Anesthesiology and Critical Care Performance Measurement Set

Transcription

1 American Board of Anesthesiology American Society of Anesthesiologists American Medical Association-convened Physician Consortium for Performance Improvement Anesthesiology and Critical Care Performance Measurement Set PCPI approved April 2014

2 Physician Performance Measures (Measures) and related data specifications are developed by the American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI ). These Measures are not clinical guidelines and do not establish a standard of medical care, and have not been tested for all potential applications. The Measures, while copyrighted, can be reproduced and distributed, without modification, for noncommercial purposes, e.g., use by health care providers in connection with their practices. Commercial use is defined as the sale, license, or distribution of the Measures for commercial gain, or incorporation of the Measures into a product or service that is sold, licensed or distributed for commercial gain. Commercial uses of the Measures require a license agreement between the user and the AMA (on behalf of the PCPI). Neither the AMA, the PCPI nor its members shall be responsible for any use of the Measures. THE MEASURES AND SPECIFICATIONS ARE PROVIDED AS IS WITHOUT WARRANTY OF ANY KIND American Medical Association. All Rights Reserved. Limited proprietary coding is contained in the Measure specifications for convenience. Users of the proprietary code sets should obtain all necessary licenses from the owners of these code sets. The AMA the PCPI and its members disclaim all liability for use or accuracy of any Current Procedural Terminology (CPT ) or other coding contained in the specifications. CPT contained in the Measure specifications is copyright American Medical Association American Medical Association. All Rights Reserved. Page 2

3 Anesthesiology and Critical Care Work Group Members Work Group Members Alexander A. Hannenberg, MD, Co-chair Andrew J. Patterson, MD, PhD, Co-chair William R. Andrews, MD, MS Rebecca A. Aslakson, MD, PhD Daniel R. Brown, MD, PhD Neal H. Cohen, MD, MPH, MS Peggy Duke, MD Heidi L. Frankel, MD Lorraine M. Jordan, BSN, MS, PhD Jeremy M. Kahn, MD, MS Jason N. Katz, MD, MHS Gerald A. Maccioli, MD Catherine L. Scholl, MD Todd L. Slesinger, MD Victoria M. Steelman, PhD, RN Avery Tung, MD Work Group Staff American Board of Medical Specialties Meredith Herzog American Society of Anesthesiologists Maureen Amos American Medical Association-convened Physician Consortium for Performance Improvement Mark Antman, DDS, MBA Elvia Chavarria, MPH Jodie Dvorkin, MD, MPH Kendra Hanley, MS Jennifer Heffernan, MPH Toni Kaye, MPH Kimberly Smuk, RHIA The Joint Commission Elvira L. Ryan, MBA, BSN, RN 2014 American Medical Association. All Rights Reserved. Page 3

4 Table of Contents Section Page Purpose of Measurement Set 5 Importance of Topic 5 Clinical Evidence Base 5 Anesthesiology and Critical Care Outcomes 6 Intended Audience, Care Setting, and Patient Population 6 Anesthesiology and Critical Care Work Group Recommendations 6 Retired Measures 8 Potential Measures Considered 8 Measure Specifications 9 Measure Exclusions and Measure Exceptions 9 Testing and Implementation of the Measurement Set 10 Measure #1: Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections 11 Measure #2: Perioperative Temperature Management 14 Measure #3: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) Measure #4: Prevention of Post-Operative Nausea and Vomiting (PONV) Combination Therapy for Adults at High Risk for PONV Measure #5: Prevention of Post-Operative Vomiting (POV) Combination Therapy for Pediatric Patients at High Risk for POV Measure #6: Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents (Quality Improvement Only) Measure #7: Surgical Safety Checklist - Applicable Safety Checks Completed Before Induction of Anesthesia Evidence Classification/Rating Schemes 26 Summary of Non-Material Interest Disclosures 27 References 28 Appendix A: Technical Specifications American Medical Association. All Rights Reserved. Page 4

