October 1, 2010 Guidelines for Using Release Notes Release Notes 3.3 provide modifications to the Specifications Manual for National Hospital Inpatient Quality Measures. The Release Notes are provided as a reference tool and are not intended to be used to program abstraction tools. Please refer to the Specifications Manual for National Hospital Inpatient Quality Measures for the complete and current technical specifications and abstraction information. The notes are organized to follow the order of the Table of Contents. Within each topic section, a row represents a change beginning with general changes followed by data elements in alphabetical order. The implementation date is 04-01-2011 unless otherwise specified. The headings are described below: Impacts - used to identify which portion(s) of the Manual Section is impacted by the change listed. Examples are Alphabetical Data Dictionary, (Measure Set) Data Element List, Measure Information Form (MIF) and Flowchart (Algorithm). The measures that the data element is collected for are identified. Description of Changes - used to identify the section within the document where the change occurs, e.g., Definition, Data Collection Question, Allowable Values, and Denominator Statement - Data Elements. Rationale - provided for the change being made. NOTE: In addition to being called out specifically in the Release Notes document, additions and deletions are listed and additions are yellow highlighted in the corresponding document. Exceptions: The additions and changes to the Algorithms are not yellow highlighted, and the Hospital Initial Patient Population and Clinical Data XML File Layouts are yellow highlighted in the cells that have a change in them and the actual changes are bolded. Data elements that cross multiple measures and contain the same changes will be consolidated. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-1
October 1, 2010 Release Notes Table of Contents... 5 Using the... 6 Table of Contents... 7 Introduction to the Data Dictionary... 8 Alphabetical Data Dictionary... 9 ACEI Prescribed at Discharge... 9 Admission Date... 9 Adult Smoking History...10 Anesthesia Start Time...11 Another Source of Infection...11 Antibiotic Administration Date...11 Anticoagulation Therapy Prescribed at Discharge...11 Antithrombotic Therapy Prescribed at Discharge...12 ARB Prescribed at Discharge...13 Aspirin Prescribed at Discharge...13 Aspirin Received Within 24 Hours Before or After Hospital Arrival...14 Beta-Blocker Prescribed at Discharge...14 Clinical Trial...15 Comfort Measures Only...15 Compromised...18 Diagnostic Uncertainty...18 Discharge Disposition...18 Discharge Instructions Address Medications...19 Discharge Status...19 Education Addresses Medications Prescribed at Discharge...19 Elective Carotid Intervention...20 First In-Hospital LDL-Cholesterol Qualitative Description...21 First In-Hospital LDL-Cholesterol Value...21 Healthcare Associated PN...21 Home Management Plan of Care Document Addresses Arrangements for Follow-up Care 22 ICD-9-CM Other Diagnosis Codes...22 ICD-9-CM Other Procedure Codes...22 ICD-9-CM Other Procedure Dates...23 ICU VTE Prophylaxis...23 In-Hospital LDL-Cholesterol Test...23 Initial ECG Interpretation...24 IV Thrombolytic Initiation...25 Lipid-Lowering Agent Prescribed at Discharge...25 Monitoring Documentation...26 Parenteral Anticoagulant Prescribed at Discharge...26 Plan for LDL-Cholesterol Test...27 Pneumococcal Vaccination Status...27 Pneumonia Diagnosis: ED/Direct Admit...28 Pre-Arrival LDL-Cholesterol Qualitative Description...28 Pre-Arrival LDL-Cholesterol Test...28 Pre-Arrival LDL-Cholesterol Value...28 Pre-Arrival Lipid-Lowering Agent...29 Reason for No Aspirin at Discharge...29 Reason for No Aspirin on Arrival...30 Reason for No LDL-Cholesterol Testing...30 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-2
October 1, 2010 Reason for No Lipid-Lowering Therapy...30 Reason for No VTE Prophylaxis-Hospital Admission...30 Reason for No VTE Prophylaxis-ICU Admission...32 Reason for Not Administering Systemic Corticosteroids...33 Reasons for Not Administering VTE Prophylaxis...33 Reason for Not Initiating IV Thrombolytic...34 Reason for Not Prescribing Anticoagulation Therapy at Discharge...35 Reason for Not Prescribing Antithrombotic Therapy at Discharge...37 Reason for Not Prescribing Statin Medication at Discharge...39 Reasons to Extend Antibiotics...40 Statin Medication Prescribed at Discharge...42 Systemic Corticosteroids Administered...43 VTE Diagnostic Test...44 VTE Prophylaxis...44 VTE Prophylaxis Date...45 VTE Prophylaxis Status...46 Warfarin Prescribed at Discharge...46 Acute Myocardial Infarction (AMI) Acute Myocardial Infarction (AMI) Measure Information Form...48 Acute Myocardial Infarction (AMI) Measure Information Flowchart (Algorithm)...52 Heart Failure (HF) Heart Failure (HF) Measure Information Form...54 Heart Failure (HF) Measure Information Flowchart (Algorithm)...55 Pneumonia (PN) Pneumonia (PN) Measure Information Form...56 Pneumonia (PN) Measure Information Flowchart (Algorithm)...59 Surgical Care Improvement