Safety: Safety

The measure addresses adherence to three types of chronic medications: statins, levothyroxine, and angiotensin converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs). The measure is divided into three submeasures:

Measure A: The percentage of eligible individuals who had at least two prescriptions for statins and who have a Proportion of Days Covered (PDC) of at least 0.8 during the measurement period (12 consecutive months).

Percentage of calendar months within a 12-month period during which a hemoglobin level is measured for patients aged 18 years and older with a diagnosis of advanced chronic kidney disease (CKD) (stage 4 or 5, not receiving Renal Replacement Therapy [RRT]) or End Stage Renal Disease (ESRD) (who are on hemodialysis or peritoneal dialysis) who are also receiving erythropoiesis-stimulating agent (ESA) therapy have a hemoglobin level > 12.0 g/dL

Percentage of ASC admissions with appropriate surgical site hair removal.

Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on anti-platelet medication

Number of acute embolus patients who have orders for anticoagulation (heparin or low-molecular weight heparin) for pulmonary embolus while in the ED.

Measure adherance to current ACOG, SMFM recommendations for use of DVT prophylaxis in women undergoing cesarean delivery. Current ACOG and SMFM recommendations call for the use of pneumatic compression devices in all women undergoing cesarean delivery who are not already receiving medical VTE prophylaxis. Numerator: Number of women undergoing cesarean delivery receiving either pneumatic compression device or medical prophylaxis prior to cesarean delivery. Denominator: All women undergoing cesarean delivery.

Percentage of emergency department acute myocardial infarction (AMI) patients or chest pain patients (with Probable Cardiac Chest Pain) without aspirin contraindications who received aspirin within 24 hours before ED arrival or prior to transfer.

Percentage of patients who are undergoing a biopsy whose biopsy results have been reviewed by the biopsying physician and communicated to the primary care/referring physician and the patient.

Percentage of intensive care patients with central lines for whom all
elements of the central line bundle are documented and in place.
The central line bundle elements include:
•Hand hygiene
•Maximal barrier precautions upon insertion
•Chlorhexidine skin antisepsis
•Optimal catheter site selection, with avoidance of the femoral vein for central venous access in patients 18 years and older
•Daily review of line necessity with prompt removal of unnecessary lines

Any time an endotracheal tube is placed into a patients airway in the Emergency Department (ED)or a patient arrives to the ED with an endotracheal tube already in place ( via EMS or hospital transfer) there should be appropriate confirmation of ETT placement and documentation of its performance in the medical record.