Other Data Source

This measure is for the risk-adjusted Standardized Infection Ratio (SIR) for all Surgical Site Infections (SSI) following breast procedures conducted at ambulatory surgery centers (ASCs) among adult patients (ages 18 - 108 years) and reported to the Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN). The measure compares the reported number of surgical site infections observed at an ASC with a predicted value based on nationally aggregated data.

Facility adjusted Standardized Infection Ratio (SIR) and Adjusted Ranking Metric (ARM) for deep incisional and organ/space Surgical Site Infections (SSI) at the primary incision site among adult patients aged >= 18 years as reported through the CDC National Health and Safety Network (NHSN).

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 patients aged 50 years to 75 years receiving a screening colonoscopy without biopsy or polypectomy who had a recommended follow-up interval of at least 10 years for repeat colonoscopy documented in their colonoscopy report.

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.

Percentage of patients undergoing cesarean section who receive appropriate prophylactic antibiotics within 60 minutes of the start of the cesarean delivery, unless the patient is already receiving appropriate antibiotics

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 all adult (>=18 years old) hemodialysis or peritoneal dialysis patients prescribed an ESA at any time during the study period or who have a Hb <11.0 g/dL in at least one month of the study period for whom serum ferritin concentration AND either percent transferrin saturation or reticulocyte Hb content (CHr) are measured at least once in a three-month period for in-center hemodialysis patients, peritoneal dialysis patients, and home hemodialysis patients.

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