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Quality Improvement (Internal to the specific organization)

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

PICU Unplanned Readmission Rate

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

CBE ID
0335

Plan All-Cause Readmissions (PCR)

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).

CBE ID
1768

Pneumococcal Immunization

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.

CBE ID
1653