5 Anesthesiology and Critical Care Performance Measurement Set Purpose of Measurement Set The American Medical Association (AMA)-convened Physician Consortium for Performance Improvement (PCPI ) convened the Anesthesiology and Critical Care Work Group (Work Group) to assess opportunities for the development of evidence-based performance measures. The objective of the Work Group was to identify and prioritize gaps in care to define quality measures toward improving the care of the surgical and/or critically ill patient with the aim of optimizing clinical outcomes. This work represents the formal periodic review and maintenance of an existing measurement set. The Anesthesiology and Critical Care Measure set was initially developed in This measure review and maintenance project aimed to review and update the existing measures to ensure they reflect the latest guideline recommendations, address gaps in care, and incorporate results from testing projects, when available. Additionally, the Work Group considered the development of new measures to complement the existing measures. Importance of Topic Each year, millions of individuals undergo surgery and/or experience a critical illness that requires hospitalization. In 2011, there were approximately 17.3 million outpatient surgeries 1 In 2011, there were approximately 9.6 million inpatient surgeries 1 According to the CDC, in 2010, the total number of inpatient surgical procedures in children under 15 years of age was 1.8 million 2 More than 5 million patients are admitted annually to ICUs in the United States 3 These topic areas were prioritized due to the level of utilization of surgical and critical care services and the need for measures that can help improve care for patients undergoing these services. Clinical Evidence Base Clinical practice guidelines serve as the foundation for the development of performance measures. A number of clinical practice guidelines and recommendations form the basis for the anesthesiology and critical care measures. This measure set is based on guidelines developed by the following: American College of Cardiology and American Heart Association (ACC/AHA) American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association, with representation from the American College of Physicians Centers for Disease Control and Prevention (CDC) Society for Ambulatory Anesthesia (SAMBA) World Health Organization (WHO) Performance measures, however, are not clinical practice guidelines and cannot capture the full spectrum of care for all the surgical and critically ill patients. Performance measures are meant to emphasize the strongest recommendations within these guidelines that represent the highest level of evidence and the greatest opportunity to improve patient care American Medical Association. All Rights Reserved. Page 5

6 Anesthesiology and Critical Care Outcomes Ideally, a set of anesthesiology and critical care measures will include measures of outcomes as well as measures of processes that are known to have a positive influence on clinical outcomes. The measures provided herein were identified as positively influencing desirable anesthesiology and critical care outcomes. Desired outcomes for anesthesiology and/or critical care addressed by these measures include to: 1. Reduce morbidity and mortality 2. Reduce incidence of adverse effects of anesthesia 3. Reduce the risk of surgical complications 4. Reduce risk of hospital-acquired infections 5. Enhance communication and coordination of care 6. Improve patient safety The Anesthesiology and Critical Care Work Group focused on current quality gaps in care in order to develop measures that will have an important role in optimizing patient outcomes. Intended Audience and Use, Care Setting and Patient Population The PCPI encourages use of these measures by physicians, other health care professionals, and healthcare systems, where appropriate, to achieve improved performance and as steps towards optimized clinical outcomes for patients undergoing an anesthetic service and/or in a critical care setting. Performance measurement serves as an important component in a quality improvement strategy but performance measurement alone will not achieve the desired goal of improving patient care. Measures can have their greatest effect when they are used judiciously and linked directly to operational steps clinicians, patients, and health plans can apply in practice to improve care. These clinical performance measures are appropriate for accountability if the appropriate methodological, statistical, and implementation rules are achieved. Additionally, the PCPI encourages that performance measure data be stratified by gender, race, ethnicity, and primary written and spoken language to assess disparities and initiate subsequent quality improvement activities addressing identified disparities. These categories are consistent with recent national efforts to standardize the collection of race and ethnicity data. Anesthesiology and Critical Care Work Group Recommendations This document includes measures that focus on reducing the risk of infection and adverse effects of anesthesia as well as promoting improved communication and coordination between providers and surgical teams. These measures also support the efficient delivery of high quality health care in many of the Institute of Medicine s (IOM) six aims for quality improvement as described in Table American Medical Association. All Rights Reserved. Page 6

7 Table 1: Relationship between IOM domains and Anesthesiology and Critical Care measures IOM Domains of Health Effective Patientcentered Safe Timely Efficient Equitable Care Quality Underuse Overuse Measures 1 Prevention of Central Venous Catheter (CVC)- Related Bloodstream Infections 2 Perioperative Temperature Management 3 Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) 4 Prevention of Post-Operative Nausea and Vomiting (PONV) Combination Therapy for Adults at High Risk for PONV 5 Prevention of Post-Operative Vomiting (POV) Combination Therapy for Pediatric Patients at High Risk for POV 6 Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents 7 Surgical Safety Checklist - Applicable Safety Checks Completed Before Induction of Anesthesia 2014 American Medical Association. All Rights Reserved. Page 7

