Quality Core Measures

ED 1- ED Arrival to ED Departure

Median time from emergency department arrival to time of departure from the emergency room for patients admitted to the facility from the emergency department.

ED 2- Admit Decision to ED Departure

Median time from admit decision time to time of departure from the emergency department for admitted patients.

IMM 2- Influenza Immunization

Hospitalized inpatients age 6 months and older who were screened for seasonal influenza immunization status and were vaccinated prior to discharge if indicated by assessment.

SEP 1- Early Management Bundle, Severe Sepsis/Septic Shock

Adults 18 years and older with a diagnosis of severe sepsis or septic shock.

Consistent with Surviving Sepsis Campaign guidelines, it assesses measurement of lactate, obtaining blood cultures, administering broad spectrum antibiotics, fluid resuscitation, vasopressor administration, reassessment of volume status and tissue perfusion, and repeat lactate measurement.

As reflected in the data elements and their definitions, the first three interventions should occur within 3 hours of presentation of severe sepsis, while the remaining interventions are expected to occur within 6 hours of presentation of septic shock.

VTE 6- Preventable Hospital acquired VTEs

Patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

PC 01- Elective Delivery

Patients with elective vaginal deliveries or elective cesarean births at >= 37 and < 39 weeks of gestation completed. Excludes patients who are in labor, who have spontaneous ruptured membranes prior to arrival, and those with diagnosis of medical reasons for premature delivery.

PC 02- Cesarean Section

Deliveries of Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth.

PC-03 Antenatal Steroids

Documentation that antenatal steroid therapy was initiated before delivery. Initial antenatal steroid therapy two doses of 12mg betamethasone IM 24hrs apart or four doses of 6mg dexamethasone IM every 12 hours. Patients at risk of preterm delivery at >=24 and <34 weeks gestation receiving antenatal steroids prior to delivering preterm newborns.

PC-04 Health Care-Associated Bloodstream Infections in Newborns

Documentation in the medical record within the first 48 hours after admission that the patient had a bloodstream infection present on admission. This includes patients with positive blood cultures or negative or inconclusive blood cultures when the patient is suspected of having a bloodstream infection or septicemia and is being treated for the condition.

PC 05 – Exclusive Breast Milk Feeding

Exclusive breast milk feeding during the newborn’s entire hospitalization. Exclusive breast milk feeding is defined as a newborn receiving only breast milk and no other liquids or solids except for drops or syrups consisting of vitamins, minerals, or medicines.

VTE 6- Preventable Hospital acquired VTEs

Patients diagnosed with confirmed VTE during hospitalization (not present at admission) who did not receive VTE prophylaxis between hospital admission and the day before the VTE diagnostic testing order date.

HBIPS 2- Physical Restraint

The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint.

HBIPS 3- Seclusion

The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion.

HBIPS 5- Multiple Antipsychotic Medications at Discharge with Appropriate Justification

Patients discharged from a hospital-based inpatient psychiatric setting on two or more antipsychotic medications with appropriate justification.

Transition Record with Specified Elements Received by Discharged Patients Patients who were admitted to inpatient psychiatric facility.

Elements are: Reason for inpatient admission, Major procedures/test performed during inpatient stay with summary of results, Principal diagnosis at discharge, Current mediations list, studies pending at discharge (lab, radiological), patient instructions, Advance Directives or surrogate decision maker documented or documented reason for not providing advance care plan to include both Medical and Psychiatric Directives, Contact information/Plan for Follow-up Care to include 24hr/7day contact info including physician for emergencies related to inpatient stay, contact information for obtaining results of studies pending at discharge, plan for follow-up care and primary physician, other health care professional, or site designated for follow-up care.

Transition Record Transmitted within 24 hours to facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge of patients admitted to inpatient psychiatric facility.

Metabolic Screening

Inpatient psychiatric facility patients discharged with one or more routinely scheduled antipsychotic medications. Screening includes: Blood Pressure, BMI, Fasting plasma glucose/HbA1c & Lipid panel (Cholesterol, Triglycerides, HDL, and LDL).

IMM 2 Influenza Immunization

Inpatient psychiatric facility patients who were screened for seasonal influenza immunization status and were vaccinated prior to discharge if indicated by assessment.

SUB 1 Alcohol Use Screening

Hospitalized patients who are screened within the first day of admission using a validated screening questionnaire for unhealthy alcohol use.

SUB-2 The number of hospitalized inpatients 18 years of age and older who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay.

Brief intervention is a single or multiple sessions conducted by a qualified healthcare professional or trained peer support person, following a positive screen for unhealthy alcohol use which includes: feedback concerning the quantity and frequency of alcohol consumed by the patient in comparison with national norms, discussion of negative physical, emotional, occupational consequences and on the overall severity of the problem.

SUB-2a The number of hospitalized inpatients 18 years of age and older who screened positive for unhealthy alcohol use who received brief intervention during the hospital stay.

SUB-3 The number of hospitalized inpatients 18 years of age and older who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment.

SUB-3a The number of hospitalized inpatients 18 years of age and older who are identified with alcohol or drug disorder who receive a prescription for FDAapproved medications for alcohol or drug use disorder OR a referral for addictions treatment.

TOB 1- Tobacco Use Screening

The number of hospitalized inpatients 18 years of age and older who are screened within the first day of admission for tobacco use (cigarettes, smokeless tobacco, pipe and cigars) within the past 30 days.

TOB 2- Tobacco Use Treatment (Education/Medication) Provided OR Offered

The number of hospitalized inpatients 18 years of age and older identified as tobacco product users within the past 30 days who receive or refused practical counseling to quit AND receive or refuse FDA-approved cessation medications during hospital stay AND had reason for not receiving FDA approved cessation medication during hospital stay.

TOB 2a Tobacco Use Treatment

The number of hospitalized inpatients 18 years of age and older identified as tobacco product users within the past 30 days who received counseling to quit AND received FDA cessation medication AND had reason for not receiving the FDA approved cessation medication during hospital stay.

TOB 3- Tobacco Use Treatment at D/C

The number of hospitalized inpatients 18 years of age and older identified as tobacco product users within the past 30 days who were referred to or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication upon discharge.

TOB-3a

The number of hospitalized inpatients 18 years of age and older identified as tobacco product users within the past 30 days who were referred to evidencebased outpatient counseling AND received a prescription for FDA-approved cessation medication upon discharge as well as those who were referred to outpatient counseling AND had reason for not receiving a prescription for medication.

Hospital Out-Patient Measures HOP

AMI/Chest Pain

Stroke

ED Throughput

Pain Management for Long Bone fractures

Colonoscopy