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Thursday, November 11, 2010

Core Measures

As a medical care professional, whether you're a respiratory therapist or a registered nurse, it's important you understand the behind the scenes politics. Sure you may wonder why you're doing breathing treatments on someone who doesn't need them, yet believe it or not, there is a good method to the madness -- most of the time.

Or if it's not a good method, at least it's a method nonetheless.

Whether or not you think government involvement in the health care system is a good or bad thing, the Centers for Medicare/Medicaid Services (CMS) established what they call "core measures" as a means of improving quality of hospital care and reducing costs. While I don't care for government involvement, I think the idea of "core measures" is a good thing.

Yes, it may result in some overkill, yet sometimes some overkill is needed to meet the ultimate goals of an institution and the overall health care system to the benefit of the patient and to assure cost effectiveness. Bare with me, because by the time this post is complete hopefully you'll have a better overall understanding of what I mean.

So, what are core measures? Please forgive me if I don't get this exactly straight, because I'm learning along with you. Yet after participating in a year's worth of administrative meetings, given presentations, interviewed coworkers and completed a ton of research where I think I have enough information to write about this nearly inexplicable subject.

Core measures are the things the medical staff must do when a patient is admitted under a specific core measure set: acute mycardial infarction, heart failure, pneumonia, and surgical care. Within these four sets there are 27 core measures that are based on scientifically-researched standards of care that have been shown to result in improved clinical outcomes for patients.

Basically, for each particular diagnosis, or diagnosis related group (DRG), the core values are all the things that the latest wisdom has proven work to increase recovery time for that patient.

They have also provided a focus for the development of Clinical Pathways and Standard Orders (post on this coming soon too), both of which assist in the consistent provision of optimal care to patients.

By Clinical Pathways we mean the creation of a system throughout the hospital that makes sure what needs to be ordered is getting ordered, and then completed. One example of this is our hospital has created order sets and protocols for several DRGs.

Now I am of the impression that order sets are bad and protocols are good. This is a topic I will discuss in more detail in an up and coming post.

These order sets and protocols act as a hymn book to make sure every professional taking care of the patient, from the doctor to RT, from the nurse to the lab techs to the x-ray tech, know exactly what their roll is for the patient.

A protocol is a standard order approved by the medical staff that gives the nurses and respiratory therapists the opportunity to do what is best for the patient given the circumstances. If used properly, these work to the benefit of the patient (improved care when needed), the staff members involved (improved morale) and the physician (decreased irritating calls).

An order set is a sheet of paper that the nurse pulls from a cabinet as soon as a patient is, for example, diagnosed with pneumonia. The set is a list of all possible options for that diagnosis. Some of the options that are most essential, such as making sure a sputum is ordered and obtained before the initial antibiotic is given, and giving that first antibiotic within six hours from the time the patient hits the door, are automatically ordered.

Many hospitals are incorporating order sets that automatically set in motion certain things that assure core measures are met, because these are scientifically proven to speed recovery and reduce costs. Examples are x-ray on admission and each morning for the next three days, labs on admission and each morning for the next three days, oxygen, IV, etc. These things must be done on all pneumonia patients, and the order set sets this in motion.

Another thing that is automatic is antibiotic selection, although the doctor will have options here. The emergency room nurses have a process in place where they will make sure the patient gets the antibiotic within six hours if the patient is still in the emergency room, and then there is another system in place to make sure this antibiotic is given within six hours if the patient is admitted to the patient floors.

When x-rays and labs are ordered, they pop up on a tracker board automatically through a computerized system both on a board in the emergency room and on similar tracker boards in the lab and x-ray departments. As time elapses, the color of each particular procedure changes from green (you have some time) to red, which means it needs to be done soon or right now or STAT or at least given top priority.

At Shoreline we have a bright orange laminated sheet that is inserted into the patient's chart right before the doctor's orders section, so that every person who looks at the orders is reminded of the importance of core measures.

Sure order sets might result in some overkill, yet all these reminders, all this motion, makes sure the hospital is meeting core measures for this patient. It also assures the hospital is meeting Intensity of Service. For example, on our order set, the options of IV, antibiotic selection, and breathing treatments are on the order set.

