CORE MEASURES

PHYSICIAN

CLINICAL ORIENTATION

2016

WHAT ARE CORE MEASURES?

Core Measures were created by The Joint

Commission and with the help of CMS

(Centers for Medicare and Medicaid) to help

with the best practice care of the most

common disease processes seen in the acute

care setting. They determined guidelines for

hospitals to use in determining the care of

these patients to improve outcomes.

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As a physician, what Core Measures do

you affect?

Hospitalist: Stroke, VTE, Sepsis, ED patient

flow (for admitted pts)

ED Physician: AMI, Chest Pain, Stroke, Long

Bone Pain Management, ED Through Put, ED

Patient Flow, Sepsis

OB/GYN/Pediatrics: Perinatal measures

(Mother and Newborns)

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WHY SHOULD I CARE ABOUT CORE

MEASURES?

Based on Best Practice to assure our patients

have the best care and better outcomes. It

affects the health of our patients and the

community at large

Affects the reimbursement the hospital

receives from Medicare

Our compliance rates to the Core Measures

are publically reported for all to view

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ED MEASURES

• Chest Pain

• AMI

• Emergency Department Throughput

• Pain Management for Long Bone Fractures

• Out Patient Stroke

• Sepsis

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AMI / Chest Pain Patients

Need documentation of patient receiving ASA prior to arrival or

during their ED visit prior to transfer to another facility

EKG is to be done prior to arrival by EMS or within the first 10

minutes after arrival

If patient has a diagnosis of AMI-ST elevation (STEMI)

Fibrinolysis needs to be done within 30 minutes of arrival or

reason documented as to why not. If fibrinolytics are not given

due to patient being transferred for acute coronary intervention

please document that the patient is being transferred for acute

coronary intervention, cardiac cath, angioplasty, etc.

Patients transferring out for Acute Coronary Interventions are to

be transferred within 90 minutes of arrival

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ED Throughput

For discharged ED patients how long does it take from

arrival to ED Departure.

After patient arrival when does the MD/PA/NP first

evaluate the patient?

Reducing the time patients remain in the ED can

improve access to treatment and increase quality of

care.

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Pain Management for Long Bone Fractures

How long does it take for the patient to receive “appropriate”

pain medication after arrival for long bone fractures? (A long

bone fracture is considered any fractured bone besides carpals,

tarsals, metacarpals, and metatarsals.)

Measures the following:

-For the age group 2 to less than 18 any pain medication (PO,

IV, intranasal) given.

-For the age group of 18 and over parenteral medication should

be given. (If the pt receives both Parenteral and PO,

Parenteral must be given first, if the pt receives PO pain

medication first we fail the measure).

Local anesthesia, anesthestetic blocks, moderate/deep sedation,

etc. will also count for this measure.

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ED Stroke

Patient Transferred to Another Facility

Time of Head CT or MRI Scan results must be within

45 minutes of ED arrival for Acute Ischemic Stroke or

hemorrhagic Stroke Patients.

Need to document the patients DATE and TIME of

Last Known Well.

Patients need to have arrived within the 2 hour

window after symptoms began.

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Inpatient Core Measures

Core Measures and changes for 2016

• Stroke

(VTE prophylaxis, Discharged on antithrombotic therapy,

Anticoagulation for atrial fib/flutter upon d/c, antithrombotic

therapy by end of hospital day 2, discharged on statin

medication, stroke education, assessed for rehabilitation

measures removed as of 1/1/2016 discharges)

• ED Patient Flow

• VTE

(VTE prophylaxis, intensive care VTE prophylaxis, patients with

anticoagulation overlap removed as of 1/1/2016 discharges)

• Immunizations – Flu shot

• PNC (perinatal) mother and newborns

• Sepsis

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STROKE

Assure that the “last known well” date and time is documented in

the chart. Can be documented by nursing.

Thrombolytic Therapy: Acute ischemic stroke patients who

arrive within 2 hours of time last known well should have

thrombolytics started within 3 hours of time last known well.

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ED Flow

How long does it take from the time a patient arrives

to the ED and is admitted to the floor?

When is the decision made for the patient to be

admitted?

What time is patient discharged from ED and

transferred to the floor?

Measures how long from decision time to when

patient is admitted to the floor?

This information is useful in trying to decrease ED

over crowding.

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VTE

(VENOUS THROMBOEMBOLISM)

If the patient has a DVT or PE and is going home on

Coumadin (Warfarin) it must be documented that

education was given to the patient on Warfarin.

Patients going home on Warfarin must have specific

education regarding their follow-up visit for the

INR/PT draws.

Patients who develop a DVT while in the hospital are

checked to see if VTE prophylaxis was ordered and

given from admission or why not.

