The next few blog posts are going to address the Joint Commission Core Measures for various Core Measure Sets as related to specific medical conditions.  Whenever I am reviewing medical records for a malpractice case I utilize templates I have devised if possible.  These templates include a list of specifics concerning the cases particular medical issues as related to acceptable standard of care.

The initial core measurement areas for hospitals were announced in May 2001 by the Joint Commission and included acute myocardial infarction, heart failure, and pneumonia. Simultaneously, The Joint Commission worked with the Centers for Medicare & Medicaid Services (CMS) on the AMI, and HF sets that were common to both organizations.  Hospitals began collecting AMI measures for patient discharges beginning July 1, 2002.  In November of 2003, CMS and The Joint Commission began to work to precisely and completely align these common measures so that they are identical.  This resulted in the creation of one common set of measure specifications documentation known as the Specifications Manual for National Hospital Inpatient Quality Measures to be used by both organizations.  The Manual contains common (i.e., identical) data dictionary, measure information forms, algorithms, etc.  The goal is to minimize data collection efforts for these common measures and focus efforts on the use of data to improve the health care delivery process (Core Measure Sets).

As of today the following are the Core Measure Sets in place:

• Pneumonia Measures
• Immunization
• Children’s Asthma Care
• Surgical Care Improvement Project
• Perinatal Care
• Substance Use
• Tobacco Treatment
• Hospital-Based Inpatient Psychiatric Services
• Venous Thromboembolism
• Stroke
• Heart Failure
• Emergency Department
• Acute Myocardial Infarction
• Hospital Outpatient Department

T

This blog post is going to address the Core Measure Set for AMI (Acute Myocardial Infarction) 

 

MYOCARDIAL INFARCTION

NATIONAL HOSPITAL INPATIENT QUALITY MEASURES

 

Set MeasureID #	MeasureShort Name
AMI-1	Aspirinat Arrival
AMI-2	AspirinPrescribedat Discharge
AMI-3	ACEI or ARBforLVSD
AMI-5	Beta-Blocker Prescribedat Discharge
AMI-7	MedianTimetoFibrinolysis
AMI-7a	Fibrinolytic TherapyReceived Within 30Minutes ofHospital Arrival
AMI-8	MedianTimetoPrimaryPCI
AMI-8a	PrimaryPCI Received Within 90Minutes ofHospital Arrival
AMI-10	StatinPrescribedat Discharge

 

AMI-1:  Aspirin at Arrival

• The early use of aspirin in patients with acute myocardial infarction results in a significant reduction in adverse events and subsequent mortality. The benefits of aspirin therapy on mortality are comparable to fibrinolytic therapy. The combination of aspirin and fibrinolytics provides additive benefits for patients with ST-elevation myocardial infarction. Aspirin is also effective in patients with non-ST-elevation myocardial infarction. National guidelines strongly recommend early aspirin for patients hospitalized with AMI (Core Measure Sets).     

 

AMI-2:  Aspirin Prescribed at Discharge

• Aspirin therapy in patients who have suffered an acute myocardial infarction reduces the risk of adverse events and mortality. Studies have demonstrated that aspirin can reduce this risk by 20%. National guidelines strongly recommend long-term aspirin for the secondary prevention of subsequent cardiovascular events in eligible older patients discharged after AMI (Core Measure Sets).

 

AMI-3:  ACEI or ARB for LVSD (Left Ventricular Systolic Dysfunction)

• LVSD is defined as chart documentation of a left ventricular ejection fraction (LVEF) less than 40% or a narrative description of left ventricular systolic (LVS) function consistent with moderate or severe systolic dysfunction.
• ACE inhibitors reduce mortality and morbidity in patients with (LVSD) after AMI.  Clinical trials have also established ARB therapy as an acceptable alternative to ACEI, especially in patients with heart failure and/or LVSD who are ACEI intolerant.  National guidelines strongly recommend ACEI for patients hospitalized with AMI who have either clinical heart failure or LVSD.  Guideline committees have also supported the inclusion of ARBs in performance measures for AMI (Core Measure Sets).

 

AMI-5:  Beta-Blocker Prescribed at Discharge

• Long-term use of beta-blockers for patients who have suffered an acute myocardial infarction can reduce mortality and morbidity. Studies have demonstrated that the use of beta-blockers is associated with about a 20% reduction in this risk and there is evidence of effectiveness in broad populations of patients with AMI.  National guidelines strongly recommend long-term beta-blocker therapy for the secondary prevention of subsequent cardiovascular events in patients discharged after AMI (Core Measure Sets).

