cathpci registry ws#21 dashboardimplications no answers.ppt€¦ · 2/26/2013 2 proportion of...

2/26/2013

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NCDR.13 Case Scenario Presentation

Cath PCI Registry

Dashboard Implications of

Some Major Metrics

Disclosures

• Tony Hermann has nothing to disclose

• Mark Hutcheson has nothing to disclose

• Cornelia Anderson has nothing to disclose

• Issam Moussa has nothing to disclose

• Discuss inclusion & exclusion criteria from five

Outcomes Reports metrics

• Discuss specific data collection and

definitions related to medications for the Cath

PCI Registry

• Demonstrate knowledge of data abstraction

through participation with the ARS

Objectives

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Proportion of Patients with Death,

Emergency CABG, Stroke or Repeat Target

Vessel Revascularization

Section G PCI ProcedureSeq#7020 (PCI Status) & Seq#7035 (PCI Indication)

Documentation:

• 47yo male c/o midsternal CP x2hrs

• Presents ambulatory to Triage/ER

• PMH: None, +Family History

• Meds: None

• ST Elevation leads II & III

• STEMI diagnosis

• STEMI protocol initiated

ARS Question # 1

What is the PCI Status and PCI Indication?

1. Urgent/Immediate PCI for STEMI

2. Urgent/Rescue PCI

3. Emergency/Immediate PCI for STEMI

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ARS Question #1

Documentation:

47yo male c/o midsternal CP x2hrs

ST Elevation leads II & III

STEMI diagnosis

STEMI protocol initiated

What is the PCI Status and PCI Indication?

1. Urgent/Immediate PCI for STEMI

2. Urgent/Rescue PCI

3. Emergency/Immediate PCI for STEMI

Section K DischargeSeq#9005 (CABG Status) & Seq#9010 (CABG Indication)

Documentation:

• Right femoral access

• Prox RCA 95%, Mid LAD 70%, Mid Cx 70-80%

• Culprit RCA lesion stented 4.0 BMS

• Pt decompensates after stent placement

• Unable to visualize Left System CP 10/10

• SBP 70’s, IABP inserted, Dopamine

• Pt prepared for CABG

ARS Question #2

What is the CABG Status and CABG Indication?

1. Urgent/PCI failure without clinical

deterioration

2. Emergency/PCI complication

3. Salvage/PCI complication

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ARS Question #2

Documentation:• Pt decompensates after stent placement



• Patient prepared for CABG

What is the CABG Status and CABG Indication?

1. Urgent/PCI failure without clinical

deterioration

2. Emergency/PCI complication

3. Salvage/PCI complication

ARS Question #3

Will this patient be included in the Numerator

for Metric 17?

1. Yes 2. No

ARS Question #3

Documentation:• Culprit RCA lesion stented 4.0 BMS

• Pt decompensates after stent placement



• Emergency CABG due to PCI Complication

Will this patient be included in the Numerator

for Metric 17?

1. Yes 2. No

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Section H Lesions and DevicesSeq#7145-7160

Documentation:

• 80 y.o. female s/p elective right hip

replacement

• PMH: Hyperlipidemia, HTN, Arthritis, stent to

mid Circumflex

• C/o chest tightness 3rd day post op

• Abnormal ECG

• Troponin 0.56, NSTEMI dx

• Cath reveals mid Circ lesion 90% - DES placed

ARS Question #4

How will Seq#7145 Previously Treated Lesion be

coded?

1. No 2. Yes

ARS Question #4

Documentation:


mid Circumflex


How will Seq#7145 Previously Treated Lesion be

coded?

1. No 2. Yes

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ARS Question #5

How will Seq#7155 Treated with Stent be

coded?

1. No 2. Yes

ARS Question #5

Documentation:


mid Circumflex


How will Seq#7155 Treated with Stent be

coded?

1. No 2. Yes

ARS Question #6Will this patient appear in the Numerator for

Metric 17?

1. Yes

2. No

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ARS Question #6 Documentation:

• 80 y.o. female s/p elective right hip

replacement

• Troponin 0.56, NSTEMI dx


Will this patient appear in the Numerator for

Metric 17?

1. Yes

2. No

Metric 17-Your hospital’s proportion of

(unadjusted) death, emergency CABG, stroke

or repeat target vessel revascularization

Medications

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Section D – Cath Lab Visit SEQ # 5300 - 5325 (Procedure Information)

Documentation:

• Stress test: a large area of reversible ischemia

• Cardiac cath:

– 40% RCA lesion

– 35% second OM lesion

– 98% mid-LAD between first and second diagonal

• PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis.