Used appropriately, one can see how order sets and protocols, when used together, can result in improved outcomes and reduced costs, improved staff morale, and decreased annoying calls to the physician.

Each individual hospital uses analysis of their own core measures as a means of evaluating performance at their own institution, and as a method of improving this performance.

Here at Shoreline Medical we analyze core measures data at our weekly keystone meetings. An example of the data we look at can be seen in the picture to the right.

The goal is to obtain a 90% rating in each core measure, as indicated by green. If the rating is less than 90%, this would be indicated as red.

The results are reported to the Joint Commission, which records this data on their website so anyone can see where each hospital stands in each area.

The Health and Human Services (HHS) has created a new website so you can check out hospital core measures. The site created is the Agency for Health Research & Quality ( Another site is HHS's new site

However, as I noted in this Keystone post, "It must be noted, however, that these measures must not be used as a report card to compare hospitals, rather as a tool for hospital improvement. What I mean by this is that if you consider 80-90% a B grade, and 90% or greater an A, you might actually be mislead.

"If you have a small hospital that has only admitted 10 patients with an MI over a span of a month, and a larger hospital has admitted over 100 such patients, and both hospitals forget to
properly chart two patients for whatever reason, the small hospital's stats will show 80% (a B grade) and the larger hospital will show 98% (an A grade). Yet both hospitals made the same amount of errors.

"So, again, these core measures and the percentages that go with them should not be used as a report card to compare hospitals, but as data to assist improvement."

At Shoreline, and other hospitals in Michigan, we get together in a monthly Keystone Meeting to discuss the recent core measures data, and then try to implement a systematic approach to improving our data. For example, back in 2007 there were many core measures where we were in the red, or less than 90%. Our current statistics are mostly green.

Thus, based on these core measures, we have created a a rapid response team, a sepsis protocol, an extubation protocol, a ventilator bundle, a sepsis bundle, a pneumonia bundle, an MI bundle, a heart failure bundle, a surgical bundle, among other successes that have reduced the number of patients being transported to the critical care, and obtaining nosocomial infections. This also includes a reduction in cases ventilator acquired pneumonia (VAP, other nosocomial pneumonia, and sepsis, and has likewise reduced readmission rates (post on this coming Sunday).

We have also created an array of order sets for pneumonia, CHF, sepsis, COPD, asthma, ventilator, ventilator extubation, etc.

So you can see these core measures are a good thing. The only problem I see is our hospital has incorporated all these order sets and no protocols to go with them (with the exception of the ventilator extubation protocol).

This ultimately results in a lot of overkill. For example, every sepsis patient gets ABGs, every pneumonia patient gets breathing treatments, and most patients get EKGs. While these procedures are needed for some patients admitted with said disease, they are not needed for all. Likewise, once breathing treatments are ordered, they are never discharged.

The result here is RT and RN burnout trying to get all these things done just so the hospital meets core measures, and the hospital gets reimbursed. It wrongly gives the hospital the impression of caring more for money than for patients.

The ultimate goal, however, I believe, for the government in all of this, is to use these core measures as a means of reimbursing hospitals based on performance rather than for each procedure provided to the patient. Now I'm not sure this is a good thing or not, yet that's the ultimate goal.

Actually, the ultimate goal for the government in all this is to reduce costs, so that when the new health care reform goes into effect, and if the United States eventually adapts a Federalized Healthcare Program such as exists in Britain or Canada, the cost to the government will be minimal.

So, what are the specific core measures? Here are the core measures that are being monitored today:

