CICU Quality Improvement
Orientation
Chief Residents
2013
Objectives

Improve quality of patient care in the CICU
by providing “just in time” teaching on the
following key aspects of discharge planning:
–
–
–
Clinical Documentation
Core Measures
Discharge Planning
Clinical Documentation

Leslie Schultz, RN, BSN
–
Clinical Documentation Improvement Specialist in
CICU
Understanding MS-DRGs

Medical Severity-Diagnostic Related Groups (MSDRG)
– The system used for hospital inpatient admission
reimbursement
– Physician documentation is the basis for coding
– Lab/Imaging can only be coded for when the
physician indicates their clinical significance in
the A&P
– Documentation needed for proper coding has
specific requirements that are different than those
needed for clinical care

Documentation of all pertinent diagnoses has a
significant impact on Severity of Illness and Risk of
Mortality scores.

In turn, accurate reporting of Severity of Illness and
Risk of Mortality has a significant impact on quality of
care reports as well as reimbursement
CDI Specialists Query in order
to…

Clarify Present on Admission (POA) status of diagnosis

Clarify Principal Diagnosis (primary reason for admission)

Ensure physician documentation includes all co-morbidities
– Include Manifestations of chronic conditions
Diabetic nephropathy, stage of CKD, hypertensive
cardiomyopathy

Clarify diagnosis when unapproved abbreviations are used
–
Example: “CRS” could have multiple meanings. Write out
meaning for accuracy
–
http://www.medabbrev.com/index.cfm for UH approved
abbreviations
CDI Specialists Query in order
to…

Clarify whether a diagnosis &/or event is a complication
of a procedure
- Provider must make the link between condition &
procedure

Clarify source of infection


Clarify possible etiology of symptoms


can be “possible”, “probable” or “suspected”
Hematuria, abdominal pain, chest pain, syncope
Capture appropriate mortality scores
–
Example: must specify “Multi System Organ Failure”
Documentation Tips
Appropriate Diagnostic Statement
(Accurate ICD-9 code can be assigned)
Common Clinical Statements -REQUIRE CLARIFICATION!
Must Specify Organ and Acute: Acute Renal
Failure/Acute Resp Failure/Acute Hepatic Failure
Multi Organ System Failure
Acute Renal Failure, Acute Kidney Injury AKI:
increase >1.5 x baseline; ARF: >3 x baseline, CKD
with stage
Renal Failure or Insufficiency, Prerenal
azotemia
Type 2 MI (not due to plaque,) specify underlying
cause and note that core measures don’t apply
Troponin leak, troponinemia, Demand
ischemia (no troponin elevation)
STEMI, NSTEMI, Unstable angina
(include site if known)
Acute Coronary Syndrome, ACS
Accelerated or Malignant HTN
Hypertensive Urgency or Crisis
Type & Acuity of Heart Failure: Systolic/Diastolic or
HFPEF, HFrEF or ADHF
combined Acute/Acute on Chronic/Chronic
Acute Respiratory Failure/ARDS
Respiratory Distress/Hypoxia
Documentation Tips
Malnutrition (include degree: moderate or
severe) **Check Nutrition Therapy notes
Recent weight loss
Cachectic, Failure to Thrive
Septicemia, Sepsis, Severe Sepsis, Septic
Shock
Urosepsis, Bacteremia or + SIRS Criteria
Shock: Septic/ Cardiogenic/ Hypovolemic/
Hemorrhagic/ Unspecified
Hypotension / Pt on Vasopressors
Sign Wound Photos and check appropriate
POA box. Can also document ulcer and type in
progress note (decubitus, venous stasis, diabetic
ulcer)
Nursing documentation and/or photos of
Wounds/Ulcers
Coma/Brain Death/Anoxic Brain Injury
Encephalopathy (specify type if known)
Obtunded/Unresponsive
Altered Mental Status
Hypo/hypernatremia/kalemia/osmolarity,
acidosis, alkalosis, etc…
Electrolyte Imbalance/low K+
Abnormal lab findings
DIC, coagulopathy, thrombocytopenia
Elevated INR or plt (especially if not iatrogenically
anticoagulated)
Opportunities to improve
documentation…

Patient admitted with AMI.

