Heart Failure Core Measures

**Patients are included in the Heart Failure core measure when they are assigned a heart failure diagnosis code upon discharge, which is determined by the coding department.Please note that even if a patient is not admitted with a primary diagnosis of heart failure, this may end up as the assigned diagnosis code.

As a reminder, the coding department and core measure abstractors cannot interpret physician documentation. There are specific rules that must be followed that are defined by the Joint Commission.

Left Ventricular Function Assessment:

  • Documentation that left ventricular systolic function (LVSF) was assessed either prior to arrival, during hospitalization, or is planned for after discharge or reason documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) for not assessing LVSF.

Medication (ACE/ARB) for LVSD at Discharge:

  • A patient with an EF <40 will be included in this measure. If a range (eg. 35-40) is documented, abstracters take an average (eg. 37.5) of the range.
  • Please note that the abstractors use the LAST documentation of left ventricular dysfunction in the medical record
  • ACE/ARB must be prescribed at discharge and documented on patient’s discharge instructions, which are signed by the patient
  • If ACE/ARB is not prescribed at discharge, must document contraindication

Discharge Instructions:

  • Address Activity: WRITTEN discharge instructions/educational material given to patient/caregiver address the patient's activity level after discharge.
  • Address Diet: WRITTEN discharge instructions/educational material given to patient/caregiver address diet/fluid intake instructions after discharge.
  • Address Follow-up: WRITTEN discharge instructions or other documentation of educational material given to the patient/caregiver address follow-up with a physician/APN/PA after discharge.
  • Address Medications: WRITTEN discharge instructions/educational material given to patient/caregiver address discharge medications.
  • Address Symptoms Worsening: WRITTEN discharge instructions/educational material given to patient/caregiver address what to do if heart failure symptoms worsen after discharge.
  • Address Weigh Monitoring: WRITTEN discharge instructions/educational material given to patient/caregiver address weight monitoring instructions after discharge.

Smoking Cessation Counseling

  • In order to be included in this measure, there must be documentation that the patient has smoked in the previous year.
  • No documentation of smoking history assumes that the patient does not smoke.

Acute Myocardial Infarction Core Measures

**Patients are included in the AMI core measure when they are assigned an AMI diagnosis code upon discharge, which is determined by the coding department. Please note, if the patient is admitted as “r/o MI” and there is no further documentation in the chart that they were ruled out, these patients will be assigned an AMI diagnosis code. There must be explicit MD documentation that the MI was ruled out.

As a reminder, the coding department and core measure abstractors cannot interpret physician documentation. There are specific rules that must be followed that are defined by the Joint Commission.

Aspirin Given at Arrival:

  • ASA may be given within 24 hours before or 24 hours after hospital arrival
  • If patient is currently taking ASA at home, documentation of “current home medication” suffices as appropriate documentation
  • If ASA not given at arrival, must document contraindication

Aspirin Prescribed at Discharge:

  • ASA must be prescribed at discharge and documented on patient’s discharge instructions, which are signed by the patient
  • If ASA is not prescribed at discharge, must document contraindication

Beta-blocker Prescribed at Discharge:

  • Beta-blocker must be prescribed at discharge and documented on patient’s discharge instructions, which are signed by the patient
  • If Beta-blocker is not prescribed at discharge, must document contraindication

Medication (ACE/ARB) for LVSD at Discharge:

  • A patient with an EF <40 will be included in this measure. If a range (eg. 35-40) is documented, abstracters take an average (eg. 37.5) of the range.
  • Please note that the abstractors use the LAST documentation of left ventricular dysfunction in the medical record
  • ACE/ARB must be prescribed at discharge and documented on patient’s discharge instructions, which are signed by the patient
  • If ACE/ARB is not prescribed at discharge, must document contraindication

Angioplasty within 90 mins of arrival

  • Door (ED triage time or time first seen by UHCMC staff) to balloon (angioplasty) time must be less than 90 mins.

Smoking Cessation Counseling

  • In order to be included in this measure, there must be documentation that the patient has smoked in the previous year.
  • No documentation of smoking history assumes that the patient does not smoke.

Pneumonia Core Measures

**Patients are included in the Pneumonia core measure when they are assigned a pneumonia DRG upon discharge, which is determined by the coding department. Please note that even if a patient is not admitted with a primary diagnosis of pneumonia, this may end up as the assigned DRG.

As a reminder, the coding department and core measure abstractors cannot interpret physician documentation. There are specific rules that must be followed that are defined by the Joint Commission.

Inclusion criteria: Documentation of the diagnosis of pneumonia either as the Emergency Department final diagnosis/impression, or as an admission diagnosis/impression for the direct admit patient.

Antibiotic administered within 6 hours of arrival:

  • Documentation that an antibiotic has been administered within 6 hours of arrival is mandatory.
  • This is only applicable for patients who come through UHCMC ED or directly admitted.
  • Exclusions to the measure apply only if the patient has allergies, sensitivities or intolerance to beta-lactam/penicillin antibiotic or cephalosporin medications.

Appropriate antibiotic selection for immunocompetent patient:

  • See Appendix A

Influenza vaccination (Oct – Dec, Jan – Feb):

  • Documentation of the patient's vaccination status during this flu season.
  • If found to be a candidate for the vaccine, documentation that the influenza vaccine was given during this hospitalization.
  • Acceptable contraindications:
  • Influenza vaccine was given during this hospitalization.
  • Influenza vaccine was received prior to admission during the current flu season*, not during this hospitalization.
  • Documentation of patient's refusal of influenza vaccine.
  • There was documentation of an allergy/sensitivity to influenza vaccine OR is medically contraindicated because of bone marrow transplant within the past 12 months OR prior history of Guillian- Barré syndrome.

Pneumonia screen/vaccination:

  • Documentation of the patient's pneumococcal vaccination status.
  • If found to be a candidate for the vaccine, documentation that the pneumococcal vaccine was given during this hospitalization.
  • Acceptable values
  • Pneumococcal vaccine was given during this hospitalization.
  • The patient received pneumococcal vaccine anytime in the past.
  • Documentation of patient's refusal of pneumococcal vaccine.
  • There is documentation of an allergy/sensitivity to pneumococcal vaccine OR is medically contraindicated because of a bone marrow transplant within the past 12 months OR currently receiving a scheduled course of chemotherapy or radiation therapy, or received chemotherapy or radiation during this hospitalization.

Pneumonia Core Measures cont.

Blood cultures before antibiotic in ED:

  • Documentation in the medical record that a blood culture was collected theday prior to arrival, the day of arrival, or within 24 hours after arrival to the hospital. Thisincludes blood cultures drawn in the emergency room or in observation beds prior toadmission order, as well as after the patient's admission to inpatient status.
  • A bloodculture can be defined as a culture of microorganisms from specimens of blood todetermine the presence and nature of bacteremia.

Smoking Cessation Counseling

  • In order to be included in this measure, there must be documentation that the patient has smoked in the previous year.
  • No documentation of smoking history assumes that the patient does not smoke.