8 Retired Measures A number of circumstances might warrant the retirement of a measure from a measurement set including, but not limited to: The measure no longer remains clinically relevant/appropriate as determined by current guidelines and scientific evidence To avoid excessive clinician burden, other performance measures, such as outcome measures, may take precedence High clinician performance, implying that the measure no longer represents an opportunity for quality improvement Testing results demonstrating poor feasibility of data collection or weak correlation with improved health outcomes Identification of significant unintended consequences of measurement. The Prevention of Ventilator-Associated Pneumonia Head Elevation measure included in the first anesthesiology and critical care measure set, finalized in 2007, has been retired and not included here. The measure was found to no longer represent a gap in care or opportunity for quality improvement. Potential Measures Considered The Work Group considered several other potential measures, though ultimately determined that they were not appropriate for inclusion in the measure set. ICU family meeting early in ICU course Overuse of blood transfusions in the ICU Risk-adjusted ICU outcome Routine chest radiographs in ICU patients Few trials have compared routine versus on-demand chest x-rays in the ICU. Screening of ALI/ARDS in the ICU Therapeutic hypothermia after out-of-hospital VF cardiac arrest Surgical Safety Checklist - Applicable safety checks completed before skin incision Surgical Safety Checklist Applicable safety checks completed before patient leaves operating room The Work Group opted not to pursue the development of these measure topics. While the topics represent clinical issues that require consideration, there is an existing dearth of published evidence and/or clinical recommendations to support these concepts as measures of accountability. The ICU family meeting and screening of ALI/ARDS measure concepts lacked a guideline recommendation and sufficient evidence to support the development of a measure. For the overuse of blood transfusion topic, guidelines recommend that the use of only hemoglobin level as a trigger for transfusion should be avoided. Furthermore, guidelines state that a decision for RBC transfusion should be based on various individual patient criteria including intravascular volume status and duration and extent of anemia. 4 A therapeutic hypothermia after out-of-hospital cardiac arrest measure was also considered. However, the development of an accountability measure was hampered by the lack of evidence regarding the optimal time to initiate hypothermia for improved patient outcomes. The Work Group had considered a measure concept related to routine chest radiographs in ICU patients. However, few trials have compared routine versus on-demand chest x-rays in the ICU. Current literature suggests the need for further studies to identify the patients that would benefit from daily routine chest radiographs, focusing on the presence of clinical indications that are not well documented as requiring daily imaging. This measure set includes a measure - Surgical Safety Checklist: Applicable Safety Checks Completed Before Induction of Anesthesia - based on the World Health Organization (WHO) Guidelines for Safe Surgery. WHO guidelines delineate three phases of surgery in its Surgical Safety Checklist. The Work Group opted to focus on the first phase of an operation before induction of anesthesia, as this was 2014 American Medical Association. All Rights Reserved. Page 8

9 felt to be the phase most relevant to anesthesiology. Therefore, measures based on the other two phases of surgery, before skin incision and before patient leaves operating room, were considered but ultimately not developed. Measure Specifications There are several data sources available for collecting performance measures; generally different data sources require different sets of measure specifications, due to the structure of the systems storing the data. The PCPI recognizes that Electronic Health Records (EHRs) are state-of-the-art for clinical encounters and is focusing significant resources and expertise toward specifying and testing measures within EHRs, as they hold the promise of providing the relevant clinical data for measures and for providing feedback to physicians and other health care providers that is timely and actionable. While the PCPI recognizes the significance of EHRs, the nature of the Anesthesiology specialty does not lend itself to the adoption of EHRs and it was determined in work group discussion that at this time, the more impactful measurement activities would happen in an administrative (claim) environment. Specifications to report on the Anesthesiology and Critical Care measurement set are designed for use in an administrative (claims) program. We have identified codes for these measures, including ICD-9-CM/ICD-10-CM, CPT (Evaluation & Management Codes, Category I and where Category II codes would apply) and HCPCS G-Codes. Measure Exclusions and Measure Exceptions Measure Exclusions In the context of physician performance measurement, exclusions arise when the intervention required by the numerator is not appropriate for a group of patients. Exclusions are absolute and are applied uniformly across a patient population and those patients are removed from the denominator before the numerator action is considered. Measure Exceptions Exceptions arise when a patient is included in the denominator but for whom the particular numerator action does not apply based on individual patient characteristics and clinical judgment. Exceptions are used to remove a patient from the denominator of a performance measure when the patient does not receive a therapy or service. The patient would otherwise meet the denominator criteria. Exceptions are not absolute, and are based on clinical judgment, individual patient characteristics, or patient preferences. For process measures, the PCPI provides two categories of reasons (exceptions) for which a patient may be removed from the denominator of an individual measure: Medical reasons Include: Contraindicated in patient (potential allergy due to previous reported allergic history, potential adverse drug interaction, other) Already received/performed Intolerance (therapy was tried and the patient was intolerant) Other medical reason(s) Patient or Non-medical reason(s) Include: Patient refused/declined Access issues or insurance coverage/payor-related limitations (patient not covered for treatment) Patient functional limitations Patient preference: Social reason(s) (eg, family or support system not supportive of intervention/treatment); Religious reason(s) (eg, religious beliefs regarding blood transfusion) Other patient or non-medical reason(s) 2014 American Medical Association. All Rights Reserved. Page 9

