1. OBMC Core Measures January 2015
Immunization (IMM) and Emergency Department (ED) CMS/TJC
MEASURE
RATIONALE
Immunization- (Oct 1st-March 31st) Complete influenza vaccine assessment on all patients 6 months and older and administer vaccine prior to discharge to all eligible patients
Influenza vaccine is recommended by the CDC for patients 6 months and older unless contraindicated
Do not give:
Hypersensitivity to eggs or other components of vaccine
Bone Marrow Transplant within past 6 months
History of Guillain-Barre Syndrome within 6 weeks after a previous flu vaccination
Anaphylactic latex allergy
Emergency Department time of arrival to departure for admitted patients
Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care. MUST be clearly documented in Triage.
Emergency Department decision to admit time to departure time for admitted patients
Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. MUST be clearly documented in Emergency Department Assessment
Page 1 of 4

2. Venous thromboembolism (VTE) CMS/TJC VTE cont.
MEASURE
RATIONALE
All inpatients with length of stay > 1day or surgery: Assess risk factors for VTE and order chem or mech VTE prophylaxis the day of admission or the day after admission or the day of or after surgery (or have MD document contraindication on day 1 or 2 or POD 1 or 2)
Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is suspected.
Thromboprophylaxis reduces VTE events, and studies have shown that fatal PE is prevented by thromboprophylaxis
All inpatients with confirmed dx of acute VTE: Overlap therapy (oral and parenteral anticoagulation) per PHARMACY protocol must be provided for a 5 day period . If discharge occurs prior to end of 5 days, the patient must be discharged on both, warfarin and parenteral anticoagulant (or contraindication documented).
Warfarin can be initiated on the first day of treatment after the first dose of a parenteral anticoagulant has been given. Because the warfarin has a very slow onset of action, it cannot be used as mono-therapy for acute VTE.
VTE cont.
MEASURE
RATIONALE
All ICU patients: Order chem or mech VTE prophylaxis the day of or the day after transfer to ICU (or document contraindication on day 1 or 2)
Criteria for admission to the Intensive Care Unit (ICU) itself puts patient’s at an increased risk for developing VTE, and subsequent increased risk of morbidity from PE.
Document a reason when ordering oral Factor Xa inhibitor for VTE prophylaxis (example: Xarelto)
Currently the only acceptable reason for ordering Oral Factor Xa is Chronic AFib/AFlutter or history of total or partial Hip or Knee replacement surgery
Provide written discharge instructions to each pt with VTE discharged on warfarin in regard to importance of taking warfarin as instructed and complying with monitoring lab tests, dietary advice, potential adverse drug effects and follow-up appointments
Anticoagulation therapy poses risks to patients due to complex dosing, requisite follow-up monitoring and inconsistent patient compliance.
Patient education is a vital component to achieve successful outcomes, and reducing hospital readmission rate.
Page 2 of 4

3. Stroke (STK) CMS/TJC Stroke cont.
MEASURE
RATIONALE
MD MUST Document a reason for not prescribing IV t-PA or a reason for delay if it was administered after 3 hrs of symptom onset.
The FDA approved the use of IV t-PA for the treatment of acute ischemic stroke when given within 3 hrs of stroke symptom onset.
Provide VTE prophylaxis on Day1 or Day 2 of Hospital admission or document reason
Stroke patients are at increased risk of developing venous thromboembolism (VTE)
Measure LDL-c or full lipid panel within 48 hrs of arrival on all ischemic stroke patients who are not on lipid lowering medication
Intensive lipid lowering therapy using statin medication was associated with a dramatic reduction in the rate of recurrent ischemic stroke and major coronary events
Prescribe statin at discharge to ischemic stroke patients
with LDL greater than 100 mg/dL,
or LDL not measured,
or who were on a statin prior to hospital arrival
Stroke cont.
MEASURE
RATIONALE
Prescribe anticoagulation for all pts with AFib/ Aflutter or document contraindication
Thromboembolic events are greatly reduced for AFib/ AFlutter patients treated with anticoagulant therapy
MD Must order an evaluation by the Rehab team or document reason why evaluation was not indicated (i.e. if patient at baseline by discharge)
Effective rehabilitation interventions initiated early following stroke can enhance the recovery process and minimize functional disability.
Provide written discharge instructions on when to call 911, follow-up after discharge, medications, risk factors for stroke and warning signs and symptoms of stroke
Patient education programs for specific chronic conditions have increased healthful behaviors, improved health status, and/or decreased health care costs of their participants
Reconcile medications correctly (Discharge Summary, Orders, and Instructions MUST match) Signed copy of instructions must be on chart.
Reduce medication errors
Page 3 of 4

4. OBMC Core Measures January 2015
Outpatient Measures (OP) CMS/TJC
MEASURE
RATIONALE
CP/AMI- Administer aspirin within 24 hours of arrival or document reason. Obtain EKG upon arrival
Early use of aspirin in patients with AMI results in significant reduction in adverse events & mortality.
Pain Management-Administer pain medication within 45 minutes of arrival for long bone fractures
Pain management in long bone fractures is undertreated. This measure includes patients ≥ 2 years of age
Stroke- Head CT or MRI interpreted within 45 minutes of arrival
Improved access to diagnostic imaging assists clinicians in the decision making process and treatment plans.
This measure includes patients > 18 years of age with an ischemic or hemorrhagic stroke
Outpatient Measures cont
MEASURE
RATIONALE
ED Throughput-Median Time from ED Arrival to ED Departure for Discharged ED Patients
Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care.
Arrival MUST be clearly documented in Triage and Departure MUST be clearly documented in Emergency Department Assessment
Median Time from ED Arrival to Provider Contact for Emergency Department Patients
Reducing this time potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. MD MUST clearly document the contact time (TIME SEEN) on the T Sheet.
Page 4 of 4