Managed Care - January 2008 - (Page 23) Physician performance crucial in ProvenCare’s success efore initiation of the ProvenCare program, 59 percent of all elective CABG patients in the Geisinger Clinic received all 40 elements of the ProvenCare process, according to an article in the Annals of Surgery that describes the program. Within three months, performance rose to 100 percent. Success? Well, up to that point. During the second three months, reliability dropped to 86 percent. That proved to be merely a temporary setback, however, as by the end of the first six months, reliability hit 100 percent again and stayed there throughout the rest of the study period. Here are the 40 elements of ProvenCare, divided into five categories: B A. Preadmission documentation 1. ACC/AHA indication 2. Screening for and consultation re: IMI (inferior myocardial infarction)/RV (right ventricular) involvement 3. Treatment options and patient preference 4. Need for warfarin — Ant.MI (myocardial infarction) or WMA (wall motion abnormality) 5. Current user of clopidogrel or warfarin? 6. Screening for stroke risk 7. Carotid doppler (if the test is indicated) 8. Vascular surgery consultation (if indicated) 9. Ejection fraction 10. Screening for need to use intra-aortic balloon pump (IABP) 11. Screening using epiaortic echo (as indicated) 12. Patient withheld clopidogrel/warfarin for 5 days pre-op? B. Operative documentation 13. Patient received correct dosing of beta-blocker (pre-op) 14. Correct use of intra-aortic balloon pump (pre-op —>post-op) 15. Pre-op Abx (within 60 minutes of incision; vancomycin within 120 minutes) 16. Blood cardioplegia (on-pump patients) 17. Epiaortic echo of the ascending aorta and the peer consult 18. Intra-operative hyperglycemia screening 19. Correct insulin management (as indicated per protocol) 20. Use of LIMA (left internal mammary artery) for LAD (left anterior descending) grafting C. Post-operative patient documentation 21. Anteroapical MI within prior 7 days: post-op echo 22. Monitoring for atrial fib for >48 hours 23. Anticoagulation therapy (as indicated) 24. Abx (antibiotics) administered (post-op for 24-48 hours) 25. Aspirin (six hours post-op or 24 hours post-op) 26. Beta-blocker (within 24 hours post-op) 27. Statin administered (post-op) 28. Surgical debridement and revascularization of any sternal wound infection 29. Plastic surgery consult regarding ongoing management of sternal wound 30. Tobacco screening and counseling D. Discharge documentation 31. Referral to cardiac rehab 32. Discharge medications (e.g., beta-blocker) 33. Discharge medication: aspirin 34. Discharge medication: statin E. Post-discharge documentation 35. Patient correctly taking beta-blocker? 36. Patient correctly taking aspirin? 37. Patient correctly taking statin? 38. Patient correctly administering anticoagulant? 39. Did patient resume smoking? 40. Patient enrolled in cardiac rehab? JANUARY 2008 / MANAGED CARE 23
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