Single Measure

The total number of patients requiring unscheduled readmission to the ICU within 24 hours of discharge or transfer.

For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:

1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission

*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).

Percent of pneumonia patients, age 18 years or older, transferred or admitted to the ICU within 24 hours of hospital arrival who had blood cultures performed within 24 hours prior to or 24 hours after arrival at the hospital.

Inpatients age 65 years and older and 5-64 years of age who have a high risk condition who are screened for Pneumococcal Vaccine status and vaccinated prior to discharge if indicated.

Percentage of home health episodes of care during which patients were determined to have ever received Pneumococcal Polysaccharide Vaccine (PPV).

Percentage of patients with pneumonia, age 65 and older, who were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated

Percent of nursing home/skilled nursing facility residents whose pneumococcal polysaccharide vaccine (PPV) status is up to date during the 12-month reporting period.

Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.

In-hospital deaths per 1,000 hospital discharges with pneumonia as a principal diagnosis for patients ages 18 years and older. Excludes obstetric discharges and transfers to another hospital.

[NOTE: The software provides the rate per hospital discharge. However, common practice reports the measure as per 1,000 discharges. The user must multiply the rate obtained from the software by 1,000 to report in-hospital deaths per 1,000 hospital discharges.]

Percentage of patients who ever received a pneumococcal vaccination