(AMI-1) Aspirin at arrival

Description: Acute myocardial infarction (AMI) patients without aspirin contraindications who received aspirin within 24 hours before or after hospital arrival.

Rationale: Early treatment with aspirin, whether alone or in conjunction with reperfusion, markedly reduces mortality from AMI. Accordingly, aspirin now plays an important role in the early management of all patients with suspected AMI and should be administered promptly.

Excludes: 

• Patients under 18 years of age,
• Patients transferred from another acute care hospital or emergency room.
• Patients transferred to another acute care hospital

(AMI-2) Aspirin prescribed at discharge

Description:  Acute myocardial infarction (AMI) patients without aspirin contraindications who are prescribed aspirin at hospital discharge.

Rationale:  The long-term use of aspirin after AMI confers a significant reduction in mortality, non-fatal re-infarction, and non-fatal stroke.

Excludes:   

• Patients less than 18 years of age,
• Patients transferred to another acute care hospital,
• Patients who expired,
• Patients who left against medical advice and
• Patients discharged to hospice.

(AMI-3) ACEI for LVSD
 
Description: Acute myocardial infarction (AMI) patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACEI) contraindications who are prescribed an ACEI at hospital discharge.  For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent with moderate or severe systolic dysfunction.

Rationale:  ACEI reduces mortality in patients with LVSD after AMI. In addition, the likelihood of a recurrent myocardial infarction may also be reduced.  Clinical trials have established that the use of ACEI initiated after recovery from an AMI improves long-term survival, with greater treatment benefit in patients with anterior infarctions or LVSD.

Includes:  Patients with chart documentation of a LVEF less than 40% or a narrative description of LVF consistent with moderate or severe systolic dysfunction

Excludes: 

• Patients less than 18 years of age
• Patients transferred to another acute care hospital
• Patients who expired
• Patients who left against medical advice
• Patients discharged to hospice
• Patients with chart documentation of participation in a clinical trial testing alternatives to ACEIs as first-line heart failure therapy
• Patients with one or more of the following ACEI contraindications/reasons for not prescribing ACEI documented in the medical record:
• ACEI allergy;
• Moderate or severe aortic stenosis;
• Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing ACEI at discharge.

(AMI-4) Adult smoking cessation advice/counseling

Description: Acute myocardial infarction (AMI) patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. For the purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.

Rationale: Smoking cessation is essential in patients with AMI. Smoking triggers coronary spasm, reduces the anti-ischemic effects of beta blockers, and doubles mortality after AMI. Patients who receive even brief smoking-cessation advice from their physicians are more likely to quit than those who receive no counseling at all. Hospitalization can be an ideal opportunity for a patient to stop smoking, and smoking cessation may promote the patient’s medical recovery.

Includes:  AMI patients with a history of smoking cigarettes anytime during the year prior to hospital arrival.

Excludes: 

• Patients less than 18 years of age
• Patients transferred to another acute care hospital
• Patients who expired
• Patients who left against medical advice
• Patients discharged to hospice

(AMI-5) Beta blocker prescribed at discharge

Description: Acute myocardial infarction (AMI) patients without beta blocker contraindications who are prescribed a beta blocker at hospital discharge.
 
Rationale: The use of beta blockers in post-myocardial infarction is associated with a lower risk of long-term morbidity and mortality. In spite of the documented benefits of these agents, there is evidence of substantial under-use in appropriate patients nationwide.

Excludes:

• Patients less than 18 years of age
• Patients transferred to another acute care hospital
• Patients who expired
• Patients who left against medical advice
• Patients discharged to hospice
• Patients with one or more of the following beta blocker contraindications/reasons for not prescribing a beta blocker documented in the medical record:
• Beta blocker allergy;
• Bradycardia (heart rate less than 60 bpm) on day of discharge or day prior to discharge while not on a beta blocker;
• Second or third degree heart block on ECG on arrival or during hospital stay and does not have a pacemaker;
• Systolic blood pressure less than 90 mm Hg on day of discharge or day prior to discharge while not on a beta blocker; or
• Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing a beta blocker at discharge.