Project (SCIP) Surgical Care Improvement Project (SCIP) Measure Information Form...61 Surgical Care Improvement Project (SCIP) Measure Information Flowchart (Algorithm)...61 Children's Asthma Care (CAC) Children s Asthma Care (CAC) Measure Information Form...64 Children s Asthma Care (CAC) Measure Information Flowchart (Algorithm)...66 Venous Thromboembolism (VTE) Venous Thromboembolism (VTE) Measure Information Form...67 Venous Thromboembolism (VTE) Measure Information Flowchart (Algorithm)...68 Stroke (STK) Stroke (STK) Measure Information Form...71 Stroke (STK) Measure Information Flowchart (Algorithm)...72 Emergency Department (ED) Emergency Department (ED) Measure Information Form...74 Emergency Department (ED) Measure Information Flowchart (Algorithm)...74 Prevention (Prev-Imm) Prevention (Prev-Imm) Measure Information Form...75 Prevention (Prev-Imm) Measure Information Flowchart (Algorithm)...75 Missing and Invalid Data...76 Data Transmission...77 Transmission Alphabetical Data Dictionary...78 Transmission Data Processing Flow: Pop and Samp...79 Hospital Clinical Data XML File Layout...79 CMS Outcome Measures (Claim Based) Risk Standardized Mortality Measures (MORT)...85 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-3
October 1, 2010 Risk Standardized Readmission Measures (READM)...95 Appendices Appendix A... 104 Appendix C... 107 Appendix D... 109 Appendix E... 110 Appendix F... 110 Appendix H... 111 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-4
October 1, 2010 Impacts: All Sections All Sections Change: Reporting Hospital Quality Data for Annual Payment Update (RHQDAPU) program to Hospital Inpatient Quality Reporting Program Rationale: To align with the CMS program name change. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-5
October 1, 2010 Using the Impacts: N/A Remove for Collected Measures from the title in Appendix E. Rationale: To reflect changes to the title of Appendix E. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-6
October 1, 2010 Table of Contents Impacts: AMI-T1a, AMI-T2 Section 2 Measure Information Remove: AMI-T1a and AMI-T2 from AMI Measure Information Form (MIF) and Flowchart (Algorithm) Rationale: Maintain concordance with latest ACC/AHA performance measures and clinical guidelines. AMI-10 covers lipid management for AMI patients. Impacts: N/A Appendices Remove for Collected Measures from the title in Appendix E. Rationale: To reflect changes to the title of Appendix E. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-7
October 1, 2010 Introduction to the Data Dictionary Impacts: All Introduction Remove Discharge Status from the listing of the general data elements. Rationale: To reduce the number of changes and potential addendums related to changes by the NUBC and make the data element more applicable to the quality measures. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-8
October 1, 2010 Alphabetical Data Dictionary Data Element Name: ACEI Prescribed at Discharge Impacts: AMI-3, HF-3 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Admission Date Impacts: All Notes for Abstraction Remove bullets: A patient of a hospital is considered an inpatient upon issuance of written doctor s order to that effect. (Refer to the Medicare Claims Processing Manual, Chapter 3, Section 40.2.2.) For patients that are admitted for surgery and/or a procedure, if the admission order states the date the orders were written and they are effective for the surgery/procedure date, then the date of the surgery/procedure would be the admission date. If the medical record reflects that the admission order was written prior to the actual date the patient was admitted and there is no reference to the date of the surgery/procedure, then the date the order was written would be the admission date. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-9
October 1, 2010 Change the last sentence in the 1 st bullet from If the abstractor determines through chart review that the date is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value. to If the abstractor determines through chart review that the date from billing is incorrect, for purposes of abstraction, she/he should correct and override the downloaded value. Add to the 3 rd bullet: Example: o Medical record documentation reflects that the patient was admitted to observation on 04-05-20xx. On 04-06-20xx the physician writes an order to admit to acute inpatient effective 04-05-2010. The Admission Date would be abstracted as 04-06-20xx; the date the determination was made to admit to acute inpatient care and the order was written. Add bullet: If there are multiple inpatient orders, use the order that most accurately reflects the date that the patient was admitted. The admission date should not be abstracted from the earliest admission order without regards to substantiating documentation. If documentation suggests that the earliest admission order does not reflect the date the patient was admitted to inpatient care, this date should not be used. Example: Preoperative Orders are dated as 04-06-20xx with an order to admit to Inpatient. Postoperative