10 These measure exception categories are not available uniformly across all measures; for each measure, there must be a clear rationale to permit an exception for a medical or patient/non-medical reason. For some measures, examples have been provided in the measure exception language of instances that would constitute an exception. Examples are intended to guide clinicians and are not all-inclusive lists of all possible reasons why a patient could be excluded from a measure. The exception of a patient may be reported by reporting the appropriate Quality Data Code: report the indicated G-Code OR by appending the appropriate modifier to the CPT Category II code designated for the measure, which includes: Medical reasons: modifier 1P Patient reasons: modifier 2P Although this methodology does not require the external reporting of more detailed exception data, the PCPI recommends that physicians document the specific reasons for exception in patients medical records for purposes of optimal patient management and audit-readiness. The PCPI also advocates the systematic review and analysis of each physician s exceptions data to identify practice patterns and opportunities for quality improvement. For example, it is possible for implementers to calculate the percentage of patients that physicians have identified as meeting the criteria for exception. Please refer to documentation for each individual measure for information on the acceptable exception categories and the codes and modifiers to be used for reporting. Testing and Implementation of this set Measures in this set are being made available without any prior testing. The PCPI recognizes the importance of testing all measures and encourages testing of the Anesthesiology and Critical Care measures by organizations or individuals. The Measure Testing Protocol was approved by the PCPI in 2010 and is available on the PCPI web site (see Position Papers at interested parties are encouraged to review this document American Medical Association. All Rights Reserved. Page 10

11 Measure #1: Prevention of Central Venous Catheter (CVC)-Related Bloodstream Infections Anesthesiology and Critical Care Measure Description Percentage of patients, regardless of age, who undergo central venous catheter (CVC) insertion for whom CVC was inserted with all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed Measure Components Numerator Statement Patients for whom CVC was inserted with all elements of maximal sterile barrier technique*, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques** followed Definitions: *Maximal sterile barrier technique includes ALL of the following elements: cap mask sterile gown sterile gloves sterile full body drape ** Sterile ultrasound techniques require sterile gel and sterile probe covers Statement Exclusion(s) Exception(s) All patients, regardless of age, who undergo CVC insertion None Documentation of medical reason(s) for not following all elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques during CVC insertion (including increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC insertion) 2014 American Medical Association. All Rights Reserved. Page 11

12 Supporting Guideline & Other References The following evidence statements are quoted verbatim from the referenced clinical guidelines: CDC Guidelines for the Prevention of Intravascular Catheter-Related Infections, recommend: Maximal Sterile Barrier Precautions Use maximal sterile barrier precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs, or guidewire exchange (Category IB) Hand Hygiene Perform hand hygiene procedures, either by washing hands with conventional soap and water or with alcohol-based hand rubs (ABHR) (Category IB) Skin Preparation Prepare clean skin with a >0.5% chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives (Category IB) Sterile Ultrasound The Food and Drug Administration recommends that policies and clinical practice standards be reviewed to ensure the use of sterile ultrasound gel. Once a container of sterile or non-sterile ultrasound gel is opened, it is no longer sterile and contamination during ongoing use is possible 6 Measure Importance Relationship to Hospital-acquired bloodstream infections are a common complication that desired outcome leads to increased costs and mortality. 7 It is estimated that approximately 51% of hospital-acquired bloodstream infections occur in an intensive care unit (ICU), with the presence of a central venous catheter being the largest risk factor for the development of a bloodstream infection in the hospital. 8 Catheter-related bloodstream infections (CRBSIs) commonly occur when the catheter becomes contaminated by microbes on the skin during insertion. The use of maximal sterile barriers, including sterile gloves, long-sleeved sterile gown, mask, cap, and full-sized sterile drape, during insertion of the catheter has been shown to cost effectively reduce CRBSI rates compared to the use of less stringent precautions. 9,10,11,12 Opportunity for Improvement Exception Justification A 2002 survey found that only 28% of ICUs have written policies requiring all five components of maximum sterile-barrier (MSB) precautions during central venous catheter insertion and 20% of ICUs had no written policies addressing sterile barrier precautions. 13 Similarly, a 2005 survey of physicians showed that only 28% used all components of MSB precautions. This survey showed that low usage was driven by the belief that MSB precautions would not have a significant impact on infection rates. 14 One study demonstrated that a one-day course on proper sterile techniques during catheter insertion for physicians resulted in increased use of MSB precautions and reduced CRBSI rates. 10 A medical reason exception is included so that clinicians may except patients in instances where the use of all elements of maximal sterile barrier technique during CVC insertion may not be indicated (eg, increased risk of harm to patient if adherence to aseptic technique would cause delay in CVC 2014 American Medical Association. All Rights Reserved. Page 12

13 insertion). Harmonization with Existing Measures The PCPI measure is specified for a level of analysis that includes the individual practitioner with the intent of providing data to clinicians and other health professionals regarding their individual performance. Similar measures exist including the Centers for Disease Control and Prevention s Central line-associated Bloodstream Infection measure (NQF measure 0139) and the Agency for Healthcare Research and Quality s Patient Safety for Selected Indicators Composite measure (NQF measure 0531). These two measures are specified and NQF endorsed for analysis at the facility level. Measure Designation Measure purpose Quality Improvement Accountability Type of measure Level of Measurement Care setting Data source Process Individual Clinician Ambulatory Care Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 13

