quality and patient safety council may 27, 2014 presented by susan m. blackhurst bs, rn & eric...
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4th Quarter 2013VTE,
IMMs and ED ThroughputCore Measures
Quality and Patient Safety CouncilMay 27, 2014
Presented BySusan M. Blackhurst BS, RN
&Eric Jean BSN, RN, CCRN
Presentation Goals Identify MMC VTE Quality Measures Initiative
CMS Specifications and ACCP Guidelines
Core Measure Data
Opportunities
Next Steps
Brief Update on IMMs/ED Throughput
Recommendations from American College of Chest Physicians (ACCP)For acutely and critically ill nonsurgical patients at increased risk for
VTE, pharmacological prophylaxis is recommended
For acutely and critically ill patients at increased risk for VTE and actively bleeding or at high risk for major bleeding, recommendation is for mechanical means over no prophylaxis; Once bleeding or risk of is no longer present, reconsideration of pharmacological prophylaxis is recommended
For acutely ill medical patients at “Low Risk” for VTE, recommendation is AGAINST pharmacologic and mechanical prophylaxis
Consider compliance, practicality, cost, etc…
(Summary of slides from “Prevention of Venous Thromboembolism in Nonsurgical Patients” Powerpoint; Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines; 2012)
CMS SpecificationsVTE 1 Prophylaxis
If neither pharmacological or mechanical means are ordered, contraindication to each must be documented explicitly by the provider
Ambulation is ONLY an allowable value IF there is documentation from the practitioner that the patient is “LOW RISK FOR VTE” and ambulation is to be used for prophylaxis
VTE Measure Set
General Prophy-laxis 514/571
ICU Prophy-laxis 41/43
Overlap Ther-apy 135/144
Heparin Nomo-gram 103/103
Warfarin In-structions 50/115
Potentially Avoid-able VTE
3/30
Overall Compli-ance
648/780
1st Quarter 0.899 1 0.957 1 0.2 0.1 0.784
2nd Quarter 0.854014598540146
1 0.911764705882353
1 0.307692307692308
0.111111111111111
0.787234042553192
3rd Quarter 0.938 0.929 0.906 1 0.519 0.2 0.868
4th Quarter 0.908 0.941 0.938 1 0.7778 0 0.885
5.0%
15.0%
25.0%
35.0%
45.0%
55.0%
65.0%
75.0%
85.0%
95.0%
VTE Core Measures 2013 All Quarter Comparison
Prophylaxis N=141
ICU Prophylaxis N=17
Potentially Avoidable N=6
No Order by Provider (31/58)
53.4%
SCD's Not Docu-mented by Nurs-
ing (27/58)
47%
VTE 1 & 2 (Prophylaxis) Noncompliant Cases By Discipline
2013 Overall
VTE 1 = 56 cases VTE 2 = 2 cases558/616 compliant = 91.5%58 cases noncompliant
OPPORTUNITIES
VTE 1 and VTE 2 (ICU)Prophylaxis
14 noncompliant cases (4Q2013) for VTE 1 and VTE 2–General and ICU Prophylaxis
Continued Reasons for Provider Noncompliance:• There were no orders for VTE prophylaxis and/or• There were no documented contraindications for
both anticoagulant and mechanical means• Only documenting risk-stratification at a rate
of approximately 50%
VTE 3 OpportunitiesVTE-3 Overlap Therapy
Ensure Warfarin Overlap Therapy is being ordered for 5 days Pharmacy is on-board! Charge nurses are now notifying Clinical Quality staff
of confirmed VTE for concurrent monitoring of measure
VTE 6 Potentially Avoidable PE/DVT
Evaluates VTE prophylaxis delivered between the day of admission and the day before the diagnostic test for confirmed VTE
Directly correlates with providing risk assessment and appropriate prophylaxis on admission and upon changes in level of care
Anticipate reduction in payment for Hospital Acquired Condition (HAC) and/or 30 day Readmission
VBP and appropriate stratification pre- and post-hospitalization
Looking AheadVTE Advisor
Provide decision support to practitioners established by evidence-based practice guidelines
iPath Project
HMS (Hospitalist Medicine Safety) Consortium-VTE Registry
Concurrent Monitoring
Influenza Vaccine
***Is now Pay-For-Performance Pay
Affects Medicare reimbursement beginning October 1, 2015
Performance Measured in calendar years 2012 (baseline rate
96.8%) and 2014 Need minimum 90% rate (achievement threshold)
with goal of 99% Benchmark is 98.8%
Pneumococcal Vaccine
Retired as a Core Measure as of January 1, 2014
Nursing administration and providers will still continue to ensure standard of care based on best-practice and ACIP Guidelines
Influenza
Overall Pneumococcal
Qtr 1 2012
Qtr 2 2012
Qtr 3 2012
Qtr 4 2012
Qtr 1 2013
Qtr 2 2013
Qtr 3 2013
Qtr 4 2013
ED 1B ED Arrival to ED Departure
269 310 327 327 319 309 333 309
CMS Top 10%
175 175 175 175 175 175 175 176
ED 2B Decision to Admit to ED Departure
157 161 164.5 181 179 172 170 181
CMS Top 10%
42 42 42 42 42 42 42 41
25
75
125
175
225
275
325
ED Throughput-Median Times
Tim
e i
n M
inu
te
s
Inpatient Sample SizeQtr 1 2012 =207Qtr 2 2012 =147Qtr 3 2012 =152Qtr 4 2012 =147Qtr 1 2013 =139Qtr 2 2013 =121Qtr 3 2013 =125Qtr 4 2013 =117
Contact Information Eric Jean BSN, RN, CCRN
RN Data Specialist Clinical Quality VTE/IMMs/ED Throughput Core Measures ejean1@mhc.net 231-392-7140
Susan M. Blackhurst BS, RN RN Data Specialist
Clinical Quality HMS Registry sblackhurst@mhc.net 231-935-5876
Questions
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