Transcript 1QFY2012x

EPRP Update
WVMI Confidential and Proprietary
 As
expected, there are several changes
to the data collection instruments for
1QFY2012
 This quarter you will notice that several
questions (and some complete modules)
have been removed
• Some questions that are not used in scoring were
deleted
 There
are also some new questions that
you will need to abstract
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 This
presentation will introduce you to
the major changes
 Please review the questions and pay
special attention to any highlighted areas
as not all the changes will be covered
here
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 As
we revise questions/rules and provide
education we have the results of quality
control monitoring in mind
 One of the places we see inconsistency is
in the recording of variable data, like
weight and height for example
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 In
an effort to be consistent, we ask that
you keep the following in mind
• When a value can only be entered as a whole
number, but the actual value may be recorded
with a decimal, enter the whole number only; do
not round regardless of the value to the right of
the decimal
• For example weight recorded as 179.8 should be
entered as 179.
• Ldl recorded as 121.6 should be entered as 121
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 At
some facilities creatinine is recorded
with 2 digits to the right of the decimal.
 The mask in the software only allows for
one digit to the right of the decimal
 Value documented as 1.25 (for example)
should be entered as 1.2
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 Q1:
Definition/Decision rule change
• Do not enter electronic capture of BP
documented by Care Coordination (CC/H) (in
question 1) as it will be entered in a
subsequent question.
 The
blood pressure questions for catnum
61 cases (SCI inpatient) that were
formerly in the SCI module are now in the
Core module (q13 and 14)
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 Note
additions to the rules for Q26
• Weight management treatment encounters could
be face-to-face visits, phone calls, or clinical
video teleconferencing.
• MOVE!Telephone Lifestyle Coaching (MOVE
TLC) is another name for a home telehealth
version of MOVE
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 Weight Watchers, TOPS, HMR, and
Optifast are examples of non-VA weight
management programs
 Programs that target only one aspect of
weight management (e.g. Nutrisytem,
Curves) are not acceptable.
 If the patient refused weight management
treatment, enter 3
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 There
are several changes to the FE
questions, particularly the Fall
Assessment questions
 Please review all the questions and rules
carefully
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 There
is a slight revision to the wording
of Q36
• During the past twelve months, was the patient
asked about the presence/absence of any falls
during the preceding 12 months?
 If
the patient was questioned about falls, enter
the date in Q36; that date will be the reference
point for the next series of questions
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 Questions
37-40 are seeking information
about whether the patient reported a fall
in the preceding 12 months and if so,
whether the fall resulted in injury
requiring treatment
• A fall with injury requiring treatment is any fall
for which the patient seeks medical attention; the
degree of treatment is not relevant
• If the patient received treatment at a (any)
VAMC, enter “1” for question 39
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 If
the patient reported a fall but no injury
requiring treatment, you will go to
question 41
• On (computer to display askfaldt), did the
 If
patient report two or more falls occurred during
the preceding 12 months?
the patient did not have a fall with
injury requiring treatment and did not
have two or more falls, you will go on to
the urinary incontinence questions.
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
Patients reporting one fall with injury
requiring treatment, or two or more falls
will go through the series of follow up
questions unless the date the patient was
questioned about the presence or
absence of falls is less than 3 months
prior to the pull list date
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 If
the patient was treated for injury at a
VAMC, the follow up questions will
display the timeframe falinjdt to
askfaldt+3 months
 For
example, if the patient had treatment for a
fall on 12/23/2010 and was asked about falls on
4/10/2011, the date in the follow up questions
would be 12/23/10-7/10/2011
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If treatment for a fall injury took place
somewhere other than a VAMC or if the patient
reported two or more falls, the time frame
displayed in the follow up questions will be
date the patient was asked about falls to the
date three months after.
 For example, if the patient was asked about
falls on 3/15/2011, the date range for the follow
up questions will be 3/15/2011 to 6/15/2011

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The follow up questions for those with a fall with injury requiring
treatment or two or more falls are the same as in the previous quarter
except that the time frame is displayed in the question




