV)

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B-lactam (IV) = ceftriaxone, cefotaxime, ampicillin/sulbactam Antipneumococcal/Antipseudomonal B-lactam (IV) = cefepime, imipenem, meropenem, piperacillin/ tazobactam, doripenem Macrolide (IV) = erythromycin, azithromycin Antipneumococcal quinolones (IV) =levofloxacin, moxifloxacin Antipseudomonal Quinolone (IV) = ciprofloxacin, levofloxacin Aminoglycoside (IV) = gentamicin, tobramycin, Amikacin

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Venous Thromboembolism (VTE)

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
  1. VTE prophylaxis ordered/administered within 24 hours
    • for all inpatients and OBS patients
    • for all ICU admissions or transfers
    • for all surgical patients
  1. For Patients with Diagnosed VTE:
  • Appropriate Anticoagulation Overlap Therapy
  • Unfractionated Heparin have Dose & platelet monitoring by protocol or nomogram
  • VTE Warfarin therapy Discharge Instructions
  • Documentation around Hospital- Acquired, Possibly-Preventable Venous Thromboembolism
Provider (physician or MLP) must “submit” Caprini VTE risk score for ALL patients.Order/administer VTE prophylaxis on the day of or day after admission, surgery end time, or transfer into the ICU.Document all contraindications to VTEP in widget & order SCD.Document reason for using Factor Xa inhibitor.Patients with diagnosed VTE must have overlap of IV or sub-Q anticoagulation WITH warfarin therapy until INR is > 2 or are discharged on both tx., or have documented reason for discontinuation of parenteral therapy.VTE patients on (IV) UFH therapy must have pharmacy heparin dosing order placed for weight-based dosing & monitoring of platelets.VTE patients discharged home on warfarin must have written DC instructions to address all the following:

  • compliance issues
  • dietary advice
  • follow-up monitoring, and
  • adverse drug reaction information.

Patients with hospital-acquired VTE must have this diagnosis placed on their EMR problem list, and the reason VTEP was not provided during 24 h prior to dx. must be documented.

Document the reason for not prescribing any/all of the recommended therapies as listed (including SCD placement) in the widget.

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Stroke

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
  1. Thrombolytic Therapy
Ischemic stroke patients must have IV thrombolytic therapy begun within 3 hours of last time known well or provider must document LTKW and any contraindications in widget.
  1. VTE Prophylaxis
Provider (physician or MLP) must “submit” Caprini VTE risk score for ALL ischemic/hemorrhagic stroke patients.
  1. Antithrombotic Therapy By End of Hospital Day 2
Administer VTE prophylaxis or on the day of or the day after admission (for both ischemic & hemorrhagic stroke) or list contraindications in widget and order SCDs.
  1. Discharged on Antithrombotic Therapy
Administer antithrombotic therapy to ischemic stroke patients by the end of Hosp Day 2.
  1. Discharged on Anticoagulation Therapy for atrial/fibrillation/flutter
Prescribe antithrombotic therapy at hospital d/c or document contraindication for pts. with ischemic stroke.
  1. Discharged on Statin Medication
Prescribe anticoagulation therapy at d/c for ischemic stroke patients with a- fib/flutter.
  1. Stroke Education
Prescribe ischemic stroke patients statin medication at d/c if LDL>100 (order LDL).
  1. Assessed for Rehabilitation
PM&R consult must be placed or document in EMR that will occur as outpatient.
  1. Document a reason for not applying the recommended therapies as listed.
Documentation of stroke education during stay- must address: 1) activation of EMS 2) need for follow-up after discharge 2) D/C medications prescribed, 3) risk factors for stroke, and 4) warning signs and symptoms of stroke.

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Perinatal Care

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
  1. Rate of patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed
Document elective delivery information in widget powerforms in maternal chart. Use as a checklist to ensure all appropriate documentation is in medical record.
  1. Rate of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section
Document gestational age in widget powerforms and reason for c-section in maternal chart.
  1. Patients at risk of preterm delivery at >=24 and <32 weeks gestation receiving antenatal steroids prior to delivering preterm newborns
Provider must complete documentation in widget powerforms in maternal chart. Document 12 mg betamethasone IM or 6 mg dexamethasone IM initiated before delivery.
  1. Rate of staphylococcal and gram negative septicemias or bacteremias in high-risk newborns
Provider must complete fetal weight and BSI attestation in discharge power form alert in baby’s chart.
  1. Exclusive breast milk feeding during the newborn’s entire hospitalization
Provider must carefully document mother’s feeding plan on admission. There is no rationale for ordering both breast milk and formula for babies whose mother’s choice is to exclusively feed breast milk.Any change in the mother’s initial feeding plan to exclusively feed breast milk must trigger additional discussion.
  1. Exclusive breast milk feeding during the newborn’s entire hospitalization considering mother’s choice
Provider must complete discharge attestation power form alert after reviewing neonatal intake form and baby feeding history. (Exceptions are medications, vitamins, minerals, or sucrose and water solution given to the newborn for the purpose of reducing discomfort during a painful procedure).

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Children’s Asthma Care

Measure Documentation Tips: 1) Use the Widget for Documentation 2) Measures Apply to Inpatients and OBSERVATION Patients
  1. Use of relievers in pediatric patients admitted for inpatient treatment of asthma. (This measure is stratified by age and includes patients age 2-17). 2. Use of systemic corticosteroids in pediatric patients admitted for inpatient treatment of asthma. 3. Documentation in the medical record that a Home Management Plan of Care (HMPC) document was given to the pediatric asthma patient/caregiver.
Providers must order relievers and corticosteroids or document contraindications for not ordering these medications.Home Management Plan of Care document must addresses:

  • Arrangements for Follow-up Care
  • Environmental Control and Control of Other Triggers
  • Methods and Timing of Rescue Actions
  • Use of Controllers
  • Use of Relievers

Provider must document that Home Management Plan of Care was given to patient/caregiver

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Surgical Care Improvement Program (SCIP)

Please click here to view the SCIP guidelines

 

GLOBAL MEASURES: Apply to All Inpatient Discharges

Immunization Measure Set:
IMM1: Pneumococcal Immunization includes inpatients 65 years and older AND inpatients between 5 and 64 years who are high risk; who were assessed and vaccinated before discharge if indicated. Both activities must occur; screening and vaccination when indicated. Patients with documented contraindications, or who were offered and declined, or who received pneumococcal vaccine anytime in the past meet this measure.

IMM2: Influenza Immunization measure includes inpatients age 6 months and older who were assessed for seasonal influenza immunization status and vaccinated prior to discharge if indicated. Both activities must occur; screening and vaccination when indicated. Patients with documented contraindications, or who were offered and declined, or who received the vaccine during the current season prior to the current hospitalization meet this measure.

 

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