IMPLEMENTATION PROTOCOL TABLE 4: QUALITY TARGET MEASURES

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1 IMPLEMENTATION PROTOCOL TABLE 4: QUALITY TARGET MEASURES APPROPRIATENESS INTRAOP BLOOD GLUCOSE MGT INTRAOP ABX REDOSING TIMEOUT Description CTSURG will document clinical appropriateness for surgical intervention in the medical PRIOR to (CTSURG consult or H&P) Continuous intravenous insulin will be started in the OR when hourly surveilance blood glucose levels rise above 180 mg/dl. Adjustments based on the GHS protocol for CTS will be made hourly to achieve a target intraoperative blood glucose concentration of between IV cefazolin (Ancef) will be repeated every 4 hours until last incision is closed. A time out should be conducted in the OR/procedure room before the procedure/incision. It should involve the entire operative team, use active communication, be briefly documented, such as in a checklist (organization should determine the type and amount of documentation) and should include: Define Numerator (specify the exclusion and inclusion criteria) Numerator: # Model 4 patients with documented clinical appropriateness by surgeon in the medical PRIOR to surgery Numerator: # patients with BS >180/dl & with documented intervention Numerator: # patients with DOS >4 hrs (ancef) & recd timely abx redose. Define Denominator (specify the exclusion and inclusion criteria) Denominator: # Model 4 patients Sources of Data Period Comparison Standard CTSURG consult or H&P Internal Denominator: # patients with BS >180/dl Anesthesia Internal Denominator: # patients with DOS > 4 hrs (Ancef) Anesthesia Internal Correct patient identity. Correct side and site (cardiac surgery exempt from site marking). Agreement on the procedure to be done. Numerator: # patients with documented TO Denominator: # patients OR Nursing, consent Internal; NPSG TEMP MGT Patients undergoing procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration (off pump only) will receive active warming measures intraoperatively to maintain body temperature. Numerator: Surgery patients for whom either active warming was used intraoperatively for the purpose of maintaining normothermia or who had at least one body temperature equal to or greater than 96.8 degrees Fahrenheit (F)/36 degrees Celsius (C) ed within the 30 minutes immediately prior to or the fifteen minutes immediately after Anesthesia End Time. Denominator: All patients, regardless of age, undergoing surgical procedures under general or neuraxial anesthesia of greater than or equal to 60 minutes duration (off Anes, PACU pump only)

2 POSTOP BLOOD GLUCOSE MGT Use of continuous intravenous insulin to achieve and maintain an early postoperative blood glucose concentration less than or equal to 180mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection, after. SCIP-Inf-4 (Cardiac patients with controlled 6 AM postop blood glucose) Numerator: Surgery patients with controlled 6 A.M. blood glucose (less than or equal to 180 milligrams per deciliter [mg/dl]) on Postoperative Day (POD) 1 and POD 2. Denominator: Cardiac surgery patients with no evidence of prior infection. PACU, Soarian nursing, lab reports, orders, progress notes POSTOP ABX DISCONTINUATION ASA RX ON D/C POSTOP STATIN STATIN RX AT D/C POST OP BB BB RX AT D/C Prophylactic antibiotics will be discontinued within 48 after surgery, unless contraindicated (infection) Unless a clinician documents a contraindication (ie bleeding), aspirin (at least 81mg orally or 600mg rectally, daily) will be: (A) initiated (or continued) at first contact with patients who are to undergo CAB, (B) given within 1 hour prior to CAB if not taken within 24 hours and (C) resumed within 24 hours following CAB. Aspirin (at least 81mg orally, daily) will be prescribed at discharge, unless a clinician documents a contraindication, and, at the post op clinic visit the patient will be advised to continue aspirin indefinitely. All CAB patients will have statin therapy initiated as soon as oral intake is possible post-op, prescribed statins at discharge and advised at the postop clinic visit to continue, unless contraindications are documented. All CAB patients will have statin therapy initiated as soon as oral intake is possible post-op, prescribed statins at discharge and advised at the post-op clinic visit to continue, unless contraindications are documented. Beta blockers will be reinstituted after in all patients without contraindications (ie allergy, need for hemodynamic support or dysrhythmias) as soon as oral intake is tolerated. If oral intake is not possible but no other contraindicatins exist, IV beta blockers will be used. (Also included as Section 5.7, Class I, #2) Beta blockers will be prescribed to all patients without a clinician's documentation of a contraindication at the time of hospital discharge. patients whose prophylactic antibiotics were discontinued within 48 hours after Anesthesia End Time Denominator: All selected surgical patients with no evidence of prior infection. (see other exclusions) Orders, MAR Numerator: patients who are prescribed aspirin at hospital discharge or have documented contraindication. Denominator: patients. MAR, orders, med rec Numerator: # patients with PO statin order or have documented contraindication. Denominator: # patients MAR, orders Numerator: patients who are prescribed a statin medication at hospital discharge or have documented contraindication. Denominator: # patients MAR, orders, med rec Numerator: # patients with PO BB order. Denominator: # patients MAR, orders Numerator: patients who are prescribed a beta-blocker at hospital discharge or have documented contraindication. Denominator: # patients d/c medication list

