Post on 24-Dec-2015
CICU Quality Improvement Orientation
Chief Residents
2013
Improve quality of patient care in the CICU by providing “just in time” teaching on the following key aspects of discharge planning: – Clinical Documentation – Core Measures – Discharge Planning
Objectives
Clinical Documentation
Leslie Schultz, RN, BSN – Clinical Documentation Improvement Specialist in
CICU
Understanding MS-DRGs
Medical Severity-Diagnostic Related Groups (MS-DRG) – The system used for hospital inpatient admission
reimbursement – Physician documentation is the basis for coding – Lab/Imaging can only be coded for when the
physician indicates their clinical significance in the A&P
– Documentation needed for proper coding has specific requirements that are different than those needed for clinical care
Documentation of all pertinent diagnoses has a significant impact on Severity of Illness and Risk of Mortality scores.
In turn, accurate reporting of Severity of Illness and Risk of Mortality has a significant impact on quality of care reports as well as reimbursement
CDI Specialists Query in order to…
Clarify Present on Admission (POA) status of diagnosis
Clarify Principal Diagnosis (primary reason for admission)
Ensure physician documentation includes all co-morbidities– Include Manifestations of chronic conditions
Diabetic nephropathy, stage of CKD, hypertensive cardiomyopathy
Clarify diagnosis when unapproved abbreviations are used
– Example: “CRS” could have multiple meanings. Write out
meaning for accuracy
– http://www.medabbrev.com/index.cfm for UH approved
abbreviations
Clarify whether a diagnosis &/or event is a complication
of a procedure
- Provider must make the link between condition & procedure
Clarify source of infectioncan be “possible”, “probable” or “suspected”
Clarify possible etiology of symptomsHematuria, abdominal pain, chest pain, syncope
Capture appropriate mortality scores
– Example: must specify “Multi System Organ Failure”
CDI Specialists Query in order to…
Documentation Tips
Appropriate Diagnostic Statement
(Accurate ICD-9 code can be assigned)
Common Clinical Statements --
REQUIRE CLARIFICATION!
Must Specify Organ and Acute: Acute Renal Failure/Acute Resp Failure/Acute Hepatic Failure
Multi Organ System Failure
Acute Renal Failure, Acute Kidney Injury AKI: increase >1.5 x baseline; ARF: >3 x baseline, CKD with stage
Renal Failure or Insufficiency, Prerenal azotemia
Type 2 MI (not due to plaque,) specify underlying cause and note that core measures don’t apply
Troponin leak, troponinemia, Demand ischemia (no troponin elevation)
STEMI, NSTEMI, Unstable angina (include site if known)
Acute Coronary Syndrome, ACS
Accelerated or Malignant HTN Hypertensive Urgency or Crisis
Type & Acuity of Heart Failure: Systolic/Diastolic or
combined Acute/Acute on Chronic/Chronic HFPEF, HFrEF or ADHF
Acute Respiratory Failure/ARDS Respiratory Distress/Hypoxia
Malnutrition (include degree: moderate or severe) **Check Nutrition Therapy notes
Recent weight loss
Cachectic, Failure to Thrive
Septicemia, Sepsis, Severe Sepsis, Septic Shock
Urosepsis, Bacteremia or + SIRS Criteria
Shock: Septic/ Cardiogenic/ Hypovolemic/ Hemorrhagic/ Unspecified
Hypotension / Pt on Vasopressors
Sign Wound Photos and check appropriate POA box. Can also document ulcer and type in progress note (decubitus, venous stasis, diabetic ulcer)
Nursing documentation and/or photos of Wounds/Ulcers
Coma/Brain Death/Anoxic Brain Injury
Encephalopathy (specify type if known)
Obtunded/Unresponsive
Altered Mental Status
Hypo/hypernatremia/kalemia/osmolarity, acidosis, alkalosis, etc…
Electrolyte Imbalance/low K+
Abnormal lab findings
DIC, coagulopathy, thrombocytopenia Elevated INR or plt (especially if not iatrogenically anticoagulated)
Documentation Tips
Opportunities to improve documentation…
Patient admitted with AMI.
