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Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Aspirin on Arrival
Collected For: AMI-1,
Definition:Contraindications/reasons for not prescribing aspirin on arrival include: aspirin allergy, Coumadin/warfarin as pre-arrival medication, or other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not giving aspirin on arrival. 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 or reasons for not prescribing aspirin present on arrival?
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 on arrival:

  • Aspirin allergy
  • Coumadin/warfarin prescribed as pre-arrival medication
  • Other reasons documented by physician/APN/PA or pharmacist for not prescribing aspirin on arrival

N   (No)   There is no documentation of contraindications/reasons for not prescribing aspirin on arrival or unable to determine from medical record documentation.

Notes for Abstraction:
  • This data element should be answered independently and irrespective of whether the patient was prescribed aspirin on arrival.
  • 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”).
  • 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 Coumadin/warfarin was a pre-arrival medication:
    • Refer to the patient’s medication regimen just prior to acute care treatment. Include Coumadin/warfarin if the patient was on it at home, the nursing home, a transferring psychiatric hospital, etc. Do NOT include Coumadin/ warfarin taken in the ambulance en route to the hospital.
    • Include cases where there is documentation that the patient was prescribed Coumadin/warfarin at home but there is indication it was on temporary hold or the patient has been non-compliant/self-discontinued their medication (e.g., refusal, side effects, cost).
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing aspirin on arrival:
    • 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,” “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, ED order to “Hold ASA,” “DC aspirin” or “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 within the first 24 hours after arrival constitutes a “clearly implied” reason for no aspirin on arrival.
      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)
      -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 already 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 on arrival.
      Examples:
      -"Begin baby aspirin tomorrow" per admitting progress note – select “No.”
      -“Consider starting Ecotrin in a.m.” per ER physician report – select “No.”
      -“Consulting cardiologist to evaluate pt. for ASA” per H&P – select “No.”
      -"Stool OB+. May start Bayer EC on nursing floor.” per ED record – select “Yes.”
      -“May add ASA when pt. can tolerate” per consultation note – select “Yes.”
      -“Add buffered aspirin if hematuria subsides” per progress note – select “Yes.”
      -“Held off on Aspirin therapy during this hospitalization. Will restart as outpatient after UGI bleed resolves” per discharge summary – select “Yes.”
    • Documentation must be clear that the given reason applies to the first 24 hour time period (e.g., “Hold buffered aspirin” per note dated/timed within 24 hours, “Unable to start aspirin until now due to hematuria” per note dated 3 days after arrival).
    • Crossing out of an aspirin order counts as an "other reason" for not prescribing aspirin on arrival 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 on arrival.
    • Pre-arrival hold or discontinuation of aspirin or notation such as "No aspirin" counts as a reason for not prescribing aspirin on arrival 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 on arrival (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)
  • Transfer 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 on Arrival
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)