14 Measure Description Measure #2: Perioperative Temperature Management Anesthesiology and Critical Care Percentage of patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Measure Components Numerator Statement Patients for whom at least one body temperature greater than or equal to 35.5 degrees Celsius (or 95.9 degrees Fahrenheit) was recorded within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Statement All patients, regardless of age, who undergo surgical or therapeutic procedures under general or neuraxial anesthesia of 60 minutes duration or longer Exclusion(s) Patients undergoing Cardiopulmonary bypass Regional nerve block Monitored anesthesia care Exception(s) Documentation of one of the following medical reason(s) for not achieving at least one body temperature greater than or equal to 35.5 degrees Celsius or 95.9 degrees Fahrenheit within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time Emergency cases Intentional hypothermia Supporting Guideline & Other References The following evidence statements are quoted verbatim from the referenced clinical guidelines: American College of Cardiology Foundation/American Heart Association recommend: Maintenance of body temperature in a normothermic range is recommended for most procedures other than during periods in which mild hypothermia is intended to provide organ protection (eg, during high aortic cross-clamping) (Class I, Level B) 15 Measure Importance Relationship to A drop in core temperature during surgery, known as perioperative desired outcome hypothermia, can result in numerous adverse effects, which can include adverse myocardial outcomes, subcutaneous vasoconstriction, increased incidence of surgical site infection, and impaired healing of wounds. The desired outcome, reduction in adverse surgical effects due to perioperative hypothermia, is affected by maintenance of normothermia during surgery American Medical Association. All Rights Reserved. Page 14

15 Opportunity for Improvement Exception Justification Harmonization with Existing Measures Unintended perioperative hypothermia occurs in up to 20% of surgical patients. 16 An observational cohort study in a pediatric setting found that more than 50% of children experienced intraoperative hypothermia. Pediatric patients undergoing major surgery were at greater risk of intraoperative hypothermia. 17 A medical reason exception is included so that clinicians may except patients in instances where achieving at least one body temperature greater than or equal to 35.5 degrees Centigrade or 95.9 degrees Fahrenheit within the 30 minutes immediately before or the 15 minutes immediately after anesthesia end time is not indicated (eg, emergency cases, intentional hypothermia). The PCPI will seek opportunities to harmonize this measure with existing normothermia measures including that of the Surgical Care Improvement Project (SCIP). Measure Designation Measure purpose Quality Improvement Accountability Type of measure Outcome Level of Measurement Care setting Data source Individual Clinician Ambulatory Care Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 15

16 Measure #3: Post-Anesthetic Transfer of Care: Use of Checklist or Protocol for Direct Transfer of Care from Procedure Room to Intensive Care Unit (ICU) Measure Description Anesthesiology and Critical Care Percentage of patients, regardless of age, who undergo a procedure under anesthesia and are admitted to an Intensive Care Unit (ICU) directly from the anesthetizing location, who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member Measure Components Numerator Statement Patients who have a documented use of a checklist or protocol for the transfer of care from the responsible anesthesia practitioner to the responsible ICU team or team member Definition: The key handoff elements that must be included in the transfer of care protocol or checklist include: 1. Identification of patient, key family member(s) or patient surrogate 2. Identification of responsible practitioner (primary service) 3. Discussion of pertinent medical history 4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed) 5. Intraoperative anesthetic management and issue/concerns to include things such as airway, hemodynamic, narcotic, sedation level and paralytic management and intravenous fluids/blood products and urine output during the procedure 6. Expectations/Plans for the early post-procedure period to include things such as the anticipated course (anticipatory guidance), complications, need for laboratory or ECG and medication administration 7. Opportunity for questions and acknowledgement of understanding of report from the receiving ICU team Statement All patients, regardless of age, who undergo a procedure* under anesthesia and are admitted to an ICU directly from the anesthetizing location *Any procedure including surgical, therapeutic or diagnostic Exclusion(s) Exception(s) Supporting Guideline & Other References None None The following evidence statements are quoted verbatim from the referenced reports: The National Quality Forum, in its Preferred Practices and Performance Measures for Measuring and Reporting Care Coordination report, recommends: Preferred Practice 23: Healthcare providers and healthcare organizations should implement protocols and policies for a standardized approach to all transitions of care. Policies and procedures related to transitions and the critical aspects should be included in the standardized approach American Medical Association. All Rights Reserved. Page 16

17 Measure Importance Relationship to A uniform transfer of care protocol or handoff tool/checklist that is utilized desired outcome for all patients directly admitted to the ICU after undergoing a procedure under the care of an anesthesia practitioner will facilitate effective communications between the medical practitioner who provided anesthesia during the procedure and the care practitioner in the ICU who is responsible for post-procedural care. This should minimize errors and oversights in medical care of ICU patients after procedures. Opportunity for Improvement Exception Justification Harmonization with Existing Measures According to data published by the Joint Commission, communication errors were indicated in 59% of reported sentinel events in 2012 and in 54% of operative/post-operative complications between 2004 and A 2006 survey among residents at Massachusetts General Hospital found that 59% of respondents reported one or more patients experiencing harm as a result of ineffective patient handoff practices during their most recent clinical rotation. 20 This measure has no exceptions. There are no known similar existing measures therefore harmonization was not applicable. Measure Designation Measure purpose Quality Improvement Accountability Type of measure Process Level of Measurement Care setting Data source Individual Clinician Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 17