Basic fall evaluation
Eye Exam
Orthostatic blood pressure
Basic gait evaluation



Balance evaluation
Neurologic exam
Assessment of home
hazards
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 Q56: If
home hazards were identified,
look for documentation that
modifications were recommended to the
patient/caregiver on the date the home
hazard assessment was completed.
 Please note the timeframe of this
question as it has changed from previous
quarters
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Catnum 54 cases with no FE flag will
continue to go to the FE instrument
 There are changes to the FE instrument
which will be detailed in a separate
presentation

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
Flu immunization
• If selckd (Chronic Kidney Disease or ESRD) is
selected in the Validation module, the computer
will auto fill fluhirsk6 (and pnuhirsk8 for
pneumovax)
• The dates of the influenza immunization season
have changed:
 September 1, 2011 to March 31, 2012
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 The
two questions about lipid testing
were deleted (hyperlip2 and hyperlip5)
A
new option has been added to q84
(medications to treat or prevent
osteoporosis)
• Option 5: other agents (denosumab)
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 New
question 3:
• Did the patient’s AMI occur during the time
frame from (computer to display stdybeg – 2
years to stdyend)?
• Note the change to a two year look back
 Please
note that All AMI’s that occurred more
than 8 weeks prior to the qualifying visit are
subject to inclusion in the IHD module
• The rules for selmi in the Validation module are
unchanged
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 Q4: enter
the discharge date from the
most recent hospitalization for AMI
during the past two years
• If the discharge was from a VAMC you should be
able to enter the exact date
• If the discharge was from a non-VHA facility,
enter a date that is as exact as possible
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
A new question has been added to the
DM module
• Q11 Is there documentation the patient had renal
(kidney) transplantation?
• Kidney transplantation is a procedure that places
a healthy kidney from a donor into the body of a
patient who has end stage renal disease.
 It
the patient had a renal transplant the
case will pass DMG34h (renal function)
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 Changes
to lipid questions
• Question 5 and 8 have been added to capture the
date of the most recent cholesterol value (q5) and
the date of the most recent HDL value (q8)
• Please note the important instruction that was added
to questions 9 (hdl value) 15, 19 and 24 (ldl value)
 Disregard any number to right of decimal (e.g., HDL
reported as 25.7; enter 25 or LDL reported as 98.6; enter 98).
 liraglutide
(Victoza) has been removed from
the list of oral diabetes medication
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 The
IHD cohort is now included in the
Lipid medication questions
 This includes
• Selmi, selpci, or selcabg is true OR
• Vascdis (PI module) is answered 1, 2, 3, 5, 6, or 8
 Cases
meeting one of these criteria will
get the series of questions starting with
ldlstatn
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SUD Group Clinic (560) has been
removed from the list of clinics that will
enable this module if catnum=51
 Primary Care was specified in the
inclusion list for question 1 (opmedrx) for
clarity

• This is not a change as Primary Care clinics are
Nexus clinics
 Option
3 was removed from Q4 (optmed)
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 There are number of skip changes
• Cases with a “yes” answer to question 5
(emergent, life threatening situation existed) will
go to question 7 (medication discrepancies)
• Cases with a “no” answer to question 6 (unable
to confirm patient’s medications will go to
question 9 (reconciled med list at discharge)
instead of going to the end
• Those with a “4” or “99” answer to question 7
(medication discrepancies) will also go to
question 9 instead of going to the end
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 Q10
is new
• At the time of discharge from the outpatient
clinic visit on (computer to display medrxdt),
is there documentation the
physician/APN/PA, pharmacist, or nurse
provided written information to the patient
on minor medication changes?
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 The
intent of question 10 is to account for
situations when the physician/APN/PA made
minor changes to the patient’s medications,
limited to no more than two medications.
 A minor medication change is defined as a
change in dosage, addition or deletion of a
medication or change in administration
instructions.
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 In
the event that a minor change is made to no
more than 2 of the patient’s medications, the
organization may opt to only provide the
patient with the information specific to the
minor medication change in writing at the time
of discharge from the outpatient setting.