(AMI-6) Beta blocker at arrival

Description: Acute myocardial infarction (AMI) patients without beta blocker contraindications who received a beta blocker within 24 hours after hospital arrival.

Rationale:   Beta blockers administered to patients with AMI during the initial hours of presentation reduce morbidity and/or mortality. Immediate administration of beta blocker therapy appears to reduce the magnitude of infarction and associated complications in subjects not receiving concomitant thrombolytic therapy. Beta blockers also reduce the rate of reinfarction in patients receiving thrombolytic therapy. Results from the National Cooperative Cardiovascular Project demonstrate that beta blockers are substantially underutilized nationwide.

Excludes:   

• Patients less than 18 years of age
• Patients transferred to another acute care hospital on day of arrival
• Patients received in transfer from another acute care hospital on day of arrival, including another emergency department
• Patients discharged on day of arrival
• Patients who expired on day of arrival
• Patients who left against medical advice on day of arrival
• Patients with one or more of the following beta blocker contraindications/reasons for not prescribing beta blocker documented in the medical record:
• Beta blocker allergy;
• Bradycardia (heart rate less than 60 bpm) on arrival or within 24 hours after arrival while not on a beta blocker;
• Heart failure on arrival or within 24 hours after arrival;
• Second or third degree heart block on ECG on arrival or within 24 hours after arrival and does not have a pacemaker;
• Shock on arrival or within 24 hours after arrival;
• Systolic blood pressure less than 90 mm Hg on arrival or within 24 hours after arrival;
• Other reasons documented by a physician, nurse practitioner, or physician assistant for not giving a beta blocker within 24 hours after hospital arrival.

(AMI-8a) PCI received within 120 minutes of hospital arrival.

Description:  Acute myocardial infarction (AMI) patients receiving primary percutaneous coronary intervention (PCI) during the hospital stay with a time from hospital arrival to PCI of 120 minutes or less.

Rationale: The early use of primary angioplasty in patients with acute myocardial infarction who present with ST-segment elevation or LBBB results in a significant reduction in mortality and morbidity.  The earlier primary coronary intervention is provided, the more effective it is (Brodie, 1998). National guidelines recommend initiation of PCI within 120 minutes after hospital arrival inpatient with ST elevation myocardial infarction (Ryan, 1999). Despite these recommendations, few older patients hospitalized with AMI receive primary angioplasty within a timely manner (Jencks, 2000).

Includes patients with:

• ST segment elevation or LBBB on the ECG performed closest to hospital arrival

AND

• PCI performed within 24 hours after hospital arrival

Excluded Populations: 

• Patients less than 18 years of age
• Patients received in transfer from another acute care hospital including another emergency department
• Patients administered thrombolytic agents

(HF-1) Discharge instructions

Description: Heart failure patients discharged home with written instructions or educational material given to patient or care giver at discharge or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment, weight monitoring, and what to do if symptoms worsen. 

Rationale: In the United States, it is estimated that 4.7 million persons have heart failure. Mortality rates are high, and as our population ages, the incidence and mortality are expected to increase. Educating patients with heart failure and their families is critical. Patient non-compliance with physician’s instructions is often a cause of re-hospitalization. It is thus important that health care professionals ensure that patients and their families understand the prognosis of heart failure, the rationale for pharmacotherapy, dietary restrictions, and activity recommendations, prescribed medication regimen, and the signs and symptoms of worsening heart failure.  Additionally, patients discharged from the hospital after an exacerbation of heart failure should have follow-up to ensure clinical stability.

Numerator Statement: Heart failure patients with documentation that they or their caregivers were given written discharge instructions or other educational material addressing all of the following:

• activity level
• diet
• discharge medications
• follow-up appointment
• weight monitoring
• what to do if symptoms worsen

Includes patients with:

• A discharge to home, home care, or home IV therapy.

Excludes:  Patients less than 18 years of age

(HF-2) LVF assessment

Description: Heart failure patients with documentation in the hospital record that left ventricular function (LVF) was assessed before arrival, during hospitalization, or is planned for after discharge.