Orders, dated 05-01-20xx, state to admit to acute inpatient. All other documentation supports that the patient presented to the hospital for surgery on 05-01-20xx. The admission date would be abstracted as 05-01-20xx. Suggested Data Sources Change PRIORITY ORDER FOR THESE SOURCES to ONLY ALLOWABLE SOURCES Add: Excluded Data Sources UB-04, Field Location: 06 Rationale: To provide clarification and minimize the potential for abstracting an inaccurate admission date. Data Element Name: Adult Smoking History Impacts: AMI-4, HF-4, PN-4 Suggested Data Sources Only Acceptable Sources: Add: Smoking/Tobacco Use assessment forms Rationale: Enable collection of smoking history information from these types of forms which are currently not covered in the Only Acceptable Sources list. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-10
October 1, 2010 Data Element Name: Anesthesia Start Time Impacts: SCIP-Inf-10, SCIP-VTE-1, SCIP-VTE-2 Inclusion Guidelines for Abstraction: Add: o Anesthesia start o Anesthesia begin o Anesthesia initiated Rationale: Inadvertently omitted from the inclusion guidelines in Version 3.2c Data Element Name: Another Source of Infection Impacts: PN6, PN-6a, PN-6b Suggested Data Sources Change: Lab Results to be above PHYSICIAN/ADVANCED PRACTICE NURSE/PHYSICIAN ASSISTANT DOCUMENTATION ONLY Rationale: Clarification for abstraction. Documentation from lab results do not have to be physician documentation. Data Element Name: Antibiotic Administration Date Impacts: PN-3b, PN-5, PN-5c, PN-6, PN-6a, PN-6b, SCIP-Inf-1, SCIP-Inf-2, SCIP-Inf-3 Note for Abstraction Remove the 7 th bullet, 2 nd example: An Admission Date of 11-20-20XX is documented but the Antibiotic Administration Date is documented as 11-19-20xx. If documentation cannot be found on that same source to support the correct date, that dose cannot be abstracted as given during the hospital stay but should be used to abstract Antibiotic Received, as applicable. Rationale: Clarification in abstraction: Note for Abstraction the way it is may lead to confusion and the example is not correct. Data Element Name: Anticoagulation Therapy Prescribed at Discharge Impacts: STK-3 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-11
October 1, 2010 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Antithrombotic Therapy Prescribed at Discharge Impacts: STK-2 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-12
October 1, 2010 there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: ARB Prescribed at Discharge Impacts: AMI-3, HF-3 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Aspirin Prescribed at Discharge Impacts: AMI-2 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-13
October 1, 2010 determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Aspirin Received Within 24 Hours Before or After Hospital Arrival Impacts: AMI-1 Notes for Abstraction: Change from: When unable to determine for certain whether aspirin was received within 24 hours prior to arrival (e.g., last dose noted as 02-27-20XX and patient arrived at hospital on 02-28-20XX at 09:00), select No. EXCEPTIONS: o When aspirin is listed only as a home or "current" medication, and the exact timing of the last dose the patient took is not noted, infer that the patient took aspirin within the 24 hour timeframe, unless documentation suggests otherwise. o When aspirin is noted only as received prior to arrival, without information about the exact time it was received (e.g., "Baby ASA X 4" per the "Treatment Prior to Arrival" section of the Triage Assessment), infer that the patient took aspirin within the 24 hour timeframe, unless documentation suggests otherwise. To: Aspirin listed as current or home" medication should be inferred as taken within 24 hours prior to arrival, unless documentation suggests otherwise. EXCEPTION: Aspirin documented as a PRN current/home medication does not count unless documentation is clear it was taken within 24 hours prior to arrival. When aspirin is noted only as received prior to arrival, without information about the exact time it was received (e.g., "Baby ASA X 4" per the "Treatment Prior to Arrival" section of the Triage Assessment), infer that the patient took aspirin within the 24 hour timeframe, unless documentation suggests otherwise. Rationale: Change abstraction guidelines to clarify how to handle cases where aspirin is noted as a home medication with last dose date but no time. Additionally, add guideline to clarify how to handle aspirin taken at home on prn basis. Data Element Name: Beta-Blocker Prescribed at Discharge Impacts: AMI-5 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-14
October 1, 2010 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Clinical Trial Impacts: AMI-T1a, AMI-T2 Collected For CMS Only: Remove: AMI-T1a (Optional Test Measure), AMI-T2 (Optional Test Measure) Rationale: Retirement of AMI-T1a and AMI-T2. Data Element Name: Comfort Measures Only Impacts: AMI-T1a, AMI-T2 Collected For CMS Only: Remove: AMI-T1a (Optional Test Measure), AMI-T2 (Optional Test Measure) Rationale: Retirement of AMI-T1a and AMI-T2. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-15
