| Name: | Reason for No Bisoprolol, Carvedilol, or Sustained-Release Metoprolol Succinate Prescribed for LVSD at Discharge |
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| Collected For: |
ACHF-01 |
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| Definition: | Reasons for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge:
- Beta-blocker allergy
- Second or third-degree heart block on ECG on arrival or during hospital stay and does not have a pacemaker
- Other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist
Bisoprolol, carvedilol, and sustained-release metoprolol succinate are agents which block beta-adrenergic receptors, thereby decreasing the rate and force of heart contractions, and reducing blood pressure. Over time beta-blockers improve the heart's pumping ability.
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| Question: | Is there documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge? |
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| Format: |
| Length: | 1 |
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| Type: | Alphanumeric |
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| Occurs: | 1 |
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| Allowable Values: |
Y (Yes) There is documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge.
N (No) There is no documentation of a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge, OR unable to determine from medical record documentation.
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| Notes for Abstraction: |
- If there is documentation in the medical record of LVSD greater than or equal to 41%, this data element is not required.
- A beta-blocker “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: Beta-blockers — Impotence” — select “Yes”).
- Documentation of an allergy/sensitivity to one particular beta-blocker is acceptable to take as an allergy to the entire class of beta-blockers (e.g., “Allergic to Toprol-XL”).
- When conflicting information is documented in a medical record, select “Yes”.
- When determining whether there is second or third-degree heart block on ECG on arrival or during hospital stay AND does not have pacemaker:
- Consider this true if (1) there are findings of second or third-degree heart block on the ECG AND this same ECG does NOT show pacemaker findings, OR (2) There is documentation of a finding of second or third-degree heart block (not specifically referenced as an ECG finding) without mention of the presence of pacemaker findings (e.g., “Second-degree heart block” per ER report).
- Disregard pacemaker findings if documentation suggests the patient has a non-functioning pacemaker.
- Second or third-degree heart block and pacemaker ECG findings can be taken from unsigned ECG reports. Physician/APN/PA documentation is not required.
- Second or third-degree heart block findings and pacemaker findings from telemetry and rhythm strips are acceptable.
- In cases where ECG findings of second- or third-degree heart block are referenced and documentation does not address the presence or absence of pacemaker findings, infer no pacemaker findings. E.g., “ECG on arrival showed second-degree heart block” per H&P.
- When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge:
- Reasons must be explicitly documented (e.g., “COPD - No BBs”, “HR running in 50s. Hold off on beta-blocker therapy”) or clearly implied (e.g., “Severe hypotension with beta-blockers in past,” “BBs contraindicated,” “Pt. refusing all medications,” “Supportive care only — no medications,” “BBs not indicated,” beta-blocker on pre-printed order form is crossed out, “No beta-blockers” [no reason given]). If reasons are not mentioned in the context of beta-blockers, do not make inferences (e.g., Do not assume that bisoprolol, carvedilol, or sustained-release metoprolol succinate is not being prescribed because of the patient's history of Peripheral Vascular Disease alone).
- Physician/APN/PA or pharmacist documentation of a hold on bisoprolol, carvedilol, or sustained-release metoprolol succinate or discontinuation of one of these beta-blockers that occurs during the hospital stay constitutes a “clearly implied” reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge. A hold/discontinuation of all p.o. medications counts if bisoprolol, carvedilol, or sustained-release metoprolol succinate p.o. was on order at the time of the notation.
EXCEPTION:
- Documentation of a conditional hold/discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate does not count as a reason for not prescribing one of these beta-blockers at discharge UNLESS (1) it exists as an order to hold/discontinue the beta-blocker if the blood pressure (BP) or heart rate (HR) falls outside certain parameters, AND (2) the beta-blocker was held due to a BP/HR outside the parameters. Nursing documentation is acceptable. E.g., “Hold bisoprolol for SBP less than 100” ordered and the nurse documents that the bisoprolol was held for a BP of 90/50 — select “Yes”.
- Discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate documented in combination with the start of a another one of these beta-blockers (i.e., switch from bisoprolol to carvedilol) does not count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge.
Examples:
- “Stop carvedilol” and “Start Coreg 12.5 mg po bid” in same physician order
- “Change metoprolol succinate to Coreg” in progress note
- “Do not continue after discharge” checked for metoprolol succinate and “Continue after discharge” checked for Toprol-XL on a physician-signed discharge medication reconciliation form
- Discontinuation of bisoprolol, carvedilol, or sustained-release metoprolol succinate at a particular dose documented in combination with the start of a different dose of that beta-blocker (i.e., change in dosage) does not count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge.
