STS: Meds: Beta Blockers

Pre & Postop Beta Blockade

A series of STS Definitions:

To Visit the Circuit Surfer STS Page  Click Here

For a list of STS posts Click here

Sniffing through the patient’s chart to establish beta blocker (BB) therapy seems simple but can be tricky.  I usually find the immediate source in one of the many H&P’s towards the beginning of the chart (locations vary- depending on the institution in terms of where this information truly lives).

The key is usually to identify it as a home med, and find the verification for it’s administration within 24 hours (prior to surgery).  The best place to look is in the preoperative checklist that most heart programs have customized to make sure they dot the “i” s and cross the “t” s.

The MAR is the next best bet, and if that well is dry, look at the anesthesia preop sheet.  The Dr.’s Orders, and Progress notes are a nice places to visit, but nets a totally ineffectual yield.

(Because while it may be in the orders,  if there is no actual documentation of the BB being administered, it’s a big fat zero in the STS world.)

At our institution we have included the timing of BB Rx as part of the mandatory  “Time Out”  report that is verbalized to the entire surgical team by the circulating nurse prior to incision.

Note:  For procedures such as a straight valve or non coronary operation, in the absence of documented coronary artery disease, the question of the necessity for Beta blockade comes to the forefront, and at this point may allow for a discussion in terms of coding the preop use of BB as “contraindicated / not indicated”.

That is a point that is somewhat hazy as far as I can see (no pun intended).

Beta Blockers Defined

Beta blockers (sometimes written as β-blockers) or beta-adrenergic blocking agents, beta-adrenergic antagonists, or beta antagonists, are a class of drugs used for various indications, but particularly for the management of cardiac arrhythmias, cardioprotection after myocardial infarction (heart attack), and hypertension.  As beta adrenergic receptor antagonists, they diminish the effects of epinephrine (adrenaline) and other stress hormones.

Beta blockers block the action of endogenous catecholamines (epinephrine (adrenaline) and norepinephrine (noradrenaline) in particular), on β-adrenergic receptors, part of the sympathetic nervous system which mediates the “fight or flight” response.  There are three known types of beta receptor, designated β1, β2 and β3 receptors.  β1-adrenergic receptors are located mainly in the heart and in the kidneys.  β2-adrenergic receptors are located mainly in the lungs, gastrointestinal tract, liver, uterus, vascular smooth muscle, and skeletal muscle.  β3-adrenergic receptors are located in fat cells.

Source:  Wikkipedia

The STS Standard for Beta Blocker therapy:

Indicate whether or not the patient received a Beta Blocker within 24 hours preceding surgery, or if it was contraindicated or not indicated. The contraindication must be documented in the medical record by a physician, nurse practitioner, or physician assistant.

Preop (STS)

Where to Find

  • Admission assessment
  • History & Physical
  • Medication administration record
  • Physician order sheet
  • Pre-anesthesia record

Indicate Responses For STS

Yes:   Received a beta blocker within 24 hours preceding surgery

No:      Did not receive a beta blocker within 24 hours preceding surgery, no reason documented

Contraindicated :  Documented evidence of contraindication: For each medication, check if the medication was not administered or ordered according to data specification timeframe as documented anywhere in the medical record. If a contraindication is documented explicitly as excluded for medical reasons, or is evidenced clearly within the medical record (notation of a medication allergy prior to arrival), check “Contraindication.” Otherwise, do not check “Contraindication.”

List of Common Beta Blockers

(Rule of thumb:  If it ends in LOL– it’s probably a Beta Blocker)

Postop (STS)

Where to Find

  • Discharge instruction sheet
  • Discharge summary
  • Medication administration record
  • Physician progress notes
  • Transfer Summary

Indicate Responses For STS

Yes:   Discharged on a beta blocker at discharge

No:      Not prescribed a beta blocker at discharge, no reason documented

Contraindicated :  Documented evidence of contraindication:
For each medication, check if the medication was not administered or ordered according to the data specification timeframe as documented anywhere in the medical record. If a contraindication is documented explicitly as excluded for medical reasons, or is evidenced clearly within the medical record (notation of a medication allergy prior to arrival), check “Contraindication.”

Otherwise, do not check “Contraindication”.

Beta Blocker FAQ (STS)

Q1 :  If I have an order for a Beta Blocker but I cannot find the documentation that it was given, can I code “Yes” because I have an order.

Answer:  Code “NO”, this data specification includes a time element, not just an order.

Q2:  What is the difference between Contraindicated and Not Indicated?

Answer:  “CMS’ Coding for Quality: A Handbook for PQRI Participation, March 20, 2008” on page 4 defines: Not Indicated (absence of organ/limb, already received performed); Contraindicated (patient allergic history, potential adverse drug interaction). http://www.cms.hhs.gov/PQRI/Downloads/2008PQRICodingforQualityHandbook

For all of the available FAQ’s on the STS website:  Click Here

The Ultimate Prize:

Shootin’ for the Stars …

It’s a 3 star system so don’t let that throw you off.

2 stars means you are are great.

3 Stars means you are insanely good at what you do…  and may require medication..

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