October 1, 2010 Impacts: AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-9, AMI-10, HF-1, HF-2, HF-3, HF-4, PN-2, PN-3, PN-3a, PN-4, PN-5, PN-5c, PN-6, PN-6a, PN-6b, PN-7, STK-1, STK-2, STK-3, STK-5, STK-6, STK-8, STK-10, VTE-1, VTE-2, VTE-3, VTE-4, VTE-6 Notes for Abstraction Change 2 nd bullet to: Determine the earliest day the physician/apn/pa DOCUMENTED comfort measures only in the ONLY ACCEPTABLE SOURCES. Do not factor in when comfort measures only was actually instituted. E.g., Discussed comfort care with family on arrival noted in day 2 progress note Select 2. Remove the 4 th bullet and its sub-bullets Change 5 th bullet to: If any of the inclusions are documented in the ONLY ACCEPTABLE SOURCES, select 1, 2, or 3 accordingly, unless otherwise specified in this data element. Add new bullet and sub-bullets: Documentation of an Inclusion term in the following situations should be disregarded. Continue to review the remainder of the ONLY ACCEPTABLE SOURCES for Inclusion terms. If the ONLY documentation found is an Inclusion term in the following situations, select value 4 : o Documentation that is dated prior to arrival or documentation which refers to the pre-arrival time period (e.g., comfort measures only order in previous hospitalization record, Pt. on hospice at home in discharge summary). EXCEPTION: State-authorized portable orders (SAPOs). SAPOs are specialized forms, Out-of- Hospital DNR (OOH DNR) or Do Not Attempt Resuscitation (DNAR) orders, or identifiers authorized by state law, that translate a patient s preferences about specific-end-of-life treatment decisions into portable medical orders. Examples: DNR-Comfort Care form MOLST (Medical Orders for Life-Sustaining Treatment) POLST (Physician Orders for Life-Sustaining Treatment) o Inclusion term not clearly selected on order form signed by the physician/apn/pa. Examples: DNR-Comfort Care order form - The only option checked is DNR/Allow Natural Death (option Comfort Care remains unchecked) Home Health/Hospice order form Hospice has not been circled in the title or selected on the form Inclusion term listed in pre-printed instruction for completing the form o Inclusion term clearly described as negative. Examples: - No comfort care" - Not a hospice candidate" - "Declines palliative care" - "Not appropriate for hospice care" - I offered palliative care consult to discuss end of life issues. Family did not show any interest. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-16
October 1, 2010 - Patient declines hospice care at this time but I feel this will be an important plan of care when his condition deteriorates further - Palliative care would also be reasonable - defer decision for now o Comfort care when explicitly documented in any of the formats listed in the Exclusion List. Example: DNR-CCA box is checked on order form Disregard ("DNR-CCA" is a listed exclusion). Change 7 th bullet to: If there is documentation of an Inclusion term clearly described as negative in one source, and an Inclusion term NOT described as negative in another source, that second source would still count for comfort measures only. Examples: o On Day 0 the physician documents The patient is not a hospice candidate. On Day 3, the physician orders a hospice consult. Select 2. o On Day 1 the physician documents the patient is comfort measures only. On Day 2 the physician documents The patient is refusing CMO. Select 1. Remove 8 th bullet: If DNR-CC is documented, select 4, unless there is documented clarification that CC stands for comfort care. Suggested Data Sources Add to PHYSICIAN/APN/PA DOCUMENTATION ONLY: IN THE FOLLOWING ONLY ACCEPTABLE SOURCES: Remove: Admitting physician orders Consultation notes Emergency department record History and physical Physician admitting note Add: DNR/MOLST/POLST forms Inclusion Guidelines for Abstraction Add: DNR-CC Exclusion Guidelines for Abstraction Change to: DNR-Comfort Care Arrest (Only terms listed below count as an Exclusion. Other arrest terminology would NOT count as Exclusion - E.g., Comfort Care Protocol will be implemented in the event of a cardiac arrest or a respiratory arrest ) Add: DNR-Comfort Care Arrest Rationale: Reduce number of false positives (false measure exclusions). Provide clarification for abstractors. Reduce abstraction burden. Improve consistency. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-17
