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Valid for Measure Submission

Urinary Incontinence: Assessment, Characterization, and Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older

  • This is a clinical performance measure which assesses whether women age 65+ were provided appropriate treatment for urinary incontinence (UI). This measure has three rates:

    (A) Assessment for UI: Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months.
    (B) Characterization of UI: Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence whose urinary incontinence was characterized at least once within 12 months

    CBE ID
    0098

Vascular Access—Functional Arteriovenous Fistula (AVF) or AV Graft or Evaluation for Placement

  • Percentage of end stage renal disease (ESRD) patients aged 18 years and older receiving hemodialysis during the 12-month reporting period and on dialysis >90 days who:

    1. have a functional autogenous AVF (defined as two needles used or a single-needle device [NOT one needle used in a two-needle device]) (computed and reported separately);

    2. have a functional AV graft (computed and reported separately); or

    CBE ID
    0251

Venous Thromboembolism Prophylaxis

  • This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission.

    CBE ID
    0371

Venouse Thromboembolism Patients with Antocoagulation Overlap Therapy

  • This measure assesses the number of patients diagnosed with confirmed VTE who received an overlap of Parenteral (intravenous [IV] or subcutaneous [subcu]) anticoagulation and warfarin therapy. For patients who received less than five days of overlap therapy, they should be discharged on both medications or have a Reason for Discontinuation of Parenteral Therapy.

    CBE ID
    0373

Ventilator Bundle

  • 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

    CBE ID
    0302