1. Acute Mycardial Infarction:
  • Aspirin at arrival
  • Aspirin prescribed at discharge
  • Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
  • Smoking cessation advice/counseling
  • Beta blocker prescribed at discharge
  • Time to percutaneous transluminal coronary angioplasty (PTCA)
  • Inpatient mortality
2. Heart Failure:
  • Aspirin at arrival
  • Aspirin prescribed at discharge
  • Angiotensin converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) for left ventricular systolic dysfunction (LVSD)
  • Smoking cessation advice/counseling
  • Beta blocker prescribed at discharge
  • Time to percutaneous transluminal coronary angioplasty (PTCA)
  • Inpatient mortality
Community Acquired Pneumonia:
  • Oxygen assessment within 24 hours of arrival
  • Pneumococcal and influenza screening and/or vaccination
  • Blood cultures prior to first antibiotic dose
  • Smoking cessation advice/counseling
  • Arrival time to first antibiotic
Surgical care improvement project: (check out this link)
  • Providing a prophylactic antibiotic within 1 hour prior to surgical incision
  • Providing a prophylactic antibiotic selection for surgical patients consistent with each type of surgical procedure
  • Discontinuing the prophylactic antibiotic within 24 hours after the end of surgery because prolonged use of antibiotics increases the risk of Clostridium difficile infection -- a bacterium that causes diarrhea and more serious intestinal conditions such as colitis -- and the development of pathogens -microorganisms such as bacteria, viruses or parasites that can cause disease -- resistant to antibiotics
  • Controlling postoperative serum glucose in cardiac surgery patients because high blood sugar weakens the immune system and increases the risk of infection
  • Clipping the hair of surgery patients rather than shaving because skin abrasions increase the risk of infection
  • Maintaining immediate postoperative normothermia (normal temperature) in colorectal surgery patients because increased temperatures pose a greater risk of infection, prolonged healing of wounds and longer hospital stays.
Based on these core measures, a major initiative of the Keystone Project was to improve outcomes of the critical care. It is actually the largest statewide collaborative ever: 76 hospitals, and 120 intensive care units. By this accomplishment it has also reduced costs for both the hospital and the government.

Interventions of the project include:
  • Implement a unit based safety program
  • Eliminate central line associated blood stream infections
  • Eliminate Ventilator associated pneumonia (VAP
  • Implement daily goal sheets
  • Implement sepsis bundles to reduce ICU mortality from severe sepsis and septic shock
So you can see that the overall idea of core values is a good thing to improve quality of patient care and reduce costs -- if done the right way. It's also a method Medicare uses to pay hospitals, and a means of making sure doctors, nurses, RTs, x-ray techs, lab techs, and administrators are on the same page (all singing from the same hymn book) when it comes to taking care of the patient.

Again, though, the bottom line as far as a specific institution is concerned is to make sure we are doing all we need to do to ensure that we will be reimbursed. We have set up order sets so that everything that the most recent evidence shows will benefit those patients is ordered.

The pneumonia order set has bronchodilators every 6 hours. This assures that a bronchodilator is ordered by the attending physician. Now we know full well that pneumonia does not cause bronchoconstriction, yet by ordering bronchodilator treatments the physician is making certain the hospitals foremost experts on the lungs are assessing the patient every six hours during the course of the day."

Reminders are in the charts for us RTs too. Since best practice evidence shows a speedy extubation reduces ventilator acquired pneunonia, our extubation protocol encourages us to think extubation as soon as the patient is intubated. So we have laminated sheets in the chart to remind everyone who cares for the patient what this protocol is. Another laminated sheet on the chart shows a simple step-by-step algorithm to extubation.

Reminders are everywhere. Some are laminated sheets, some are signs on bulleton boards, some are on the tracker board, some are sheets of paper that print of in respective departments. Likewise, our department supervisors double check our charting to assure we are properly charting. It's the job of your boss to make sure everything is charted properly so core measures and Intensity of Service is met.

Yes, you might think your boss is hounding you at times. You may get lots of notes. Yet this is the job of your boss. His job is to make sure you are doing everything for that patient based on core measures. If core measures are not met, the hospital may not be reimbursed. So if you get the feeling your boss is paying too much attention to your charting and not enough attention to the patient, now you know that's not actually the case.

Yes, there is some overkill. Yes, there will be some needless procedures (such as bronchodilators on all pneumonia patients), yet the ultimate goal is to improve quality and reduce costs (which is the bottom line).

The neat thing about the monthly keystone meetings at Shoreline is that any time any person who cares for the patient has an idea to improve the process, or if new wisdom is learned, this gets reviewed and better clinical pathways are created.

If you're still confused about core measures, don't worry because so are the same people responsible for monitoring them.

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