 

AMI-7:  Median Time to Fibrinolysis (preventing blood clots from growing and becoming problematic)

• Median time from arrival to administration of fibrinolytic therapy in acute myocardial infarction (AMI) patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time.
• Time to fibrinolytic therapy is a strong predictor of outcome in patients with an acute myocardial infarction. Nearly 2 lives per 1000 patients are lost per hour of delay.  National guidelines recommend that fibrinolytic therapy be given within 30 minutes of hospital arrival in patients with ST-elevation myocardial infarction (Core Measure Sets).     

 

AMI-7a:  Fibrinolytic Therapy Received Within 30 Minutes of Hospital Arrival

• Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving fibrinolytic therapy during the hospital stay and having a time from hospital arrival to fibrinolysis of 30 minutes or less.
• Time to fibrinolytic therapy is a strong predictor of outcome in patients with an acute myocardial infarction. Nearly 2 lives per 1000 patients are lost per hour of delay.  National guidelines recommend that fibrinolytic therapy be given within 30 minutes of hospital arrival in patients with ST-elevation myocardial infarction (Core Measure Sets).

 

AMI-8:  Median Time to Primary PCI (Percutaneous coronary intervention)

• Median time from hospital arrival to primary PCI in AMI patients with ST-segment elevation or left bundle branch block (LBBB) on the electrocardiogram (ECG) performed closest to hospital arrival time.
• The early use of primary angioplasty in patients with ST-segment myocardial infarction (STEMI) results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is.  National guidelines recommend the prompt initiation of PCI in patients presenting with ST-elevation myocardial infarction (Core Measure Sets).

 

AMI-8a:  PCI Received Within 90 Minutes of Hospital Arrival

• Acute myocardial infarction (AMI) patients with ST-segment elevation or LBBB on the ECG closest to arrival time receiving primary PCI during the hospital stay with a time from hospital arrival to PCI of 90 minutes or less.
• The early use of primary angioplasty in patients with ST-segment myocardial infarction (STEMI) results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is.  National guidelines recommend the prompt initiation of PCI in patients presenting with ST-elevation myocardial infarction (Core Measure Sets).

 

AMI-10:  Statin Prescribed at Discharge

• Several randomized clinical trials have proven the benefits of statin drugs in reducing the risk of death and recurrent cardiovascular events in a broad range of patients with established cardiovascular disease, including those with prior myocardial infarction.  Current ACC/AHA guidelines place a strong emphasis on the initiation or maintenance of statin drugs for patients hospitalized with AMI, particularly those with LDL-cholesterol levels above 100 mg/dL.  As a result of the strength of the evidence and guideline support, the ACC/AHA has developed a performance measure to assess this aspect of care for patients with acute myocardial infarction.  Because statins are generally well-tolerated, most patients with AMI are appropriate candidates for this therapy (Core Measure Sets).

 

Beta-Blockers:  Medications that target the beta receptor, which are found on cells of the heart muscles, smooth muscles, and arteries (this is not an all-inclusive list).

• Acebutolol (Sectral)
• Atenolol (Tenormin)
• Bisoprolol (Zebeta)
• Metoprolol (Lopressor, Toprol-XL)
• Nadolol (Corgard)
• Propranolol (Inderal LA, InnoPran XL)

 

ACEI (Angiotensin-converting-enzyme inhibitor):  Inhibits the angiotensin-converting enzyme (a component of the blood pressure-regulating renin-angiotensin system), thereby decreasing the tension of blood vessels and the blood volume, thus lowering blood pressure.

• Lisinopril
• Altace
• Enalapril
• Ramparil
• Zestril

 

When reviewing a case that involves an Acute Myocardial Infarction utilize the Core Measure Set to determine if all of the expected therapies were performed and the timeliness of the treatment.  Set up a spreadsheet with all of the core measures, place where in the file you find each of the areas, and the healthcare personnel involved in that aspect of the patients’ care.

Please contact Carol at Alvin and Associates, Legal Nurse Consultants for the review of any case involving an Acute Myocardial Infarction.  Carol received her Cardiac Medicine Certification in 2010 and has extensive experience in working with patients with AMI’s.

Works Cited

Core Measure Sets. (n.d.). Retrieved August 15, 2014, from The Joint Commission: http://www.jointcommission.org/core_measure_sets.aspx

 

Alvin & Associates, Legal Nurse Consultants

927 summit Avenue

Cincinnati, OH 45204

513-264-0352