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Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Aspirin at Discharge
Collected For: AMI-2,
Definition:Contraindications/reasons for not prescribing aspirin at discharge include: aspirin allergy, Coumadin/warfarin prescribed at discharge, or other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not prescribing aspirin at discharge. Aspirin reduces the tendency of blood to clot by blocking the action of a type of blood cell involved in clotting. Aspirin improves chances of surviving a heart attack and reduces the risk of recurrence in patients who have experienced a heart attack.
Suggested Data Collection Question:Is one or more of the following potential contraindications/reasons for not prescribing aspirin at discharge documented?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y   (Yes)   Documentation that the patient has one or more of the following potential contraindications/reasons for not prescribing an aspirin at discharge:

  • Aspirin allergy
  • Coumadin/warfarin prescribed at discharge
  • Other reasons documented by physician/APN/PA or pharmacist for not prescribing aspirin at discharge.

N   (No)   There is no documentation of potential contraindications/reasons for not prescribing aspirin at discharge, or unable to determine from medical documentation.

Notes for Abstraction:
  • This data element should be answered independently and irrespective of whether the patient was prescribed aspirin at discharge.
  • When there is documentation of an aspirin “allergy” or “sensitivity,” regard this as documentation of an aspirin allergy regardless of what type of reaction might be noted. Do not attempt to distinguish between true allergies/sensitivities and intolerances, side effects, etc. (e.g., “Allergies: ASA – Upsets stomach” – select “Yes.”)
  • Documentation of an allergy/sensitivity to one particular type of aspirin is acceptable to take as an allergy to the entire class of aspirin-containing medications (e.g., “Allergic to Empirin”).
  • If Coumadin/warfarin is on hold at discharge and there is documentation of a plan to restart it after discharge, consider this a contraindication to aspirin at discharge. E.g., “Resume Coumadin after INR normalizes.”
  • The abstractor should search every suggested data source listed for the collection of information. When conflicting information is documented in a medical record, a positive finding should take precedence over a negative finding (e.g., answer “Yes”), unless otherwise specified.
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing aspirin at discharge:
    • Reasons must be explicitly documented (e.g., “Chronic hepatitis – No ASA”) or clearly implied (e.g., “GI bleeding with aspirin in past,” “ASA contraindicated,” “Intolerant of aspirin,” “Problems with aspirin in past,” “c/o upset stomach, will DC ASA,” "Withheld aspirin due to GI bleeding," “Pt. refusing all medications,” "Limited life expectancy, no further treatment,” “Supportive care only – no medications," “Aspirin not indicated,” aspirin on pre-printed order form is crossed out, mid-stay order to “Hold ASA” or “DC aspirin,” “No aspirin” [no reason given]). If reasons are not mentioned in the context of aspirin, do not make inferences (e.g., Do not assume that aspirin is not being prescribed because of the patient's history of PUD alone).
    • Physician/APN/PA or pharmacist documentation of a hold on aspirin or discontinuation of aspirin that occurs during the hospitalization constitutes a “clearly implied” reason for not prescribing aspirin at discharge.
      EXCEPTIONS:
      -Discontinuation of a particular aspirin medication in combination with documentation to start a different aspirin medication (switch in type of aspirin - e.g., “DC aspirtab” followed by “Start Ecotrin” in physician orders)
      -Aspirin holds/discontinuations which are clearly labeled or identified as preop/pre-procedure.
      -Discontinuation of aspirin at a particular dosage in combination with documentation to start a different dosage of aspirin (increase/decrease in dosage - e.g., “DC aspirin 325 mgs. po qd” followed by “Start aspirin 81 mgs. po q am” in physician orders)
      -*Order* for a one-time hold. One-time holds include the holding of just one dose of a medication or holding of a medication for a defined time period. The order of the one-time hold needs to be explicit and able to stand on its own. (Do not cross-reference with other medical record documentation to determine one-time holds.)
      Examples:
      ►“Hold aspirin in a.m."
      ►"Hold Ecotrin x 24-48 hours"
      ►"Hold Bayer EC this evening. Resume dose in a.m."
      ►"Hold ASA until a.m."
      ►"Hold Entaprin today"
      ►“No aspirin today”
      -Documentation of a conditional hold or discontinuation of aspirin (e.g., “Hold ASA if OB+ stool,” “Stop aspirin if blood in urine recurs”).
      -Documentation of a hold on aspirin because patient received aspirin prior to arrival (e.g., "Hold ASA. Pt. took this a.m." per ED note).
      -Hold/discontinuation documentation, which refers to a more general medication class (e.g., “Hold all anticoagulants”).
    • If there is documentation of a plan to initiate/restart aspirin, and the reason/problem underlying the delay in starting/restarting aspirin is also noted, this constitutes a “clearly implied” reason for not prescribing aspirin at discharge.
      Examples:
      -"Begin aspirin therapy at first clinic visit" per discharge progress note – select “No.”
      -“Consider starting Ecotrin in a.m.” per mid-stay progress note – select “No.”
      -“Consulting cardiologist to evaluate pt. for ASA” per H&P – select “No.”
      -"Stool OB+. May start Bayer EC as outpatient.” per discharge summary – select “Yes.”
      -“May add ASA when pt. can tolerate” per consultation note – select “Yes.”
      -“Add buffered aspirin if hematuria subsides” per admitting progress note – select “Yes.”
      -“Will restart baby aspirin after UGI bleed resolves” per discharge progress note – select “Yes.”
    • Reasons do NOT need to be documented at the time of discharge or otherwise associated specifically with discharge prescriptions: Documentation of contraindications anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating no aspirin “due to rectal bleeding” - select “Yes,” even if documentation indicates that the rectal bleeding has resolved by the time of discharge and aspirin was restarted.)
    • Crossing out of an aspirin order counts as an "other reason" for not prescribing aspirin at discharge only if on a pre-printed order form.
  • In cases where there is a pre-arrival contraindication or physician/APN/PA or pharmacist documented reason for not prescribing aspirin, the following guidelines apply regardless of whether this documentation is included in a transfer record or outpatient record made part of the current record during hospitalization or whether it is re-noted by hospital staff during the current hospitalization:
    • Notation of an aspirin allergy prior to arrival counts as a contraindication to aspirin at discharge.
    • Pre-arrival hold or discontinuation of aspirin or notation such as "No aspirin" counts as a reason for not prescribing aspirin at discharge ONLY if the underlying reason/problem is also noted (e.g., “ASA held in transferring hospital ER due to possible GI bleed”).
    • Pre-arrival "other reason" (other than aspirin hold/discontinuation or notation of "No aspirin") counts as reason for not prescribing aspirin at discharge (e.g., "Intolerance to aspirin", "Hx GI bleeding with aspirin").

Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Nursing notes
  • Progress notes
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
  • Discharge instruction sheet
  • Medication reconciliation form
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
  • Refer to Appendix C, Table 1.1 for a comprehensive list of Aspirin and Aspirin-Containing medications.

  • Refer to Appendix C, Table 1.4 for a comprehensive list of Warfarin medications.

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

Contraindication to Aspirin at Discharge
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)
Questions? Ask Question to Joint Commission staff Copyright © 2010 by The Joint Commission.