Emergency & Acute Care Clinical Registry Quality Measures: 2024

Quality Id	Measure Name	High Priority	Measure Type	Measure Description
ACEP59	Chest Pain: Avoidance of admission for adult patients with low-risk chest pain	Yes	Outcome	Percentage of adult patients who came to the Emergency Department with low-risk chest pain and were discharged	View
AQI48	Patient-Reported Experience with Anesthesia	Yes	PRO-PM	Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care and who reported a positive experience. This measure will consist of two performance rates: AQI48a: Percentage of patients, aged 18 and older, who were surveyed on their patient experience and satisfaction with anesthesia care AQI48b: Percentage of patients, aged 18 and older, who completed a survey on their patient experience and satisfaction with anesthesia care who report a positive experience with anesthesia care NOTE: The measure requires that a valid survey, as defined in the numerator of AQI48a, be sent to patients between discharge from the facility and within 30 days of facility discharge. To report AQI48b, a minimum number of 20 surveys with the mandatory question completed must be reported. ** In order to be scored on this measure, clinicians must report BOTH AQI48a AND AQI48b.	View
AQI72	Perioperative Anemia Management	Yes	Process	Percentage 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 consult	View
ECPR39	Avoid Head CT for Patients with Uncomplicated Syncope	Yes	Process	Percentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider.	View
ECPR46	Avoidance of Opiate Prescriptions for Low Back Pain or Migraines	Yes	Process	Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate	View
ECPR51	Discharge Prescription of Naloxone after Opioid Poisoning or Overdose	Yes	Process	Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge.	View
ECPR52	Appropriate Treatment of Psychosis and Agitation in the Emergency Department	No	Process	Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department.	View
ECPR55	Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain	Yes	Process	Percentage 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 Pain.	View
ECPR56	Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment	Yes	Process	Percentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication-Assisted Treatment and Referred to Outpatient Opioid Treatment.	View
HCPR20	Clostridium Difficile- Risk Assessment and Plan of Care	Yes	Process	Percentage 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 Admission	View
HCPR23	Avoidance of Echocardiogram and Carotid Ultrasound for Syncope	Yes	Process	Percentage of Patients Presenting with Syncope Who Did Not Have an Echocardiogram or Carotid Ultrasound Ordered	View
HCPR24	Appropriate Utilization of Vancomycin for Cellulitis	Yes	Process	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View
AQI18	Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse Measure	Yes	Outcome	Percentage 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 consult	View
AQI49	Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – Composite	No	Process	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View
HCPR27	Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) Placement	Yes	Process	Percentage 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 consult	View
ECPR59	Patient Reported Trust in Provider	Yes	Patient Engagement/Experience	Percentage 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 consult	View
ECPR50	Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients	Yes	Process	Percentage 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 consult	View
HCPR25	Physician’s Orders for Life-Sustaining Treatment (POLST) Form	Yes	Process	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View
HCPR26	Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD)	No	Process	Percentage 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 consult	View
AQI65	Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary Bypass	Yes	Outcome	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View
AQI67	Consultation for Frail Patients	Yes	Process	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View
AQI71	Ambulatory Glucose Management	No	Process	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View

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