CARDIOLOGY WARDS

Introduction to 7 south

CARDIOLOGY WARDSMedical Director 7 South – Bart Cox, MD

Unit Director 7 South – Melissa Johnson, RN, MSN

Pharmacist – Tiffany Montoya, PharmD, PhC

Chief Resident – Mark Garcia, MD

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

INPATIENT CARDIOLOGYGoals and Objectives

Inpatient Cardiology Wards - Orientation

• Read the University Cardiology Rotation Handout • in the email packet

• Be familiar with email 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

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

PERFORMANCE MEASURES• Core Measures and why it is this important to you• Heart Failure Performance Indicators

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.?

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

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

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

UNMH Core Measures - Below Target

Covers January 2011 to December 2011Core

MeasuresApr 2011 –

March 2012

Observed%

Oct – Dec 2011 (Q4)

Observed%

Jan – March 2012

(Q1)Observed

%

April – June 20122012(Q2)Observed

%

Target%

(Per UHC)

% HF-3 ACEI or ARB for LVSD

96 97 90 100 95

% AMI-3: ACEi or ARB for

LVSD95 90 100 100 95

% HF-1: Discharge

Instructions88 81 87 92 94

UNMH Core Measures - Below Target

Apr 2011 – March 2012 Oct – Dec 2011 (Q4) Jan – March 2012 (Q1) April – June 2012 (Q2) 70

80

90

100

70

75

80

85

90

95

100

% HF-3 ACEI or ARB for LVSD% AMI-3: ACEi or ARB for LVSD% HF-1: Discharge InstructionsTarget

AREAS NEEDING IMPROVEMENT AND AREAS OF SUCCESSMedications

Discharge

Documentation

Ward Specific

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

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

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

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

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”

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

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

Upcoming Events and Ongoing Research

• Ultrafiltration (Aquapheresis™) started August 2012

• Educational DVDs

• Pulmonary hypertension continuous infusion

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

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

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

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.

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