October 1, 2010 Data Element Name: Compromised Impacts: PN-6, PN-6a, PN-6b Notes For Abstraction Add to last bullet: value 1 after If there is physician/apn/pa documentation of significant or marked neutropenia, select Remove from last bullet: Yes after If there is physician/apn/pa documentation of significant or marked neutropenia, select Inclusion Guidelines for Abstraction Add to Compromising Conditions Within the Last 3 Months: Systemic Chemotherapy Systemic Corticosteroid/Prednisone therapy Systemic Immunosuppressive therapy Rationale: Clarification for abstraction Data Element Name: Diagnostic Uncertainty Impacts: PN-5, PN-5c Notes for Abstraction: Change the 6th bullet to: Documentation of the delay can refer to either the pneumonia diagnosis or to antibiotic administration. Rationale: Due to practitioner and physician feedback, documentation of a delay in antibiotic administration will now be accepted. Data Element Name: Discharge Disposition Impacts: AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-9, AMI-10, HF-1, HF-2, HF-3, HF-4, PN-2, PN-3b, PN-4, PN-5, PN-5c, PN-7, CAC-3, STK-2, STK-3, STK-6, STK-8, STK-10, VTE-3, VTE-4, VTE-5, Prev-1, Prev-2 Add data element Discharge Disposition. Rationale: To reflect what the final disposition of the patient was to determine if the appropriate care, treatment, education, etc. was provided. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-18
October 1, 2010 Data Element Name: Discharge Instructions Address Medications Impacts: HF-1 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Discharge Status Impacts: AMI-1, AMI-2, AMI-3, AMI-4, AMI-5, AMI-9, AMI-10, HF-1, HF-2, HF-3, HF-4, PN-2, PN-3b, PN-4, PN-5, PN-5c, PN-7, CAC-3, STK-2, STK-3, STK-6, STK-8, STK-10, VTE-5, Prev-1, Prev-2 Alphabetical Data Dictionary Remove data element Discharge Status from the Alphabetical Data Element List and the Data Dictionary. Rationale: To reduce the number of changes and potential addendums related to changes by the NUBC and make the data element more applicable to the quality measures. Data Element Name: Education Addresses Medications Prescribed at Discharge Impacts: STK-8 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-19
October 1, 2010 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Elective Carotid Intervention Impacts: All Stroke Notes for Abstraction: Remove: When conflicting information is documented in a medical record, e.g., internist documents elective and surgeon documents non-elective or unspecified, select No. Change bullet From: When documentation clearly indicates that the carotid intervention is elective, (e.g., admitting orders to obtain informed consent for a carotid procedure, preoperative testing completed prior to admission ), select Yes. To: When documentation clearly indicates that the carotid intervention is elective, (e.g., admitting orders to obtain informed consent for a carotid procedure; preoperative testing completed prior to admission; surgical orders for carotid endarterectomy dated prior to arrival; physician office visit documentation prior to arrival stating, CEA with Dr. X planned in the near future ), select Yes. Change bullet from: Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-20
October 1, 2010 If the patient was admitted following elective carotid intervention performed as outpatient, select No. To: When the patient is directly admitted to the hospital post-procedure following an elective carotid intervention performed as an outpatient, select Yes. Example: Patient scheduled for elective carotid endarterectomy right side on 05/17/20XX at 08:30. Patient checks into outpatient surgery at 06:13 and proceeds to the O.R, then to PACU. Patient status is changed to inpatient at 11:35 on 05/17/20XX. Patient discharged home on 05/18/20XX. EXCEPTION: Patients with documentation of an elective carotid intervention performed and discharged from the outpatient setting prior to hospital admission for stroke. Example: Patient scheduled for outpatient placement of an elective right carotid stent on 05/17/20XX. Patient discharged home on 05/17/2010 following the procedure. Patient arrives in the ED two days later with complaints of syncope and left-sided numbness, and is admitted to the hospital on 05/19/20XX. Guidelines for Abstraction - Inclusion: Add sub-bullet o Asymptomatic o Prophylactic Rationale: Provide clarification for the abstractor. Data Element Name: First In-Hospital LDL-Cholesterol Qualitative Description Impacts: AMI-T2 Remove data element from the data dictionary Rationale: Retirement of AMI-T2 Data Element Name: First In-Hospital LDL-Cholesterol Value Impacts: AMI-T2 Remove data element from the data dictionary Rationale: Retirement of AMI-T2. Data Element Name: Healthcare Associated PN Impacts: PN-6, PN-6a, PN-6b Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-21
October 1, 2010 Definition: Remove: calendar days Notes for Abstraction: Change the 5 th bullet to: Do not make an assumption as to the patient s admission or hospitalization based on the procedure they received. Only use phrases such as in the hospital last month, etc. Rationale: Clarification that documentation of length of stay is not required. If there is documentation of a hospitalization or admission, assume it was an acute care hospitalization unless there is documentation that states otherwise. Data Element Name: Home Management Plan of Care Document Addresses Arrangements for Follow-up Care Impacts: CAC-3 Notes for Abstraction Add a 4 th bullet: If the patient s home is out of state or out of the country and there is documentation that provider contact information is not accessible to the health care organization, AND there is documentation that the patient/caregiver were given a time frame for appointment for follow-up care, select Allowable Value 2. Example: Patient lives outside of US, unable to access provider contact information. Caregiver instructed to make appointment for follow-up care as soon as possible upon return home. Rationale: A revision is being made to the data element to address circumstances beyond provider control that could cause a case to fail the measure. Data Element Name: ICD-9-CM Other Diagnosis Codes Impacts: All Records Format: Change Occurs from 17 to 24 Rationale: To align with the IPPS Final Rule. Data Element Name: ICD-9-CM Other Procedure Codes Impacts: All Records Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-22
