Surgical Care and Blood Management Update for 1QFY11

1. 1QFY11 Update Surgical Care, Blood Management, and Inpatient Med Recon WVMI Confidential and Proprietary

2. Purpose • Review 1Q11 changes for: • Surgical care • Blood management • Inpatient medication reconciliation WVMI Confidential and Proprietary

3. Surgical Care • Point of origin question deleted • Blood management significantly revised and moved to separate module • No changes to informed consent module WVMI Confidential and Proprietary

4. Dates and Times • There have been several changes to anesthesia and surgery date and time definitions/decision rules. • For some elements, documentation of other relevant dates and times may be used to determine the applicable date. • Please read D/D rules carefully. WVMI Confidential and Proprietary

5. Anesthesia Start Date q18 (anebegdt) • If an Anesthesia Start Date is not documented, surrounding documentation may be used to determine the date anesthesia started. • Example: The Anesthesia End Date is 10/02/2010, Anesthesia Start Time is 23:30 and Anesthesia End Time is 00:45. Abstract Anesthesia Start Date as 10/01/2010 because the date would change if the anesthesia ended after midnight and the start time was prior to midnight. WVMI Confidential and Proprietary

6. Anesthesia Start Time q19 (anebegtm) • Anesthesia record is still the priority data source • Look for inclusion terms (anesthesia start/begin/initiated) first • Enter the earliest time associated with inclusion term • Other suggested data sources may be used WVMI Confidential and Proprietary

7. Anesthesia Start Time cont’d • If the time is invalid (not a valid format/range such as 26:33 or after Anesthesia End Time) and no other documentation is found with the correct time, enter 99:99. • If the time is incorrect, but valid, and no other documentation is found with the correct time, enter the time documented in the record (abstract at face value). WVMI Confidential and Proprietary

8. New element: Surgical Incision Date • Q20 incizedt asks for the date the incision was made for the principal procedure. • If the date that the incision was made is not specified, surrounding documentation may be used to determine the date the incision was made. • Read D/D rules carefully. WVMI Confidential and Proprietary

9. Surgical Incision Date:Three Exceptions • Cystoscopy • If a patient has a cystoscopy after 00:00 (midnight) with stent placement, prior to the Principal Procedure during the same surgical episode, AND antibiotics were given prior to this procedure, use the start date for the cystoscopy. • If no stents were placed OR if no antibiotics were given prior to the start of the Principal Procedure, use the date that the Principal Procedure began as the Surgical Incision Date. WVMI Confidential and Proprietary

10. Exception #2 (INCIZEDT) • Laparoscopic to Open • If the procedure starts as a laparoscopic procedure AND antibiotics were given prior to this procedure and it is converted to an open procedure, abstract the Surgical Incision Date that is documented for the laparoscopic procedure. • If the procedure starts as a laparoscopic procedure AND antibiotics were NOT given prior to this procedure and it is converted to an open procedure, abstract the Surgical Incision Date that is documented for the open procedure. WVMI Confidential and Proprietary

11. Exception #3 (INCIZEDT) • Multiple Procedures • If multiple procedures occur during the same surgical episode, and the Principal Procedure is not the first of those, the Surgical Incision Date captured will be the date that the first incision occurs. WVMI Confidential and Proprietary

12. Surgical Incision Time q21 (incizetm) • Times designated as Surgical Incision Time or including the term incision time are to be taken as first priority terms. • Changes to Laparoscopy to Open mirror the D/D rules for surgical incision date • If the procedure starts as a laparoscopic procedure AND antibiotics were given prior to this procedure and it is converted to an open procedure, abstract the Surgical Incision Time that is documented for the laparoscopic procedure. • If the procedure starts as a laparoscopic procedure AND antibiotics were NOT given prior to this procedure and it is converted to an open procedure, abstract the Surgical Incision Time that is documented for the open procedure. WVMI Confidential and Proprietary

13. Anesthesia End Date q22 (anesendt) • Same addition to D/D rules as seen in Anesthesia Start Date related to use of surrounding documentation if Anesthesia End Date is not documented. WVMI Confidential and Proprietary

