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CICU Quality Improvement Orientation Chief Residents 2013

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CICU Quality Improvement Orientation. Chief Residents 2013. Objectives. 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. - PowerPoint PPT Presentation

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Page 1: CICU Quality Improvement Orientation

CICU Quality Improvement Orientation

Chief Residents

2013

Page 2: CICU Quality Improvement Orientation

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

Page 3: CICU Quality Improvement Orientation

Clinical Documentation

Leslie Schultz, RN, BSN – Clinical Documentation Improvement Specialist in

CICU

Page 4: CICU Quality Improvement Orientation

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

Page 5: CICU Quality Improvement Orientation

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

Page 6: CICU Quality Improvement Orientation

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

Page 7: CICU Quality Improvement Orientation

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…

Page 8: CICU Quality Improvement Orientation

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

Page 9: CICU Quality Improvement Orientation

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

Page 10: CICU Quality Improvement Orientation

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

Page 11: CICU Quality Improvement Orientation

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…

Page 12: CICU Quality Improvement Orientation

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

Page 13: CICU Quality Improvement Orientation

Core Measures

Page 14: CICU Quality Improvement Orientation

14

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

Page 15: CICU Quality Improvement Orientation

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

15

Inpatient Core Measure Sets 2013

Page 16: CICU Quality Improvement Orientation

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

16

Inpatient Core Measure Sets 2013

Page 17: CICU Quality Improvement Orientation

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

17

Required in 2014 by TJC for hospitals with > 1, 100 births

Inpatient Core Measure Sets 2013

Page 18: CICU Quality Improvement Orientation

18

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?

Page 19: CICU Quality Improvement Orientation

19

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

Page 20: CICU Quality Improvement Orientation

20

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

Page 21: CICU Quality Improvement Orientation

21

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

Page 22: CICU Quality Improvement Orientation

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

Page 23: CICU Quality Improvement Orientation

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

Page 24: CICU Quality Improvement Orientation

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

Page 25: CICU Quality Improvement Orientation

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

Page 26: CICU Quality Improvement Orientation

2011 26

Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252

Page 27: CICU Quality Improvement Orientation

27

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

Page 28: CICU Quality Improvement Orientation

28

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

Page 29: CICU Quality Improvement Orientation

29

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

Page 30: CICU Quality Improvement Orientation

30

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

Page 31: CICU Quality Improvement Orientation

2011 31

Guidelines For a Healthy Lifestyle

Page 32: CICU Quality Improvement Orientation

32

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

Page 33: CICU Quality Improvement Orientation

Discharge Planning

Page 34: CICU Quality Improvement Orientation

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

Page 35: CICU Quality Improvement Orientation

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.

Page 36: CICU Quality Improvement Orientation

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

Page 37: CICU Quality Improvement Orientation

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.