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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

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    1. 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

    2. 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. 2

    3. Q1: What is SCIP? 3

    4. Surgical Care Improvement ProjectNational Goal • To reduce preventable surgical morbidity and mortality by 25% by 2010. 4

    5. 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 5

    6. Surgical Care Improvement Project (SCIP) Preventable Complication Measures Surgical infection prevention Cardiovascular complication prevention Venous thromboembolism prevention 6

    7. Surgical Care Improvement Project 7 *NQF endorsed

    8. Q2: What is the Card-2 Measure? 8

    9. 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, clicking on the “Hospitals-Inpatient” tab, then clicking on the Specifications Manual option.] 9

    10. Q3: Can you help us understand why Card-2 is such a high-priority topic? 10

    11. 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. 11

    12. Q4: My patient’s home medications include antihypertensive and cardiac medications, as well as a beta-blocker. Why the concern for beta- blockers specifically? 12

    13. 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. 13

    14. Q5: What exactly is required to meet the Card-2 beta- blocker measure? 14

    15. 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. 15

    16. 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. 16

    17. Q6: How do I know if a patient takes a beta-blocker as a home medication? 17

    18. 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. 18

    19. 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: 19

    20. Q7: What is the “perioperative period” in which a patient should receive a beta- blocker? How are the start- and end-times determined? 20

    21. 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. 21

    22. Q8: What are the contra-indications to receiving a beta-blocker, and how are contraindications documented? 22

    23. 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: 23

    24. 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. 24

    25. 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.   25

    26. SCIP Beta-Blocker While NPO Reminder Poster • This reminder poster is available at several Web sites: • • • • 26

    27. Q9: How have other hospitals found success with the Card-2 measure? 27

    28. 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 28

    29. 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.” 29

    30. 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 30

    31. 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 31

    32. 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. 32

    33. 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. 33

    34. The Take-Home Messages For additional SCIP resources, including the supporting documents for this Webinar, go to: Arizona = California = Florida = 34

    35. 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),(Arizona), or (California) 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 35