See the definition/decision rules for a specific example
The question is included in scoring for mrec 28 and 29
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 Alcohol
Misuse
• Several questions have been removed including
 Questions about history of alcohol misuse, substance
abuse, alcohol related problems, alcohol treatment
 Questions about who offered brief alcohol counseling
and where and referral for alcohol treatment
 Questions about alcohol treatment
• Option 1 of question 18 (brief alcohol
counseling) has been removed
 Patient drinks within recommended limits
(documented from patient self-report)
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 The
treatment questions for those with a
diagnosis of depression have been
removed
 If a patient had a encounter for
depression or bipolar disorder in the
past year (as evidenced by the code) the
depression screening questions will be
skipped
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 If
there is no diagnosis of depression or
bipolar disorder, the case will go through
the depression screening questions as
before
 If the depression screen is positive, you
will go to the depression triage questions
• These questions are mostly the same, although a
few questions have been deleted
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The treatment questions for patients with
a PTSD diagnosis have been removed
 Those with no PTSD diagnosis will get the
screening questions as before
 Those with a positive PTSD screen will
get the triage questions

• These questions are mostly the same, although a
few questions have been deleted
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 Validation: no
changes
 The SMI module has been deleted
 The SCI module has been deleted
• The inpatient BP questions were moved to the
Core module
 CHF: no
changes
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 There
is a change in the format of the
CGPI exit report
• The column for “type” has been deleted
• Also, the narrative information at the beginning
of the report no longer refers to Accountability
Measures
• The bolded lines are those that are eligible for
reconsideration
 You
will notice the same change on the
other exit reports as well
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
The following indicators have been removed from the exit report
•
•
•
•
•
•
•
•
•
•
•
•
P6h Colorectal Screen age 51 – 80
p31Breast Screen age 50 – 74
ihd18hn: CVD LDL < 100
dmg25h: LDL < 100
scid6: LDL < 100
mdd 45: Positive depression screen or affirmative PHQ-9 question
9 result with disposition documented
mdd46: Positive depression screen or affirmative PHQ-9 question 9
result with timely disposition documented
ptsd54: Positive PC-PTSD screen with disposition documented
ptsd55: Positive PC-PTSD screen with timely disposition
documented
sci_renl: Assess kidney function by acceptable test
sci_phy::Assess physical function/disability status
sci_soc: Assess psychological or social status
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 There
are some changes to the current
scoring
• These changes will be noted as applicable in the
CGPI exit report guide
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 There
are three new indicators
 Ihd18hns: CVD LDL < 100 or moderate dose
statin
 Dmg25hs: DM LDL < 100 or moderate dose
statin
 Scid6s: LDL-C < 100 or moderate dose statin
 The indicators identify cases with LDL <100 or
statin medications prescribed when LDL is
>=100
 The CGPI exit report guide will provide details
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
No changes to TBI questions or scoring
for 1Q FY2012
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 There
is a change to the
definition/decision rules for question 25
(Enter the date of the assessment of
cognitive function using a standardized
and published tool)
• The tool must be named and the result of the assessment must be
documented in accordance with the specific tool used (e.g., positive or
negative, numeric value, or other designation).

The same guidance is in the rules for question 26 with
regard to “other” standardized and published tools that
might be used to assess cognitive function
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There are new questions in the caregiver
strain section of HBPC
 Q30 Is the patient receiving hospice
care?

• Hospice may be Medicare or VA funded,
delivered at home, in a nursing home, or a
hospice facility
• Palliative care is not included
• If the answer is yes, the review ends
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

If the caregiver screen was positive, you will
answer some new questions
Q37: Following the positive caregiver strain screen, was
short term individualized therapy offered to the
caregiver?
• Look for documentation that the caregiver was
offered short term therapy, individualized therapy or
talk therapy
• A referral or order for short term therapy is
acceptable
• Offer of or referral to group therapy is excluded
• Answer yes, no or caregiver refused
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 If
the caregiver was offered short term therapy,
enter which discipline was requested to
provide or did provide short term
individualized therapy in question 38
 Which discipline was requested to or provided
the short term individualized therapy?
• 3. Social worker
• 4. Psychologist
• 5. Other
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 If
there is documentation that short term
therapy was provided prior to the
positive screen by a social worker or
psychologist, answer 3 or 4 as
appropriate
 Use option 5 for any other discipline
 If short-term therapy was not offered or
was refused go to question 39
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 In
Q39 you will look for other follow up for a
positive caregiver screen
• Caregiver education related to caregiver strain or
•
•
•
•
•
concerns
Completion of additional screening focused on the
caregiver
Offer of caregiver respite
Referral to support group
Mental Health referral for reason other than short
term individualized therapy or reason unspecified
Other methods documented as caregiver support
 To
answer “98” (refused) the caregiver must
have refused offer of all interventions
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


