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Your Medicare QIO* Answers Your Questions The SCIP Card-2 Beta-Blocker Measure . Susan Hiyama, RN, MSN, CPHQ Health Services Advisory Group of California, Inc. Henrietta Hight, RN, BA, BSN FMQAI, Inc.

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your medicare qio answers your questions the scip card 2 beta blocker measure

Your Medicare QIO* Answers Your QuestionsThe SCIP Card-2 Beta-Blocker Measure

Susan Hiyama, RN, MSN, CPHQ

Health Services Advisory Group of California, Inc.

Henrietta Hight, RN, BA, BSN

FMQAI, Inc.

*QIO = Quality Improvement Organization. This Presentation is brought to you by the QIOs of California, Arizona, and Florida

sponsoring organizations
Sponsoring Organizations
  • Health Services Advisory Group, Inc.
    • Medicare Quality Improvement Organization for Arizona since 1979.
  • Health Services Advisory Group of California, Inc.
    • Medicare Quality Improvement Organization for California since 2008
  • FMQAI, Inc.
    • Medicare Quality Improvement Organization for Florida since 1993.

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q1 what is scip
Q1: What is SCIP?

www.medqic.org/scip

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surgical care improvement project national goal
Surgical Care Improvement ProjectNational Goal
  • To reduce preventable surgical morbidity and mortality by 25% by 2010.

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SIP/SCIP National Expert Panel/Steering Committee

  • American College of Surgeons
  • American Hospital Association
  • Agency for Healthcare Research and Quality
  • American Association of Critical Care Nurses
  • American College of Chest Physicians
  • American College of Obstetricians & Gynecologists
  • American Geriatrics Society
  • American Academy of Orthopedic Surgeons
  • American Society of Anesthesiologists
  • American Society of Health System Pharmacists
  • Association of Professionals in Infection Control and Epidemiology
  • Association of PeriOperative Registered Nurses
  • Centers for Disease Control and Prevention
  • Centers for Medicare & Medicaid Services
  • Department of Veteran’s Affairs
  • Institute for Healthcare Improvement
  • The Joint Commission
  • Society for Critical Care Medicine
  • Society of Colon and Rectal Surgeons
  • Surgical Infection Society
  • Society for Healthcare Epidemiology of America
  • Society of Thoracic Surgeons
  • The Medical Letter
  • Sanford Guide

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surgical care improvement project scip
Surgical Care Improvement Project (SCIP)

Preventable Complication Measures

Surgical infection prevention

Cardiovascular complication prevention

Venous thromboembolism prevention

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the scip card 2 measure
The SCIP Card-2 Measure

Description: Surgery patients on a beta- blocker prior to arrival who received a beta- blocker during the perioperative period.

[The information on this and the following slides is adapted from the Specifications Manual for National Hospital Inpatient Quality Measures, version 3.0b. You can always find the most up-to-date information about quality measures in the Specifications Manual, which can be found by going to www.qualitynet.org, clicking on the “Hospitals-Inpatient” tab, then clicking on the Specifications Manual option.]

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card 2 measure as a priority
Card-2 Measure as a Priority
  • The American College of Cardiology and American Heart Association recommend continuation of beta-blocker therapy in the perioperative window.
  • Accumulating evidence suggests that titration to maintain tight heart rate control should be the goal.
  • Adverse cardiac events occur in 2%–5% of patients undergoing noncardiac surgery, and in almost 34% of patients undergoing vascular surgery.
  • Current studies suggest that appropriately administered beta-blockers reduce perioperative ischemia, especially in patients considered to be at risk.

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Q4: My patient’s home medications include antihypertensive and cardiac medications, as well as a beta-blocker. Why the concern for beta- blockers specifically?

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card 2 rationale
Card-2 Rationale
  • Beta-blockers are agents that block beta-adrenergic receptors.
  • Their actions include:
    • Decrease in the rate and force of heart contractions.
    • Reduction of blood pressure.
  • Other anti-hypertensives focus on the muscle of blood vessels rather than cardiac muscle.

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measure requirements
Measure Requirements
  • Patients on home beta-blocker therapy must receive a beta-blocker during the perioperative period.
  • If the patient does not receive a beta- blocker within the perioperative period, clear documentation of contraindications must be noted in the medical record.

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measure requirements beta blocker documentation
Measure Requirements – Beta-Blocker Documentation

Beta-blocker documentation should:

  • Be provided in the operating room by the anesthesiologist on the anesthesia record – include the beta-blocker name, date, time, and route of administration.

Or

  • Be provided in the PACU (Post-Anesthesia Care Unit/Recovery Room) by the nurse or anesthesiologist on the PACU record – include the beta-blocker name, date, time, and route of administration.

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home medication beta blocker
Home Medication – Beta-Blocker

Check any and all History & Physical documentation (medicine, surgery, anesthesia):

  • There may be contradictory entries, so verify.
  • Check Medication Reconciliation records completed at admission.
  • Ask the patient what medications are taken at home and when they were last taken ― document the patient’s response.

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home medication beta blocker19
Home Medication – Beta-Blocker
  • Check the list in the CMS Specifications Manual, Appendix C, Table  1.3.
  • Manual revisions come out every 6 months for discharges starting with April 1st and October 1st discharges.

Compare the patient’s home medication list to the CMS source:

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Q7: What is the “perioperative period” in which a patient should receive a beta- blocker? How are the start- and end-times determined?

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card 2 perioperative timeframe
Card-2 Perioperative Timeframe
  • For this measure, the perioperative period is defined as 24 hours prior to surgical incision through discharge from the post-anesthesia care/recovery room (PACU).
  • If a patient goes directly from the OR to the ICU or any area other than the PACU, the time frame ends upon leaving the OR.   
  • Start- and end-times are located on the anesthesia record, OR record, and/or surgery record.

