CORE MEASURES
PHYSICIAN
CLINICAL ORIENTATION
2016
WHAT ARE CORE MEASURES?
Core Measures were created by The Joint
Commission and with the help of CMS
(Centers for Medicare and Medicaid) to help
with the best practice care of the most
common disease processes seen in the acute
care setting. They determined guidelines for
hospitals to use in determining the care of
these patients to improve outcomes.
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As a physician, what Core Measures do
you affect?
Hospitalist: Stroke, VTE, Sepsis, ED patient
flow (for admitted pts)
ED Physician: AMI, Chest Pain, Stroke, Long
Bone Pain Management, ED Through Put, ED
Patient Flow, Sepsis
OB/GYN/Pediatrics: Perinatal measures
(Mother and Newborns)
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WHY SHOULD I CARE ABOUT CORE
MEASURES?
Based on Best Practice to assure our patients
have the best care and better outcomes. It
affects the health of our patients and the
community at large
Affects the reimbursement the hospital
receives from Medicare
Our compliance rates to the Core Measures
are publically reported for all to view
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ED MEASURES
• Chest Pain
• AMI
• Emergency Department Throughput
• Pain Management for Long Bone Fractures
• Out Patient Stroke
• Sepsis
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AMI / Chest Pain Patients
Need documentation of patient receiving ASA prior to arrival or
during their ED visit prior to transfer to another facility
EKG is to be done prior to arrival by EMS or within the first 10
minutes after arrival
If patient has a diagnosis of AMI-ST elevation (STEMI)
Fibrinolysis needs to be done within 30 minutes of arrival or
reason documented as to why not. If fibrinolytics are not given
due to patient being transferred for acute coronary intervention
please document that the patient is being transferred for acute
coronary intervention, cardiac cath, angioplasty, etc.
Patients transferring out for Acute Coronary Interventions are to
be transferred within 90 minutes of arrival
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ED Throughput
For discharged ED patients how long does it take from
arrival to ED Departure.
After patient arrival when does the MD/PA/NP first
evaluate the patient?
Reducing the time patients remain in the ED can
improve access to treatment and increase quality of
care.
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Pain Management for Long Bone Fractures
How long does it take for the patient to receive “appropriate”
pain medication after arrival for long bone fractures? (A long
bone fracture is considered any fractured bone besides carpals,
tarsals, metacarpals, and metatarsals.)
Measures the following:
-For the age group 2 to less than 18 any pain medication (PO,
IV, intranasal) given.
-For the age group of 18 and over parenteral medication should
be given. (If the pt receives both Parenteral and PO,
Parenteral must be given first, if the pt receives PO pain
medication first we fail the measure).
Local anesthesia, anesthestetic blocks, moderate/deep sedation,
etc. will also count for this measure.
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ED Stroke
Patient Transferred to Another Facility
Time of Head CT or MRI Scan results must be within
45 minutes of ED arrival for Acute Ischemic Stroke or
hemorrhagic Stroke Patients.
Need to document the patients DATE and TIME of
Last Known Well.
Patients need to have arrived within the 2 hour
window after symptoms began.
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Inpatient Core Measures
Core Measures and changes for 2016
• Stroke
(VTE prophylaxis, Discharged on antithrombotic therapy,
Anticoagulation for atrial fib/flutter upon d/c, antithrombotic
therapy by end of hospital day 2, discharged on statin
medication, stroke education, assessed for rehabilitation
measures removed as of 1/1/2016 discharges)
• ED Patient Flow
• VTE
(VTE prophylaxis, intensive care VTE prophylaxis, patients with
anticoagulation overlap removed as of 1/1/2016 discharges)
• Immunizations – Flu shot
• PNC (perinatal) mother and newborns
• Sepsis
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STROKE
Assure that the “last known well” date and time is documented in
the chart. Can be documented by nursing.
Thrombolytic Therapy: Acute ischemic stroke patients who
arrive within 2 hours of time last known well should have
thrombolytics started within 3 hours of time last known well.
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ED Flow
How long does it take from the time a patient arrives
to the ED and is admitted to the floor?
When is the decision made for the patient to be
admitted?
What time is patient discharged from ED and
transferred to the floor?
Measures how long from decision time to when
patient is admitted to the floor?
This information is useful in trying to decrease ED
over crowding.
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VTE
(VENOUS THROMBOEMBOLISM)
If the patient has a DVT or PE and is going home on
Coumadin (Warfarin) it must be documented that
education was given to the patient on Warfarin.
Patients going home on Warfarin must have specific
education regarding their follow-up visit for the
INR/PT draws.
Patients who develop a DVT while in the hospital are
checked to see if VTE prophylaxis was ordered and
given from admission or why not.