– Fluoro time - 7.8 min., contrast 215cc

ARS question #1

What is the Fluoro Dose in mGy?

1. Unknown, leave blank

2. 3300 mGy

3. 7.8 mGy

4. Ask your physician

ARS question #1

What is the Fluoro Dose in mGy?

1. Unknown, leave blank

2. 3300 mGy

3. 7.8 mGy

4. Ask your physician

Documentation:


• Cardiac cath:

– 40% RCA lesion



• PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis

Fluoro time - 7.8 min., contrast 215cc

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ARS question #2

What Procedures are coded?

1. Diagnostic cath only

2. PCI only

3. Both Diagnostic cath and PCI

4. Diagnostic cath, PCI and Other Procedure

ARS question #2

What Procedures are coded?

1. Diagnostic cath only

2. PCI only

3. Both Diagnostic cath and PCI

4. Diagnostic cath, PCI and Other Procedure

Documentation:


• Cardiac cath:

– 40% RCA lesion



• PCI: 3.0 x 18mm Resolute Integrity Rx with 0% residual stenosis.

Fluoro time - 7.8 min., contrast 215cc

Section G – PCI ProcedureSEQ # 9500 (Procedure Medications)

Documentation:

• Ms. Jansen has 500u unfractionated Heparin added to

flush

• Loading dose of 300mg Clopidogrel

• A PCI with a 3.0 x 18mm DES Rx with 0% post stenosis

• Fluoro time was 7.8 min

• Contrast 215cc

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ARS question #3

What Procedure Medication(s) are coded?

1. Unfractionated Heparin only

2. Unfractionated Heparin and Clopidogrel

3. Unfractionated Heparin and Glycoprotein IIb/IIIa

4. Clopidogrel only

ARS question #3

What Medication(s) are coded?

1. Unfractionated Heparin only

2. Unfractionated Heparin and Clopidogrel

3. Unfractionated Heparin and Glycoprotein IIb/IIIa

4. Clopidogrel only

Documentation:

• Ms. Jansen has 500u unfractionated Heparin added to

flush

• Loading dose of 300mg Clopidogrel

• A PCI with a 3.0 x 18mm DES Rx with 0% post stenosis

• Fluoro time was 7.8 min

• Contrast 215cc

Section H – Lesions and DevicesSEQ # 7225 (Intracoronary Device(s) Used)

Documentation:

• A PCI with a 3.0 x 18mm Resolute Integrity Rx

• IVUS post procedure of LAD due to haziness

• Stent patent with lack of expansion of stent struts

• Additional inflation with balloon from stent to 8 atm

• Repeat IVUS shows full expansion of the stent, 0%

stenosis

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ARS question #4

What Elements of the Device(s) are coded?

1. IVUS diameter and Resolute Integrity diameter and length

2. Resolute Integrity leave diameter and length blank

3. IVUS diameter and leave length blank

4. Resolute Integrity diameter and length

ARS question #4

What Elements of the Device(s) are coded?

1. IVUS diameter and Resolute Integrity diameter and length

2. Resolute Integrity leave diameter and length blank

3. IVUS diameter and leave length blank

4. Resolute Integrity diameter and length

Documentation:





• Repeat IVUS shows full expansion of the stent, 0% stenosis

ARS question #5

What Device(s) are coded?

1. Resolute Integrity Rx, Resolute Balloon

2. Resolute Integrity Rx

3. IVUS and Resolute Integrity OTW

4. IVUS, Resolute Integrity Rx, Resolute Balloon

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ARS question #5

What Device(s) are coded?

1. Resolute Integrity Rx, Resolute Balloon

2. Resolute Integrity Rx

3. IVUS and Resolute Integrity OTW

4. IVUS, Resolute Integrity Rx, Resolute Balloon

Documentation:





• Repeat IVUS shows full expansion of the stent, 0% stenosis

Section K – DischargeSEQ # 9505 (Discharge Medications)

Documentation:

• A Mynx – M5 is used

• Patient discharged home the next morning

• Discharge medications Diovan 80mg qd, due to an adverse

reaction to ACE I

• Simvastatin the same as prior to admission

• New Meds - ASA, Plavix 80 mg, daily

ARS question #6

What Medication(s) are coded as “Yes” for discharge?