H&P notes PMH of CHF

Home meds include Lisinopril and Lasix daily

Recent echo with EF 10-15%

BNP noted to be elevated on admission

Documentation indicates pt with “volume overload” and
diuresis initiated
Impact of improved
documentation…
AMI
AMI
Chronic Systolic
Heart Failure
AMI
Acute Systolic
Heart Failure
MS-DRG 282 w/o CC
or MCC
GLOS 2.2
MS-DRG 281
w/ CC
GLOS 3.4
MS-DRG 280
w/ MCC
GLOS 5.0
Reimbursement
Reimbursement
Reimbursement
$6494
$9202
$45,110
SOI 1
ROM 2
SOI 2
ROM 3
SOI 2
ROM 3
Clinical Documentation
Improvement Program Goal

Complete and accurate documentation in the
EHR to reflect the patient’s true severity of
illness and risk of mortality
Core Measures
What are Core Measures?

National standardized evidence-based performance measures
defined by the Joint Commission

Derived from quality indicators defined by the Centers for
Medicare and Medicaid Services (CMS)

Hospitals improve quality of patient care by focusing on results of
care
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
14
Inpatient Core Measure Sets
2013
Acute MI
Heart Failure
Pneumonia
SCIP (Surgical Care)
- Aspirin at Arrival
- Discharge Instructions
- Blood Cultures
Performed in the ED
Prior to Initial Antibiotic
Administration
- Antibiotic Received
- Antibiotic Selection
- Aspirin Prescribed at
Discharged
- Evaluation for LVSD
- Initial Antibiotic
selection for CAP
Immunocompotent
patients
- Antibiotic Discontinued
- Cardiac Surgery
Controlled 6am Blood
glucose
- Timing of Receipt of PCI
- ACEI and ARB for
LSVD
- Statin Prescribed at
Discharge
- Urinary Catheter
- Peri - op
Temperature Mgmt.
– Surgery Pts. On BB
Therapy
- Received VTE within
24 hours prior to or after
surgery
2011
University Hospitals Case Medical Center
15
Inpatient Core Measure Sets
2013
ED Throughput
Immunization
- Median Time form ED arrival
to ED departure for admitted
ED Patients
- Pneumococcal
Immunization
- Admit Decision Time to ED
departure time for admitted
patients
2011
Stroke
-VTE
Prophylaxis
VTE
-VTE
Discharged on
antithrombotic therapy
-
-Influenza
-Anticoagulation
-VTE
Immunization
(Oct 1 – March 31)
for atrial
fibrillation/flutter
-
University Hospitals Case Medical Center
therapy
Prophylaxis
Intensive Care Unit
VTE
patients with
anticoagulation overlap
therapy
-Thrombolytic
therapy
-Antithrombobotic
therapy by end of
hospital day 2
- VTE patients receiving
unfractionated heparin
with dosage/platelet
count monitoring by
protocol or nomogram
- Discharged on a statin
medication
- VTE warfarin therapy
discharge instructions
-Stroke
- Hospital acquired
preventable VTE
education
- Assessed for
rehabilitation
16
Inpatient Core Measure Sets
2013
Hospital Based
Psychiatry Services
(HBIPS)
-
Admission Screening
-Hours
in Physical Restraint Use
-Hours
of Seclusion Use
Perinatal Care
Required in 2014 by TJC for
hospitals with > 1, 100 births
-Elective
delivery
Childhood
Asthma
Relievers for Inpatients
- Cesarean Section
Systemic Corticosteroids
for Inpatients
- Patients discharged on
multiple antipsychotic
medications with appropriate
justification
- Antenatal Steroid
Home Management Plan
of Care (HMPC)
- Post discharge care plan
created
- Healthcare associated
BSI
- Patients discharged on Multiple
antipsychotic medications
- Post discharge care plan
- Exclusive
2011
University Hospitals Case Medical
Center
transmitted
Breastfeeding
17
Where is data reported to the
public?
Hospital Compare www.hospitalcompare.hhs.gov
•
Improving care through information
•
4500 hospital across the country report
•
More than 50 quality measures
The Joint Commission www.qualitycheck.org
Ohio Department of Health www.odh.ohio.gov
•
Ohio Hospital Compare
Leapfrog www.leapfroggroup.org
•
Self Reported Survey
•
Encourage health providers to publicly report
•
Consumers make informed health choices
Health Grades www.healthgrades.com/
•
Independent rating company
•
Use Medicare Claims Data
•
721,356 patients in Cleveland used information between January and June 2011
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How are Core Measure Patients
Identified?

Core Measure diagnosis is not always clear on admission

Identified by Coding after discharge based on documentation
by Physician or Licensed Independent Practitioner (LIP)

Goal is to identify patients early in admission and achieve all
components of care by discharge

Patients with symptoms of Core Measure diagnosis should have
core measure parameters followed
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Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Value Based Purchasing
Basics


Began in 2011
Non-compliance results in–
–

2013 - 1% reduction total Medicare payment
2017 - 2% reduction total Medicare payment
Potential impact at UH
–
–
2013 – $ 5.9 million
2017 - $18.8 million
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Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
UHCare Order Set Utilization and Core
Measures

UHCare order sets have been created to help practitioners
satisfy the Core Measure indicators that are monitored in the UH
System

Each disease specific Core Measure order set contains options
for all needed components

UHCare order sets are care paths that communicate treatment
and interventions to the interdisciplinary team members
–
(ie. Nursing, Respiratory, Pharmacy, Laboratory,
and Ancillary Departments).
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Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
UHCare Order Set Utilization and Core
Measures

Compliance depends on:
–
–
–
–

Licensed independent practitioners selection of each order as
appropriate
Licensed independent practitioners selection of omission order
when a medication is not indicated
Non-use of order sets requires documentation in the medical record
of omission reason
Orders being followed as written for the patient
Disease specific order sets include everything needed to meet
core measure requirements
22
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Disease Specific Core Measure:
Acute Myocardial Infarction
2011
23
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Acute Myocardial Infarction

Admission Indicators:
–
–

Aspirin prescribed at Arrival – within 24 hours
Angioplasty within 90 minutes of arrival
Discharge Indicators:
–
–
–
–
Aspirin prescribed at discharge
Beta Blocker prescribed at discharge
Medication (Ace at discharge for left ventricular dysfunction
(Ejection Fraction <40%*)
Statin Prescribed at Discharge
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Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Acute Myocardial Infarction Order Set

Physicians and other LIP’s can access the Acute Myocardial Infarction order set
by typing “AMI, Acute Myocardial Infarction, or STEMI” in the UHCare order
browse
25
2011
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Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Disease Specific Core Measure:
Heart Failure
27
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Heart Failure

Indicators
–
–
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Left ventricular function assessment
ACE1 or ARB ordered at discharge for left ventricular dysfunction
(Ejection Fraction <40%*)
Patient education
 Activity
 Diet
 Weight monitoring
 Symptoms worsening
 Follow up appointments
 Accurate medication reconciliation
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Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Heart Failure Order Set

Physicians and other LIP’s can access the
Heart Failure Order by typing “Heart Failure
or CHF” into the order browse in UHCare
29
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Please use omission orders when
indicated
Or you will get this error
message 
30
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Guidelines For a Healthy Lifestyle
2011
31
Conclusion - Key Points

Use of prepared order sets makes compliance with core
measures and “best practice” easier for end user

Core measures
– contribute to better patient outcomes
– Affect our payment for services rendered
– Publicly available for evaluation

EVERYONE plays a role in meeting core measure
compliance
32
Confidential Quality Assurance Peer Review Report Privileged Pursuant to O.R.C. Sections 2305.24, 2305.25, 2305.251, 2305.252
Discharge Planning
The Bottom Line: Discharge Begins on
Admission

The CICU discharges many patients to home, long term care
facilities, and short term rehab.

The impact of improper discharge planning can extend the stay
of CICU patients for days or hours which has a direct impact
on:
–
–
–
–
Patient Satisfaction Scores
Increased Length of Stay (LOS)
Non-Compliance of Core Measures such as HF and AMI
Patient Readmission
Team Collaboration and Communication
Provides the Best Care

Touch base rounds occur daily for each
patient to determine patient needs and
update developments in care

Interdisciplinary Rounds occur every
Tuesday and Thursday 10:00 @ the CICU
center table.
Your Role in Discharge Planning

Participate in Interdisciplinary Rounds (One intern to attend and
report out to group)
–
–
–

Anticipate and communicate the expected date of discharge
Anticipating discharge can alleviate common needs that delay
discharge
Common barriers: inability to afford medications, PT/OT consults,
home care arrangements, SNF and long term placement
approvals, home IV therapy approvals, and transportation issues
When discharge is anticipated, the recommendation is to have
the discharge profile completed the night before discharge
–
This includes medication reconciliation, discharge instructions,
home care orders, cardiac rehabilitation orders, and a gold form
The Day of Discharge

Medication Reconciliation can be a time consuming
process. Proper admission medication reconciliation
will alleviate many discharge errors and decrease
the time it takes for you to discharge a patient.

The CICU RN will perform a discharge timeout with
you to ensure that your instructions and medications
meet the needs for our patients and hospital
standards of care.