If there was a follow up intervention for a positive
caregiver screen, specify which intervention was
documented in Q40
The answer options have been revised from the
previous quarter
What follow-up intervention(s) are documented in the
medical record?
Indicate all that apply:
• 1. Provided caregiver education related to strain
• 2. Completed additional screening focused on the caregiver
• 5. Offered respite care
• 6. Referred to support group
• 7. Referred for follow-up with Mental Health for reasons specified
other than short term, individualized counseling or reasons
unspecified
• 8. Other
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
An exclusion has been added to hc22
(Caregiver with Zarit Burden score of 8 or greater and
received appropriate intervention) and to hc25
(Patients with caregiver strain assessment using Zarit
Burden scale) for patients receiving hospice care
 HC28
is a new indicator: Caregiver offered
short term, individualized therapy
• If short term individualized therapy was offered when the
caregiver screen was positive, the case will pass
• If therapy was refused, the case is excluded
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 No
changes to HBIPS questions or
scoring
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 In
previous years we have usually seen
several changes to the Joint Commission
instruments in the first quarter of the FY.
 Joint Commission has changed their
schedule for revisions, so you will see
most of those changes in 2Q, rather than
1Q
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Q12 Did the patient receive care or services in the
ED?
 There are changes to the definition/decision rules

• If a patient is transferred in from any emergency department
(ED) or observation unit OUTSIDE of the VAMC under review,
select “2”. This applies even if the emergency department or
observation unit is part of this hospital’s system (e.g., this
VAMC’s free-standing or satellite emergency department), has
a shared medical record or provider number, or is in close
proximity. Select “2”, even if the transferred patient is seen in
this facility’s ED.
• If the patient is transferred to your hospital from an outside
hospital where he was an inpatient or outpatient, select “2”.
This applies even if the two hospitals are close in proximity,
part of the same hospital system, have the same provider
number, and/or there is one medical record. Select “2”, even if
the transferred patient is seen in this facility’s ED.
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The questions about ED services that
previously followed q12 are now in a new
Global Measures instrument
 Review of the Global Measures
instrument questions will follow in
another presentation

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 The
four questions about pulse oximetry
and arterial blood gases have been
deleted
 The cap1 measure was also deleted
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The only other change to scoring is the
change of the discharge date range for
scoring of influenza immunization
 Cases with a discharge date
>=10/1/2011 and <=3/31/2012 are
included in scoring for cap15j

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 As
in PN, the ED questions have been
moved to the Global Measures
instrument
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
There is a skip pattern change in the atrial
fibrillation questions
• If the patient does not have chronic or recurrent atrial fib
during this hospital stay, the questions about warfarin at
discharge are skipped

Discharge instructions for insulin patients
• Wording was added to the definition/decision rules for
consistency with other discharge instruction questions
• Use only the documentation provided in the medical
record itself. Do not review and use outside materials in
abstraction. Do not make assumptions about what content
may be covered in material documented as given to the
patient/caregiver.
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 There
are no changes to IHF scoring in
1QFY2012
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 ED
questions moved to Global Measures
instrument
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The past medical history question (q1)
remains, however several of the answer
options have been deleted
 There are several changes to the series of
questions about lipids

