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Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Beta-Blocker at Discharge
Collected For: AMI-5,
Definition:Contraindications/reasons for not prescribing beta-blockers at discharge include: beta-blocker allergy, bradycardia (heart rate less than 60 beats per minute [bpm]) on day of discharge or day prior to discharge while not on a beta-blocker, second- or third-degree heart block on ECG on arrival or during hospital stay and does not have a pacemaker, or other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not prescribing beta-blocker at discharge. Beta-blockers 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.
Suggested Data Collection Question:Is one or more of the following potential contraindications/reasons for not prescribing a beta-blocker 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 a beta-blocker at discharge:

  • Beta-blocker allergy
  • Bradycardia (heart rate less than 60 beats per minute [bpm]) on day of discharge or day prior to discharge while not on a beta-blocker
  • 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/APN/PA or pharmacist for not prescribing a beta-blocker at discharge

N   (No)   There is no documentation of contraindications/reasons for not prescribing to beta-blocker at discharge 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 a beta-blocker at discharge.
  • When there is documentation of a beta-blocker “allergy” or “sensitivity,” regard this as documentation of a beta-blocker 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: 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 Lopressor”).
  • 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 bradycardia (heart rate less than 60) on day of discharge or day prior to discharge while not on a beta-blocker:
    • Documentation of “bradycardia” alone is not acceptable. Bradycardia must be substantiated by documentation of a heart rate of less than 60 beats per minute [bpm] on the day of discharge or the day prior to discharge.
    • Consider the patient “on a beta-blocker” if the patient received a beta-blocker on the day of discharge or the day prior to discharge.
  • 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 or 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 a beta-blocker at discharge:
    • Reasons must be explicitly documented (e.g., “COPD - No BBs”) or clearly implied (e.g., “Severe hypotension with beta-blockers in past,” “BBs contraindicated,” “Intolerant of beta-blockers,” “Problems with beta-blockers in past,” “c/o drowsiness, will DC beta-blocker,” “Pt. refusing all medications,” “Limited life expectancy, no further treatment,” “Supportive care only – no medications,” “BBs not indicated,” beta-blocker on pre-printed order form is crossed out, mid-stay order to “Hold Coreg,” “DC atenolol” or “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 a beta-blocker is not being prescribed because of the patient's history of Peripheral Vascular Disease [PVD] alone).
    • Physician/APN/PA or pharmacist documentation of a hold on a beta-blocker or discontinuation of a beta-blocker that occurs during the hospitalization constitutes a “clearly implied” reason for not prescribing a beta-blocker at discharge.
      EXCEPTIONS:
      -Discontinuation of a particular beta-blocker in combination with documentation to start a different beta-blocker (switch in type of beta-blocker - e.g., “DC sotalol” followed by “Start Tenormin” in physician orders).
      -Beta-blocker holds/discontinuations which are clearly labeled or identified as preop/pre-procedure.
      -Documentation of hold/discontinuation of IV beta-blocker.
      -Discontinuation of a beta-blocker at a particular dosage in combination with documentation to start a different dosage of that beta-blocker (increase/decrease in dosage - e.g., “DC propranolol 80 mgs. po t.i.d.” followed by “Start propranolol 80 mgs. po b. i.d.” 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 metoprolol in a.m."
      ►"Hold Inderal x 24-48 hours"
      ►"Hold Tenormin this evening. Resume dose in a.m."
      ►"Hold sotalol until a.m."
      ►"Hold timolol today"
      ►“No Coreg today"
      -Documentation of a conditional hold or discontinuation of a beta-blocker (e.g., “Hold Lopressor if pulse drops below 60,” “Stop propranolol if HR < 50”).
      -Documentation of a hold on beta-blocker because patient already received one prior to arrival (e.g., "Hold Lopressor. Pt. took this a.m." per ED note).
      -Hold/discontinuation documentation, which refers to a more general medication class (e.g., “Hold all BP meds,” “DC antihypertensive drugs”).
    • If there is documentation of a plan to initiate/restart a beta-blocker, 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 at discharge.
      Examples:
      -"Begin beta-blocker therapy at first clinic visit" per discharge progress note – select “No.”
      -“Consider starting Corgard in a.m.” per mid-stay progress note – select “No.”
      -“Consulting cardiologist to evaluate pt. for BB treatment” per H&P – select “No.”
      -"BPs running low. May start Atenolol as outpatient.” per discharge summary – select “Yes.”
      -“May add beta-blockers when pt. can tolerate” per consultation note – select “Yes.”
      -“Add Toprol if HR stabilizes” per admitting progress note – select “Yes.”
      -“Will restart Coreg after hypotension 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 prescription: Documentation of contraindications anytime during the hospital stay are acceptable (e.g., mid-hospitalization note stating no beta-blockers “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 a beta-blocker order counts as an "other reason" for not prescribing a beta-blocker 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 a beta-blocker, 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 a beta-blocker allergy prior to arrival counts as a contraindication to beta-blocker at discharge.
    • Pre-arrival hold or discontinuation of a beta-blocker or notation such as "No beta-blockers" counts as a reason for not prescribing a beta-blocker at discharge ONLY if the underlying reason/problem is also noted (e.g., “Atenolol discontinued two weeks ago secondary to hypotension”).
    • Pre-arrival "other reason" (other than a beta-blocker hold/discontinuation or notation of "No beta-blockers") counts as reason for not prescribing a beta-blocker at discharge (e.g., "Intolerance to beta-blockers", "Hx severe hypotension with Lopressor").
Suggested Data Sources:
  • Consultation notes
  • Emergency department record
  • History and physical
  • Vital signs graphic record
  • Nursing notes
  • Progress notes
  • Physician orders
  • Discharge summary
  • Medication administration record (MAR)
  • ECG reports
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
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 2:1, 3:1, second-degree, or third-degree
  • Atrioventicular (AV) dissociation
  • Heart block (HB) described as 2:1, 3:1, complete (CHB), high degree, high grade, second-degree, or third-degree
  • Heart block, type/degree not specified
  • Mobitz Type 1 or 2
  • Wenckebach

Pacemaker findings

  • Atrial pacing
  • AV pacing
  • Dual chamber pacing
  • Paced rhythm
  • Paced spikes
  • Ventricular pacing

Refer to Appendix C, Table 1.3 for a comprehensive list of Beta-Blockers

Beta-blocker allergy
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
  • Atrioventricular (AV) conduction block
  • First-degree atrioventricular (AV) block
  • First-degree heart block (HB)
  • Intraventricular conduction delay (IVCD)

Contraindication to Beta-Blocker 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.