Rationale: In the United States, it is estimated that 4.7 million persons have heart failure. Mortality rates are high, and as our population ages, the incidence and mortality are expected to increase. Measurement of left-ventricular performance is a critical step in the evaluation and management of almost all patients with suspected or clinically evident heart failure. The combined use of history, physical examination, chest x-ray, and electrocardiography cannot reliably distinguish between the major categories of heart failure: left-ventricular systolic dysfunction, left-ventricular diastolic dysfunction, or a non-cardiac etiology. If a measurement of ventricular performance is not obtained in patients presenting with heart failure, appropriate treatment may be withheld. Specifically, patients with left ventricular systolic dysfunction will not be identified and treated with agents known to prolong life.

Excludes: 

• Patients less than 18 years of age
• Patients transferred to another acute care hospital
• Patients who expired
• Patients who left against medical advice
• Patients discharged to hospice
• Patients with reasons documented by a physician, nurse practitioner, or physician assistant for no LVF assessment

(HF-3) ACEI for LVSD

Description: Heart failure patients with left ventricular systolic dysfunction (LVSD) and without angiotensin converting enzyme inhibitor (ACEI) contraindications who are prescribed an ACEI at hospital discharge.  For purposes of this measure, LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular function (LVF) consistent with moderate or severe systolic dysfunction.

Rationale: In the United States, it is estimated that 4.7 million persons have heart failure. Mortality rates are high, and as our population ages, the incidence and mortality are expected to increase. Treatment with ACEI reduces morbidity and mortality in patients with heart failure and LVSD.

Includes patients with:

• Chart documentation of a LVEF less than 40% or a narrative description of LVF consistent with moderate or severe systolic dysfunction.

Excludes: 

• Patients less than 18 years of age
• Patients transferred to another acute care hospital
• Patients who expired
• Patients who left against medical advice
• Patients discharged to hospice
• Patients with chart documentation of participation in a clinical trial testing alternatives to ACEIs as first-line heart failure therapy
• Patients with one or more of the following ACEI contraindications/reasons for not prescribing ACEI documented in the medical record:
• ACEI allergy;
• Moderate or severe aortic stenosis;
• Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing ACEI at discharge

(HF-4) Adult smoking cessation advice/counseling
 
Description: Heart failure patients with a history of smoking cigarettes, who are given smoking cessation advice or counseling during hospital stay. For purposes of this measure, a smoker is defined as someone who has smoked cigarettes anytime during the year prior to hospital arrival.
 
Rationale: Smoking cessation is essential in patients with heart failure. Patients who receive even brief smoking-cessation advice from their physicians are more likely to quit than those who receive no counseling at all. Hospitalization can be an ideal opportunity for a patient to stop smoking, and smoking cessation may promote the patient’s medical recovery.

Includes patients with:

• A history of smoking cigarettes anytime during the year prior to hospital arrival

Excluded Populations: 

• Patients less than 18 years of age
• Patients transferred to another acute care hospital
• Patients who expired
• Patients who left against medical advice
• Patients discharge to hospice

(PN-1) Oxygenation assessment

Description: Pneumonia patients who had an assessment of arterial oxygenation by arterial blood gas measurement or pulse oximetry within 24 hours prior to or after arrival at the hospital.

Rationale: Hypoxemia is a known risk factor for poor outcomes in patients with pneumonia.  Supplemental oxygen has been shown to decrease mortality in patients with pneumonia.

Excludes:

• Patients received in transfer from another acute care or critical care access hospital, including another emergency department
• Patients who have no working diagnosis of pneumonia at the time of admission
• Patients receiving Comfort Measures Only
• Patients less than 18 years of age

(PN-2) Pneumococcal screening and/or vaccination

Description: Pneumonia patients age 65 and older who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated.

Rationale: Pneumococcal vaccination is indicated for persons 65 years of age and older because it is up to 75% effective in preventing pneumococcal bacteremia and meningitis. It is also an important vaccine due to increasing antibiotic resistance among pneumococci. In the United States today, vaccine coverage is suboptimal.  Although inpatient vaccine screening and administration are recommended, hospitalization is an underutilized opportunity for adult vaccination.

