Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction CDAC Abstraction CDAC Educational Comments ACEI Prescribed at Discharge Yes No Found Benazepril given in the hospital; however, unable to locate an ACEI prescribed at discharge. Anesthesia End Time 10:08 09:56 Provider's time of 10:08 was noted on the anesthesia record as the incision end time however this is not an included term for anesthesia end. Found anesthesia end time of 09:56 on the anesthesia record. Per guidelines, use the latest time "associated with an inclusion term" that represents the Anesthesia End Time. Anesthesia End Time UTD 12:50 Found PACU admission time of 12:50 on the anesthesia record. The anesthesia record is the priority source. Anesthesia End Time 14:05 14:15 Found both “14:05 Anes. stop symbol” on grid and “14:15 anes. Stop” on the Anesthesia Record. Abstract the latest time associated with an inclusion term that represents the Anesthesia End Time. Anesthesia Type Neuraxial Neuraxial and general Found documentation on the anesthesia record that neuraxial anesthesia was used for the procedure and documentation on page 1 of 2 of the intraop record that general anesthesia was used. Per guidelines if there is documentation that the procedure was performed using both neuraxial and general anesthesia select value 3. Anesthesia Type General Neuraxial and general Found documentation on the Pain management report that an epidural catheter was placed on 12/28 (DOS). Per guidelines if an epidural is placed preoperatively or up to 24 hours after the anesthesia end time or for other reasons such as post op pain control this is an inclusion for neuraxial anesthesia. If there is documentation that the procedure was performed using both neuraxial and general anesthesia select value 3. Antibiotic Dose (time) 08:00 UTD Found IV Levaquin given at an illegible time on the 2/5 ED record. Per guidelines, if the time an antibiotic is administered is unable to be determined, select UTD. Antibiotic Dose (time) 11:45 09:41 Ancef IV 3/17 at 09:41 was found given documented on st anes record as 1 dose administered. Surgery incision time: 3/17 at 10:15. Per guidelines abstract 1st dose, last dose, and dose closest to incision of each specific antibiotic/route to 48 hours after anes end time. Antibiotic Dose (time) 17:00 16:59 Found Rocephin IV noted/initialed off on the ED record dated 12-25-10 under orders with an arrow up at 16:59.This represents actual administration of this abx. Also found a later start time of 17:00 on the Emergency Care Flow Sheet. Per guidelines, abstract the first dose of each specific abx administered from arrival through 24 hrs after patient's arrival at the hospital. 1 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction Antibiotic Dose N/A [did not abstract] Antibiotic Dose N/A [did not abstract first or last dose] Reason to Extend Antibiotics CDAC Abstraction CDAC Educational Comments Cefazolin | 03 01-2011 | 08:30 | IV (Intravenous) Ciprofloxacin | 12-29-2010 | 13:00 | PO/NG/PEG tube (Oral) Found 3/1 08:30 as the 1st IV dose of Ancef given on the Intraop Record. Abstract the 1st dose, closest dose given prior to incision, and last dose for each specific abx/route given within 48hr postop. Found first dose of Cipro PO given on 12/29/10 at 13:00 on pg. 3, of the MAR. Anes. end time was 14:26 on 12/28/10. Per guidelines, abstract the first and last dose and dose closest prior to incision time for each specific abx administered from arrival through the 48 hrs after Anesthesia end time (72hr postop for cardiac surgeries). N/A [not enabled as did not abstract Cipro] Physician documentation within 2 days of infection Antibiotic Received Only in hospital Prior to and during hospital Antibiotic Received Only in hospital Prior to and during hospital ARB Prescribed at Discharge Arrival Time No Yes 18:51 19:10 Arrival Time 14:20 14:14 Element did not enable due to missing both po doses of Cipro given. Found physician documentation on the progress notes, dated 12/30/10 (POD #2) that the patient has an UTI. Therefore, this is value #4, there is physician/APN/PA documentation within 2 days (3 days for CABG or Other Cardiac Surgery) following the principal procedure with the day of surgery being day zero that the patient had an infection. In addition to the ABX given during the stay, Found documentation on the H&P that the pt was seen in the ER on the day prior to arrival and her Antibiotic was "modified". Per guidelines, if other documentation suggests antibiotics were taken within 24 hours or the day prior to arrival, this will be appropriate for antibiotics prior to arrival. In addition to the ABX given during the stay, Found Cephalexin and Ampicillin listed as Home medications on the pt's medication list dated the day of arrival. Per guidelines, antibiotics listed as "current" or "home meds" should be inferred as taken within 24 hours or the day prior