H&P notes PMH of CHF
Home meds include Lisinopril and Lasix daily
Recent echo with EF 10-15%
BNP noted to be elevated on admission
Documentation indicates pt with “volume overload” and diuresis initiated
AMI AMI
Chronic Systolic Heart Failure
AMI
Acute Systolic
Heart Failure
MS-DRG 282 w/o CC or MCC
GLOS 2.2
MS-DRG 281
w/ CC
GLOS 3.4
MS-DRG 280
w/ MCC
GLOS 5.0
Reimbursement
$6494
Reimbursement
$9202
Reimbursement
$45,110
SOI 1
ROM 2
SOI 2
ROM 3
SOI 2
ROM 3
Impact of improved documentation…
Clinical Documentation Improvement Program Goal
Complete and accurate documentation in the EHR to reflect the patient’s true severity of illness and risk of mortality
Core Measures
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National standardized evidence-based performance measures defined by the Joint Commission
Derived from quality indicators defined by the Centers for Medicare and Medicaid Services (CMS)
Hospitals improve quality of patient care by focusing on results of care
What are Core Measures?
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
2011 15University Hospitals Case Medical Center 15
Acute MI Heart Failure Pneumonia SCIP (Surgical Care)
- Aspirin at Arrival - Discharge Instructions - Blood Cultures
Performed in the ED Prior to Initial Antibiotic Administration
- Antibiotic Received
- Antibiotic Selection
- Aspirin Prescribed at Discharged
- Evaluation for LVSD - Initial Antibiotic selection for CAP Immunocompotent patients
- Antibiotic Discontinued
- Cardiac Surgery Controlled 6am Blood glucose
- Timing of Receipt of PCI - ACEI and ARB for LSVD
- Urinary Catheter
- Peri - op
Temperature Mgmt.
- Statin Prescribed at Discharge
– Surgery Pts. On BB Therapy
- Received VTE within 24 hours prior to or after surgery
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Inpatient Core Measure Sets 2013
2011 16University Hospitals Case Medical Center 16
ED Throughput Immunization Stroke VTE
- Median Time form ED arrival to ED departure for admitted ED Patients
- Pneumococcal Immunization
-VTE Prophylaxis
- Discharged on antithrombotic therapy
-VTE Prophylaxis
- Intensive Care Unit VTE
- Admit Decision Time to ED departure time for admitted patients
-Influenza Immunization
(Oct 1 – March 31)
-Anticoagulation therapy for atrial fibrillation/flutter
-VTE patients with anticoagulation overlap therapy
-Thrombolytic therapy-Antithrombobotic therapy by end of hospital day 2
- VTE patients receiving unfractionated heparin with dosage/platelet count monitoring by protocol or nomogram
- Discharged on a statin medication
- VTE warfarin therapy discharge instructions
-Stroke education- Assessed for rehabilitation
- Hospital acquired preventable VTE
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Inpatient Core Measure Sets 2013
2011 17University Hospitals Case Medical Center 17
Hospital Based Psychiatry Services
(HBIPS)
Perinatal Care Childhood Asthma
- Admission Screening
-Hours in Physical Restraint Use
-Elective delivery Relievers for Inpatients
-Hours of Seclusion Use
- Patients discharged on Multiple antipsychotic medications
- Cesarean Section Systemic Corticosteroids for Inpatients
- Patients discharged on multiple antipsychotic medications with appropriate justification
- Antenatal Steroid Home Management Plan of Care (HMPC)
- Post discharge care plan created
- Healthcare associated BSI
- Post discharge care plan transmitted
- Exclusive Breastfeeding
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Required in 2014 by TJC for hospitals with > 1, 100 births
Inpatient Core Measure Sets 2013
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Hospital Compare www.hospitalcompare.hhs.gov• Improving care through information • 4500 hospital across the country report • More than 50 quality measures
The Joint Commission www.qualitycheck.org
Ohio Department of Health www.odh.ohio.gov • Ohio Hospital Compare
Leapfrog www.leapfroggroup.org• Self Reported Survey• Encourage health providers to publicly report • Consumers make informed health choices
Health Grades www.healthgrades.com/• Independent rating company • Use Medicare Claims Data • 721,356 patients in Cleveland used information between January and June 2011
Where is data reported to the public?
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How are Core Measure Patients Identified?
