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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Reason for No ACEI and No ARB at Discharge

Release Notes:
Data Element
Version 2015A

Data Element Name: Reason for No ACEI and No ARB at Discharge
Collected For: CAH-03, HF-3,
Definition:Reasons for not prescribing either an angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at discharge:
  • ACEI allergy AND ARB allergy
  • Moderate or severe aortic stenosis
  • Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not prescribing an ACEI AND not prescribing an ARB at discharge.
    Note: Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions only:
    • Angioedema
    • Hyperkalemia
    • Hypotension
    • Renal artery stenosis
    • Worsening renal function/renal disease/dysfunction
  • Reason documented by physician/APN/PA or pharmacist for not prescribing an ARB at discharge AND an ACEI allergy
  • Reason documented by physician/APN/PA or pharmacist for not prescribing an ACEI at discharge AND an ARB allergy
ACEIs and ARBs widen or dilate blood vessels, lowering blood pressure and making it easier for the heart to pump blood. They also inhibit the adverse effects of neurohormonal activation on the heart. These effects help reduce the risk of adverse outcomes such as death or hospitalization.
Suggested Data Collection Question:Is there documentation of BOTH a reason for not prescribing an ACEI at discharge AND a reason for not prescribing an ARB at discharge?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y (Yes)   There is documentation of BOTH a reason for not prescribing an ACEI at discharge AND a reason for not prescribing an ARB at discharge.