October 1, 2010 Format: Change Occurs from 5 to 24 Rationale: To align with the IPPS Final Rule. Data Element Name: ICD-9-CM Other Procedure Dates Impacts: All Records Format: Change Occurs from 5 to 24 Rationale: To align with the IPPS Final Rule. Data Element Name: ICU VTE Prophylaxis Impacts: VTE-2 Format Change Occurs from 1-8 to 1-7 Allowable Values Remove: 8 Oral Factor Xa Inhibitor Notes for Abstraction Change first bullet from: Selection of allowable values 1-8 includes any prophylaxis that was initially admintered on the same date. To: Selection of allowable values 1-7 includes any prophylaxis that was initially admintered on the same date. Rationale: Rivaroxaban has not been approved by the FDA Data Element Name: In-Hospital LDL-Cholesterol Test Impacts: AMI-T1a, AMI-T2 Remove data element from data dictionary Rationale: Retirement of AMI-T1a and AMI-T2. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-23
October 1, 2010 Data Element Name: Initial ECG Interpretation Impacts: AMI-7, AMI-7a, AMI-8, AMI-8a Notes for Abstraction Change from: 3. If there is no signed tracing, or in the absence of an Exclusion on the signed tracing, proceed to other interpretations that you can say clearly refer to the ECG done closest to arrival. Documentation which cannot be tied to the ECG performed closest to arrival should not be used. Do not cross reference findings between interpretations unless otherwise specified. If you encounter an Exclusion in any of the other interpretations, select No, regardless of other documentation, and there is no need to review further. To 3. If there is no signed tracing, or in the absence of an Exclusion on the signed tracing, proceed to other interpretations that you can say clearly refer to the ECG done closest to arrival. Only those terms specifically identified or referred to by the physician/apn/pa as ECG findings AND where documentation is clear it is from the ECG performed closest to arrival should be considered in abstraction (e.g., STEMI listed only as a physician diagnosis or impression would not be used). Do not cross reference findings between interpretations unless otherwise specified. If you encounter an Exclusion in any of the other interpretations, select No, regardless of other documentation, and there is no need to review further. Rationale: Clarify for the abstractor how to handle notations not specifically identified as initial ECG findings (e.g., Impressions, Diagnoses). Change from: If at least one interpretation describes an LBBB as old, chronic, or previously seen, all LBBB findings should be disregarded. To: If at least one interpretation describes an LBBB as old, chronic, or previously seen, or states LBBB and "no changes," "unchanged," "no acute changes," "no new changes," or "no significant changes" when compared to a prior ECG, all LBBB findings should be disregarded. Change from: Notations which describe ST-elevation as old, chronic, or previously seen, or as a range where it cannot be determined if elevation is less than 1 mm/.10mv (e.g., "0.5-1 mm ST-elevation"), should be disregarded. Other documentation of STelevation not described as such may still count as an Inclusion. To: Notations which describe ST-elevation as old, chronic, or previously seen, or which state ST-elevation and "no changes," "unchanged," "no acute changes," "no new changes," or "no significant changes" when compared to a prior ECG should be disregarded. Other documentation of ST-elevation not described as such may still count as an Inclusion. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-24
October 1, 2010 Notations which describe ST-elevation as a range where it cannot be determined if elevation is less than 1 mm/.10mv (e.g., "0.5-1 mm ST-elevation"), should be disregarded. Other documentation of ST-elevation not described as such may still count as an Inclusion. Rationale: Provide clarification for abstractors and reduce the number of false measure inclusions. Guidelines for Abstraction - Left bundle branch block (LBBB) - Exclusion Remove: Intraventricular conduction delay (IVCD) or block Rationale: Reduce number of false measure exclusions by allowing IVCD findings (not described as LBBB type) to be disregarded. Data Element Name: IV Thrombolytic Initiation Impacts: STK-4 Notes for Abstraction: Add When IV thrombolytic therapy is administered beyond 3 hours (180 min.) because a reason for not initiating IV thrombolytic therapy