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VACCINATIONS
INFLUENZA
All inpatients age 6 months and older must be
screened to see if they require the administration of
the Influenza Vaccine during the months of October
through March. For OB cases, this requires a
rescreen after delivery
Please give the vaccine if required as early in the
hospital stay as possible---do not wait till the day of
discharge
If Vaccinations are refused, the refusal must be
documented
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INPATIENT MEASURES
PERINATAL MEASURE
ELECTIVE DELIVERY
Includes all patients with elective vaginal deliveries or elective C
section at >37 and <39 weeks gestation. Prefer to wait till
patients are in labor.
CESAREAN SECTION
Looking at how many first time vertex presentation pregnancies
have a C Section
ANTENATAL STERIODS
Patients at risk of preterm delivery at >=24 and <32 weeks
gestation who receive antenatal steroids prior to delivering
preterm newborns.
**Gestational Age should be documented for the above
measures.
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PERINATAL MEASURE CONT.
HEALTH CARE ASSOCIATED BLOODSTREAM
INFECTIONS IN NEWBORNS
Staphylococcal and gram negative septicemia or
bacteremia in high risk newborns
EXCLUSIVE BREAST FEEDING
Exclusive breast milk feeding during the newborn’s
entire hospitalization—only breast milk
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SEPSIS
This measure can and usually begins in the ED.
Patients 18 years and older with an ICD 10 code of Sepsis will
fall into the measure and remain in the measure if criteria or
documentation for severe sepsis and septic shock are met.
If the patient is to receive “comfort care” please dictate this in the
progress notes. If dictated prior to or within 3 hours of
presentation of severe sepsis and prior to or within 6 hours of
septic shock it will remove the patient from the measure.
The next slides will review the criteria for “severe sepsis” and
“septic shock”. All these components must be met within 6 hours
of each other. The date and time on which the last criteria or
severe sepsis was dictated is the date and time that is used for
presentation. This is the date and time that the timed components
of the measure must meet, 6 hours prior to and 3 hours following
severe sepsis criteria.
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SEPSIS Criteria
Documented source or suspected source of clinical infection (except viral and
fungal infections) by a physician/APN/PA.
AND
2 or more SIRS criteria
• Temp > 38.3˚C (100.9) or < 36˚C (98.6)
• Heart Rate > 90min
• Respiratory Rate > 20min
• WBC > 12,000 or < 4,000 or 10% Bands
AND
Organ Dysfunction (any one) (except from chronic conditions or medications)
• Systolic BP < 90, or mean arterial pressure <65, or a decrease in SBP by
40mmHg from baseline with physician/APN/PA documentation that the decrease
is related to infection, severe sepsis or septic shock and not other causes.
• Acute Respiratory Failure evidenced by a new need for invasive or non-invasive
ventilation. ET/Tracheostomy Tube or Bipap
• Creatinine > 2.0, or urine output < 0.5ml/kg/hour for 2 hours
• Bilirubin > 2 mg/dl
• Platelet count < 100,000
• INR > 1.5 or PTT > 60 sec
• Lactate > 2 mmol/l
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Should occur within 3 hours of presentation date/time of Severe Sepsis
Assess measurement of lactate (6 hours prior to until 3 hours after)
Obtain Blood Cultures (48 hours prior to until 3 hours after)
Administer Broad Spectrum Antibiotics (24 hours prior until 3 hours after)
Make sure the first ordered antibiotic is administered promptly. If not
administered prior to presentation time, the first Antibiotic has to be started
within 3 hours of presentation time.
Should occur within 6 hours of presentation of Severe Sepsis
Repeat lactate measurement if >2
Please use the Sepsis Order Set .
Will automatically re-order lactate level if >2.
Should occur within 6 hours of presentation of Septic shock
Fluid Resuscitation (30ml/kg) (0.9% Normal Saline or Lactated Ringers
given for hypotension or lactate level >= 4. Total volume infused must be
at least 30ml/kg which should be specified in the physician order. The
Sepsis Order Set will calculate this for you.)
-Vasopressor administration
-Reassessment of volume status
-Tissue Reprofusion
Best Practice
The concept of Core Measures has been around for
many years. There are several Core Measures that
have been retired that we still monitor for compliance.
Pneumonia—Blood Cultures drawn prior to antibiotics,
appropriate Antibiotic coverage
Heart Failure—ECHO completed with known EF%. If EF is
below 40% patient needs an ACEI or ARB
In Patient AMI—ASA given
In Patient SCIP—Appropriate prophylactic antibiotics prior to
surgery and discontinued within 24 hours post op. Appropriate
hair removal, Beta Blocker and discontinuation of Foley catheter.
VTE prophylaxis
Stroke discharge instructions
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References
• The Specification Manual for National Hospital
Inpatient Quality Measures. (2016)Version 5.0b
(for discharges 10/1/15-6/30/16)
Inpatient Quality Measures. (2016) Version 5.1
(for discharges 7/1/16-12/31/16)
Retrieved from: http://www.qualitynet.org.
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QUESTIONS?
Please contact one of the Quality Improvement
Specialists:
Deborah Priebe ext. 5286
Pam Wise ext. 5288
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