to arrival, unless there is documentation they were Not taken within the last 24 hours. Found Valsartan listed as a discharge med on p. 6 of the Discharge Reports. Found on the ER Record/ER Registration form, a registration date/time of 01/25/11 at 18:51 but this does not physically place the pt at the hosp nor does it reflect any processes done in the ER/hosp. Found on pg 3 of the EMS report that the ambulance arrived the hosp at 19:07.Pt was triaged at 19:10 as per the ER nursing record. Per guidelines, arrival time should NOT be abstracted simply as the earliest time in the acceptable sources without regard to other substantiating documentation. Enter 19:10. Found a time of 14:20 on the ED nurse's first note, but also found an earlier time of 14:14 on the ED registration sheet. Per guidelines, select the earliest arrival date and time from any of the acceptable sources (same case for both data elements) 2 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction CDAC Abstraction Arrival Time 13:46 15:15 ASA before or after arrival No Yes Beta-blocker Current Med No Yes Beta-blocker Current Med No Yes Beta-blocker Perioperative No Yes Beta-blocker Perioperative No Yes Blood Culture Collected Collected in ED prior to adm order Collected during hospitalization but after adm order Blood Culture Collected Collected in ED prior to adm order Collected during hospitalization but after adm order CDAC Educational Comments Pt is a direct admit. Found time of 13:46 on admission form. However, the next earliest time is 15:15 on the Quick Start Admission Form (page 1 of 47). Found no other documentation to support that the pt was at hospital between 13:46 and 15:15. Per guidelines, if documentation suggests that the earliest time does not reflect the time that the patient arrived, this time should not be used. Found ASA given w/in 24 hours after arrival on the MAR 2/6/11 at 09:00. The arrival time was 2/5/11 at 17:12. Per guidelines, select yes if aspirin was received within 24 hours before or 24 hours after hospital arrival. Found documentation that the patient was on a daily betablocker therapy prior to arrival. Found on H and P, carvedilol listed as a home med. Found documentation that the patient was on a daily betablocker therapy prior to arrival documented on history and physical 12/29 Bystolic is listed as a home medication. Found documentation on the anes. record, on the grid, that the patient received a Beta-Blocker (Esmolol) on 02/08/11 intraoperatively. Therefore this is a yes to Beta-Blocker periop as per guidelines; the perioperative period for the SCIP cardiac measures is defined as 24 hours prior to surgical incision through discharge from the post anes care/recovery area. The surgical incision time was 17:50 on 02/08/11. Found on the Admission Screen form, under Medications section, Atenolol with the last dose taken on 03-07-11. Surgery date is 03-07-2011; therefore, this is within the timeframe. Per guidelines, the perioperative period for the SCIP cardiac measures is defined as 24 hours prior to surgical incision through discharge from the post anes care/recovery area. Found on the ED Nursing Data Base a "blood culture sent" date and time of 3/1/11 at 19:00. Found on the ED Record a Disposition Date and Time of 18:30 on 3/1. This is earlier than the physician admit order date and time of 3/2 at 08:50 found on the Medicine Admission Orders. Per guidelines, if the BC is collected within 24 hours after arrival but at the same time or after the earliest physician admit order time; you would select 2, BC collected after admission. Found a BC collection time of 17:46 on the ED Nurse's note, however, the ED Physician's Disposition to admit is timed 17:20. Per manual, in order to select value 1, the BC must be collected before the timed admission order/ED Physician's Disposition to admit; select value 2. 3 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Hospital Abstraction CDAC Abstraction Catheter Removed Removed POD 0-2 No documentation removed POD 0-2 Chest X-Ray Normal/chronic Abnormal Chest X-Ray Normal/chronic Abnormal Chest X-Ray Abnormal Normal/chronic Comfort Measures Only No/UTD Day 0 or 1 Comfort Measures Only Day 2 or after Day 0 or 1 Comfort Measures Only No/UTD Day 2 or after Compromised No Yes Discharge Instructions: Meds Yes No Data Element CDAC Educational Comments Unable to verify provider's answer of value #1 there is documentation that the urinary catheter was removed on POD 0 through POD 2, in the record received. No documentation was found in the record received of the urinary catheter being removed on POD 0 (02/08/11) through POD 2 (02/10/11) with the anes end date being POD 0. Therefore this is value #2 there is no documentation that the urinary catheter was removed on POD 0 through POD 2. CDAC Found on Physician Progress note dated 2/21/2011, under Impression: 1. Pulmonary infiltrates. Congestive