1. Documenting for Success
Core Measures
- Evidence based practices
- Joint Commission/ Centers for Medicare and Medicaid Services (CMS) requirements
Organ Donation

2. What are Core Measures?
Core measures are specific clinical measures that, when viewed together, permit an assessment of the quality of care provided in a given focus area, such as acute myocardial infarction (AMI).
They are research based or evidenced based best practices
They have been developed by CMS (Centers for Medicare and Medicaid Services) and Joint Commission
Hospitals are required to abstract data on these clinical measures and submit to CMS. We analyze our data, share data with appropriate departments and implement performance improvement efforts to minimize variances in these best practices

3. Why are they important? These are evidenced-based practices
These outcomes are publically reported. Consumers of health care can access this information to decide where they will get their care
Many of these measures promote cost efficient care by reducing the risk of complications which is vital for our accountable care organization (ACO)
Many of the measures involve Patient Education to prevent readmission. Starting in 2013, readmission within 30 days may affect reimbursement.

4. Why are they important? $$
VBP: Value Based Purchasing
New scoring system to determine reimbursement based on: - Clinical measures (Core Measures)
- Satisfaction measures (Press Ganey results)
These measures can change annually
Starting in 2011, Medicare withheld 1% of all payments. Hospitals get that 1% back if we achieve improvement in measures. Starting in 2017, it will be 2% withheld and potentially lost IF we don’t meet measures

5. Nursing’s Role is Pivotal
Coordinating patient care in the multi-disciplinary team
Understanding the details of the Core Measures and ensuring their compliance / documentation
Ensure documentation that best practices were followed or document WHY a best practice was not followed for a particular patient
Providing daily education and discharge instructions to enhance patient success in managing their illness
Preventing costly readmissions or complications

6. What are the Measures? Acute Myocardial Infarction (AMI) Heart Failure
Pneumonia
Surgical Care Improvement Project (SCIP)
Stroke
Venous Thromboembolism (VTE)

7. MI Core Measures
Patient’s with Acute MI:
EKG within 10 min (AHA Standard) if new STEMI or LBBB the goal is for PCI (Percutaneous Coronary Intervention) within 90 minutes of arrival.
Assess left ventricular function with Echo, Stress test or TEE and get Lipid panel on admission
Must have Aspirin administered as soon as ordered. If the patient cannot take po ASA, get order changed to PR route
All MI patients should be discharged on a STATIN if LDL >/= 100mg/dl, beta blocker and Aspirin
If Left ventricular systolic dysfunction present (Low EF< 40) an ACE inhibitor or Angiotensin receptor blocker should be order (MD documentation)

8. CHF Core Measures
Patients with CHF are often admitted for another diagnosis. Regardless of the admitting diagnosis, if a patient has CHF the core measures are applicable.
All patients admitted with CHR or with a history of CHF must receive education on:
Monitoring their weight
Symptoms of worsening CHF
Activity
Diet
Medication
Medical Follow-up
These elements must be documented in the Nursing Discharge instructions. This is a heart failure booklet to assist with this education.
Utilize teach back questions to validate patient understanding

9. Pneumonia Core Measures
Blood Cultures must be obtained within 24 hours of arrival to hospital (if admission to ICU anticipated); preferably in the ED. Blood cultures should
be collected PRIOR to the administration of any antibiotics.
If more than one antibiotic is ordered and both are not given in the ED, it is imperative that this be communicated in the handoff. The second
antibiotic should be given immediately after completion of the first antibiotic.
Transfer from the ED to the inpatient floor must not result in delayed
administration of antibiotics. A delay in antibiotic treatment if bacteremia
is present can lead to poor outcomes.

10. Pneumococcal Vaccination
Patient’s “AT RISK” must receive the pneumococcal vaccine
every 5 years up to the age 65.
After the age of 65, they only receive it once more; additional doses after the age of 65 provide no additional benefit.
Patient’s AT RISK includes most patients in the hospital:
Chronic heart or lung disease (including asthma)
Cigarette smoker Diabetes Kidney disease Alcoholism Chronic liver disease Compromised immunity: Hodgkins,leukemia, lymphoma, cancer, HIV splenectomy CSP leaks or cochlear implants

11. Pneumococcal Vaccine Exclusions
Patient with history of serious reaction (anaphylaxis) after a previous dose
of pneumococcal vaccine
Patients who refuse
When patient meet criteria, the vaccine must be offered when the order is acknowledged.
On the nursing assessment, if the At risk field pre-populated YES (do not change !) There is something in the past medical history that has triggered the patient to be at risk
If for any reason the patient does not accept the vaccine AT THIS TIME. Document the vaccine as REFUSED. If the patient wants to wait or check on prior vaccination, a new order should be obtained.

