Quality and Patient Safety Council May 27, 2014 Presented By Susan M. Blackhurst BS, RN & Eric Jean BSN, RN, CCRN.

4th Quarter 2013VTE,

IMMs and ED ThroughputCore Measures

Quality and Patient Safety CouncilMay 27, 2014

Presented BySusan M. Blackhurst BS, RN

&Eric Jean BSN, RN, CCRN

Presentation Goals Identify MMC VTE Quality Measures Initiative

CMS Specifications and ACCP Guidelines

Core Measure Data

Opportunities

Next Steps

Brief Update on IMMs/ED Throughput

Recommendations from American College of Chest Physicians (ACCP)For acutely and critically ill nonsurgical patients at increased risk for

VTE, pharmacological prophylaxis is recommended

For acutely and critically ill patients at increased risk for VTE and actively bleeding or at high risk for major bleeding, recommendation is for mechanical means over no prophylaxis; Once bleeding or risk of is no longer present, reconsideration of pharmacological prophylaxis is recommended

For acutely ill medical patients at “Low Risk” for VTE, recommendation is AGAINST pharmacologic and mechanical prophylaxis

Consider compliance, practicality, cost, etc…

(Summary of slides from “Prevention of Venous Thromboembolism in Nonsurgical Patients” Powerpoint; Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines; 2012)

CMS SpecificationsVTE 1 Prophylaxis

If neither pharmacological or mechanical means are ordered, contraindication to each must be documented explicitly by the provider

Ambulation is ONLY an allowable value IF there is documentation from the practitioner that the patient is “LOW RISK FOR VTE” and ambulation is to be used for prophylaxis

VTE Measure Set

General Prophy-laxis 514/571

ICU Prophy-laxis 41/43

Overlap Ther-apy 135/144

Heparin Nomo-gram 103/103

Warfarin In-structions 50/115

Potentially Avoid-able VTE

3/30

Overall Compli-ance

648/780

1st Quarter 0.899 1 0.957 1 0.2 0.1 0.784

2nd Quarter 0.854014598540146

1 0.911764705882353

1 0.307692307692308

0.111111111111111

0.787234042553192

3rd Quarter 0.938 0.929 0.906 1 0.519 0.2 0.868

4th Quarter 0.908 0.941 0.938 1 0.7778 0 0.885

5.0%

15.0%

25.0%

35.0%

45.0%

55.0%

65.0%

75.0%

85.0%

95.0%

VTE Core Measures 2013 All Quarter Comparison

Prophylaxis N=141

ICU Prophylaxis N=17

Potentially Avoidable N=6

No Order by Provider (31/58)

53.4%

SCD's Not Docu-mented by Nurs-

ing (27/58)

47%

VTE 1 & 2 (Prophylaxis) Noncompliant Cases By Discipline

2013 Overall

VTE 1 = 56 cases VTE 2 = 2 cases558/616 compliant = 91.5%58 cases noncompliant

OPPORTUNITIES

VTE 1 and VTE 2 (ICU)Prophylaxis

14 noncompliant cases (4Q2013) for VTE 1 and VTE 2–General and ICU Prophylaxis

Continued Reasons for Provider Noncompliance:• There were no orders for VTE prophylaxis and/or• There were no documented contraindications for

both anticoagulant and mechanical means• Only documenting risk-stratification at a rate

of approximately 50%

VTE 3 OpportunitiesVTE-3 Overlap Therapy

Ensure Warfarin Overlap Therapy is being ordered for 5 days Pharmacy is on-board! Charge nurses are now notifying Clinical Quality staff

of confirmed VTE for concurrent monitoring of measure

VTE 6 Potentially Avoidable PE/DVT

Evaluates VTE prophylaxis delivered between the day of admission and the day before the diagnostic test for confirmed VTE

Directly correlates with providing risk assessment and appropriate prophylaxis on admission and upon changes in level of care

Anticipate reduction in payment for Hospital Acquired Condition (HAC) and/or 30 day Readmission

VBP and appropriate stratification pre- and post-hospitalization

Looking AheadVTE Advisor

Provide decision support to practitioners established by evidence-based practice guidelines

iPath Project

HMS (Hospitalist Medicine Safety) Consortium-VTE Registry

Concurrent Monitoring

Influenza Vaccine

***Is now Pay-For-Performance Pay

Affects Medicare reimbursement beginning October 1, 2015

Performance Measured in calendar years 2012 (baseline rate

96.8%) and 2014 Need minimum 90% rate (achievement threshold)

with goal of 99% Benchmark is 98.8%

Pneumococcal Vaccine

Retired as a Core Measure as of January 1, 2014

Nursing administration and providers will still continue to ensure standard of care based on best-practice and ACIP Guidelines

Influenza

Overall Pneumococcal

Qtr 1 2012

Qtr 2 2012

Qtr 3 2012

Qtr 4 2012

Qtr 1 2013

Qtr 2 2013

Qtr 3 2013

Qtr 4 2013

ED 1B ED Arrival to ED Departure

269 310 327 327 319 309 333 309

CMS Top 10%

175 175 175 175 175 175 175 176

ED 2B Decision to Admit to ED Departure

157 161 164.5 181 179 172 170 181

CMS Top 10%

42 42 42 42 42 42 42 41

25

75

125

175

225

275

325

ED Throughput-Median Times

Tim

e i

n M

inu

te

s

Inpatient Sample SizeQtr 1 2012 =207Qtr 2 2012 =147Qtr 3 2012 =152Qtr 4 2012 =147Qtr 1 2013 =139Qtr 2 2013 =121Qtr 3 2013 =125Qtr 4 2013 =117

Contact Information Eric Jean BSN, RN, CCRN

RN Data Specialist Clinical Quality VTE/IMMs/ED Throughput Core Measures [email protected] 231-392-7140

Susan M. Blackhurst BS, RN RN Data Specialist

Clinical Quality HMS Registry [email protected] 231-935-5876

Questions