heart failure versus healthcare-associated pneumonia. Per guidelines, physician documentation of infiltrate, density, markings, haziness, opacity, patchiness, or reticulonodular pattern are acceptable to select 1. The only way to know if one of these exists is via CXR/CT scan. Found on radiology report dated 2/22/11 lung fields show accentuated interstitial markings. This is an inclusion for abnormal chest x-ray. The cxr done PTA at the jail is noted with an infiltrate on the ER Medicine Continuation sheet & with a density on the consultation request from the MD at the jail but there is no mention of when this PTA cxr was done. The findings from the cxr and CT done during the stay do not provide an included term that is not attributed to something else. Without a timeframe for the cxr done PTA we will not be able to pick up the included terms documented in reference to that PTA cxr. Select value 2. Found the CMO inclusion term "hospice" on the physician signed D/C Summary dictated the day after arrival. This is a CMO inclusion for Day 0-1; answer 1. Found the CMO inclusion term "hospice" on the physician signed Progress Notes dated 12/30/10. This is a CMO inclusion for Day 1; answer Day 0-1. Found a palliative care consult ordered on 12/28/10 at 09:58.Per guidelines, if any of the inclusions are documented by a physician, select 1, 2, or 3 accordingly unless otherwise specified, select value 2. Found on the Discharge summary that the patient was immunosuppressed. Per guidelines, if there is physician documentation that the patient is immunocompromised or immunosuppressed, select Value 1. Found Aspirin 81 mg listed as a D/C med on the DCS. This med, however, was not listed on the DCI, therefore creating a mismatch. Per guidelines, ALL DC meds must be listed by NAME on written DC instructions given to the patient. Select No. 4 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction CDAC Abstraction Discharge Instructions: Meds Yes No Discharge Instructions: Meds Yes No Discharge Instructions: Meds Yes No Discharge Instructions: Meds Yes No Discharge Instructions: Medications No Yes Discharge Instructions: Symptoms Worsening Yes No Discharge Instructions: Weight Monitoring First PCI Time Yes No 08:48 08:45 CDAC Educational Comments The Discharge Summary states to 'see MAR or Rx' for discharge medications. All medications listed on the Rx are listed on the Discharge medication list that is given to the patient; however, the MAR 1/3 has numerous medications that are not listed on the DC med list. Per guidelines, ALL DC meds must be listed by NAME on written DC instructions given to the patient. The Discharge summary states to resume Levaquin daily for one week after discharge; however, it is not listed on the Discharge Medication list given to the patient. Per guidelines, ALL DC meds must be listed by NAME on written DC instructions given to the patient. Found ipratropium bromide/Atrovent marked as both "C" and "DC" on the Discharge Med Reconciliation. In determining meds prescribed at discharge, if documentation is contradictory, the case should be deemed "unable to be determined" (select NO), regardless of whether the med in question is included in the written discharge instructions. Found Doxazosin prescribed at discharge on the DC Summary, however, it is stopped on the Instructions for Care at Home Medications. Per guidelines if after careful examination of circumstances, context, timing, etc, documentation raises enough questions about what meds are being prescribed at DC, the case should be deemed UTD and select No. Found all Discharge Meds documented on the DCS addressed on the Physician Discharge Report. Since the "canary-patient" statement is documented on the bottom of the Physician Discharge Report, consider this as documentation the pt received a copy and select yes. Found instructions to contact physician if condition worsens or new symptoms appear on Discharge Summary/Instructions given to the patient; however, the symptoms are not specified as HF symptoms. Per guidelines, instructions on what to do if symptoms worsen, problems occur, the patient's condition changes or worsens, etc., without being specified or described as heart failure in nature, is an exclusion. Unable to locate documentation of written instructions or other educational material given to the pt that address weight monitoring in the record submitted to the CDAC. Found 0848 "Door to Device" on page 2 of the Event Log; however, this is not an acceptable inclusion. Found on the same page a time of 08:45 6 Fr AP Medtromic (Aspiration Catheter) which is an inclusion. Per guidelines use the earliest allowable time. 5 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction CDAC Abstraction Glucose POD 2 121 90 Glucose POD 2 139 153 Healthcare Associated PN No Yes Healthcare Associated PN No Yes Infection Prior to Anesthesia No Yes Infection Prior to Anesthesia