Excludes:

• Patients received in transfer from another acute care or critical access hospital, including another emergency department
• Patients who left against medical advice
• Patients who were discharged to a federal hospital
• Patients who have no working diagnosis of pneumonia at the time of admission
• Patients receiving Comfort Measures Only
• Patients less than 65 years of age
• Patient expired
• Patients who were discharged to hospice care
• Patients who were transferred to another short term general hospital for inpatient care

(PN-3b) Blood cultures

Description: Collection of blood culture prior to first dose of antibiotic.

Rationale: Published pneumonia treatment guidelines recommend performance of blood cultures for all inpatients to optimize therapy.  Improved survival has been associated with optimal therapy.  In addition, the yield of clinically useful information is greater if the culture is collected before antibiotics are administered. 

Excludes:

• Patients received in transfer from another acute care or critical care access hospital, including another emergency department
• Patients who have no working diagnosis of pneumonia at the time of admission
• Patients receiving Comfort Measures Only
• Patients less than 18 years of age
• Patients having no blood cultures obtained

(PN-4) Adult smoking cessation advice/counseling

Description: Pneumonia patients with a history of smoking cigarettes who are given smoking cessation advice or counseling during hospital stay.

Rationale:  The publication “Treating Tobacco Use and Dependence, Quick Reference Guide for Clinicians” states that tobacco use has been cited as the single greatest cause of disease in the United States today.  Smoking accounts for one out of every five deaths in the United States and is the most important modifiable cause of premature death. The above-mentioned Reference Guide for Clinicians also indicates that a high percentage of all smokers (at least 70%) have expressed a desire to quit smoking. Smoking cessation treatments ranging from brief clinician advice to specialist-delivered intensive programs, including pharmacotherapy, are not only clinically effective, but also are extremely cost-effective relative to other commonly used disease prevention interventions and medical treatments.  Hospitalization can be an ideal opportunity for a patient to stop smoking, and smoking cessation may promote the patient’s medical recovery. Patients who receive even brief smoking-cessation advice from their physicians are more likely to quit than those who receive no counseling at all.

Includes patients with:

• A history of smoking cigarettes anytime during the year prior to hospital arrival

Excludes: 

• Patients transferred to another acute care hospital
• Patients received in transfer from another hospital’s emergency department
• Patients who left against medical advice
• Patients transferred to a federal hospital
• Patients discharged to hospice
• Patients who expired
• Patients who have no working diagnosis of pneumonia at the time admission
• Patients receiving Comfort Measures Only
• Patients less than 18 years of age

(PN-6) Initial antibiotic selection for Community- Acquired Pneumonia (CAP)
in immunocompetent patients (CMS)

Description: Immunocompetent ICU patients with CAP who receive an initial antibiotic regimen during the first 24 hours that is consistent with current guidelines.

Rationale: The current North American antibiotic guidelines for CAP in immunocompetent patients are from the Centers for Disease Control and Prevention (CDC), the Infectious Diseases Society of America (IDSA), the Canadian Infectious Disease Society / Canadian Thoracic Society (CIDS/CTS), and the American Thoracic Society (ATS). All four reflect that Streptococcus pneumoniae is the most common cause of PN, that treatment that covers “atypical” pathogens (e.g., Legionella species, Chlamydia pneumoniae, Mycoplasma pneumoniae) can be associated with improved survival, and that the prevalence of antibiotic resistant S. pneumoniae is increasing.

The CMS convened a conference of guideline authors, including Julie Gerberding, MD (CDC), John Bartlett, MD (IDSA), Ronald Grossman, MD (IDSD/CTS), and Michael Niederman, MD (ATS), to reach consensus on the antibiotic regimens that could be considered consistent with all four organizations’ guidelines. These regimens are reflected in this measure, and in the Pneumonia Antibiotic Consensus Recommendation which follows later in this section.

Numerator Includes: ICU PN patients on the following antibiotics:

• IV Beta-Lactam (ceftriaxone, cefotaxime, ampicillin-sulbactam) plus IV Macrolide
  
  
• (erythromycin, azithromycin).
  OR
  
  
• IV Beta-Lactam plus Quinolone IV (levofloxacin, gatifloxacin, moxifloxacin)
  OR
  
  
• If documented beta-lactam allergy: IV Quinolone plus IV Clindamycin or IV Quinolone plus IV Vancomycin.

