| ACEP50 | ED Median Time from ED arrival to ED departure for all Adult Patients | Yes | Outcome | Time (in minutes) from ED arrival to ED departure for all Adult Patients | Details |
| HCPR14 | Venous Thromboembolism (VTE) Prophylaxis | Yes | Process | Percentage of Adult Patients Who Had VTE Prophylaxis Ordered at the Time of Admission OR Have Documentation of Reason for No VTE Prophylaxis | Details |
| 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 | Details |
| 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 | Details |
| ECPR57 | Clinician Reporting of Loss of Consciousness to State Department of Public Health or Department of Motor Vehicles | Yes | Process | Percentage 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 Vehicles | Details |
| 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 | Details |
| 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 | Details |
| ECPR46 | Avoidance of Opiates for Low Back Pain or Migraines | Yes | Process | Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate | Details |
| ECPR41 | Rh Status Evaluation and Treatment of Pregnant Women at Risk of Fetal Blood Exposure | No | Process | Percentage 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-negative | Details |
| 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 | Details |
| 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 | Details |
| AQI73 | Prevention of Arterial Line-Related Bloodstream Infections | Yes | Process | Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial catheter for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed.
This measure will consist of three performance rates:
a. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the brachial, radial, posterior tibial or dorsalis pedis artery for whom the arterial line was inserted with all indicated elements of sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound techniques followed
b. Percentage of patients, regardless of age, who undergo placement of a peripheral intra-arterial line in the femoral or axillary artery for whom the arterial line was inserted with all indicated elements of maximal sterile barrier technique, hand hygiene, skin preparation and, if ultrasound is used, sterile ultrasound technique is followed
Note: The overall measure score will be calculated as an average of the total cases of part A (rate 2) and part B (rate 3). The overall measure score is rate 1. | Details |
| AQI69 | Intraoperative Antibiotic Redosing | Yes | Process | Percentage of patients, aged 18 years and older, who received preoperative antibiotic prophylaxis within 60 minutes prior to incision (if fluoroquinolone or vancomycin, two hours) and undergo a procedure greater than two hours duration who received intraoperative antibiotic redosing at a maximum interval of two half-lives of the selected prophylactic antibiotic. | Details |
| ACQR16 | COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation | Yes | Efficiency and Cost/Resource Use | Patients 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 available | Details |
| ACQR13 | Sepsis: Hour One bundle | No | Process | Surviving Sepsis Campaign's Hour One bundle initiation in patients with Sepsis and acute organ dysfunction | Details |
| ACQR12 | ABCDEF Bundle - Early mobility for ICU patients | Yes | Process | Patients 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. | Details |
| ACEP19 | Emergency Medicine: Emergency Department Utilization of CT for Minor Blunt Head Trauma for Patients Aged 18 Years and Older | Yes | Process | Percentage 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 CT | Details |
| HCPR16 | Physician’s Orders for Life-Sustaining Treatment (POLST) Form | Yes | Process | Percentage of Patients Greater Than or Equal to 65 Years of Age with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed | Details |
| HCPR17 | Pressure Ulcers – Risk Assessment and Plan of Care | Yes | Process | Percentage of Adult Post-acute Facility Patients That Had a Risk Assessment for Pressure Ulcers and a Plan of Care for Pressure Ulcer Prevention/Treatment Completed | Details |
| HCPR18 | Unintentional Weight Loss – Risk Assessment and Plan of Care | Yes | Process | Percentage 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 Provider | Details |
| 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 | Details |
| 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 | Details |
| 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 | Details |
| ACEP61 | Avoidance of Chest X-ray in pediatric patients with Asthma, Bronchiolitis or Croup | Yes | Process | Percentage of ED visits for pediatric patients with Asthma, Bronchiolitis or Croup for whom a Chest X-ray was ordered/performed. | Details |