14. Anesthesia End Time q23 (anendtm) • The anesthesia end time is the time associated with the end of anesthesia for the principal procedure. • If multiple procedures occur during the same surgical episode as the principal procedure, the Anesthesia End Time will be the time associated with the end of anesthesia for the end of the surgical episode that included the principal procedure. WVMI Confidential and Proprietary

15. Anesthesia End Time cont’d • Other D/D rule changes similar to those reviewed for Anesthesia Start Time • Inclusion terms (anesthesia end/finish/stop) • Use the latest time associated with an inclusion term that represents Anesthesia End Time. • Software will not allow an anesthesia end time prior to incision time WVMI Confidential and Proprietary

16. Anesthesia Type q24 (anestype) • Guidance added for epidural catheters • If general anesthesia is used AND an epidural catheter is placed preoperatively or up to 24 hours after Anesthesia End Time for anesthesia or other reasons such as postoperative pain control, select “3.” • If an epidural catheter is placed preoperatively or up to 24 hours after Anesthesia End Time for anesthesia or other reasons such as for postoperative pain control, select “2.” WVMI Confidential and Proprietary

17. Anesthesia Type cont’d • Inclusions • Deleted intravenous general anesthesia • Exclusions • Added paravertebral blocks • Deleted saddle block and deep sedation WVMI Confidential and Proprietary

18. Perioperative Temperature • In q25 hypotemp, removed requirement for physician/APN/CRNA/PA documentation • Added clarification that the end of perioperative period for patients discharged from surgery to non-PACU location is a maximum of 6 hours after arrival to recovery area. WVMI Confidential and Proprietary

19. Perioperative Temperature cont’d • Documentation must indicate that intentional hypothermia was used during the perioperative period. • The documentation that intentional hypothermia was used does NOT need to be found during the perioperative period. WVMI Confidential and Proprietary

20. Active Warming q26 (actvwarm) • Removed requirement for documentation of over-the-body placement of the warming device • Resistive warming was added as separate modality WVMI Confidential and Proprietary

21. Temperature • For q27 and q28, added reminder that any temperature values (such as axillary) that may need converting should be converted prior to recording in the medical record for purposes of abstraction. • The abstractor is not allowed to convert temperature values. WVMI Confidential and Proprietary

22. Infection Prior to Anesthesia q34 (infecdoc) • Please ready D/D rules carefully • If there is documentation that the principal procedure was a joint revision or that hardware was removed during the principal procedure, answer “yes.” • The requirement for a culture prior to administration of the prophylactic antibiotic was removed. WVMI Confidential and Proprietary

23. Antibiotic Received q35 (recvanti) • For antibiotics received prior to arrival: • If listed as “current” or “home” meds, still can infer as taken within 24 hours prior to arrival or the day prior to arrival unless there is documentation the antibiotics were not taken • Otherwise, documentation must support that the antibiotic was taken within 24 hours prior to arrival or the day prior to arrival WVMI Confidential and Proprietary

24. Antibiotic Received cont’d • If the date and/or time for an antibiotic dose is an obvious error but is a valid date and/or time that is prior to the patient’s arrival, the chart must be abstracted at face value and this information should be used to answer “yes” to antibiotics prior to arrival as applicable. • Example: An arrival time is documented as 1400 and the antibiotic is documented as given at 1352 on the same date. The dose cannot be abstracted as given during the hospital stay and should be used to abstract Antibiotic Received as Value 1 or 2 as applicable. WVMI Confidential and Proprietary

25. ORAL Antibiotics q36 (oralabx) • The intent of this question is to determine if either oral Neomycin Sulfate + Erythromycin Base or oral Neomycin Sulfate + Metronidazole were the ONLY antibiotics administered prior to hospital arrival or more than 24 hours prior to incision. • Oral antibiotics may be given less than 24 hours prior to incision, but this data element is only concerned with those antibiotics given GREATER than 24 hours prior to incision or prior to hospital arrival. WVMI Confidential and Proprietary

26. ORAL Antibiotics cont’d • Examples: • There is documentation that oral neomycin and erythromycin were taken the day prior to arrival and no other antibiotics were given more than 24 hours prior to incision, answer “1.” • Antibiotics were not given prior to arrival, but there is documentation that oral neomycin and erythromycin were given less than 24 hours prior to incision, answer “2.” WVMI Confidential and Proprietary

