August 2009

Surgical Care Improvement Project – CARD-2 – Beta-Blocker Perioperative

By Yvonne Acker, RN, BSN, CPHQ

The Surgical Care Improvement Project (SCIP) focuses on quality measures that are centered around evidence-based practices that reduce the incidence of preventable surgical complications from infection, blood clots, and cardiac events.

The SCIP CARD-2 measure addresses Beta-Blockers in the perioperative period. Beta-Blockers are drugs which block beta-adrenergic receptors. When these receptors are blocked, the heart rate and force of heart contractions are decreased which then reduces blood pressure. Studies have shown that the abrupt discontinuation of Beta-Blockers during the perioperative period in patients who were on chronic Beta-Blocker therapy prior to surgery can lead to increased mortality during the intraoperative and postoperative periods. The American College of Cardiology/American Heart Association has given the continuation of Beta-Blocker therapy throughout the perioperative period a Class I recommendation. The perioperative period is defined as 24 hours prior to surgical incision through discharge from the post anesthesia care/recovery area (for patients that go directly to the ICU after surgery, the recovery period would end a maximum of six hours after arrival to the ICU).

The CARD-2 measure applies to all surgical patients that fall into a hospital’s SCIP population. The only exclusions are the following:

• Patients under 18 years of age.
• Patients who have a length of stay > 120 days.
• Patients whose ICD-9-CM principal procedure was performed entirely by laparoscope.
• Patients enrolled in clinical trials.
• Patients whose ICD-9-CM principal procedure occurred prior to the date of admission.
• Patients who expired during the perioperative period.
• Pregnant patients taking a beta-blocker prior to arrival.
• Patients with a documented Reason for Not Administering Beta-Blocker Perioperative.

The data abstractor must first determine if a patient was on a Beta-Blocker prior to hospital arrival. Suggested data sources to determine if a Beta-Blocker was a “home” or “current” medication include but are not limited to the following:

• Admitting record
• Anesthesia records
• Consultation notes
• Medication reconciliation form
• History and physical
• Nursing admission assessment
• Preoperative record
• Progress notes

If the Beta-Blocker is only taken “PRN” at home or if the patient stopped taking the Beta-Blocker prior to arrival, then the patient is considered to NOT be on Beta-Blocker therapy prior to hospital arrival.

Once the data abstractor ascertains that the patient was on Beta-Blocker therapy prior to hospital arrival, then the abstractor must determine if the patient received a Beta-Blocker during the perioperative period. Suggested data sources to determine if the patient received a Beta-Blocker during the perioperative period include, but are not limited to the following:

• Anesthesia records
• Consultation notes
• History and physical
• Medication administration record
• Nursing admission assessment
• Operative report
• Preoperative record
• Procedures notes
• Progress notes

For patients having surgery on the same day as hospital admission, it is important to determine when the patient took their last dose of Beta-Blocker prior to hospital arrival. Unless there is specific documentation that the patient took their Beta-Blocker on the day of surgery, then there must be a date and time to indicate when the last dose of Beta-Blocker was taken.

If the patient did not receive a Beta-Blocker within the perioperative period, then the abstractor must determine if there was a Reason for Not Administering Beta-Blocker Perioperative which would include the following:  

• Bradycardia (heart rate less than 50 bpm) – documentation of “bradycardia” alone will not suffice unless there is also evidence of heart rate less than 50 bpm.  Note: Do not use a heart rate that is documented while patient is on cardiopulmonary bypass machine to determine bradycardia.
• Other reasons documented by physician/APN/PA or pharmacist - documentation of reasons for not administering a Beta-Blocker must apply to the perioperative period but the timing of the written documentation itself is not limited to the perioperative period timeframe.

In addition, if the physician orders the Beta-Blocker to be held for certain vital sign parameters and the Beta-Blocker is held according to the physician’s order, then that situation would suffice as a documented “Reason for Not Administering Beta-Blocker Perioperative.” Suggested data sources to determine if there was a “Reason for Not Administering Beta-Blocker Perioperative” include, but are not limited to the following:

• Anesthesia record
• Consultation notes
• Discharge summary
• ECG reports
• Emergency department record
• History and physical
• Medication administration record
• Nursing notes
• Physician orders
• Progress notes
• Vital signs/graphic record

For questions that are not clearly addressed in the Specifications Manual for National Hospital Inpatient Quality Measures, it is recommended that you use QNet Quest which is an online questions and answers database. QNet Quest can be found on the Quality Net website (www.qualitynet.org).

Editor’s note: Yvonne Acker, RN, BSN, CPHQ is a Data Abstractor in Chapel Hill, NC for Clinical-Insights

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