2021 AQI55: Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients

Measure Description

Percentage of patients, regardless of age, who are admitted to an intensive care unit (ICU) for ≥48 hours and who received critical care services who have documentation by managing physician of

1. attempted or actual identification of a surrogate decision maker,
2. an advance directive, and
3. the patient’s preference for cardiopulmonary resuscitation, within 48 hours of ICU admission

Denominator

All patients, regardless of age, who are admitted to an intensive care unit for ≥48 hours and who received critical care services

Denominator Criteria (Eligible Cases):

All patients, regardless of age
AND
Admitted to an intensive care unit for ≥48 hours: 10A58
AND
Received critical care services (CPT): 99291, 99468, 99469, 99471, 99472, 99475, 99476

Numerator

Patients who have documentation by managing physician of

1. attempted or actual identification of a surrogate decision maker,
2. an advance directive, and
3. the patient’s preference for cardiopulmonary resuscitation, within the first 48 hours of ICU admission.

Numerator Note: To meet this measure, the managing physician must either document the required information or confirm that they have reviewed existing documentation of the information. Numerator Quality-Data Coding Options for Reporting Satisfactorily

Performance Met:

10A59 Patient has documentation by managing physician of

1. attempted or actual identification of a surrogate decision maker,
2. an advance directive, and
3. the patient’s preference for cardiopulmonary resuscitation within the first 48 hours of ICU admission

OR
Denominator Exception:
10A60 Documentation of patient reason(s) for not documenting all three required numerator elements within the first 48 hours of ICU admission (e.g., patient declines, patient unable to participate in discussion, other patient reason(s))
OR
Performance Not Met:
10A61 Patient does not have documentation by managing physician of

1. attempted or actual identification of a surrogate decision maker,
2. an advance directive, and
3. the patient’s preference for cardiopulmonary resuscitation within the first 48 hours of ICU admission

Numerator Exclusions

None

NQF ID Number

N/A

NQS Domain

Communication and Care Coordination

High Priority Measure

Yes

Includes Telehealth?

No

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be calculated and submitted

1

Risk-Adjusted Status?

No