Percentage of patients aged 18 years and older undergoing isolated coronary artery bypass graft (CABG) who received an internal mammary artery (IMA) graft
This measure assesses the percentage of patients 40 years of age and older with a new diagnosis of COPD or newly active COPD, who received appropriate spirometry testing to confirm the diagnosis.
Percentage of patients aged 18 years and older with a diagnosis of end stage renal disease (ESRD) with a catheter after 90 days on hemodialysis who are seen/evaluated by a vascular surgeon or other surgeon qualified in the area of vascular access for permanent vascular access at least once during the 12-month reporting period.
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
This measure assesses the number of patients diagnosed with confirmed VTE that
This measure assesses the number of patients diagnosed with confirmed venous thromboembolism (VTE) who received intravenous (IV) unfractionated heparin (UFH) therapy dosages AND had their platelet counts monitored using defined parameters such as a nomogram or protocol. This measure is part of a set of six prevention and treatment measures that address VTE (VTE-1: VTE Prophylaxis, VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Incidence of Potentially-Preventable VTE).
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.
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.
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 patients aged 18 years and older with a diagnosis of community-acquired bacterial pneumonia with vital signs documented and reviewed