• Questions deleted
• New questions added
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 Q63-65
ask about LDL and total
cholesterol tests performed within the
first 24 hours after hospital arrival
• Both direct and calculated (indirect) LDL-c
values are acceptable
• If all LDL-c values within the first 24 hours after
arrival are not calculated (e.g. due to high
triglycerides) select no to q63
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 Review
all LDL and total cholesterol values from
testing done within the first 24 hours after
arrival to see if any were less than 100 mg/dL
• If there are no LDL-c values less than 100 mg/dL from testing
done within the first 24 hours after Arrival Time but there is a
total cholesterol (TC or “cholesterol”) value less than 100
mg/dL from testing done during this timeframe, infer the LDL-c
was less than 100 mg/dL and select “Yes”.
 These
questions are used in the scoring
of ihi9 (statin prescribed at discharge)
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 If
there is no value <100, you will go to
the next 3 questions about levels within
30 days prior to arrival
 Q65-67 are the same as the 3 preceding
questions except the timeframe is within
30 days prior to hospital arrival
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 The
questions about assessment of
cardiac pain using the 0-10 scale and the
entry of the level of pain have been
deleted from the ACS at Initial
Presentation and the ACS after Admission
modules
 The question about the first heart rate
closest to the time of presentation was
also deleted from the Presentation
module
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 You
no longer have to answer the
questions about the ECG findings for
patients who were transferred in from a
community hospital
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 The
questions about heparin prescribed
at discharge were deleted
 There is an addition to the
definition/decision rules for the question
nostawhy (reasons for not prescribing a
statin medication at discharge)
• Examples of reasons for not prescribing a statin
medication at discharge include, but are not
limited to: hepatic failure, hepatitis, myalgias,
rhabdomyolysis
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
Three indicators have been deleted from
the ACS exit report
• Ihi5 (BB within 24 hours of arrival)
• Ihi50j (LDL cholesterol assessment documented)
• Ihi51j (Lipid lowering therapy prescribed at
discharge for at risk LDL level)
 Ihi9
(statin prescribed at discharge) was
changed from a QI to an AM
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 The
changes to the Surgical Care
instrument involve wording or format
changes to the definition/decision for
increased clarity
 There are no changes to the Informed
Consent Module
 There are no changes to SC scoring
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 Please
remember that when entering the
antibiotics for the question bioname,
biodate, biotime, bioroute that you must
Document the name of each antibiotic
dose (s) administered from arrival
through the first 48 hours after
Anesthesia End Time (72 hours postop
for CABG or Other Cardiac Surgery).
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 Please
be careful when selecting the type of
VTE prophylaxis administered (q 56
vtelaxis)
 Be sure you correctly determine whether
the patient was given low dose
unfractionated heparin or low molecular
weight heparin and choose the appropriate
option
 IPC devices and GCS are sometimes
confused. Please review the
definition/decision rules carefully to see
what falls under each option.
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 There
are several changes to the Blood
Management module
• skip pattern changes,
• changes in question order
• some new questions
• a few questions have been deleted
 There
are some important definition/decision
rule changes so please read highlighted
material carefully
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 Elective
cardiac surgeries, knee and hip
replacements and gynecologic surgeries
will start with question1
 Q1 is new
• Was a type and screen (T&S) or a type and
crossmatch (T&C) ordered prior to anesthesia
start time?
 The type & cross or type & screen must be associated
with the selected surgical procedure and ordered
prior to the anesthesia start date and time
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 If
a hemoglobin or hematocrit was not
done during the 45 days prior to the
anesthesia start date, or if the test was
done less than 14 days prior to the
anesthesia start date, you will get new
question 8
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 Q8:
Was there physician/APN/PA/CRNA
documentation of a reason why the patient was
not screened for preoperative anemia 14 to 45
days prior to Anesthesia Start Date?
• If the test was done less than 14 days prior to the
anesthesia start date due to patient preference,
answer “1”
• If there is documentation the patient was
bleeding and the test was performed 14 days or
less from the anesthesia start date, select “1”
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 If
the patient received an RBC transfusion
during the episode of care under review,
there is a new question about RBC
exclusions
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
Were ALL of the RBC unit(s) transfused for one or
more of the RBC exclusions?
• Massive transfusion protocol
• Hemorrhagic shock
• Acute bleeding
• Uncrossmatched transfusion
 In
order to answer “1” the documentation must
clearly indicate that ALL RBC transfusions given
during this hospitalization were for one or more
of the RBC exclusions.
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 There
is new guidance in the
definition/decision rules of q12
(signcons)
 In order to select option 2 (the initial
blood transfusion was deemed a medical
emergency) there must be
documentation of a physician note stating
there was no time to obtain consent prior
to the initial blood transfusion.
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 Q13
(ictrans): In order to answer “yes” to
this question, there must be
documentation that information about
risks, benefits and alternatives to
transfusion were provided, e.g.
documentation of only risks and
alternatives would be a “no” answer.
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 Questions
14 and 15 have changed in the
timeframe
 You will need to look for a pre-transfusion
hemoglobin result within 12 hours prior to the
start of the RBC transfusion
• Previously the timeframe was 24 hours prior
• If there is no hemoglobin you will look for a
hematocrit within 12 hours prior to the start of the
RBC transfusion
 The
same change applies to questions 17,18, 20
and 21
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Please review the revisions to the
definition/decision rules for q16, 19, and 22
(clinical indication for transfusion)
 Acceptable documentation:

• physician/APN/PA/CRNA documentation of bleeding
with additional documentation about the need for
transfusion
• e.g. Acute GI bleed with decreased hemoglobin,
transfuse 2 units PRBCs

Suggested data sources: anesthesia record,
consultation notes, ED record, operative notes,
physician orders, progress notes, procedure
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
Examples of unacceptable documentation of clinical
indication:
• Documentation of "low hemoglobin" or “acute blood loss” for
the RBC unit in the absence of bleeding without additional
documentation about the need for the transfusion
• Documentation of "symptomatic anemia" for the RBC unit in the
absence of bleeding without additional information (e.g.,
tachycardia, change in mental status, cardiac ischemia or
shortness of breath preferably with a fluid challenge) prior to
the transfusion

Exclude:
• Estimated blood loss without additional documentation of a
clinical indication
• “symptomatic anemia” without additional information
• any pre-transfusion laboratory result without additional
documentation of a clinical indication
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
Please review the revised definition/decision
rules for q26 (rbcordr1)
• Transfusion order = An order to transfuse was written by
the physician/advance practice nurse/physician
assistant/certified registered nurse anesthetist
(physician/APN/PA/CRNA) prior to the initiation of the
transfusion.
• A transfusion order from a physician/APN/PA/CRNA
documented as verbal, phone or fax can be written by a
nurse.
• Note: The data element Transfusion Order may apply to
more than one unit/dose (bag). For example: An order
written to "Transfuse two units RBCs" would apply to both
units that were administered, so select "1"..
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 Please
note the changed wording of q27
(rbcid1)
 Was
there documentation that patient’s ID was
checked by two staff or automated
identification was used during the verification
process prior to the administration of the blood
transfusion?
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 In
addition to the questions about
monitoring blood pressure and
temperature, there is a new question
about monitoring pulse (q30) before,
during and post transfusion
 The timeframe for post-transfusion
temperature monitoring has changed to
within one hour of transfusion completion
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 There
are some changes to the rules for
abstraction of vital signs associated with
transfusions
• Vitals documented at the start of the transfusion
are considered “within one hour of transfusion
initiation".
• If blood is transfused within 15 minutes, confirm
that vitals were taken within one hour post
transfusion to select "1".
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 There
are some changes to the scoring of
the blood management indicators
 The Pilot Exit Report guide will reflect
those changes
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 The
question which asks you to enter the
total score of the first Morse Fall Scale is
now q2 (change in question order only)
 If the total score of the first MFS is >=45,
you will skip the questions asking if any
MFS during the hospital stay was >=45
 There are no changes to scoring of the
Fall Assessment indicators
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 No
changes to the Delirium Risk module
 No changes to fe8
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 There
are only a few changes to this
module ; those involve skip pattern
changes
 Scoring changes will be detailed in the
Pilot Exit Report guide
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
We will not collect data for the VTE
instrument in 1QFY2012
• We may resume data collection for VTE later in
FY2012
 The
questions that were previously in the
Prevention module have been moved to
the new Global Measures instrument
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 Please
feel free to contact your RM, Anna,
Tanja or Alice if you have questions about
the instruments or scoring
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 The
changes reviewed in this
presentation will be effective with pull
lists beginning 11/14/2011
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