No Yes Influenza Vaccination Refused Received prior Influenza Vaccination Refused Received prior to adm Initial BC Collection Time 23:10 UTD Initial BC Collection time 10:30 10:20 Initial BC Collection Time 10:20 10:25 CDAC Educational Comments Unable to find glucose value of 121. Found closest to 6 AM on POD 2 a glucose value of 90 on 10/7/10 lab report at 03;20. Found provider's POD #2 glucose level of 139 on pg. 10 of the summary discharge report, done on 12/30/10 at 07;39. However, found a POD #2 glucose level of 153 on pg. 3 of the summary discharge report, done on 12/30/10 at 05;00. Therefore, the POD #2 glucose level is 153, as, per guidelines, abstract the glucose value closest to 06:00 (whether prior to or after 06:00). Found on the ED Record under MDM/Attending/ Progress/Procedure Notes: a note, "? pneumonitis vs hospital acquired". Per guidelines if a physician notes that a pt has or is suspected of having healthcare associated PN, then this is an inclusion; answer Yes. Found documentation on the H&P that the pt was admitted to the hospital last on January 6, 2011 for 3 days. Per guidelines, acute care hospitalization within the last 90 days is an inclusion. Found patient had an infection; possible UTI during this hospitalization prior to the principal procedure 2/22 at 12:45, documented on pre-anes evaluation sheet signed by the anesthesiologist 2/22 at 11:50. Possible UTI is acceptable for an infection. Found patient had an infection during this hospitalization prior to the principal procedure done 2/25 documented on history and physical with diverticulitis. Diverticulitis is acceptable for infection. Flu vaccine documented as received prior to arrival during current flu season on page 8 of electronic record. Per guidelines if there is documentation of more than one allowable value in the record, select the lower value, value 2. Found documentation on page 6 of the Admission Assessment Report that the pt received the flu vaccine; select value 2. Found documentation on the Emergency Room Report that the pt had Blood cultures drawn prior to the dictated date and time of 2/20 at 23:56, however, unable to locate an actual BC collection time. Found a BC Collection time of 10:30 on the lab reports, but also found an earlier BC time of 10:20 on the ED Nurse's record. Per guidelines, if multiple times of collection are documented, abstract the earliest time. Found "Lab @ BS for blood Cx" on the 2/7 10:20 ED Nursing Note, however, this does not represent a collection of a BC. Found an actual BC collection time of 10:25 on the lab reports. 6 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction CDAC Abstraction Initial ECG Interpretation Yes No Initial ECG Interpretation Initial ECG Interpretation Yes No Yes No Initial ECG Interpretation Yes No Intentional Hypothermia No Yes Anesthesia Start Date 2/5/11 2/7/11 Laparoscope Yes No CDAC Educational Comments Unable to determine which EKG was done closest to arrival because some of the dates and times are cut-off of the EKG tracings. Per guidelines, if unable to determine which ECG was performed closest to arrival, select "No". Unable to locate documentation of ST elevation or LBBB on the initial EKG tracing or interpretations. Found documentation of 'incomplete left bundle branch block' on the initial EKG tracing 3/2 at 22:03. Per guidelines, incomplete LBBB is an exclusion; therefore, answer is no. Found "minimal voltage criteria for LVH, may be normal variant...ST elevation, consider lateral injury or acute infarct..." documented on the initial EKG tracing dated 2/18/11 at 00:55. Per guidelines, if you have an exclusion, select No regardless of other documentation. ST elevation with mention of LVH or normal variant is an exclusion, therefore, select No. Found cardiopulmonary bypass start at 13:25 and stop at 16:29 on the anesthesia record. Per guidelines, cardiopulmonary bypass is an inclusion. Comments for both data elements: Repair of duodenal perforation and cholecystectomy performed on 2/7 is the procedure of interest for this stay and was not performed laparoscopically. ERCP performed on 2/5 is not an included procedure. [Note: Hospital used information from the wrong surgery to abstract both data elements! Be sure to abstract procedure of interest.] (same case for both data elements) Laparoscope Yes No LVF Assessment Yes No LVSD No Yes Found documentation on the operative report that a midline incision was made and a Gelport was placed therefore the procedure was not done entirely by laparoscope or other fiber optic scope and No should have been selected. Unable to find documentation of Left ventricular systolic function (LVSF) assessment at anytime prior to arrival or during this hospitalization or a plan for LVSF assessment after discharge in the submitted medical record. Found EF 45% on Cardiac Cath Lab Procedure Log; however, also found "abnormal left ventricular function" under the Impression section of Consultation and Procedure Report. Per guidelines "Use the report from the most recent test. The Conclusion/Impression section takes priority over other sections. Left ventricular function described as abnormal is an inclusion for LVSD. Select "Yes". 