11 measures Antibiotic

Stewardship• #66: Pharyngitis patients

given an abx who had strep test performed

• #91: Patients with Otitis Externa given a topical abx

• #93: Patients with Otitis Externa not given a systemic abx

• #116: 18-64 y/o with bronchitis not given abxwithin 3 days of encounter

Choosing Wisely:Head CT Utilization

• #416: 2-17 y/o with appropriate head CT for blunt head trauma (PECARN rules)

• #415: 18+ y/o with appropriate head CT ordering for blunt head trauma

PregnancyMeasures

• #254: US localization of pregnancy in pregnant pts with abd pain

• #255: Rhogam for Rh negative patients at risk

Miscellaneous

• #54: EKG for non-traumatic chest pain

• #76: Proper sterile technique for CVC placement

• #317: BP Screening and follow up documented

#415 and #416:

Head CT utilization for minor head injury adults/pediatrics

Week 2

#415 and #416:Important!

1. Documentation of clinical thinking is optimal for excellent medical and legal charting.

2. CMS recommends following these clinical guidelines and may impose penalties in the future for not following these guidelines.

However, provider judgment always overrides decision rules for individual patients and those who do not clearly fall

within the decision rule guidelines.

#416ED utilization of Head CT for

minor blunt head trauma for patients 2-17 years old

#416.Inclusion

Numerator:• Patient low risk by PECARN decision

rules

Denominator:• Patients 2-17 years old• Minor head injury (GCS 15 or no

documentation of mental status)• Seen <=24 hours after event and

receiving head CT

#416.Inclusion: following pecarn rules

• No Altered Mental Status• No Severe Headache• No Loss of Consciousness• No Vomiting• No Sign of Basilar Skull Fracture• No Severe Mechanism

• MVC with Ejection• Death of Another Passenger• Rollover• Fall < 5 Feet• Peds/Cyclist without Helmet Struck by Car• Head Struck by High Impact Object• Other Documented Severe Mechanism

#416.Exclusion

Patient reasons:• Brain Tumor• Coagulopathy• Ventricular Shunt• Other Documented Reason

Alternate reasons:• Patient seen >24 hours after injury,

patient GCS<15

Best PracticesRemember, coders (and not hospital chart extractors) are excellent at following rules but have

limited clinical ability, so it is best to clearly “spell out” your thinking!

Best practice is to state risk and give reason for decision to perform or not perform Head CT:1. “Patient is low risk for head injury by PECARN rules and head CT deferred after discussion with parents.”2. “Patient is moderate risk with nausea and emesis and head CT ordered.”3. “Patient not acting normal per parents, patient not low risk and head CT ordered.”4. Also acceptable would be “Patient is moderate (or high risk) head injury and head CT ordered.”

Not Acceptable:1. “Patient with headache and head CT ordered.”2. No reason given for ordering head CT in Pediatric patient with minor head injury.

#415ED utilization of Head CT for

minor blunt head trauma for patients >=18 years old

#415.Inclusion

Numerator:• Patient with proper indication for

Head CT

Denominator:• Patients 18+ years old• Seen <=24 hours after event with

Minor Head Injury (GCS 15 or no documentation of mental status)

• Head CT ordered

#415.Inclusion: followingACEP guideline for head ct with minor head injury

any of the below: • >= 65 years old • Severe Headache• Vomiting• Signs of Basilar Skull Fracture• Focal Neurological Deficit• Elevated bleeding risk (Coagulopathy,

Low platelets, Anticoagulant such as Pradaxa, Heparin, Coumadin)

• Serious Mechanism (Pedestrian vs Car, Ejection, Fall from >3 ft or 5 Stairs, Other)

#415.Inclusion: followingacep headct guideline

Either loss of consciousness or amnesia and:

• >= 60 years old • Any Headache• Intoxication• Short term memory deficits• Any physical evidence of injury above

clavicles• Seizure

#415.Exclusion

Patient reasons:• Brain Tumor• Coagulopathy• Medication• Ventricular Shunt• On Antiplatelet Medication

(essentially all other than aspirin)• Other Reason

Alternate reasons:• Patient seen >24 hours after injury,

patient GCS<15

Best PracticesRemember, similar for pediatrics, coders (and not hospital chart extractors) are excellent at

following rules but have limited clinical ability. Remember to specifically state you are following guideline or ACEP guideline!

Best practice is to state risk and give reason for decision to perform or not perform head ct.1. “Patient has severe headache, and per guideline, head CT ordered.”

2. “Patient is intoxicated with mild confusion after minor head injury and, per guideline, head CT ordered.”

3. “Patient is intoxicated and precludes reliable exam, therefore Head CT ordered.” or “Patient is intoxicated and not oriented to time, and head CT ordered.”

4. “Patient has mild headache only and no other symptoms after minor head injury, per ACEP guideline no head CT ordered.” (This patient would not be included in the measure as no CT done, but would be acceptable documentation.)

5. “Patient is 65 years old after minor head injury and per guideline head CT ordered.” (While this would satisfy guideline, not all patients would require Head CT.)

Not Acceptable:1. “Patient with mild headache after minor head injury and head CT ordered.” (Patient <65).

2. No reason given for ordering head CT in patient with minor head injury.

Cheat SheetThese head injury rules are a little tricky to remember, so we have an attached “Cheat Sheet” to post for easy reference.

(Inclusion: Patients seen < 24 hours after minor head injury with GCS 15.)

Age 2-17PECARN Rules

CT not recommended if:• No Altered Mental Status• No Loss of Consciousness• No Severe Headache• No Vomiting• No Sign of Basilar Skull Fracture• No Severe Mechanism

Age 18+ACEP Guidelines Head CT is OK if:

Any of the following:

• Age ≥65 years old• Severe Headache• Vomiting• Signs of Basilar Skull Fracture• Serious Mechanism• Neurological Deficit• Elevated Bleeding Risk

o Medical Conditiono Anticoagulants (such as

Pradaxa, Coumadin, Heparin, Plavix, Aggrenoxbut No Aspirin Exclusion)

OR

Loss of Consciousness or Amnesia AND

• ≥60 years old• Headache (any)• Intoxication• Short Term Memory Deficit• Physical Evidence Injury above

Clavicles• Seizure