27. Antibiotic Administration q38 • Please read D/D rules carefully • Abbreviations or minor misspellings in an antibiotic name can be overlooked as long as the abbreviated name/spelling error is readily recognizable or if it can be determined using supporting documentation from the same source as that antibiotic dose. • Example: Ansef would be abstracted as Ancef. WVMI Confidential and Proprietary

28. Antibiotic Administration cont’d • Antibiotic administration information should only be abstracted from documentation that demonstrates actual administration of the specific antibiotic. • Do not abstract antibiotics from sources that do not represent actual administration. • Do not abstract antibiotics from narrative charting unless there is no other documentation that reflects that the same antibiotic was given during the specified timeframe. WVMI Confidential and Proprietary

29. Reasons to Extend Antibiotics q45 (extndabx5) • In order to answer “yes” the principal procedure must be an original arthroplasty or is a revision of a previous joint revision surgery. WVMI Confidential and Proprietary

30. Urinary Catheter q53 (urincath2) • Extensive changes to question and D/D rules • Question 53 asks if there is documentation that the patient had a urinary catheter placed in the perioperative period and that the catheter was still in place at the time of discharge from the recovery/post-anesthesia care area? WVMI Confidential and Proprietary

31. Urinary Catheter cont’d • For the purposes of this data element, the perioperative timeframe is defined as from hospital arrival through discharge from the recovery/post-anesthesia care area. • Read options carefully. WVMI Confidential and Proprietary

32. Urinary Catheter cont’d • Primary intent of the changes are to clarify how to handle documentation when more than one option applies ( e.g. option 1 AND options 3 or 4) • Documentation of urinary catheterization (indwelling, suprapubic, or intermittent) prior to perioperative timeframe (option 3) OR documentation that a suprapubic catheter was placed or the patient was intermittently catheterized during the perioperative period (option 4) take precedence over placement of an indwelling catheter during the perioperative period. WVMI Confidential and Proprietary

33. Catheter Removed q54 (cathout) • Documentation of catheter removal does NOT need to be found only within the perioperative period, but must reflect that the catheter was removed on POD 0 through POD 2. • If the catheter was removed on either POD 0 through POD 2, but had to be reinserted, enter “1.” • If there is documentation that the patient voided/urinated on POD 0 through POD 2, enter “1.” • If the patient expires on POD 0 – POD 2 prior to removal of the indwelling urinary catheter, enter “1.” WVMI Confidential and Proprietary

34. VTE Prophylaxis q59 • Reminder: For the purposes of abstraction, mechanical VTE prophylaxis does not require a physician order to be abstracted. • Abstract any form of mechanical VTE prophylaxis that is documented as ordered or as placed on the patient at anytime from hospital arrival to 24 hours after Anesthesia End Time. WVMI Confidential and Proprietary

35. VTE Pharmacologic Prophylaxis • Wording added to clarify directions for abstraction when one VTE prophylaxis medication is ordered, but another is substituted. • Example: Lovenox is ordered and not received and is substituted with Arixtra, which is received by the patient. Abstract Lovenox as Value "2" for VTE Prophylaxis and "No" for VTE Timely. Abstract Arixtra as Value "5" for VTE Prophylaxis and abstract VTE Timely accordingly. WVMI Confidential and Proprietary

36. Surgical Care: Scoring Changes • No new measures • The date parameter for inclusion was changed to >=10/1/10 • New data element INCIZEDT replaced ANEBEGDT in sip1, sip10, and sip3 • For sip26, documentation of infection prior to anesthesia no longer excludes the case. • Please see exit report guide for more information. WVMI Confidential and Proprietary

37. Blood Management Pilot • With exception of five questions, there have been extensive revisions for 1Q11. • Due to extensive revisions and new questions, changes are not highlighted. • Please read questions and D/D rules carefully. WVMI Confidential and Proprietary

38. Type and ScreenType and Crossmatch • First 7 questions apply only to elective surgery cases. • The first 4 questions are unchanged from last quarter. WVMI Confidential and Proprietary

39. Preoperative Anemia Screening • q5 asks if there was documentation of a hemoglobin or hematocrit result during the 45 days prior to Anesthesia Start Date • If yes, enter the date of the most recent in q6. WVMI Confidential and Proprietary

40. Other Anemia Screening • Q7 asks if there was documentation of preoperative anemia screening during the 45 days prior to Anesthesia Start Date? 1. Preoperative anemia screening performed 14 to 45 days prior to Anesthesia Start Date 2. Preoperative anemia screening performed less than 14 days prior to Anesthesia Start Date 99. No documentation preoperative anemia screening was performed during the 45 days prior to Anesthesia Start Date WVMI Confidential and Proprietary

41. Q7 ANEMISCR • Acceptable documentation: • Patient received iron alone • Patient received iron in conjunction with epogen (ESAs) • Other clinician documentation that the patient was screened for anemia • For example, the physician notes, “Preoperative anemia screen negative.” WVMI Confidential and Proprietary

42. Red Blood Cell Transfusion • Q8 recvprbc was retained from the previous questions • If the patient did not receive an RBC transfusion during the episode of care or if unable to determine from the record, the review ends. • The remainder of the questions are new and focus on RBC transfusion events. WVMI Confidential and Proprietary

43. RBC events • A RBC event is determined by the transfusion order associated with the administration of the RBCs. • In q9 (rbcevent), enter the number of RBC events that occurred during the episode of care. • Examples: • An order by the surgeon to “give 2 units PRBCs today” would count as one event. • RBC transfusions administered during surgery would be considered one event. WVMI Confidential and Proprietary

44. Signed consent (signcons) • Q10 asks if there was documentation of a signed consent prior to the first blood transfusion event 1. There was documentation of a signed consent prior to the first blood transfusion event 2. The first blood transfusion event was deemed a medical emergency 99. No documentation of a blood transfusion consent prior to the first blood transfusion event or unable to determine WVMI Confidential and Proprietary

45. Signed Consent: Acceptable Documentation • The consent may be signed by either the patient or caregiver. • If organizations require consent prior to every transfusion, then review the record for the first transfusion event to answer this data element. • For hospitals that use a general consent for treatment that includes transfusions, select “yes.” • If a patient receives chronic transfusions and a previous consent is acceptable for a defined timeframe within the organization, select “1” if the consent is valid. WVMI Confidential and Proprietary

46. Information regarding Transfusion q11 (ictrans) • Similar to old question • Asks if there is documentation that information regarding risks, benefits, and alternatives to transfusion was given to the patient/caregiver prior to the first blood transfusion event • If the patient refused information about the risks, benefits, and alternatives to transfusion, select “1.” WVMI Confidential and Proprietary

47. RBC Events: Required components • Clinical Indication q12 (clinind1) • Pre-transfusion hematocrit q13 (prehct1) OR hemoglobin q14 (prehgb1) • Total Number of RBC units (bags) transfused q15 (rbcnum1) • Will answer the series of questions for up to 3 RBC events WVMI Confidential and Proprietary

48. Clinical Indication q12 • For RBC event 1, what was the clinical indication documented by the physician/APN/PA for the RBC transfusion event? 1. Bleeding 2. No bleeding, but evidence of inadequate oxygen delivery 3. Other 99.No documentation of clinical indication for the RBC transfusion WVMI Confidential and Proprietary

49. Clinical Indication cont’d • Must be documented within 24 hours after the start of the transfusion event. • Bleeding documentation • ‘hemorrhagic shock' or • 'evidence of acute hemorrhage and hemodynamic instability or • inadequate oxygen delivery' or • a 'massive transfusion protocol' was used • Evidence of inadequate oxygen delivery (NO bleeding) • Example (see D/D rules for others) could be shortness of breath at rest (with no other cause such as underlying pulmonary dysfunction) • Other clinical indication documented by physician/APN/PA WVMI Confidential and Proprietary

50. Pre-transfusion hematocrit or hemoglobin • Must be completed within 24 hours prior to start of the RBC transfusion for event 1. • The measure accepts documentation of either. • For purposes of abstraction, will look for hematocrit first WVMI Confidential and Proprietary