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VACCINATIONS

INFLUENZA

All inpatients age 6 months and older must be

screened to see if they require the administration of

the Influenza Vaccine during the months of October

through March. For OB cases, this requires a

rescreen after delivery

Please give the vaccine if required as early in the

hospital stay as possible---do not wait till the day of

discharge

If Vaccinations are refused, the refusal must be

documented

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INPATIENT MEASURES

PERINATAL MEASURE

ELECTIVE DELIVERY

Includes all patients with elective vaginal deliveries or elective C

section at >37 and <39 weeks gestation. Prefer to wait till

patients are in labor.

CESAREAN SECTION

Looking at how many first time vertex presentation pregnancies

have a C Section

ANTENATAL STERIODS

Patients at risk of preterm delivery at >=24 and <32 weeks

gestation who receive antenatal steroids prior to delivering

preterm newborns.

**Gestational Age should be documented for the above

measures.

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PERINATAL MEASURE CONT.

HEALTH CARE ASSOCIATED BLOODSTREAM

INFECTIONS IN NEWBORNS

Staphylococcal and gram negative septicemia or

bacteremia in high risk newborns

EXCLUSIVE BREAST FEEDING

Exclusive breast milk feeding during the newborn’s

entire hospitalization—only breast milk

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SEPSIS

This measure can and usually begins in the ED.

Patients 18 years and older with an ICD 10 code of Sepsis will

fall into the measure and remain in the measure if criteria or

documentation for severe sepsis and septic shock are met.

If the patient is to receive “comfort care” please dictate this in the

progress notes. If dictated prior to or within 3 hours of

presentation of severe sepsis and prior to or within 6 hours of

septic shock it will remove the patient from the measure.

The next slides will review the criteria for “severe sepsis” and

“septic shock”. All these components must be met within 6 hours

of each other. The date and time on which the last criteria or

severe sepsis was dictated is the date and time that is used for

presentation. This is the date and time that the timed components

of the measure must meet, 6 hours prior to and 3 hours following

severe sepsis criteria.

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SEPSIS Criteria

Documented source or suspected source of clinical infection (except viral and

fungal infections) by a physician/APN/PA.

AND

2 or more SIRS criteria

• Temp > 38.3˚C (100.9) or < 36˚C (98.6)

• Heart Rate > 90min

• Respiratory Rate > 20min

• WBC > 12,000 or < 4,000 or 10% Bands

AND

Organ Dysfunction (any one) (except from chronic conditions or medications)

• Systolic BP < 90, or mean arterial pressure <65, or a decrease in SBP by

40mmHg from baseline with physician/APN/PA documentation that the decrease

is related to infection, severe sepsis or septic shock and not other causes.

• Acute Respiratory Failure evidenced by a new need for invasive or non-invasive

ventilation. ET/Tracheostomy Tube or Bipap

• Creatinine > 2.0, or urine output < 0.5ml/kg/hour for 2 hours

• Bilirubin > 2 mg/dl

• Platelet count < 100,000

• INR > 1.5 or PTT > 60 sec

• Lactate > 2 mmol/l

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Should occur within 3 hours of presentation date/time of Severe Sepsis

Assess measurement of lactate (6 hours prior to until 3 hours after)

Obtain Blood Cultures (48 hours prior to until 3 hours after)

Administer Broad Spectrum Antibiotics (24 hours prior until 3 hours after)

Make sure the first ordered antibiotic is administered promptly. If not

administered prior to presentation time, the first Antibiotic has to be started

within 3 hours of presentation time.

Should occur within 6 hours of presentation of Severe Sepsis

Repeat lactate measurement if >2

Please use the Sepsis Order Set .

Will automatically re-order lactate level if >2.

Should occur within 6 hours of presentation of Septic shock

Fluid Resuscitation (30ml/kg) (0.9% Normal Saline or Lactated Ringers

given for hypotension or lactate level >= 4. Total volume infused must be

at least 30ml/kg which should be specified in the physician order. The

Sepsis Order Set will calculate this for you.)

-Vasopressor administration

-Reassessment of volume status

-Tissue Reprofusion

Best Practice

The concept of Core Measures has been around for

many years. There are several Core Measures that

have been retired that we still monitor for compliance.

Pneumonia—Blood Cultures drawn prior to antibiotics,

appropriate Antibiotic coverage

Heart Failure—ECHO completed with known EF%. If EF is

below 40% patient needs an ACEI or ARB

In Patient AMI—ASA given

In Patient SCIP—Appropriate prophylactic antibiotics prior to

surgery and discontinued within 24 hours post op. Appropriate

hair removal, Beta Blocker and discontinuation of Foley catheter.

VTE prophylaxis

Stroke discharge instructions

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References

• The Specification Manual for National Hospital

Inpatient Quality Measures. (2016)Version 5.0b

(for discharges 10/1/15-6/30/16)

Inpatient Quality Measures. (2016) Version 5.1

(for discharges 7/1/16-12/31/16)

Retrieved from: http://www.qualitynet.org.

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QUESTIONS?

Please contact one of the Quality Improvement

Specialists:

Deborah Priebe ext. 5286

Pam Wise ext. 5288

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