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
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
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
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
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