Inpatient/Hospital

In-hospital deaths per 1,000 hospital discharges with acute stroke as a principal diagnosis for patients ages 18 years and older. Includes metrics for discharges grouped by type of stroke. 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.]

Median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status

This measure identifies patients with diabetes mellitus taking insulin that had evidence of self-monitoring blood glucose testing in last 12 reported months.

This measure identifies adults with diabetes mellitus that had a serum creatinine test in last 12 reported months.

This measure estimates the risk-standardized rate of unplanned, all-cause readmissions for patients (Medicare fee-for-service [FFS] beneficiaries) discharged from an Inpatient Rehabilitation Facility (IRF) who were readmitted to a short-stay acute-care hospital or a Long-Term Care Hospital (LTCH), within 30 days of an IRF discharge. The measure is based on data for 24 months of IRF discharges to non-hospital post-acute levels of care or to the community.

A risk-adjusted readmission rate for each facility is calculated as follows:

Percent of patients aged 18 years and older undergoing isolated CABG who were discharged on a lipid lowering statin

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.

Percent of adult patients who presented within 24 hours of a non-penetrating head injury with a Glasgow coma score (GCS) >13 and underwent head CT for trauma in the ED who have a documented indication consistent with guidelines(1) prior to imaging.