7 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Hospital Abstraction CDAC Abstraction LVSD Yes No LVSD Yes No Pneumococcal Vaccination Status Reason for No Beta-Blocker at Discharge Received in the past None of the above No Yes Reason for Not Administering VTE Prophylaxis Reason not documented Reason documented Reason for Not Administering VTE Prophylaxis Reason not documented Reason documented Reason for Not Administering VTE Prophylaxis Risk Factors for Drug Resistant Pneumococcus Statin Prescribed at Discharge Temperature Reason documented Reason not documented No Yes Yes No Only listed at least one body temp greater… Listed body temp, but also “Active warming performed…” CDAC Educational Comments Unable to locate documentation of the left ventricular systolic function (LVSF) documented as an ejection fraction (EF) less than 40% or a narrative description consistent with moderate or severe systolic dysfunction. Unable to locate provider's answer in submitted record. Pt did not have an echo done during this hospital stay. DCS documents "Outpatient echo revealed normal LVEF" and the Cardiology consult also documents "outpatient echo recently performed demonstrated a LVEF of 65-70%". Select NO to LVSD. Unable to locate physician/APN/PA or pharmacist documentation of a reason for not administering pharmacological VTE prophylaxis in the submitted record. Found documentation of "sotalol on hold" on physician progress note, page 111 and physician order 3/7/11. Per guidelines, physician documentation of a hold or is continuation of a beta blocker that occurs during the hospital stay constitutes a "clearly implied" reason for not prescribing a beta blocker at discharge. Found documentation of "bleeding from the urogenital tract" on the consult dated 01/04. The DOS was 1/7. The time frame for this element is from arrival through 24 hours after the anesthesia end time. Per guidelines, this is an inclusion for a reason for not administering pharmacological VTE prophylaxis. Found documentation of a reason for not administering pharmacological VTE prophylaxis documented on anes record grid as PRBC's administered during principal procedure 1/20. Per guidelines blood products administered intraoperatively and documented on the anes record or the in operative report should be considered an order for transfusion. Unable to locate physician/APN/PA or pharmacist documentation of a reason for not administering pharmacological VTE prophylaxis in the submitted record. Found documentation on the H&P that the pt has been on ABX prior to arrival. Per guidelines, systemic antibiotic therapy in the last 3 months prior to arrival is an inclusion. Unable to find a statin medication prescribed at discharge in the submitted medical record. Found active warming performed intraop documented on 2/22 anes record as Bair Hugger is used. Bair Hugger is acceptable for active warming 8 Q1 2011 Inpatient Hospital Validation Mismatch Educational Comments Data Element Temperature Pre-op Hair Removal VTE Prophylaxis/ Timely www.fmqai.com Hospital Abstraction CDAC Abstraction There is no documentation of Allowable Values 1 AND 2. Clippers/ scissors Documentation of at least one body temperature greater than… Clippers/ scissors, PLUS “Razor” GCS / yes IPC / yes CDAC Educational Comments Found at least one body temperature greater than or equal to 96.8 degrees F/36 degrees C within the 15 minutes immediately after Anesthesia End Time 3/8 at 11:25. Temp value 98.6 degree F was done 3/8 at 11:30 documented on periop nursing notes. Found documentation on the periop nurses notes that shave prep was adequate and done in OR. Per guidelines shaved is an inclusion for razor. If there is more than one method documented select all of the methods that are documented. Found doc on pg 5 of surgical case record that pt had PAS stockings (IPC) in place on 02/08/11 intraop. Therefore this is a yes to VTE prophylaxis documented and also a yes to VTE timely as the PAS Stockings(IPC) were in place within the time frame of 24 hrs prior to the anes start time to 24 hrs after the anes end time. Anes was from 17:00 to 19:25 on 2/8/11. No doc found in record received of the pt having GCS in place within the above mentioned time frame. Therefore GCS should not be selected. This material was prepared by FMQAI, the Medicare Quality Improvement Organization for Florida, and Health Services Advisory Group of California, Inc., the Medicare Quality Improvement Organization for California, 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. FL-10SOW-2012FLC706-2-12703, CA-10SOW-7.4-021012-08 www.hsag.com 9