3 POSTOP ACE/ARB CAB patients on ACE and/or ARB preoperatively will have them stopped for 48 hours before operation to decrease post-op vasodilation, and will have them restarted following operation one day after initiation of optimal (HR <= 70) postoperative Beta Blockers, as long as the SPB is greater than 100 and the patient's renal function is determined stable by a clinician. If the ACE and/or ARB is withheld per clinician judgement, then the patient should be reevaluated each subsequent day and drug started when SBP and renal function allows. The med should continue indefinitely.these should be perscribed at discharge and confirmed at post op visit. CAB patients NOT on ACE and/or ARB preoperatively and with LVEF > 40%, and without hypertension, or DM,will NOT have ACE and/or ARB started post-op. Numerator: # patients with PO ACE/ARB order Denominator: # patients without contraindications transfer s D/C PREOP ACE/ARB SMOKING CESSATION FOLLOW UP APPT CAB patients on ACE and/or ARB preoperatively will have them stopped for 48 hours before operation to decrease post-op vasodilation, and will have them restarted following operation one day after initiation of optimal (HR <= 70) postoperative Beta Blockers, as long as the SPB is greater than 100 and the patient's renal function is determined stable by a clinician. If the ACE and/or ARB is withheld per clinician judgement, then the patient should be reevaluated each subsequent day and drug started when SBP and renal function allows. The med should continue indefinitely.these should be perscribed at discharge and confirmed at post op visit. All patients who indicate current tobacco use before CAB will receive in-hospital educational counseling and be offered smoking cessation therapy during CAB hospitalization. They will be advised not to smoke at discharge and in clinic visit. At discharge all patients will be given a follow-up visit with a clinician (PCP, Cardiologist, CT surgeon or AP) for no later than 14 days after the date of D/C (eg d/c date = day 0) Numerator: # patients with PO ACE/ARB order Numerator: # patients with documented smoking cessation educatoin. Numerator: # patients with documented appt within 14 days. Denominator: # patients without contraindications Denominator: # patients with smoking hx (1 year) Denominator: # patients transfer s MAR, ORDERS, MED REC, D/C FORM, SOARIAN RN, CARE MGR P. NOTE D/C form, progress note Internal

4 VTE PROPHYLAXIS D/C POSTOP FOLEY All CAB patients will have some means of DVT prophylaxis ordered. Acceptable options include Subcutaneous heparin, Anti-embolism stockings and Ace wraps to both legs. Ambulation alone is NOT sufficient. Any of the following: Low-dose unfractionated heparin (LDUH) Low molecular weight heparin (LMWH) Factor Xa Inhibitor LDUH or LMWH or Factor Xa Inhibitor combined with IPC or GCS Any of the following: Graduated Compression stockings (GCS) Intermittent pneumatic compression devices (IPC) Timely postop d/c Foley Numerator: Surgery patients who received Venous Thromboembolism (VTE) prophylaxis 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time. patients whose urinary catheter is removed on POD 1 or POD 2 with day of surgery being day zero. Denominator: All patients. Denominator: All patients with a catheter in place postoperatively. orders, MAR, soarian nursing orders, progress note, soarian nursing APPROP ABX SELECTION APPRP ABX DOSE SELECTION Approved abx: Cefazolin, Cefuroxime,Table 3.1 or Vancomycin1 Table 3.8 If β-lactam allergy: Vancomycin2 Table 3.8 or Clindamycin2 Table 3.9 All abx will be prescribed using pharmacy weight-based dosing protocol: Ancef 1 g (< 80kg); 2 g (>100kg);, Vanco 1 g (<100 kg); 1.5 g (>100kg) patients who received prophylactic antibiotics recommended for their specific surgical procedure. ( Table 5.01) Numerator: # patients appropriate wt based abx (Ancef/Vanco). Denominator: All patients Denominator: # patients with abx (Ancef/Vanco) prescribed Orders, Weight (multiple sources), Allergies (multiple sources) orders, anesthesia TIMELY PREOP ABX Preopabx will be administered within recommended guidelines. Ancef <60 minutes, Vanco < 120 minutes. In patients undergoing operation will be deferred for at least five 24 hour periods from the last dose of clopidogrel or ticagrelor to incision (for prasugrel, at least seven 24 hour periods.) (Also included as Section 5.8, Class1, #3). Exclusion: Unless platelet assay is therapeutic. patients with prophylactic antibiotics initiated within one hour prior to surgical incision (two hours if receiving Denominator: All patients with vancomycin or fluoroquinolone). no evidence of prior infection. Anes D/C PREOP PLAVIX, BRILINTA, EFFIENT Numerator: # patients with plavix, brilinta, effient d/c preop as recommended OR with normal platelet assay. Denominator: # patients with preop hx of plavix, brilinta, effient. Cath report,med rec, ED, transfer s, MAR D/C PREOP INTEGRILIN, AGGRASTAT, REOPRO In patients referred for, short acting intravenous glycoprotein llb/llla inhibitors (eptifibatide or tirofiban) will be discontinued for at least 6 hours before incision and abciximab for at least 24 hours unless the attending surgeon documents that delay is dangerous. (Also included as Section 5.8, Class I, #5) Numerator: # patients with integrilin, aggrastat, reopro d/c preop Denominator: # patients with as recommended OR with documented preop hx of integrilin, aggrastat, contraindication. reopro Med rec, MAR, orders, transfer s, ED