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Q8: What are the contra-indications to receiving a beta-blocker, and how are contraindications documented?

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beta blocker contraindication documentation physician
Beta-Blocker Contraindication Documentation―Physician
  • The physician must clearly and legibly document in the medical record specific reasons why the patient did not receive the medication; or
  • The physician’s order or other documentation should contain hold parameters such as heart rate or blood pressure.
    • The beta-blocker may be held if the heart rate is below 50 (49 or below).
    • The blood pressure parameters are at the discretion of the physician.

If a beta-blocker is not ordered within this time frame:

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beta blocker contraindication documentation nursing
Beta-Blocker Contraindication Documentation―Nursing

If a beta-blocker is not administered within this time frame:

  • The nurse “holding” the medication must document the BP and HR measurements as the reason for the hold.
  • This is best documented alongside the notation indicating the held beta-blocker dose.
  • If the patient is allergic to the ordered beta-blocker, the nurse must notify the ordering physician and request an order for a substitute beta-blocker.

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beta blocker contraindication documentation
Beta-Blocker Contraindication Documentation

NOTE: NPO status is not a contraindication to the patient receiving a beta-blocker medication.

  • Many surgeons and anesthesiologists will allow pills to be taken with a sip of water.
  • The medication may be given IV.  

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scip beta blocker while npo reminder poster
SCIP Beta-Blocker While NPO Reminder Poster
  • This reminder poster is available at several Web sites:
    • http://www.hsag.com/azhospitals/scip/resources.aspx
    • http://www.hsag.com/cahospitals/scip/resources.aspx
    • http://www.fmqai.com/library/attachment-library/ID-55%20FMQAI_SCIP-NPOv2.pdf
    • https://www.qualitynet.org/dcs/ContentServer?c=MQTools&pagename=Medqic%2FMQTools%2FToolTemplate&cid=1228751144401&parentName=Category

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card 2 measure implementation
Card-2 Measure Implementation

Educate staff on the benefits to the patient of continued beta-blocker therapy.

Provide staff education on the beta-blocker measure as it pertains to morbidity, cost, and care measures.

Post beta-blocker reminder signs  in very visible areas around the pre-op area, OR, PACU, physician call-rooms and nurses stations.

Provide clear documentation of home beta-blocker therapy

Computer decision support systems

Protocols, preprinted orders

Periodic audit and feedback

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card 2 measure implementation29
Card-2 Measure Implementation
  • Provide patients with very specific pre-op instructions regarding their medications – “NPO except for meds” may not be understood by patients.
  • Institute a policy that “hold parameters” must be included in every beta-blocker order.
  • Set a nursing standard that states that BP/HR must be documented on the Medication Administration Record when a beta-blocker dose is held.
  • Include beta-blocker questions on the pre-op surgical checklist.
  • Include beta-blocker questions in pre-op “Time Out.”

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card 2 measure implementation30
Card-2 Measure Implementation
  • Create and educate a dedicated in-hospital team, and provide them with necessary tools to implement the beta-blocker quality measure:
    • Hospitalist/surgeon/anesthesiologist as chairperson(s) on the SCIP team
    • Pharmacists and nurses as key team members
    • Foster an integrated patient management approach

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role of the scip physician champion card 2
Role of the SCIP Physician Champion – Card 2
  • Has the ability to influence others’ attitudes and behaviors
  • Serves as an informal leader and competent role model
  • Supports change and innovation
  • Communicates the case for change to others
  • Stands up for ideas that he or she supports
    • Cardiology Department Leader
    • Anesthesiologist

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card 2 measure implementation32
Card-2 Measure Implementation
  • Utilize all available quality improvement resources and tools (QIO, MedQIC, TJC, IHI, AHRQ, etc.)
  • Stay aware of the current measures and updates.
    • Support activities that raise awareness and implementation of pending measures.
  • Partner with other organizations in efforts to improve quality.
  • Post monthly or quarterly core measure results.
  • Discuss measure fallouts and corrective action plans.
  • Recognize the efforts of all to succeed.

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the take home messages
The Take-Home Messages
  • Preventing surgical cardiovascular complications is the goal of SCIP Card 2.
  • Patients on beta-blocker therapy prior to admission should receive a beta-blocker within the perioperative time frame.
  • Clear documentation of the beta-blocker dose received or beta-blocker contraindications are required.
  • Everyone involved in the patient’s care, from pre-operative planning through discharge from the PACU, can help meet this SCIP measure.
  • Having a strong SCIP team and a strong SCIP physician champion will foster success.

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the take home messages34
The Take-Home Messages

For additional SCIP resources, including the supporting documents for this Webinar, go to:

Arizona = http://www.hsag.com/azhospitals/scip/resources.aspx

California = http://www.hsag.com/cahospitals/scip/resources.aspx

Florida =

http://www.fmqai.com/PatientSafety-SCIP-Tools.aspx

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Over 1 million drug-related injuries occur every year in health care settings. The Institute of Medicine estimates that at least a quarter of these injuries are preventable. To find out how to prevent medication errors, go to

(Florida) http://www.fmqai.com/PatientSafety-FMSI.aspx,(Arizona) http://www.hsag.com/azproviders/drugsafety.aspx, or (California) http://www.hsag.com/caproviders/drugsafety.aspx.

www.hsag.com www.fmqai.com

This material was prepared by Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California; Health Services Advisory Group, Inc., the Medicare Quality Improvement Organization for Arizona; and FMQAI, Inc., the Medicare Quality improvement Organization for Florida, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. Publication Nos. CA-9SOW-6.2.3-122109-01, AZ-9SOW-6.2.3-122109-01, FL2009F62ST1611497

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