18 Measure #4: Prevention of Post-Operative Nausea and Vomiting (PONV) Combination Therapy for Adults at High Risk for PONV Measure Description Anesthesiology and Critical Care Percentage of patients, aged 18 years and older, who undergo a procedure under an inhalational general anesthetic, AND who have three or more risk factors for post-operative nausea and vomiting (PONV), who receive combination therapy consisting of at least two prophylactic pharmacologic antiemetic agents of different classes preoperatively or intraoperatively Measure Components Numerator Statement Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively Definition: The recommended first- and second-line classes of pharmacologic anti-emetics for PONV prophylaxis in patients at moderate to severe risk of PONV include (but are not limited to): 5-hydroxytryptamine (5-HT3) receptor antagonists dexamethasone phenothiazines phenylethylamines butyrophenones antihistamines anticholinergics The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA s web site page entitled Drug Safety Communications for up-to-date drug recall and alert information when prescribing medications. Statement All patients, aged 18 years and older, who undergo a procedure* under an inhalational general anesthetic, AND who have three or more risk factors for PONV Definition: Risk factors for PONV are: 1. female gender, 2. history of PONV or a history of motion sickness, 3. non-smoker, and 4. intended administration of opioids for post-operative analgesia** *Any procedure including surgical, therapeutic or diagnostic **This includes use of opioids given intraoperatively and whose effects extend into the post anesthesia care unit (PACU) or post-operative period, or opioids given in the PACU, or opioids given after discharge from the PACU. Exclusion(s) None 2014 American Medical Association. All Rights Reserved. Page 18

19 Exception(s) Documentation of medical reason(s) for not administering combination therapy of at least two prophylactic pharmacologic anti-emetic agents of different classes (eg, intolerance or other medical reason) Supporting Guideline & Other References The following evidence statements are quoted verbatim from the referenced clinical guidelines: Society for Ambulatory Anesthesia (SAMBA) PONV Prophylaxis Recommendations: Administer prophylactic therapy with combination ( 2 ) interventions/multimodal therapy in patients at high risk for PONV 21 Measure Importance Relationship to PONV is common occurring in more than 70% of high-risk post-surgical desired outcome patients. 22 Treatment with antiemetics has been found to reduce PONV. Combination therapy has been found to be more effective than monotherapy consisting of a single antiemetic. 23,24 One randomized controlled trial found a 26% reduction in the relative risk of PONV for each additional antiemetic used. 24 Opportunity for Improvement Exception Justification Harmonization with Existing Measures There is evidence to suggest variation in treatment for PONV. A small study of anesthesiologist found that 67% would administer a 5-HT3 antagonist as first choice for PONV treatment. About 26% of the anesthesiologists who administered prophylaxis using a 5HT3 antagonist would repeat administration of a 5-HT3. 25 The same study found that 3% 7% of anesthesiologists would repeat a dose of metoclopramide or dexamethasone as monotherapy for PONV. 25 A medical reason exception is included so that clinicians may except patients in instances where administering pharmacologic prophylaxis is not indicated (eg, intolerance or other medical reason). There are no known similar existing measures therefore harmonization was not applicable. Measure Designation Measure purpose Quality Improvement Accountability Type of measure Process Level of Measurement Care setting Data source Individual Clinician Ambulatory Care Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 19

20 Measure #5: Prevention of Post-Operative Vomiting (POV) Combination Therapy for Pediatric Patients at High Risk for POV Measure Description Anesthesiology and Critical Care Percentage of patients, aged 3 through 17 years of age, who undergo a procedure under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for post-operative vomiting (POV), who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively Measure Components Numerator Statement Patients who receive combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes preoperatively or intraoperatively Definition: The recommended pharmacologic anti-emetics for POV prophylaxis in pediatric patients at risk of POV include (but may not be limited to): 5-hydroxytryptamine (5-HT3) receptor antagonists (recommended as the first choice for prophylaxis for POV in children) dexamethasone antihistamines butyrophenones The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA s web site page entitled Drug Safety Communications for up-to-date drug recall and alert information when prescribing medications. Statement All patients, aged 3 through 17 years of age, who undergo a procedure* under general anesthesia in which an inhalational anesthetic is used for maintenance AND who have two or more risk factors for POV Definition: Risk factors for POV are: 1. Surgery 30 minutes 2. Age 3 years 3. Strabismus surgery 4. History of POV or PONV in parent or sibling *Any procedure including surgical, therapeutic or diagnostic Exclusion(s) Exception(s) Patients in which an inhalational anesthetic is used only for induction Documentation of medical reason(s) for not receiving combination therapy consisting of at least two prophylactic pharmacologic anti-emetic agents of different classes (eg, intolerance or other medical reason) Supporting Guideline & Other The following evidence statements are quoted verbatim from the referenced clinical guidelines: 2014 American Medical Association. All Rights Reserved. Page 20