5 DO NOT D/C STATIN PREOP D/C PREOP NSAIDS APPROP HAIR REMOVAL PREOP BB Discontinuation of statin or other dyslipidemic therapy is not recommended before or after in patients without adverse reactions to therapy. In all CAB patients, NSAIDS will be stopped at the point of initial contact. Hair removal Beta blockers should be administered for at least 24 hours before to all patients without contraindications to reduce the incidence of clinical sequelae of postoperative AF (also included as Section 5.7, Class I, #1) Numerator: # patients with statin order pre/postop. Numerator: # patients without NSAIDS orders preop or NSAIDS on admission med rec Numerator: Surgery patients with surgical site hair removal with clippers or depilatory or with no surgical site hair removal. Numerator: Surgery patients on betablocker therapy prior to arrival who received a beta-blocker during the perioperative period. Denominator: # patients with statin on admission med rec MAR, orders, med rec Denominator: # patients MAR, orders, consult, H&P, med rec Denominator: All patients. OR Nursing Denominator: All surgery patients on beta-blocker therapy prior to arrival. ED, transfer PREOP ASA CCL Indication CCL Consent Unless a clinician documents a contraindication (ie bleeding), aspirin (at least 81mg orally or 600mg rectally, daily) will be: (A) initiated (or continued) at first contact with patients who are to undergo CAB, (B) given within 1 hour prior to CAB if not taken within 24 hours and (C) resumed within 24 hours following CAB. Aspirin (at least 81mg orally, daily) will be prescribed at discharge, unless a clinician documents a contraindication, and, at the post op clinic visit the patient will be advised to continue aspirin indefinitely. All patients who are candidates for catheterization should have proper documentation of clinical presentation and functional studies. All patients undergoing catheterization will be consented for the appropriate procedure which includes emergency # patients w/asa prescribed p/t 24 hrs of. CCL patients with documented criteria and referral for in the MR # CCL Consents appropriately completed Denominator: # patients without documented ASA contraindications # patients with preop JSUMC Med rec, ED, transfer s, MAR, orders Cath report, PCI registry Internal # patients with preop JSUMC Med rec (OP REPORT) R&R CCL Time out A time out should be conducted in the procedure room prior to sedation. It should include the CVL staff, physician and be documented # patients with documented timeout (N) # patients with preop JSUMC Cath lab nurses notes (stamp); cath lab log; Lumedex (future) NPSG CCL Pre op CBC, SMAC7, PT/PTT/INR, EKG, Chest X-ray Pre op blood work and testing should be performed within 30 days and chest x-ray in 6 months prior to procedure (elective ONLY) # patients with pre-op testing (elective ONLY) # patients with preop JSUMC Med rec, orders Internal

6 CCL - Risk stratify Inpatients who meet class I or II indication for and outpatients who meet class I and II criteria for with unstable symptoms and/or low EF should be admitted with proper documentation # Class I/II criteria admitted (with documented unstable S/S or low EF) # Class I/II criteria CCL Internal