June 2009

Acute Myocardial Infarction (AMI) and Chest Pain – OP 4 – Aspirin at Arrival

By Ella Nix, RN, BSN, CCS-P

To meet the Centers for Medicare & Medicaid (CMS) Hospital Outpatient Department Quality Measures requirements and receive reimbursement under the Outpatient Prospective Payment System (OPPS), hospitals must submit data for seven quality measures for three medical conditions: Acute Myocardial infarction (AMI), Chest Pain and Surgical Care Improvement.

Aspirin at Arrival is used for the principal diagnosis of both AMI and Chest Pain (Probable Cardiac Chest Pain). Studies have shown that the early use of aspirin results in a significant reduction in adverse events and subsequent mortality – comparable to thrombolytic therapy. Despite these recommendations, aspirin remains under-utilized. The specification manual defines the data element of aspirin on arrival as: “Aspirin received within 24 hours before emergency department arrival or administered prior to transfer.”

Patients seen in a hospital emergency department are included in the AMI and Chest Pain measures and are eligible to be sampled if they meet the following criteria:

• Received a discharge or transfer to a short-term general hospital for inpatient care, to a federal health care facility, or to a Critical Access Hospital (Discharge Status).
• Age 18 or older.
• Have an ICD-9-CM Principal Diagnosis Code for AMI or Chest Pain.

CMS suggests review of an ambulance record or emergency department record as the data source but the data abstractor is not restricted to these pages of medical records and is encouraged to review the entire record.

Some specific events that a data abstractor should keep in mind are:

• If a medication is written in the physician orders has been initialed and signed off with a time, do not presume that the medication was administered. The documentation MUST indicate that the medication was actually given. Those initials may belong to the unit secretary and not the nurse. However, documentation on an ED or ambulance record that says “ASA 325mg po 13:00” with no other documentation available would be acceptable.
• When aspirin is listed only as a “home” or "current" medication, and the exact timing of the last dose the patient took is not noted, infer that the patient took aspirin within the 24-hour timeframe, unless documentation suggests otherwise.
• When aspirin is noted only as received prior to emergency department arrival (e.g., in an ambulance or physician office), without information about the exact time it was received (e.g., "Baby ASA X 4" per the "Treatment Prior to Arrival" section of the Triage Assessment), infer that the patient took aspirin within the 24-hour timeframe, unless documentation suggests otherwise.
• There are several drugs that have aspirin in them, so be familiar with such names as:  Empirin, Ascriptin, Goody’s Headache Powder, etc.

Reasons that aspirin was not administered are divided into 4 categories:

• Aspirin allergy or sensitivity.
• Documentation of Coumadin/warfarin prescribed pre-arrival, (since the addition of aspirin will increase the bleeding times, making it difficult to regulate the Coumadin dose).
• Other documented reasons by MD, APN, PA, or pharmacist.
• No documented reason or Unable to Determine (UTD).

Excluded populations include those patients that are less than 18 years of age and those with a contraindication to aspirin. Reasons for not prescribing aspirin may include:

• Aspirin allergy.
• Coumadin/warfarin as pre-arrival medication.
• Other reasons that are documented by MD, APN, PA or pharmacist.

Look for co-morbidities such as a history of GI bleeding or peptic ulcer, gastritis, cerebral hemorrhage, hematuria, Reye’s syndrome, blood cell disorders, recent surgery, etc. These conditions, if current, could be the reason the aspirin was withheld. Contraindications can be absolute or relative contraindications, and the provider notes are usually vague or absent as to the reason aspirin was not prescribed. In addition to co-morbidities, current drug regimens prescribed to the patient might preclude the use of aspirin.

Other places in the medical record that one might find a note about aspirin administration in the ER might be found in the records of the receiving hospital. For example, the initial nursing assessment of the patient after he is transferred to an ICU bed at another hospital may read, “ASA 325mg po 1045 ER at ABC Hospital.” Other sources for aspirin administration may be found in the transfer records, the H&P, pre-op cath lab notes, progress notes, or ambulance records. These sources might document that the patient was given aspirin in the ER, even though one can’t find the documentation in ER records.

Sometimes the best path to take when uncertain is to search the Quality Net website. CMS has designated FMQAI as the support contractor for these types of questions. FMQAI provides technical support and feedback to assist hospitals with outpatient quality data reporting. Another way to reach FMQAI is to submit questions by email to hopqdrp@fmqai.com, or by calling toll-free, (866) 800-8756 weekdays from 7:00 a.m. to 6:00 p.m. ET.

Editor’s note: Ella Nix, RN, BSN, CCS-P is a Data Abstractor in Winston-Salem, NC for Clinical-Insights.

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