Critical Path Network

EMR triggers, concurrent review help hospital scores

Automation, checks and balances are part of the process

A series of initiatives, including automatic triggers for quality measures in the hospital's electronic medical record and concurrent review by case managers for core measures, has resulted in significant increases in quality measure scores at Russellville (AL) Hospital, a 100-bed facility.

For instance, the rate of acute myocardial infarction (AMI) patients prescribed a beta-blocker at discharge rose to 100% from 83.3%, and the rate of AMI patients receiving a beta-blocker at arrival rose to 100% from 80% from the first quarter of 2006 through the second quarter of 2007.

During the same time period, the rate of patients with pneumonia receiving the pneumonia vaccine rose to 100% from 73.5%, and blood cultures performed in the emergency department prior to initial antibiotic increased from 83.3% to 100%.

Surgical patients who received a prophylactic antibiotic within one hour prior to surgical incision increased to 91.7%from 76.7%.

Automation critical

"We tried to build in as much automation for recommended care as possible and to include a lot of checks and balances in the system," says Pamela Welborn, RN, CPUR, director of case management, medical records, and quality, who began the initiative when the case management department combined with medical records and quality in 2006.

A key component of the initiatives is the hospital's electronic medical record, which is fully functional and allows communications between all disciplines.

"It really helps when we want to discuss the record with someone in another department. They can pull the record up, rather than having to come to the floor and pull up the chart," she says.

CM duties

Case managers cover the hospital from 6 a.m. to 6 p.m. Monday through Friday and alternate being on call during night and evening hours and on weekends.

Three of the four case managers are responsible for utilization review, care coordination, discharge planning, and other social work issues. They are assigned by unit and physician and manage the care of an average of 15 patients a day.

The fourth case manager is the quality case manager and monitors readmissions and mortality and conducts reviews of procedures outside the operating room and operating room procedures.

Welborn handles all the validation and internal review for core measures.

At Russellville Hospital, the nursing assessment includes an automatic trigger for a case management consult whenever a patient is admitted with pneumonia, congestive heart failure, or a possible acute myocardial infarction.

This triggers the case managers to monitor the patient's chart and conduct concurrent review for core measures.

For instance, when a patient is admitted with congestive heart failure and the case manager receives the trigger, he or she determines if the patient has had the required echocardiogram. If so, she prints it off and places it in the paper record for the physician to see. If the patient's left ventricular function is below 40%, the case manager reminds the physician to address this condition with appropriate treatment, such as an ACE inhibitor or angiotensin receptor blocker.

"Since the case managers also are discharge planners, they follow these patients through the continuum and ensure that the physician has addressed the continuing medication needs, such as being discharged on an ACE inhibitor," Wellborn says.

Ensuring vaccines are given

To ensure that appropriate patients receive the influenza and pneumonia vaccines, the nursing assessment in the electronic medical records includes a place for the RN to assess if the patient has had the vaccines.

If the nurse fails to do so, the case managers are automatically alerted and conduct the assessment when they make their daily rounds with the physicians.

"We receive a daily printout showing what patients haven't received the vaccines. When the case managers round with the physicians, they remind the doctors that the patients may benefit from the vaccine and talk to the patients about receiving the vaccine," Welborn says.

If the patient says he or she doesn't want the vaccine, the case manager can document the patient's refusal in the progress notes.

The medical record has automated discharge instructions for congestive heart failure and smoking cessation instructions. If the patient doesn't have congestive heart failure or doesn't smoke, the nurse just omits those instructions.

"This helps us ensure that the patients who need this information get it. The nurse doesn't have to remember to print the information out. It automatically is included in the discharge information," Welborn says.

The electronic medical record also includes triggers for a pharmacy review.

For instance, when a patient comes in with pneumonia, the pharmacy department receives a trigger that prompts the pharmacist to check the admitting order to ascertain appropriate antibiotic selection. The pharmacy receives a similar trigger for surgical patients.

If the recommended prophylaxis has not been ordered, the pharmacist contacts the physicians.

In addition, the hospital's care paths incorporate core measures evidence-based medical treatment.

"The emergency room staff knows to pull the care paths for these patients and to follow them, ensuring that the patients receive all the recommended treatments and procedures in the specified time frames," Welborn says.

The hospital, in conjunction with the medical staff, has developed preprinted orders for pneumonia and congestive heart failure that include the recommended prophylaxis for both ICU and non-ICU admissions.

"Since these are administered through the emergency department, we have utilized an extensive collaborative program with the emergency room physicians to ensure that the orders are used," Welborn says.

With input from the medical staff, the hospital has developed venous thromboembolism (VTE) protocol for total knee replacement surgery and total hip replacement surgery and built as many of the Surgical Care Improvement Project (SCIP) measures as possible into the physician's preoperative and postoperative orders.

The protocol includes postoperative orders for T.E.D. anti-embolism hose and sequential compression pumps as well as a check box for physicians to prescribe the appropriate medications to aid in prevention of VTE.

"To meet the SCIP requirements, patients have to receive the prophylaxis within 24 hours of the surgical close time. Our medical record automatically triggers a time for the medication to be administered according to the order," she says.

In addition to concurrent review by case managers for quality measures, Welborn reviews every patient on every quality measure and conducts a thorough review to determine the reasons why the recommended care wasn't followed.

She pulls a daily report from the medical record that shows any patient who has not received the care recommended in the core measures and drills down to find the cause and the person responsible.

For instance, if a blood culture isn't ordered or a prophylactic antibiotic isn't utilized for a pneumonia patient, she often finds that there is an opportunity to educate new staff or physicians.

If the omission is related to nursing knowledge, she generates a quality variance form and sends it to the manager of the nurse responsible. The manager educates the nurse on the importance of following the core measures guidelines.

"When the occasional problem does occur, it usually is related to medications being administered outside the recommended time frame or when the nurse fails to document the use of T.E.D. hose or sequential compression pumps," she says.

(For more information, contact Pamela Welborn, RN, CPUR, director of case management, medical records, and quality, Russellville Hospital, e-mail: