Emergency & Acute Care Clinical Registry Quality Measures: 2021

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
ECPR462021 ECPR46: Avoidance of Opiates for Low Back Pain or MigrainesYESProcessPercentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an OpiateView
HCPR202021 HCPR20: Clostridium Difficile – Risk Assessment and Plan of CareYESProcessPercentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital AdmissionView
HCPR182021 HCPR18: Unintentional Weight Loss – Risk Assessment and Plan of CareYESProcessPercentage of Adult Post-acute Facility Patients that Had a Risk Assessment for Unintentional Weight Loss and a Plan of Care for Unintentional Weight Loss Documented by ProviderView
HCPR172021 HCPR17: Pressure Ulcers – Risk Assessment and Plan of CareYESProcessPercentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment CompletedView
HCPR162021 HCPR16: Physician’s Orders for Life-Sustaining Treatment (POLST) FormYESProcessPercentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms CompletedView
HCPR142021 HCPR14: Venous Thromboembolism (VTE) ProphylaxisYESProcessPercentage of Adult Patients Who Had VTE Prophylaxis Ordered at the Time of Admission OR Have Documentation of Reason for No VTE ProphylaxisView
ECPR542021 ECPR54: Avoidance of Co-Prescribing of Opioid Analgesic and BenzodiazepineYESProcessPercentage of Patients Who Were Not Concurrently Prescribed Opioid Analgesic and Benzodiazepine MedicationsView
ECPR522021 ECPR52: Appropriate Treatment of Psychosis and Agitation in the Emergency DepartmentNOProcessAny patient ≥ 18 years of age evaluated by the Eligible Professional in the Emergency Department (ED) PLUS ED length of stay of 4 hours or more PLUS ICD-10 diagnosis codes for psychosis, psychotic disorder NOS, psychotic features, hallucinations, schizophrenia, schizoaffective disorder, agitation due to psychosis (Not including eloped or AMA patients)View
ECPR512021 ECPR51: Discharge Prescription of Naloxone after Opioid Poisoning or OverdoseYESProcessPercentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at DischargeView
AQI552021 AQI55: Team-Based Implementation of a Care-and-Communication Bundle for ICU PatientsYESProcessPercentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for ≥48 hours and who received critical care services who have documentation by managing physician of 1) attempted or actual identification of a surrogate decision maker, 2) an advance directive, and 3) the patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admissionView
ECPR412021 ECPR41: Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood ExposureNOProcessPercentage of Women Aged 14-50 Years at Risk of Fetal Blood Exposure Who Had Their Rh Status Evaluated in the Emergency Department (ED) and Received Rh-Immunoglobulin (Rhogam) if Rh-negativeView
ECPR402021 ECPR40: Initiation of the Initial Sepsis BundleNOProcessPercentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis BundleView
ECPR392021 ECPR39: Avoid Head CT for Patients with Uncomplicated SyncopeYESProcessPercentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the ProviderView
AQI722021 AQI72: Perioperative Anemia ManagementYESProcessPercentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge.View
AQI712021 AQI71: Ambulatory Glucose ManagementNOProcessPercentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period.View
AQI702021 AQI70: Prevention of Arterial Line Related Bloodstream InfectionsYESProcessPercentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial catheter for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.View
AQI692021 AQI69: Intraoperative Antibiotic RedosingYESProcessPercentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision and undergo a procedure greater than two hours duration who received intraoperative antibiotic redosing at a maximum interval of two half-lives of the selected prophylactic antibiotic.View
AQI572021 AQI57: Safe Opioid Prescribing PracticesYESProcessPercentage of patients, aged 18 years and older, prescribed opioid medications for longer than six weeksView
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