21 References Society for Ambulatory Anesthesia (SAMBA) recommendations: Administer prophylactic antiemetic therapy to children at increased risk for POV; as in adults, use of combination therapy is most effective 21 All prophylaxis in children at moderate or high risk for POV should include combination therapy using a 5-HT3 antagonist and a second drug. Because the effects of interventions from different drug classes are additive, combining interventions has an additive effect in risk reduction 21 Measure Importance Relationship to PONV is common occurring in more than 70% of high-risk post-surgical desired outcome patients. 22 PONV occurs twice as frequently in children as in adults. 26 Treatment with antiemetics has been found to reduce PONV. Combination therapy has been found to be more effective than monotherapy consisting of a single antiemetic. 23,24 One randomized controlled trial found a 26% reduction in the relative risk of PONV for each additional antiemetic used. 24 Opportunity for Improvement Exception Justification Harmonization with Existing Measures There is evidence to suggest variation in treatment for PONV. One study of anesthesiologist found that 67% would administer a 5-HT3 antagonist as first choice for PONV treatment. About 26% of the anesthesiologists who administered prophylaxis using a 5HT3 antagonist would repeat administration of a 5-HT3. 25 The same study found that 3% 7% of anesthesiologists would repeat a dose of metoclopramide or dexamethasone as monotherapy for PONV. 25 A medical reason exception is included so that clinicians may except patients in instances where administering pharmacologic prophylaxis is not indicated (eg, intolerance or other medical reason). There are no known similar existing measures therefore harmonization was not applicable. Measure Designation Measure purpose Quality Improvement Accountability Type of measure Level of Measurement Care setting Data source Process Individual Clinician Ambulatory Care Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 21

22 Measure #6: Preoperative Use of Aspirin for Patients with Drug-Eluting Coronary Stents (QI Only) Measure Description Anesthesiology and Critical Care Percentage of patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia, who receive aspirin 24 hours prior to surgical start time Measure Components Numerator Statement Patients who receive* aspirin 24 hours prior to surgical start time Definition: * Patient reports taking aspirin OR hospital staff administered aspirin The foregoing list of medications/drug names is based on clinical guidelines and other evidence. The specified drugs were selected based on the strength of evidence for their clinical effectiveness. This list of selected drugs may not be current. Physicians and other health care professionals should refer to the FDA s web site page entitled Drug Safety Communications for up-to-date drug recall and alert information when prescribing medications. Statement All patients, aged 18 years and older with a pre-existing drug-eluting coronary stent, who undergo a surgical or therapeutic procedure under anesthesia Exclusion(s) Exception(s) None Documentation of medical reasons for not receiving aspirin 24 hours prior to anesthesia start time (eg, risks of preoperative aspirin therapy are greater than the risks of withholding aspirin, other medical reasons) Supporting Guideline & Other References The following evidence statements are quoted verbatim from the referenced clinical guidelines: American College of Cardiology and American Heart Association (ACC/AHA) recommendation: In patients who have received drug-eluting coronary stents and who must undergo urgent surgical procedures that mandate the discontinuation of thienopyridine therapy, it is reasonable to continue aspirin if at all possible and restart the thienopyridine as soon as possible. (Class IIa, Level of Evidence: C) 27 For patients treated with DES who are to undergo subsequent procedures that mandate discontinuation of thienopyridine therapy, aspirin should be continued if at all possible and the thienopyridine restarted as soon as possible after the procedure because of concerns about late-stent thrombosis 28 Measure Importance Relationship to Late stent thrombosis is a relatively rare but serious complication of stent desired outcome placement, with an estimated case fatality rate of up to 45%. 29,30 Multiple studies have shown that premature discontinuation of dual antiplatelet 2014 American Medical Association. All Rights Reserved. Page 22

23 Opportunity for Improvement Exception Justification Harmonization with Existing Measures therapy is associated with increased risk of stent thrombosis in patients with drug-eluting stents. 29,30,31,32 Late stent thrombosis, or thrombosis >1 year after stent placement, is of particular concern for drug-eluting stents. 31,33 This concern indicates a need for a longer course of dual antiplatelet therapy for patients with drug-eluting stents compared to those with bare metal stents. Patients on an aspirin regimen commonly have their aspirin discontinued prior to surgery due to a perceived increased risk of bleeding complications. 34 However, evidence shows that perioperative aspirin does not increase the risk of bleeding and can actually decrease the risk of some complications. 35,36 A medical reason exception is included so that clinicians may except patients in instances where the use of aspirin is not indicated(eg, risks of preoperative aspirin therapy are greater than the risks of withholding aspirin). There are no known similar existing measures therefore harmonization was not applicable. Measure Designation Quality Improvement Measure purpose Type of measure Level of Measurement Care setting Data source Process Individual Clinician Ambulatory Care Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 23