1. ACE, ARB, ASA

2. ACE, ARB, Lipid Lowering Non-Statin

3. ARB, ASA, Lipid Lowering Statin, Thienopyridine(P2Y12)

4. ARB, Lipid Lowering Statin, Thienopyridine(P2Y12)

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ARS question #6

What Medication(s) are coded as “Yes” for discharge?

1. ACE, ARB, ASA

2. ACE, ARB, Lipid Lowering Non-Statin

3. ARB, ASA, Lipid Lowering Statin, Thienopyridine(P2Y12)

4. ARB, Lipid Lowering Statin, Thienopyridine(P2Y12)

Documentation:




reaction to ACE I



ARS question #7

Documentation:




reaction to ACE I



ARS question #7

Would this patient be included in the numerator for

Metric #9, Proportion of patients with a P2Y12 inhibitor

prescribed at discharge?

1. No

2. Yes

Documentation:




reaction to ACE I



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ARS question #8

Documentation:




reaction to ACE I



ARS question #8

Would this patient be included in the denominator for

Metric #9, Proportion of patients with a P2Y12 inhibitor

prescribed at discharge?

1. No

2. Yes

Documentation:




reaction to ACE I



ARS question #9

Documentation:




reaction to ACE I



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ARS question #9

Would this patient be included in the denominator for

Metric #38, Composite Medications on Discharge?

1. No

2. Yes

Documentation:




reaction to ACE I



ARS question #10

Documentation:




reaction to ACE I



ARS question #10

Would this patient be included in the numerator for

Metric #38, Composite Medications on Discharge?

1. No

2. Yes

Documentation:




reaction to ACE I



2/26/2013

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Dashboard

Post Procedure MI with/without Biomarkers

Objectives:

• Demonstrate how to capture post procedure MI

Seq#8000

• Demonstrate the differences in the criteria and

timeframe

• Demonstrate the impact of the element in the

Outcomes Report

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2007

2012

Metric 13:

Metric 14:

Metrics 13 & 14 Inclusion Criteria

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Causes of Procedural/PeriProcedural MI

Include:

• Acute Artery Closure

• Embolization

• No reflow

• Side Branch Occlussion

• Acute stent Thrombosis

• Dissection

http://content.onlinejacc.org/cgi/content/full/51/21/2068

Patient Drilldown view in Dashboard

Select

2/26/2013

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Section J – Intra/Post Procedure EventsSeq# 8000 (Myocardial Infarction)

Documentation:

• Patient presents to ED w/ angina on 10/16/12 @ 1200

• STEMI diagnosed

• Pt has a PCI to Mid Lcx, baseline CK-MB was 4.5 ng/ml

• Post PCI CK-MB drawn 8 hrs was 17.3 ng/ml

• Pt con’t to have STE and taken back to the lab

• Previously placed stent in the Mid Lcx occluded

• PCI performed, additional stent deployed

ARS Question #1

Would this be captured as a post procedure event in

Seq#8000?1. Yes

2. No


Documentation:• Patient presents to ED w/ angina on 10/16/12 @ 1200

• STEMI diagnosed






Would this be captured as a post procedure event in

Seq#8000?

1. Yes

2. No

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ARS Question #2

If this facility collects pre/post biomarkers on all

patients, would this patient be included in the metric

13 denominator?

1. Yes

2. No

Post Procedure MI with/without Biomarkers

Documentation:

• Patient presents to ED w/ angina on 10/16/12 @ 1200

• STEMI diagnosed






If this facility collects pre/post biomarkers on all

patients, would this patient be included in the metric 13

denominator?

1. Yes 2. No


Documentation:

• Pt scheduled for elective cath on 09/18/12 @ 0910

• Mild disease in LAD and Lcx

• Anamolous RCA, which had a 20% stenosis in the prox RCA

• Baseline Troponins I normal

• 09/20/12 @ 0700 the patient was taken back to lab w/ STE

• Trop I 5.6 ng/ml prior to the procedure

• Spiral dissection of the RCA, resulted in PCI

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ARS Question #3

How should Seq#8000 be captured for the 1st cath lab

visit?

1. Yes

2. No

3. N/A

Section J – Intra/Post Procedure Events

Seq# 8000 (Myocardial Infarction)Documentation:

• Pt scheduled for elective cath on 09/18/12 @ 0910

• Mild disease in LAD and Lcx

• Anamolous RCA, which had a 20% stenosis in the prox RCA

• Baseline Troponins I normal

• 09/20/12 @ 0700 the patient was taken back to lab w/ STE

• Trop I 5.6 ng/ml prior to the procedure

• Spiral dissection of the RCA, resulted in PCI

How should Seq#8000 be captured for the 1st cath lab visit?

