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Release Notes:
Data Element
Version 2010A1

Data Element Name: Contraindication to Beta-Blocker on Arrival
Collected For: AMI-6,
Definition:Contraindications/reasons for not prescribing beta-blockers on arrival include: beta-blocker allergy, bradycardia (heart rate less than 60 beats per minute [bpm]) on arrival or within 24 hours after arrival while not on a beta-blocker, heart failure on arrival or within 24 hours after arrival, second- or third-degree heart block on ECG on arrival or within 24 hours after arrival and does not have a pacemaker, shock on arrival or within 24 hours after arrival, or other reasons documented by physician/advanced practice nurse/physician assistant (physician/APN/PA) or pharmacist for not prescribing a beta-blocker on arrival. 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 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 a beta-blocker on arrival:

  • Beta-blocker allergy
  • Bradycardia (heart rate less than 60 beats per minute [bpm]) on arrival or within 24 hours after arrival while not on a beta-blocker
  • Heart failure on arrival or within 24 hours after arrival
  • Second- or third-degree heart block on ECG on arrival or within 24 hours after arrival AND does not have a pacemaker
  • Shock on arrival or within 24 hours after arrival
  • Other reasons documented by physician/APN/PA or pharmacist for not prescribing a beta-blocker on arrival

N   (No)   There is no documentation of a contraindication/reason for not prescribing beta-blocker 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 a beta-blocker on arrival.
  • 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 arrival or within 24 hours after arrival 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 arrival or within 24 hours of arrival.
    • Consider the patient “on a beta-blocker” if one of the following conditions is met:
      -A beta-blocker is noted as a part of the patient’s medication regimen just prior to acute care treatment. This includes beta-blockers the patient was on at home, the nursing home, a transferring psychiatric hospital, etc., regardless of whether there is an indication that it was on temporary hold or the patient has been non-compliant/self-discontinued their medications (e.g., refusal, side effects, cost). INCLUDE beta-blockers taken in the ambulance en route to the hospital.
      -The patient received a beta-blocker in the hospital within 24 hours after hospital arrival.
  • When determining whether there is heart failure on arrival or within 24 hours after arrival:
    • Do NOT use chest x-ray reports. However, physician/APN/PA references to chest x-ray findings are acceptable, provided the finding documented is one of the listed inclusion terms.
    • If heart failure is listed as an admitting diagnosis (e.g., H&P, discharge summary), infer heart failure was present within the first 24 hours after arrival.
  • When determining whether there is a second- or third-degree heart block on ECG on arrival or within 24 hours after arrival 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.
  • For those potential contraindications which stipulate a 24 hour timeframe: When unable to determine for certain whether a condition occurred either on arrival or within 24 hours after arrival, select “No.”
  • When determining whether there is a reason documented by a physician/APN/PA or pharmacist for not prescribing a beta-blocker on arrival:
    • 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,” “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, ED 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 within the first 24 hours after arrival constitutes a “clearly implied” reason for no beta-blocker on arrival.
      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).
      -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 on arrival.
      Examples:
      -"Begin Betapace tomorrow" per admitting progress note – select “No.”
      -“Consider starting Corgard in a.m.” per ER physician report – select “No.”
      -“Consulting cardiologist to evaluate pt. for BB treatment” per H&P – select “No.”
      -"BPs running low. May start Atenolol on nursing floor.” per ED record – select “Yes.”
      -“May add beta-blockers when pt. can tolerate” per consultation note – select “Yes.”
      -“Add Toprol if HR stabilizes” per progress note – select “Yes.”
      -“Held off on beta-blocker therapy during this hospitalization. Will restart as outpatient after hypotension 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 Inderal” per note dated/timed within 24 hours, “Patient’s BP too low to start beta-blockers until now” per note dated 3 days after arrival).
    • Crossing out of a beta-blocker order counts as an "other reason" for not prescribing a beta-blocker 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 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 on arrival.
    • 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 on arrival 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 on arrival (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)
  • Chest x-ray reports
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
Heart failure
  • Biventricular failure
  • Cardiac decompensation
  • Cardiac failure
  • Congestive heart failure (CHF)
  • Edema described as alveolar, diffuse interstitial, diffuse interstitial pulmonary, interstitial, pulmonary, or pulmonary interstitial
  • Edema of the lungs
  • Edema not described as pulmonary in nature, if referenced as chest x-ray finding (e.g., “CXR shows mild edema”)
  • Fluid overload
  • Heart failure described as left, right, or unspecified
  • Killip class III
  • Perihilar congestion
  • Pulmonary congestion
  • Pulmonary vascular redistribution
  • Pump failure
  • Vascular congestion
  • Venous congestion
  • Ventricular failure
  • Volume overload
  • Wet lungs

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
  • Atrioventricular (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

Shock:

  • Anaphylactic shock
  • Cardiogenic shock
  • Cardiovascular collapse
  • Hypovolemic shock
  • Intravascular collapse
  • Killip class IV
  • Septic shock
  • Shocky

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

Heart failure

  • Cardiomyopathy
  • Heart failure, or any of the other heart failure inclusion terms, 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)

Shock

  • Cardiovascular instability
  • Hypotension
  • Shock, or any of the other shock inclusion terms, described using one of the negative modifiers or qualifiers listed in Appendix H, Table 2.6, Qualifiers and Modifiers Table

Contraindication to Beta-Blocker on Arrival
Specifications Manual for Joint Commission National Quality Core Measures (2010A1)
Discharges 04-01-10 (2Q10) through 09-30-10 (3Q10)