Core Measure diagnosis is not always clear on admission
Identified by Coding after discharge based on documentation by Physician or Licensed Independent Practitioner (LIP)
Goal is to identify patients early in admission and achieve all components of care by discharge
Patients with symptoms of Core Measure diagnosis should have core measure parameters followed
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
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Value Based PurchasingBasics
Began in 2011 Non-compliance results in-
– 2013 - 1% reduction total Medicare payment– 2017 - 2% reduction total Medicare payment
Potential impact at UH– 2013 – $ 5.9 million– 2017 - $18.8 million
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
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UHCare Order Set Utilization and Core Measures
UHCare order sets have been created to help practitioners satisfy the Core Measure indicators that are monitored in the UH System
Each disease specific Core Measure order set contains options for all needed components
UHCare order sets are care paths that communicate treatment and interventions to the interdisciplinary team members
– (ie. Nursing, Respiratory, Pharmacy, Laboratory, and Ancillary Departments).
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
22
UHCare Order Set Utilization and Core Measures
Compliance depends on:
– Licensed independent practitioners selection of each order as appropriate
– Licensed independent practitioners selection of omission order when a medication is not indicated
– Non-use of order sets requires documentation in the medical record of omission reason
– Orders being followed as written for the patient
Disease specific order sets include everything needed to meet
core measure requirements Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
2011 23
Disease Specific Core Measure:Acute Myocardial Infarction
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
24
Acute Myocardial Infarction
Admission Indicators:– Aspirin prescribed at Arrival – within 24 hours– Angioplasty within 90 minutes of arrival
Discharge Indicators: – Aspirin prescribed at discharge– Beta Blocker prescribed at discharge – Medication (Ace at discharge for left ventricular dysfunction
(Ejection Fraction <40%*)– Statin Prescribed at Discharge
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
25
Acute Myocardial Infarction Order Set
Physicians and other LIP’s can access the Acute Myocardial Infarction order set by typing “AMI, Acute Myocardial Infarction, or STEMI” in the UHCare order browse
2011 26
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
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Disease Specific Core Measure:Heart Failure
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
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Heart Failure
Indicators
– Left ventricular function assessment– ACE1 or ARB ordered at discharge for left ventricular dysfunction
(Ejection Fraction <40%*) – Patient education
Activity Diet Weight monitoring Symptoms worsening Follow up appointments Accurate medication reconciliation
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
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Heart Failure Order Set
Physicians and other LIP’s can access the Heart Failure Order by typing “Heart Failure or CHF” into the order browse in UHCare
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
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Please use omission orders when indicated
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Or you will get this error message
2011 31
Guidelines For a Healthy Lifestyle
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Conclusion - Key Points
Use of prepared order sets makes compliance with core measures and “best practice” easier for end user
Core measures– contribute to better patient outcomes– Affect our payment for services rendered– Publicly available for evaluation
EVERYONE plays a role in meeting core measure compliance Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Discharge Planning
The Bottom Line: Discharge Begins on Admission
The CICU discharges many patients to home, long term care facilities, and short term rehab.
The impact of improper discharge planning can extend the stay of CICU patients for days or hours which has a direct impact on:
– Patient Satisfaction Scores– Increased Length of Stay (LOS)– Non-Compliance of Core Measures such as HF and AMI– Patient Readmission
Team Collaboration and Communication Provides the Best Care
Touch base rounds occur daily for each patient to determine patient needs and update developments in care
Interdisciplinary Rounds occur every Tuesday and Thursday 10:00 @ the CICU center table.
Your Role in Discharge Planning
Participate in Interdisciplinary Rounds (One intern to attend and report out to group)
– Anticipate and communicate the expected date of discharge– Anticipating discharge can alleviate common needs that delay
discharge – Common barriers: inability to afford medications, PT/OT consults,
home care arrangements, SNF and long term placement approvals, home IV therapy approvals, and transportation issues
When discharge is anticipated, the recommendation is to have the discharge profile completed the night before discharge
– This includes medication reconciliation, discharge instructions, home care orders, cardiac rehabilitation orders, and a gold form
The Day of Discharge
Medication Reconciliation can be a time consuming process. Proper admission medication reconciliation will alleviate many discharge errors and decrease the time it takes for you to discharge a patient.
The CICU RN will perform a discharge timeout with you to ensure that your instructions and medications meet the needs for our patients and hospital standards of care.