1. Yes 2. No 3. N/A


Documentation:

• Patient comes to ED w/ STE

• Multi-vessel CAD, culprit artery LAD treated on 9/15/12

• Trop T not drawn pre PCI, post Trop T 21.5 n/gl

• Elective Staged PCI on 9/20/12 of the Ramus/OM1

• Pre procedure biomarkers were normal

• Stents deployed, Trop T drawn 2hrs post 7.2 n/gl

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ARS Question #4

How should Seq#8000 be coded for the 2nd cath lab

visit?

1. Yes

2. No


Documentation:







How should Seq#8000 be coded for the 2nd cath lab visit?

1. Yes 2. No

ARS Question #5

Would this patient be included or excluded from the

metric?

1. Included

2. Excluded

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Post Procedure MI with/without BiomarkersDocumentation:







Would this patient be included or excluded from the metric?

1. Included

2. Excluded

ARS Question #6

Is the patient placed in the numerator or denominator

for the metric?

1. Numerator

2. Denominator

Post Procedure MI with/without BiomarkersDocumentation:







Is the patient placed in the numerator or denominator for

the metric?

1. Numerator 2. Denominator

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Documentation:

• Patient has elective cath on 12/01/12 @ 0700

• Pre-procedure biomarkers normal

• Successful PCI is performed on the LAD

• Post procedure labs drawn on 12/2/12 @ 1301

• CK-MB 6.5 n/gl, no chest pain or ECG changes

• Taken to the cath lab, stent was patent

• IVUS performed, NC balloon used for malposition

ARS Question #7

This Post MI should be captured in Seq#8000 for the 1st

visit?

1. True

2. False


Documentation:

• Patient has elective cath on 12/01/12 @ 0700

• Pre-procedure biomarkers normal

• Successful PCI is performed on the LAD

• Post procedure labs drawn on 12/2/12 @ 1301

• CK-MB 6.5 n/gl, no chest pain or ECG changes

• Taken to the cath lab, stent was patent

• IVUS performed, NC balloon used for malposition

This Post MI should be captured in Seq#8000 for the 1st

visit?

1. True 2. False

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Keys to evaluating Post MI Seq#8000

• Determine the initial CAD Presentation (ACS)

• Lab results pre/post, knowing ULN

• Troponins vs. CK-MB

• Knowing the criteria <24hrs, >24hrs, Peri-

CABG

• Intra/Post procedure events

Risk Adjusted Mortality

Outcomes Report Measure #1

Executive Summary Measure #1 Risk Adjusted Mortality

Documentation:

• 85 y.o. male s/p cardiac arrest

• Transported via EMS to tertiary care, trauma/STEMI ctr

• Cardiogenic shock upon arrival to the cath lab

• CPR ongoing, PCI performed under Salvage status

• Pt deceased during salvage PCI

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ARS Question # 1: Considering the associated risk

factors for mortality, how does this patient’s death

influence the hospital’s RAM outcome?

1. All deaths worsen the RAM outcome.

2. The severity of his risk factors increase the risk of

mortality to a point that it is reflected in the

expected mortality. This will then balance ratio

between the observed and expected mortality.

3. This is a tertiary care center, so their rate is already

likely higher then the mortality rate at a county

hospital. This patient will not change that trend.

How does this death influence the RAM?

1. All deaths worsen the RAM outcome.

2. The severity of his risk factors increase the risk of mortality to a

point that it is reflected in the expected mortality. This will

then balance ratio between the observed and expected

mortality.

3. This is a tertiary care center, their rate is already likely higher

then the mortality rate at a county hospital. This patient will

not change that trend.

Documentation:

• 85 y.o. male s/p cardiac arrest

• Transported via EMS to tertiary care, trauma/STEMI ctr

• Cardiogenic shock upon arrival to the cath lab

• CPR ongoing, PCI performed under Salvage status

• Pt deceased during salvage PCI

Rationale to incorrect responses

1) All deaths worsen the RAM outcome.

• This is not true. The RAM is a ratio of observed over expected

mortalities.

3) This is a tertiary care center, their rate is already likely higher then

the mortality rate at a county hospital. This patient will not change

that trend.

• This is not true. The Risk Adjustment allows all hospitals to be

compared equally.

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Dashboard RAM

cathpci registry ws#21 dashboardimplications no answers.ppt€¦ · 2/26/2013 2 proportion of...

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