Examples:
- “Stop sustained-release metoprolol succinate 25 mg po” and “Start sustained-release metoprolol succinate 50 mg po” in same physician order
- “Increase bisoprolol 5 mg to 10 mg” in progress note
- “Do not continue after discharge” checked for Coreg 3.125 mg bid and “Continue after discharge” checked for Coreg 6.25 mg bid on a physician-signed discharge medication reconciliation form
- Reason documentation which refers to a more general medication class is not acceptable (e.g., “Hold all BP meds”).
- Deferral from one physician/APN/PA or pharmacist to another does NOT count as a reason for not prescribing bisoprolol, carvedilol, or sustained-release metoprolol succinate at discharge unless the problem underlying the deferral is also noted.
Examples:
- “Consulting cardiologist to evaluate pt. for beta-blocker treatment” - select “No”.
- “Pt. hypotensive. Start Coreg if OK with cardiology.” - select "Yes”.
- If there is documentation of a plan to initiate/restart bisoprolol, carvedilol, or sustained-release metoprolol succinate, and the reason/problem underlying the delay in starting/restarting the beta-blocker is also noted, this constitutes a “clearly implied” reason for not prescribing a beta-blocker discharge.
- Acceptable examples (select “Yes”):
- “BPs running low. May start Zebeta as outpatient.”
- “Add Toprol-XL if HR stabilizes”
- Unacceptable examples (select "No"):
- “Consider starting Coreg in a.m.”
- “May add beta-blockers when pt. can tolerate”
- 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 bisoprolol due to hypotension” - select “Yes,” even if documentation indicates that the hypotension had resolved by the time of discharge and the beta-blocker was restarted).
- Crossing out of bisoprolol, carvedilol, or sustained-release metoprolol succinate counts as a "clearly implied reason" for not prescribing one of these beta-blockers at discharge only if on a pre-printed form.
- When the current record includes documentation of a pre-arrival reason for no bisoprolol, carvedilol, or sustained-release metoprolol succinate, 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 beta-blocker allergy
- Pre-arrival hold/discontinuation or notation such as "No carvedilol" IF the underlying reason/problem is also noted (e.g., “Coreg discontinued in transferring hospital secondary to hypotension”).
- Reasons for not prescribing a Beta-blocker must be documented by a physician/APN/PA or pharmacist with one exception: Patient/family refusal of Beta-blocker (e.g., “Bisoprolol refused,” “Patient refusing Beta-blocker”) may be documented by a nurse.
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| Suggested Data Sources: |
- Emergency department record
- History and physical
- Nursing notes
- Physician orders
- Physician's notes
- Discharge summary
- Medication administration record (MAR)
- Transfer sheet
- Consultation notes
- ECG reports
- Vital signs graphic record
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| Additional Notes: |
Excluded Data Sources: Any documentation dated/timed after discharge, except discharge summary and operative/procedure/diagnostic test reports (from procedure done during hospital stay). |
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| Guidelines for Abstraction: |
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| Inclusion |
Exclusion |
2nd/3rd degree heart block (HB)
Note: The following inclusive terms may stand alone or be modified by “variable” or “intermittent.”
- Atrioventricular (AV) block described as 2 to 1, 3 to 1, second-degree, or third-degree
- Atrioventicular (AV) dissociation
- Heart block (HB) described as 2 to 1, 3 to 1, complete (CHB), high degree, high grade, second-degree, or third-degree
- Mobitz Type 1 or 2
- Wenckebach
Pacemaker findings
- Paced rhythm
- Paced spikes
- Pacing described as atrial, AV, dual chamber, or ventricular
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Beta-blocker allergy
- Allergy to beta-blocker eye drops (e.g., Cosopt)
- Beta-blocker allergy described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
2nd/3rd degree heart block (HB)
- 2nd/3rd degree heart block (HB), or any of the other 2nd/3rd degree heart block inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table
- Atrial flutter
- Atrioventricular (AV) block or conduction block, type/degree not specified
- First-degree atrioventricular (AV) block
- First-degree heart block (HB)
- Heart block, type/degree not specified
- Intraventricular conduction delay (IVCD)
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