existed during the 3 hour timeframe, select No. Examples: o Patient arrives in the emergency department within 2 hours of time last known well. Blood pressure 195/110 mmhg on arrival. Physician documents that patient is within the t-pa window, but blood pressure is an issue. Elevated blood pressure treated prior to t-pa administration. IV thrombolytic therapy administered at 3 hours and 30 minutes from time last known well. o Patient arrives in the emergency department within 2 hours of time last known well and refuses t-pa. Family arrives and after further discussion with them, patient consents to t-pa. IV thrombolytic therapy administered 4 hours later. Rationale: Prevent false inclusions. Data Element Name: Lipid-Lowering Agent Prescribed at Discharge Impacts: AMI-T2 Remove data element from data dictionary Rationale: Retirement of AMI-T2. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-25
October 1, 2010 Data Element Name: Monitoring Documentation Impacts: VTE-4 Definition Change from: Documentation that defined parameters such as a nomogram or protocol were used to manage the intravenous (IV) unfractionated heparin (UFH) AND platelet counts were monitored according to the defined specifications. To: Documentation that defined parameters such as a nomogram or protocol were used to manage the intravenous (IV) unfractionated heparin (UFH) AND platelet counts. Notes for Abstraction Change 1 st bullet from: Pathways or orders that state that a nomogram or protocol was used to calculate the UFH therapy dosages are acceptable. The pathways or orders must specify that the platelet counts were being monitoring within the defined specifications. To: Pathways, orders or documentation that state that a nomogram or protocol was used to calculate the UFH therapy dosages and platelet count monitoring are acceptable. Remove 3 rd bullet: Platelet count monitoring must be within the defined specifications of the inclusion guidelines in order to select Yes. Change 4 th bullet from: For orders that state that UFH therapy is ordered per pharmacy dosing or per pharmacy protocol select Yes if the platelet counts were also monitored within the defined specifications. To: For orders that state that UFH therapy is ordered per pharmacy dosing or per pharmacy protocol select Yes if there is documentation that platelet counts were also monitored. Suggested Data Sources Add 2 nd bullet Physician and Pharmacist Notes Rationale: Since none of the ACCP platelet count monitoring recommendations are Grade 1A and the platelet count monitoring varies based on the patients risk for heparin-induced thrombocytopenia (HIT) the inclusion guidelines cannot be applied to all patient receiving UFH therapy. Data Element Name: Parenteral Anticoagulant Prescribed at Discharge Impacts: VTE-3 Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-26
October 1, 2010 Notes for Abstraction: Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Plan for LDL-Cholesterol Test Impacts: AMI-T1a Remove data element from data dictionary Rationale: Retirement of AMI-T1a. Data Element Name: Pneumococcal Vaccination Status Impacts: PN-2 Allowable Values Add to Value 4: OR received the shingles vaccine (Zostavax) within the last 4 weeks Rationale: Clinical evidence of drug- drug interaction with concomitant administration of vaccines. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-27
October 1, 2010 Data Element Name: Pneumonia Diagnosis: ED/Direct Admit Impacts: PN-3a, PN-3b, PN-5, PN-5c, PN-6, PN-6a, PN-6b Notes for Abstraction: Pneumonia Diagnosis in the Emergency Department Add as 7 th bullet: ED face sheets can only be used if signed by a physician/apn/pa Medical Records containing an ED form completed by the ED physician: Add at end of heading: APN/PA Inclusion Guidelines for Abstraction: This list is ALL Inclusive Add Admission Pneumonia Diagnosis Codes (except for aspiration pneumonia) Rationale: Clarification for abstraction. Data Element Name: Pre-Arrival LDL-Cholesterol Qualitative Description Impacts: AMI-T1a, AMI-T2 Remove data element from data dictionary Rationale: Retirement of AMI-T1a and AMI-T2. Data Element Name: Pre-Arrival LDL-Cholesterol Test Impacts: AMI-T1a, AMI-T2 Remove data element from data dictionary Rationale: Retirement of AMI-T1a and AMI-T2. Data Element Name: Pre-Arrival LDL-Cholesterol Value Impacts: AMI-T1a, AMI-T2 Remove data element from data dictionary Rationale: Retirement of AMI-T1a and AMI-T2. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-28
