Emergency Department Transfer Communication

Care Transitions

Percentage of patients who are transferred from an ED to another health care facility that have all necessary communication with the receiving facility.

Importance

Timely, accurate, and direct communication facilitates the handoff to the receiving facility, provides continuity of care, and avoids medical errors and redundant tests.

Sample Size

Quarterly:
0-44 - submit all cases
> 45 - submit 45 cases

Monthly:
0-15 - submit all cases
> 15 - submit 15 cases

Data Elements

• Q1
• Q2
• Q3
• Q4
• Q5
• Q6
• Q7
• Q8
• ALL-EDTC

Data Reported To

MBQIP-DB

Measure Set

EDTC

Reporting Period

Quarterly

Improvement

Increased on rate (percent)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients admitted to the emergency department and transferred from the emergency department to another health care facility (e.g., other hospital, nursing home, hospice, etc.)

Fibrinolytic Therapy Received Within 30 Minutes

Outpatient

Percentage of outpatients with chest pain or possible heart attack who got drugs to break up blood clots within 30 minutes of arrival.

Importance

Time-to-fibrinolytic therapy is a strong predictor of outcome in patients with AMI. Nearly 2 lives per 1,000 patients are lost per hour of delay. National guidelines recommend fibrinolytic therapy within 30 minutes of hospital arrival for patients with STEMI.

Sample Size

Quarterly:
0-80 - submit all cases
> 80 - see specifications manual

Monthly:
Monthly sample size requirements are based on anticipated quarterly patient population

Data Elements

• Arrival Time
• Birthdate
• Discharge Code
• E/M Code
• Fibrinolytic Administration
• Fibrinolytic Administration Date
• Fibrinolytic Administration Time
• ICD-10-CM Principal Diagnosis Code
• Initial ECG Interpretation
• Outpatient Encounter Date
• Reason For Fibrinolytic Therapy Delay

Data Reported To

QNet

Measure Set

AMI

Reporting Period

Quarterly

Improvement

Increase in rate (percent)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients seen in a Hospital Emergency Department for whom all of the following are true:

• Discharged/transferred to a short-term general hospital for inpatient care or to a Federal Healthcare facility

• A patient age ≥ 18 years

• An ICD-10-CM Principal Diagnosis Code for AMI An ICD-10-CM Principal Diagnosis Code for AMI as defined in Appendix A, OP Table1.1, of the CMS Hospital OQR Specifications Manual.

Median Time to Transfer to Another Facility for Acute Coronary Intervention

Outpatient

Median number of minutes before outpatients with chest pain or possible heart attack who needed specialized care were transferred to another hospital.
Note: Hospital Compare described measure as "average number of minutes"

Importance

The early use of primary angioplasty in patients with STEMI results in a significant reduction in mortality and morbidity. The earlier primary coronary intervention is provided, the more effective it is. Times to treatment in transfer patients undergoing primary PCI may influence the use of PCI as an intervention. Current recommendations support a door-to-balloon time of 90 minutes or less.

Sample Size

Quarterly:
0-80 - submit all cases
> 80 - see specifications manual

Monthly:
Monthly sample size requirements are based on anticipated quarterly patient population

Data Elements

• Arrival Time
• Birthdate
• Discharge Code
• ED Departure Date
• ED Departure Time
• E/M Code
• Fibrinolytic Administration
• ICD-10-CM Principal Diagnosis Code
• Initial ECG Interpretation
• Outpatient Encounter Date
• Reason for Not Administering Fibrinolytic Therapy
• Transfer for Acute Coronary Intervention

Data Reported To

QNet

Measure Set

AMI

Reporting Period

Quarterly

Improvement

Decrease in median value (time)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients seen in a Hospital Emergency Department for whom all of the following are true:

• Discharged/transferred to a short-term general hospital for inpatient care or to a Federal Healthcare facility

• A patient age ≥ 18 years

• An ICD-10-CM Principal Diagnosis Code for AMI as defined in Appendix A, OP Table1.1, of the CMS Hospital OQR Specifications Manual.

Median Time from ED Arrival to ED Departure for Discharged ED Patients

Outpatient

Average time patients spent in the emergency department before being sent home

Importance

Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.

Sample Size

Quarterly:
0-900 - Submit 63 cases
> 900 - Submit 96 cases

Monthly:
0-900 - submit 21 cases
> 900 - submit 32 cases

Note: Monthly sample size requirements for this measure are based on the quarterly patient population.