• For patients with pseudomonal risk the following antibiotics should be used:
  • IV antipseudomonal â -lactam (cefepime, imipenem, meropenem, piperacillin-tozobactam) plus IV antipseudomonal quinolone (ciprofloxacin, levofloxacin), OR
  • IV antipseudomonal â -lactam and IV aminoglycoside (gentamicin, tobramycin, amikacin) plus either an IV antipneumococcal quinolone(levofloxacin, gatifloxacin, moxifloxacin) or IV macrolide (azithromycin, erythromycin)
  • If documented beta-lactam allergy: Aztreonam IV plus IV Aminoglycoside plus IV Antipneumococcal quinolone.

Excludes:

• Patients received in transfer from another acute care or critical access hospital,
• including another emergency department
• Patients who have no Working Diagnosis of pneumonia at the time of admission
• Patients receiving Comfort Measures Only
• Patients who are Compromised as defined in the Data Dictionary
• Patients who have initial antibiotic more than 36 hours from the time of arrival
• PN patients not in the ICU
• Patients who do not receive antibiotics during hospitalization
• guidelines.

(PN-5b) Initial Antibiotic Received within 4 Hours of Hospital Arrival.  (NQF-ENDORSED VOLUNTARY CONSENSUS STANDARDS FOR HOSPITAL CARE)

Description: PN 5a:  Pneumonia patients who receive their first dose of antibiotics within 8 hours after arrival at the hospital.
PN 5b:  Pneumonia patients who receive their first dose of antibiotics within 4 hours after arrival at the hospital.

Rationale: There is growing clinical evidence of an association between timely inpatient administration of antibiotics and improved outcome among pneumonia patients.  One study found that Medicare pneumonia patients had improved survival if they received antibiotics within 4 hours of admission (Kahn 1990).  Another study found that shortening the time-to-first-dose to 4 hours was associated with improved survival (McGarvey 1993).  In 1995 over 14,000 randomly selected Medicare pneumonia hospitalizations were examined.  They found that patients who received their first dose of antibiotic within 3 hours were less likely to die within 30 days than were patients whose antibiotics were delayed, although this association did not become statistically significant until 8 hours following arrival, when a 15% (P<0.001) reduction was noted (Meehan 1995).  More recently, a study of 13,771 Medicare pneumonia hospitalizations from 1998-99 found that 30-day mortality was 10% (P=0.04) lower and length of hospital stay was shorter among patients whose first antibiotic was administered within 4 hours when compared with those whose time to first dose was longer.  Among patients who had not received antibiotics before arriving at the hospital, administration within 4 hours was associated with 17% reductions in mortality during both hospitalization (P=0.01) and the 30 days following admission (P=0.001) (Bratzler 2001).

Based on these studies, the Infectious Diseases Society of America (2000) and the American Thoracic Society (2001) suggests 8 hours as the maximum time to first antibiotic administration.  Data collected by the National Pneumonia Project indicate that among Medicare pneumonia patienst age 65 or older who were hospitalized during 1998-99, the first dose was administered within 8 hours for 83.4%, within 6 hours for 74.9%, and within 4 hours for 57.7%.  This represents a significant improvement from 1995, when corresponding rates were 79.4% at 8 hours, 68.8% at 6 hours, and 49.9% at 4 hours (CMS unpublished data).  For 1998-99, the rates of administration within 8 hours ranged from 38% to 91% among the states and territories.

Excludes:  

• Patients received in transfer from another acute care or critical access hospital, including another emergency department
• Patients who had no working diagnosis of pneumonia at the time of admission
• Patients who do not receive antibiotics during hospitalization
• Patients who received  Comfort Measures Only
• Patients less than 18 years of age
• Patients whose initial antibiotic was administered more than 2160 minutes (36 hours) from the time of arrival
• Patients who have received antibiotics within 24 hours prior to hospital arrival