2024 Emergency & Acute Care Clinical Registry quality measures

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Description
ACEP59Chest Pain: Avoidance of admission for adult patients with low-risk chest painYesOutcomePercentage of adult patients who came to the Emergency Department with low-risk chest pain and were dischargedView
AQI48Patient-Reported Experience with AnesthesiaYesPRO-PMPercentage 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
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 consult
View
ECPR39Avoid Head CT for Patients with Uncomplicated SyncopeYesProcessPercentage of Adult Syncope Patients Who Did Not Receive a Head CT Scan Ordered by the Provider.View
ECPR46Avoidance of Opiate Prescriptions 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 Discharge.View
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 Department.View
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 Pain.View
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 Treatment.View
HCPR20Clostridium 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
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
AQI18Coronary Artery Bypass Graft (CABG): Prolonged Intubation – Inverse MeasureYesOutcomePercentage 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
AQI49Adherence to Blood Conservation Guidelines for Cardiac Operations using Cardiopulmonary Bypass (CPB) – CompositeNoProcessPercentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was IdentifiedView
HCPR27Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) PlacementYesProcessPercentage 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
ECPR59Patient Reported Trust in ProviderYesPatient Engagement/ExperiencePercentage 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
ECPR50Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care PatientsYesProcessPercentage 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
HCPR25Physician’s Orders for Life-Sustaining Treatment (POLST) FormYesProcessPercentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was IdentifiedView
HCPR26Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD)NoProcessPercentage 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
AQI65Avoidance of Cerebral Hyperthermia for Procedures Involving Cardiopulmonary BypassYesOutcomePercentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was IdentifiedView
AQI67Consultation for Frail PatientsYesProcessPercentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was IdentifiedView
AQI71Ambulatory Glucose ManagementNoProcessPercentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was IdentifiedView