October 1, 2010 Data Element Name: Pre-Arrival Lipid-Lowering Agent Impacts: AMI-T1a Collected For CMS Only: Remove: AMI-T1a (Optional Test Measure) Rationale: Retirement of AMI-T1a. Data Element Name: Reason for No Aspirin at Discharge Impacts: AMI-2 Notes for Abstraction: Change from: Reason documentation which refers to a more general medication class is not acceptable (e.g., Hold all anticoagulants ). To: Reason documentation which refers to a more general medication class is not acceptable (e.g., Hold all anticoagulants ). Exception: Documentation of a reason for not prescribing "antiplatelets" should be considered implicit documentation of a reason for no aspirin at discharge (e.g., "Antiplatelet therapy contraindicated ). Rationale: Reduce number of false measure inclusions. A documented reason for not prescribing antiplatelets is an acceptable reason for not prescribing aspirin. Change from: If two discharge summaries are included in the medical record, use the one with the latest date. If one or both are not dated, and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Examples: Two discharge summaries, one dated 5/22 (day of discharge) and one dated 5/27 - Use the 5/27 discharge summary. To If two discharge summaries are included in the medical record, use the one with the latest date/time. If one or both are not dated or timed and you cannot determine which was done last, use both. This also applies to discharge medication reconciliation forms. Use the dictated date/time over transcribed date/time, file date/time, etc. Examples: Two discharge summaries, one dictated 5/22 (day of discharge) and one dictated 5/27 - Use the 5/27 discharge summary. Rationale: Clarify for the abstractor how to determine discharge medications where Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-29
October 1, 2010 there is more than one discharge summary (or discharge medication reconciliation form) in the record that have the same date but different times. Data Element Name: Reason for No Aspirin on Arrival Impacts: AMI-1 Notes for Abstraction: Change from: Reason documentation which refers to a more general medication class is not acceptable (e.g., Hold all anticoagulants ). To: Reason documentation which refers to a more general medication class is not acceptable (e.g., Hold all anticoagulants ). Exception: Documentation of a reason for not prescribing "antiplatelets" should be considered implicit documentation of a reason for no aspirin on arrival (e.g., "Antiplatelet therapy contraindicated ). Rationale: Reduce number of false measure inclusions. A documented reason for not prescribing antiplatelets is an acceptable reason for not prescribing aspirin. Data Element Name: Reason for No LDL-Cholesterol Testing Impacts: AMI-T1a Remove data element from data dictionary Rationale: Retirement of AMI-T1a. Data Element Name: Reason for No Lipid-Lowering Therapy Impacts: AMI-T2 Remove data element from data dictionary Rationale: Retirement of AMI-T2.. Data Element Name: Reason for No VTE Prophylaxis-Hospital Admission Impacts: STK-1, VTE-1 Notes for Abstraction: Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-30
October 1, 2010 Change bullet From: Patient refusal may be documented by a nurse, but should be documented within the same timeframe as the reason for no VTE prophylaxis. To: Patient/family refusal may be documented by a nurse, but should be documented within the same timeframe as the reason for no VTE prophylaxis. Patient/family refusal of any form of prophylaxis is acceptable to select Yes. For example, patient refused heparin, select Yes. Add bullet If VTE prophylaxis is not administered because the patient is ambulatory, documentation must explicitly state that ambulation is the reason. For example, No VTE prophylaxis needed. Patient OOB and ambulating in hallway. Documentation that the patient is ambulating alone without mention of VTE prophylaxis is insufficient. Rationale: Provide clarification for the abstractor. Add 4 th bullet: Select Yes if Comfort Measures Only (CMO) was documented beyond the day after arrival (Day 1) but by the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. Examples: o Patient arrives in the ED on 06/01/20XX but is in observation until admission to the hospital on 06/03/20XX. If CMO is documented by 06/04/20XX, select Yes. o The patient was admitted on 5/31/20XX and the surgery end date was 06/01/20XX, select Yes if CMO was documented by 06/02/XX. Rationale: The definition for Comfort Measures Only (CMO) is based on arrival date and the measure numerator statements use admission date to calculate the timeframe for prophylaxis. Since only allowable value 1 can be used to exclude cases from prophylaxis, patients with CMO value 2 documented the day after arrival date but prior to the day after admission should select Yes for this data element. Notes for Abstraction Change 1 st sentence in the 1 st bullet from: Documentation of the reason for no VTE prophylaxis must be located within the timeframe of the day of or the day after hospital admission. To Documentation of the reason for no VTE prophylaxis must be written by the day after hospital admission or surgery end date. Documentation written after arrival but prior to admission is acceptable. Rationale: Need to expand the acceptable timeframe for documentation of a reason for No Prophylaxis. Documentation of a reason for no VTE prophylaxis written after arrival and up to the day after admission (non-icu) would be acceptable. For ICU Admission, documentation of the reason should be written by the day after ICU admission/transfer and be associated with the ICU admission/transfer. Discharges 04-01-11(2Q11) through 12-31-11(4Q11) 1-31