Emergency & Acute Care Clinical Registry Quality Measures: 2022

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
ACEP19Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and OlderYesProcessPercentage of emergency department visits for patients aged 18 years and older who presented with a minor blunt head trauma who had a head CT for trauma ordered by an emergency care provider who have an indication for a head CTView
ACEP50ED Median Time from ED arrival to ED departure for all Adult PatientsYesOutcomeTime (in minutes) from ED arrival to ED departure for all Adult PatientsView
ACQR12ABCDEF Bundle - Early mobility for ICU patientsYesProcessPatients admitted to the intensive care unit (ICU) for > or = 4 days should be included in an early mobility program (E of ABCDEF Bundle) to improve their recovery process.View
ACQR13Sepsis: Hour One bundleNoProcessSurviving Sepsis Campaign's Hour One bundle initiation in patients with Sepsis and acute organ dysfunctionView
ACQR16COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care EvaluationYesEfficiency and Cost/Resource UsePatients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapnic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available; and patients admitted with AHA Class D heart failure and/or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if availableView
AQI69Intraoperative Antibiotic RedosingYesProcessPercentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision (if fluoroquinolone or vancomycin, two hours) 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
AQI73Prevention 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. This measure will consist of three performance rates: a. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the brachial, radial, posterior tibial or dorsalis pedis artery 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 b. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the femoral or axillary artery for whom the arterial line was inserted with all indicated elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound technique is followed Note: The overall measure score will be calculated as an average of the total cases of part A (rate 2) and part B (rate 3). The overall measure score is rate 1.View
AQI72Perioperative 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. Management strategies include one or more of the following: • Cell salvage techniques employed intraoperatively • Intraoperative antifibrinolytic therapy or tourniquet, if not contraindicated • Preoperative iron supplementation, epoetin alpha • Use of evidence-based preoperative anemia management algorithm supplemented with laboratory testing and/or multidisciplinary consultView
ECPR39Avoid Head CT for Patients with Uncomplicated SyncopeYesProcessPercentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the ProviderView
ECPR41Rh 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
ECPR46Avoidance of Opiates for Low Back Pain or MigrainesYesProcessPercentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an OpiateView
ECPR51Discharge 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
ECPR52Appropriate Treatment of Psychosis and Agitation in the Emergency DepartmentNoProcessPercentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency DepartmentView
ECPR57Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor VehiclesYesProcessPercentage of Patients At Risk for Recurrent Loss of Consciousness For Whom Loss of Consciousness Information Was Submitted to Department of Public Health or Department of Motor VehiclesView
ECPR55Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute PainYesProcessPercentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation and for Whom the Prescription Duration Was Not Greater than 3 days for Acute PainView
ECPR56Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid TreatmentYesProcessPercentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication-Assisted Treatment and Referred to Outpatient Opioid TreatmentView
HCPR14Venous 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
HCPR16Physician’s Orders for Life-Sustaining Treatment (POLST) FormYesProcessPercentage of Patients Greater Than or Equal to 65 Years of Age with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms CompletedView
HCPR17Pressure 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
HCPR18Unintentional 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
HCPR23Avoidance of Echocardiogram and Carotid Ultrasound for SyncopeYesProcessPercentage of Patients Presenting with Syncope Who Did Not Have an Echocardiogram or Carotid Ultrasound OrderedView
HCPR24Appropriate Utilization of Vancomycin for CellulitisYesProcessPercentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was IdentifiedView
ACEP59Chest Pain – Avoidance of admission for adult patients with low-risk chest pain.YesOutcomePercentage of adult patients who came to the Emergency Department with low-risk chest pain and were dischargedView
ACEP61Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or CroupYesProcessPercentage of ED visits for pediatric patients with Asthma, Bronchiolitis or Croup for whom a Chest X-ray was ordered/performed.View