| ECPR46 | 2021 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 | | |
| HCPR20 | 2021 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 | Details | | |
| HCPR18 | 2021 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 | | |
| HCPR17 | 2021 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 | | |
| HCPR16 | 2021 HCPR16: Physician’s Orders for Life-Sustaining Treatment (POLST) Form | YES | Process | Percentage of Patients Aged 65 Years and Older with Physician’s Orders for Life-Sustaining Treatment (POLST) Forms Completed | Details | | |
| HCPR14 | 2021 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 | | |
| ECPR54 | 2021 ECPR54: Avoidance of Co-Prescribing of Opioid Analgesic and Benzodiazepine | YES | Process | Percentage of Patients Who Were Not Concurrently Prescribed Opioid Analgesic and Benzodiazepine Medications | Details | | |
| ECPR52 | 2021 ECPR52: Appropriate Treatment of Psychosis and Agitation in the Emergency Department | NO | Process | Any patient ≥ 18 years of age evaluated by the Eligible Professional in the Emergency Department (ED) PLUS ED length of stay of 4 hours or more PLUS ICD-10 diagnosis codes for psychosis, psychotic disorder NOS, psychotic features, hallucinations, schizophrenia, schizoaffective disorder, agitation due to psychosis (Not including eloped or AMA patients) | Details | | |
| ECPR51 | 2021 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 | | |
| AQI55 | 2021 AQI55: Team-Based Implementation of a Care-and-Communication Bundle for ICU Patients | YES | Process | 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 | Details | | |
| ECPR41 | 2021 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 | | |
| ECPR40 | 2021 ECPR40: Initiation of the Initial Sepsis Bundle | NO | Process | Percentage of Adult Emergency Department Patients Diagnosed with Severe Sepsis or Septic Shock That Have Initiation of the Initial Sepsis Bundle | Details | | |
| ECPR39 | 2021 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 | 2021 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. | Details | | |
| AQI71 | 2021 AQI71: Ambulatory Glucose Management | NO | Process | Percentage of diabetic patients, aged 18 years and older, who receive an office-based or ambulatory surgery whose blood glucose level is appropriately managed throughout the perioperative period. | Details | | |
| AQI70 | 2021 AQI70: 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. | Details | | |
| AQI69 | 2021 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 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 | | |
| AQI57 | 2021 AQI57: Safe Opioid Prescribing Practices | YES | Process | Percentage of patients, aged 18 years and older, prescribed opioid medications for longer than six weeks | Details | | |