24 Measure #7: Surgical Safety Checklist Applicable Safety Checks Completed Before Induction of Anesthesia Measure Description Anesthesiology and Critical Care Percentage of patients, regardless of age, who undergo a surgical procedure under anesthesia who have documentation that all applicable safety checks from the World Health Organization (WHO) Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of anesthesia Measure Components Numerator Statement Patients who have documentation that all applicable safety checks of the WHO Surgical Safety Checklist (or other surgical checklist that includes the applicable safety checks for the specific procedure) were performed before induction of anesthesia Definition: The WHO Surgical Safety Checklist includes the following items Before Induction of Anesthesia Has the patient confirmed his/her identity, site, procedure and consent? Is the site marked? Is the anaesthesia machine and medication check complete? Is the pulse oximeter on the Patient And Functioning? Does the Patient have a: Known Allergy? Difficult Airway/Aspiration Risk? Risk of >500 ml Blood Loss (7ml/kg in children)? Statement Exclusion(s) Exception(s) Supporting Guideline & Other References All patients, regardless of age, who undergo a surgical procedure under anesthesia None None WHO Guidelines for Safe Surgery 37 The World Health Organization s Surgical Safety Checklist reinforces established safety practices and ensures beneficial preoperative, intraoperative and postoperative steps are undertaken in a timely and efficient way. Introducing key safety elements into the operating routine, teams could maximize the likelihood of the best outcome for all surgical patients without placing an undue burden on the system or the providers. WHO Surgical Safety Checklist is available at American Medical Association. All Rights Reserved. Page 24

25 Measure Importance Relationship to In 2009, the World Health Organization (WHO) Safe Surgery Saves Lives desired outcome Study Group published a study showing that utilization of a surgical safety checklist resulted in reduced perioperative mortality and complication rates. 38 Since then, surgical safety checklists have been widely implemented around the world. Further studies confirm the WHO findings that implementation of the surgical safety checklist improves communication among members of the surgical team and reduces perioperative morbidity and mortality. 39,40,41,42 Opportunity for Improvement Exception Justification Harmonization with Existing Measures While the number of surgery-related sentinel events has decreased over the past several years, operative care still remains one of the top ten root causes for sentinel events. 19 To address patient safety concerns in the operating room, surgical safety checklists have been widely implemented in recent years. However, compliance with surgical safety checklists and safety checklist protocols has been shown to vary widely, 40,43,44,45. The level of checklist compliance has been shown to vary depending on the implementation strategy. 43 This measure has no exceptions. There are no known similar existing measures therefore harmonization was not applicable. Measure Designation Measure purpose Quality Improvement Accountability Type of measure Process Level of Measurement Care setting Data source Individual Clinician Ambulatory Care Hospital/Acute Care Facility Claims 2014 American Medical Association. All Rights Reserved. Page 25

26 EVIDENCE CLASSIFICATION/RATING SCHEMES The Centers for Disease Control and Prevention (CDC): Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB. Strongly recommended for implementation and supported by some experimental, clinical, or epidemiologic studies and a strong theoretical rationale; or an accepted practice (e.g., aseptic technique) supported by limited evidence. Category IC. Required by state or federal regulations, rules, or standards. Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. Unresolved issue. Represents an unresolved issue for which evidence is insufficient or no consensus regarding efficacy exists American College of Cardiology Foundation (ACCF)/American Heart Association (AHA)/ Society for Cardiac Angiography and Interventions (SCAI) Classification of Recommendations Class I: Conditions for which there is evidence and/or general agreement that a given procedure or treatment is beneficial, useful, and effective. Class II: Conditions for which there is conflicting evidence and/or a divergence of opinion about the usefulness/efficacy of a procedure or treatment. Class IIa: Weight of evidence/opinion is in favor of usefulness/efficacy. Class IIb: Usefulness/efficacy is less well established by evidence/opinion. Class III: Conditions for which there is evidence and/or general agreement that a procedure/treatment is not useful/effective and in some cases may be harmful. Level of Evidence Level of Evidence A: Data derived from multiple randomized clinical trials or meta-analyses. Level of Evidence B: Data derived from a single randomized trial, or nonrandomized studies. Level of Evidence C: Only consensus opinion of experts, case studies, or standard-of-care. Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting (SAMBA) A variety of grading systems has been proposed to document the strength of evidence of randomized and observational studies supporting a treatment. The panel decided not to grade the included literature but to base its recommendations exclusively on valid studies with a minimal risk of bias. Thus, recommendations were made only if they were supported by randomized trials and systematic reviews of randomized trials that documented efficacy and harm of antiemetic interventions, and by nonrandomized studies that used logistic regression to identify risk factors of PONV American Medical Association. All Rights Reserved. Page 26