12. Flu Vaccination
All patients must be offered the flu vaccine during flu season
(September - April)
The only patients that should NOT received a flu shot are:
Those already immunized this season
Those allergic to eggs
Those with a prior reaction to the flu shot
History of Guillain Barre
Patients who refuse
The vaccine must be given when acknowledged and if the patient
does not wish to accept the vaccine AT THIS TIME. Document the vaccine as REFUSED

13. Stroke Core Measures Ischemic, Hemorrhagic Strokes and TIA
Patients treated with a STROKE / TIA must receive education on:
Risk factors
Warning signs of a stroke
Calling 911
Medications
Follow up with PCP after discharge Patient MUST receive the stroke booklet to assist in this education. When the education is completed, the sticker that is attached to the booklet is placed in the progress notes to provide documentation of the education All patients coming in with symptoms of a stroke MUST have a dysphagia screen BEFORE taking anything by mouth and this MUST be documented
Resource: Marie McCune RN

14. Review all information in this packet with all STROKE and (TIA)
Transient Ischemic Attack
patients

15. Stroke Core Measures
Assessment for rehab is performed prior to discharge
Thrombolytics (TPA) within 3 hours if ischemic stroke
Discharged on anti-thrombotic therapy (ASA, Plavix) and Statin if LDL>100
Physician documentation must be present when an element was not completed and why

17. STOKE CORE MEASURES

19. Surgical Care Improvement Project (SCIP) Resource Gail Poirier RN
This CMS project was developed to minimize infections and complications in high risk procedures ( cardiac, total joint replacement, colon, hysterectomy, and lower extremity bypass graft procedures) HOWEVER they are best practices and should be done for all surgical patients
SCIP 1: Antibiotics given within 1 hour of incision time. No antibiotics should be given “on call” They should be administered just prior to the incision
SCIP 2: Choice of preoperative antibiotics per protocol in OR
SCIP 3: Post-operative antibiotics should be discontinued within 24hrs unless infection documented. Avoid changing times for administration which can result in antibiotic administration outside the 24hr window. Antibiotics offer NO clinical benefit after closure
of the incision
SCIP 4: Glucose monitoring in Cardiac Surgery patients; Blood glucose <200

20. Surgical Care Improvement Project (SCIP)
SCIP 9: Urinary catheters MUST be discontinued post-op Day 1 or Those that acknowledge the order to discontinue the foley are responsible to remove the foley or obtain an order to continue
Cardiac: Patients on a chronic beta blocker should receive their beta blocker during the perioperative period and resume beta blockers postoperatively by POD # 1 or # 2
Venous Thromboembolism VTE:
DVT prophylaxis ( anticoagulant, venodynes, or TEDS) are to start within 24hours of the end of surgery unless contraindicated. If ordered and patient refuses, that refusal must be documented and other ways to prevent DVT must be considered. If no venodynes, must consider SQ heparin and/or TEDS

21. Venous Thromboembolism (VTE) Core Measure
All (Medical and Surgical) patients should be evaluated for the need for VTE prophylaxis (both anticoagulants and mechanical “TEDS or venodynes”)
Whoever acknowledges the order for TEDS/venodynes is responsible for implementing this intervention. It is essential that patients begin VTE prophylaxis on the day of admission
Venodynes/TEDS MUST be documented as ON, removed and reapplied each shift when ordered
Any barriers to implement VTE prophylaxis MUST be documented in rL solutions so that efforts can be made to remove the barrier. ie. Lack of supplies or equipment
If a patient has a confirmed DVT or PE and is discharged on COUMADIN The patient must receive the booklet “ Your Guide to Coumadin/Warfarin Therapy”.

22. Education about anticoagulants is also a JCAHO standard
This is the patient education brochure that includes all core measure education needed for patients going home on Coumadin
There is a separate brochure “Your Guide to your Blood Thinner” that can be used for other anticoagulants

23. Samples of Common Teach-Back Questions
Tell me what you understand about your diagnosis?
What types of foods would be typical for your diet?
It is beneficial for you to be active when you go home. What might you do to increase your activity?
Tell me about your medications
Can you explain to me any signs/symptoms that you could experience that would suggest that your condition has worsened
Why is it important to keep your follow up appointment with your physician after discharge?
Do you know how to access education and/or support groups related to your condition?

24. Organ Donations
In Massachusetts, the New England Organ Bank is the only person authorized to request organs from families
therefore
We must notify the NEOB of all deaths within the hour
Send a Death Notice to admitting so they can notify the New England Organ Bank
In Meditech: Pick (OE) order entry)
Enter Orders
Enter Patients Name
Enter MD name
Category: PTC =Patient Communication
Procedure: EXP= expiration notice
Enter time of death
Pronouncing MD
Autopsy: Yes, No TBD for to be determined

25. Discharge the Patient with the Correct Date and Time of Death
Click on ADM: admissions
Click # 10. Inpatients
Click # 26. Discharge
Enter Patient’s Name
Make sure date entered is the date of death if not change date. For payment purposes this must be the Date of death
Enter time of Death
Discharge Disposition: EXP expired
Discharge Diagnosis: Enter admitting diagnosis