Public Reporting

Percentage of intensive care unit patients on mechanical ventilation
at time of survey for whom all five elements of the ventilator bundle are documented and in place. The ventilator bundle elements are:
•Head of bed (HOB) elevation 30 degrees or greater (unless medically contraindicated)
•Daily “”sedation interruption” and daily assessment of readiness to extubate •Peptic ulcer disease prophylaxis
•Deep Venous Thrombosis prophylaxis
•Daily oral care with Chlorhexidine

Percentage of ICU and HRN patients who over a certain amoint of days have ventilator-associated pneumonia

This measure is a 30-day malfunction rate for hospitals that perform cerebrospinal ventriculoperitoneal shunt operations in children between the ages of 0 and 18 years.

Percentage of patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed

NSC-11.1 Total number of full-time and part-time Registered Nurse (RN) and Advanced Practice Nurse (APN) voluntary uncontrolled separations occurring during the calendar month
NSC-11.2 Total number of full-time and part-time Licensed Practical Nurse (LPN), Licensed Vocational Nurse (LVN) voluntary uncontrolled separations occurring during the calendar month
NSC-11.3 Total number of full-time and part-time Unlicensed Assistive Personnel (UAP) voluntary uncontrolled separations occurring during the calendar month

The percentage of patients taking warfarin who had PT/INR monitoring

This measure identifies the percentage of patients taking warfarin during the measurement year who had at least one PT/INR test within 30 days after the first warfarin prescription in the measurement year

This metric is designed to measure the critical care transport team's utilization of waveform capnography during critical care medical transport.  Waveform capnography has evolved as the standard for the safe placement and maintenance of advanced airways (e.g., endotracheal tubes) in adult and pediatric patients.  The metric specifically focuses on transported patients with advanced airways in whom continuous waveform capnography is appropriately used.  This metric is stratified by age into the following three categories: neonatal (defined as infants <29 days), pediatric (

Percentage of patients 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of the following during the measurement year:
- Body mass index (BMI) percentile documentation
- Counseling for nutrition
- Counseling for physical activity

Percentage of children 15 months old who had well-child visits with a primary care physician during the measurement year.