The Joint Commission Core Measures

                Check List Card

 

AMI

CHF

Pneumonia

Indicators During Admission

√ ASA within 24 hrs

√ Beta Blockers within 24 hrs

√ ACE Inhibitor/ARB

√ Smoking Cessation  

   advised/counseling

Indicators During Admission

√ Document LVEF

√ ACE Inhibitor/ARB (If LVEF <40%)

√ Smoking Cessation 

    advised/counseling

Indicators During Admission

√ First dose of antibiotic within 4 hrs from   

   triage

√ Oxygen assessment within 24 hrs

√ Blood cultures done prior to antibiotics

√ Appropriate antibiotic selection

√ Smoking Cessation

    advised/counseling

Indicators at Time of Discharge

√ ASA

√ Beta Blockers

√ ACE Inhibitor/ARB

√ Smoking Cessation 

   advised/counseling

 

 

Indicators at Time of Discharge

√ ACE Inhibitors/ARB (If LVEF <40%)

√ Smoking Cessation 

   advised/counseling

√ Discharge Instructions: (all 6 must   

   be documented)

·          Activity

·          Diet

·          Follow-up appointments

·          Medication instructions

·          Weight monitoring

·          What to do if symptoms worsen

Indicators at Time of Discharge

√ Pneumococcal screen/vaccination

√ Influenza screen/vaccination

√ Smoking Cessation  

    advised/counseling

 Please document contraindication or reason for omission for any of the above medications.

Reminder-AMI, CHF and Pneumonia Pathways are available in the ECC.

 

 

 

 

 

 

 

 

 

 

 

 

 

                                                                        DVT Prophylaxis

 

Low-risk factors (Prophylaxis is generally indicated if TWO OR MORE of these are present)

 

Moderate-risk factors (Prophylaxis is generally indicated if ANY of these are present)

 

Major-risk factors (Prophylaxis is generally indicated if ANY of these are present)

·          Minor surgery (less than 45 minutes)

·          Age 60-74 years

·          Hip/Knee arthroplasty

·          Oral contraception or hormone replacement therapy

·          Factor V Leiden/Activated protein C resistance

·          Multiple trauma within last 30 days (nonambulatory patients)

·          Age 41 - 59 years

·          History or family history of thrombosis

·          Hip/pelvic fracture in last 30 days

·          Recent (less than 30 days) major surgery

·          Current or history of malignancy

·          Acute spinal cord injury within 30 days

·          Varicose veins

·          Major surgery more than 45 minutes

·          Long bone fractures

·          Inflammatory bowel disease

·          Patient confined to bed more than 72 hours

 

·          Obesity (BMI more than 30)

·          Acute or decompensated heart failure

 

·          Acute myocardial infarction

·          Nonhemorrhagic stroke within last 30 days

 

·          Pregnancy or postpartum within 30 days

·          Congenital or acquired thrombophilia

 

·          Compensated heart failure

 

 

·          Serious lung disease/ current smoker

 

 

·          Nephrotic syndrome

 

 

·          Laparoscopic surgery

 

 

·          Elective spinal surgery

 

 

                                                            DVT Prophylaxis Contraindications

Absolute: If any box is checked, pharmacologic anticoagulation is not recommended; use mechanical prophylaxis if indicated

Relative: Balance risks and benefits before determining best option for individual patients

·          History of heparin-induced

         thrombocytopenia (HIT)

·          Epidural or spinal tap within last 12 hours

·          Uncontrolled hypertension*

        (SBP >200, DBP >120, crisis)

    *MD, please reassess in 24   

     hours

·          Coagulopathy (PT >18        seconds)

·          Patient is currently

Anticoagulated

·          Active bleeding

·          Intracranial

        bleed/neoplasm/monitor

·          History of cerebral hemorrhage

·          History of GI or GU bleed in

         last 6 months

·          Solid organ laceration

·          Intracranial or intraocular

         surgery within last 14   

         days

·          Spinal injury/surgery

·          Thrombocytopenia

         (platelet < 50,000/mL)

·          Proliferative retinopathy

·          Renal failure on dialysis

·          Biopsy site or vascular device inaccessible to compression

·          Epidural catheter removal

          within 4 hours