N (No)   There is no documentation of BOTH a reason for not prescribing an ACEI at discharge AND a reason for not prescribing an ARB at discharge, or unable to determine from medical record documentation.
Notes for Abstraction:
  • An “"allergy”" or "“sensitivity"” documented at anytime during the hospital stay counts as an allergy regardless of what type of reaction might be noted (e.g., "“Allergies: ACEIs -– Cough”" -– consider as ACEI allergy).
  • Documentation of an allergy/sensitivity to one particular ACEI is acceptable to take as an allergy to the entire class of ACEIs. Same for ARBs (e.g., "“Allergic to Valsartan"”- consider as ARB allergy).
  • When conflicting information is documented in a medical record, select "“Yes.”"
  • In the absence of explicit documentation that the patient has current moderate/severe aortic stenosis, this should be inferred when there is documentation of a history of moderate/severe aortic stenosis without mention of repair or replacement, valvuloplasty, or commissurotomy.
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing an ACEI or an ARB at discharge:
    • Documentation of a reason for not prescribing one class (either ACEI or ARB) should be considered implicit documentation of a reason for not prescribing the other class for the following five conditions ONLY:
      • Angioedema
      • Hyperkalemia
      • Hypotension
      • Renal artery stenosis
      • Worsening renal function/renal disease/dysfunction
        Examples of statements that count as a reason for not prescribing ACEI and a reason for not prescribing ARB at discharge:
      • "“Creatinine high. Hold losartan."”
      • “"Hx angioedema with ACEIs.”"
      • "“No ACEI. Bilateral renal artery stenosis."”
      • “"BPs running low. Discontinue losartan."”
      • "“Potassium 5.5 – No ACEI.”"
      • "“Severe hypotension with ACEIs in past."”
      • “"Add ARB if hyperkalemia resolves.”"
    • Reasons for no ACEIs and reasons for no ARBs must be explicitly documented (e.g., "“POTASSIUM 5.5 –- No ACEI”") or clearly implied (e.g., "“Severe hypotension with ACEIs in past,"” “"Hx ACEI-induced cough,"” "“ARBs contraindicated,"” "“Pt. refusing all medications,"” "“Supportive care only -– no medications,"” “"ACEI therapy not indicated,"” ACEI on pre-printed order form is crossed out, "“No ACEI/ARB”" [reason not given]). If reasons are not mentioned in the context of ACEIs/ARBs, do not make inferences (e.g., Do not assume that an ACEI/ARB is not prescribed because of the patient's chronic renal disease alone).
    • Physician/APN/PA or pharmacist documentation of a hold on an ACEI or discontinuation of an ACEI that occurs during the hospital stay constitutes a “"clearly implied"” reason for not prescribing an ACEI at discharge. A hold/discontinuation of all p.o. medications counts if an ACEI p.o. was on order at the time of the notation. Same for ARBs.
      EXCEPTIONS:
      • Documentation of a conditional hold/discontinuation of an ACEI/ARB does not count as a reason for not prescribing an ACEI/ARB at discharge UNLESS (1) it exists as an order to hold/discontinue the ACEI/ARB if the blood pressure (BP) falls outside certain parameters, AND (2) the ACEI/ARB was held due to a BP outside the parameters. Nursing documentation is acceptable. E.g., "“Hold perindopril for SBP less than 100”" ordered and the nurse documents that the perindopril was held for a BP of 90/50 -– select “"Yes."”
      • Discontinuation of a particular ACEI medication documented in combination with the start of a different ACEI medication (i.e., switch in type of ACEI medication) does not count as a reason for not prescribing an ACEI at discharge. Same for ARBs.
        Examples:
        • "“Stop benazepril"” and “"Start captopril 50 mg po bid”" in same physician order
        • "“Change Diovan to Verdia"” in progress note
        • "“Do not continue after discharge"” checked for Lotensin and "Continue after discharge"” checked for Zestril on a physician-signed discharge medication reconcilliation form
      • Discontinuation of an ACEI medication at a particular dose documented in combination with the start of a different dose of that ACEI (i.e., change in dosage) does not count as a reason for not prescribing an ACEI at discharge. Same for ARBs.
        Examples:
        • “Stop lisinopril 20 mg po q am” and “Start lisinopril 30 mg po q am” in same physician order
        • “Increase Altace 5 mg to 10 mg” in progress note
        • “Do not continue after discharge” check for Cozaar 25 mg and “Continue after discharge” checked for Cozaar 50 mg on a physician-signed discharge medication reconcilliation form
    • Reason documentation which refers to a more general medication class is not acceptable (e.g., "“Hold all BP meds"”).
    • Deferral of an ACEI from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing an ACEI at discharge unless the problem underlying the deferral is also noted. Same for ARBs.
      Examples:
      • “"Consulting cardiologist to evaluate pt. for ACEI therapy"” - select "“No"” (Do NOT consider as reason for not prescribing ACEI at discharge).
      • “"Pt. hypotensive. Start ARB if OK with cardiology."” - select "Yes" (Consider as reason for not prescribing ACEI and reason for not prescribing ARB at discharge).
    • If there is documentation of a plan to initiate/restart an ACEI, and the reason/problem underlying the delay in starting/restarting the ACEI is also noted, this constitutes a "“clearly implied"” reason for not prescribing ACEI at discharge. Same for ARBs.
      Acceptable examples (select “"Yes"”):
      • "Pt. hemodynamically unstable. May start ACEI/ARB as outpatient.”"
      • "“Add ARB if hyperkalemia resolves."”
        Unacceptable examples (select "“No”"):
      • “"Consider starting Cozaar in a.m.”" (Do NOT consider as reason for not prescribing ARB at discharge).
      • "“May add accupril when pt. can tolerate”" (Do NOT consider as reason for not prescribing ACEI at discharge).
    • Reasons do NOT need to be documented at discharge or otherwise linked to the discharge timeframe: Documentation of reasons anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating "“no ACEIs due to acute renal failure"” - consider as reason for not prescribing ACEI and reason for not prescribing ARB at discharge, even if documentation indicates that the acute renal failure had resolved by the time of discharge and ACEI was restarted).
    • Crossing out of an ACEI counts as a "clearly implied reason" for not prescribing an ACEI at discharge only if on a pre-printed form. Same for ARBs.
    • ACEIs/ARBs are sometimes described as RAS (renin-angiotensin system) or RAAS (renin-angiotensin-aldosterone system) blockers/inhibitors. Documentation of a reason for not prescribing "RAS" or "RAAS" blockers or inhibitors should be considered implicit documentation of a reason for no ACEI and no ARB at discharge (e.g., "Hold all RAS blockers").
  • When the current record includes documentation of a pre-arrival reason for no ACEI or no ARB, the following counts regardless of whether this documentation is included in a pre-arrival record made part of the current record or whether it is noted by hospital staff during the current hospital stay:
    • Pre-arrival ACEI allergy (reason for not prescribing ACEI) or ARB allergy (reason for not prescribing ARB).
    • Pre-arrival moderate/severe aortic stenosis (reason for not prescribing an ACEI and a reason for not prescribing an ARB).
    • Pre-arrival hold/discontinuation of an ACEI or notation such as "No ACEIs" IF the underlying reason/problem is also noted (e.g., "“Prinivil held in transferring hospital due to hypotension”"). Same for ARBs.
    • Pre-arrival "other reason" (other than hold/discontinuation or notation of "No ACEIs") (e.g., "Hx severe hypotension with enalapril" in transferring ED record). Same for ARBs.
Suggested Data Sources:

  • Consultation notes
  • Diagnostic test reports
  • Discharge instruction sheet
  • Discharge summary
  • Emergency department record
  • History and physical
  • Medication administration record
  • Nursing notes
  • Physician orders
  • Progress notes
  • Transfer sheet

Excluded Data Sources: Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay).
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Angioedema
  • Angioneurotic edema
  • Edema of the eyelid, glottis, larynx, nasopharynx, or pharynx
  • Periorbital edema described as acute

Hyperkalemia
  • Patient's potassium (K+) level noted (e.g., "Last Potassium 6.5. Will hold off on ACEI therapy"”)
  • Potassium level described as elevated
  • References to potassium not specified or described as hyperkalemia (e.g., “"Hold off on ACEI therapy. Check potassium.”," "“Start candesartan once potassium improved"”)

Hypotension
  • Blood pressure (BP) described as low
  • Patient's blood pressure measurement noted (e.g., "BP systolic running in 80s. Will not prescribe ARBs at this time"”)
  • References to blood pressure not specified or described as hypotension (e.g., "“Hold off on ACEI therapy. Check BP in a.m.”," “"Start candesartan after BP normalizes”")
  • Shock

Moderate/severe aortic stenosis (AS)
  • Aortic stenosis described as 3+, 4+, critical, or significant
  • Aortic stenosis, degree of severity not specified
  • Aortic valve area of less than 1.0 square cms
  • Subaortic stenosis, moderate/severe or degree of severity not specified

Worsening renal function/renal disease/dysfunction
  • Acute kidney injury (AKI)
  • Azotemia
  • Chronic kidney disease (CKD)
  • Dialysis
  • End stage renal disease (ESRD)
  • Nephritis
  • References to creatinine not specified or described as elevated (e.g., "“Hold off on ACEI therapy. Check creatinine.”," “"Start candesartan once creatinine improved"”)
  • References to renal/renal function not specified or described as renal dysfunction (e.g., "“Hold on ACEI pending kidney function panel in a.m.”")
  • Renal failure, acute or chronic (ARF, RF, CRF)
  • Renal insufficiency (RI, CRI)
  • Renal/kidney transplant (RT, RTx, s/p renal transplant, KT)
  • Serum creatinine (Cr, Cre) level described as abnormal or elevated
  • Serum creatinine (Cr, Cre) noted (e.g., "“No ACEIs. Creatinine 2.0"”)

Refer to Appendix C, Table 1.2 for a comprehensive list of ACEIs and Table 1.7 for a comprehensive list of ARBs.

ACEI allergy
ACEI allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

ARB allergy
ARB allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Moderate/severe aortic stenosis (AS)
  • Aortic insufficiency only
  • Aortic regurgitation only
  • Aortic stenosis described as 1+ or 2+
  • Moderate/severe aortic stenosis, or any of the other moderate/severe aortic stenosis inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Reason for No ACEI and No ARB at Discharge
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
Questions? Ask Question to Joint Commission staff Copyright © 2014 by The Joint Commission.
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