Data Elements

• Arrival Time
• Discharge Code
• E/M Code
• ED Departure Date
• ED Departure Time
• ICD-10-CM Principal Diagnosis Code
• Outpatient Encounter Date

Data Reported To

QNet

Measure Set

ED Throughput

Reporting Period

Quarterly

Improvement

Decrease in median value (time)

Data Collection Approach

Chart Abstracted

Cases to Submit

Patients seen in a Hospital Emergency Department that have an E/M code in Appendix A, OP Table 1.0 of the CMS Hospital OQR Specifications Manual.

Patient Left Without Being Seen

Outpatient

Percentage of patients who left the emergency department before being seen

Importance

Reducing patient wait time in the ED helps improve access to care, increase capability to provide treatment, reduce ambulance refusals/diversions, reduce rushed treatment environments, reduce delays in medication administration, and reduce patient suffering.

Sample Size

No Sampling
Report all cases

Data Elements

Numerator: What was the total number of patients who left without being evaluated by a physician/APN/PA?
Denominator: What was the total number of patients who presented to the ED?

Data Reported To

QNet

Measure Set

ED Throughput

Reporting Period

Yearly

Improvement

Decrease in rate (percent)

Data Collection Approach

Hospital Tracking

Cases to Submit

Definition of patients who present to the ED:
Patients who presented to the ED are those that signed in to be evaluated for emergency services.

Definition of provider includes:
• Residents/interns
• Institutionally credentialed provider
• APN/APRNs

Hospital Consumer Assessment of Healthcare Providers and Systems

Patient Engagement

Percentage of patients surveyed who reported “Yes” or “Always” to questions involving their hospital stay

Importance

Growing research shows positive associations between patient experience and health outcomes, adherence to recommended medication and treatments, preventive care, health care resource use and quality and safety of care.

Sample Size

Sampling determined by HCAHPS vendor or self-administered if in compliance with program requirements

Data Elements

• Communication with Doctors
• Communication with Nurses
• Responsiveness of Hospital Staff
• Communication about Medicines
• Discharge Information
• Cleanliness of the Hospital Environment
• Quietness of the Hospital Environment
• Transition of Care

Data Reported To

QNet

Measure Set

HCAHPS

Reporting Period

Quarterly

Improvement

Increased in percent always

Data Collection Approach

Survey (typically conducted by a certified vendor)

Cases to Submit

Patients discharged from the hospital following at least one overnight stay sometime between 48 hours and 6 weeks ago who are over the age of 18 and did not have a psychiatric principal diagnosis at discharge.

Antibiotic Stewardship

Patient Safety/Inpatient

Centers for Disease Control and Prevention (CDC) National Healthcare Safety Network (NHSN) Annual Survey

Importance

Improving antibiotic use in hospitals is imperative to improving patient outcomes, decreasing antibiotic resistance, and reducing healthcare costs. According to the Centers for Disease Control and Prevention (CDC), 20-50 percent of all antibiotics prescribed in U.S. acute care hospital are either unnecessary or inappropriate, which leads to serious side effects such as adverse drug reactions and Clostridium difficile infection. Overexposure to antibiotics also contributes to antibiotic resistance, making antibiotics less effective.

In 2014, CDC released the “Core Elements of Hospital Antibiotic Stewardship Programs” that identifies key structural and functional aspects of effective programs and elements designed to be flexible enough to be feasible in hospitals of any size.

Sample Size

No Sampling
Report all information as requested

Data Elements

Questions as answered on the Patient Safety Component Annual Hospital Survey inform whether the hospitals has successfully implemented the following core elements of antibiotic stewardship:

• Leadership
• Accountability
• Drug Expertise
• Action
• Tracking
• Reporting
• Education

Data Reported To

NHSN

Measure Set

N/A

Reporting Period

Yearly

Improvement

Increase in number of core elements met

Data Collection Approach

Hospital Tracking

Cases to Submit

N/A
This measure uses administrative data and not claims to determine the measure's denominator population.

Admit Decision Time to ED Departure Time for Admitted Patients

Patient Safety/Inpatient

Median time from admit decision time to time of departure from the emergency department for admitted patients.

Importance

Reducing the time patients remain in the emergency department (ED) can improve access to treatment and increase quality of care, potentially improves access to care specific to the patient condition and increases the capability to provide additional treatment. In recent times, EDs have experienced significant overcrowding. Although once only a problem in large, urban, teaching hospitals, the phenomenon has spread to other suburban and rural healthcare organizations. When EDs are overwhelmed, their ability to respond to community emergencies and disasters may be compromised.

Sample Size

Quarterly
0-152 - 100% of initial pt. pop
153-764 - 153
765-1529 - 20% of initial pt. pop
>1529 - 306

Monthly
<51 - 100% of initial population
51-254 - 51
255-509 - 20% of initial pt. pop
>509 - 102

Data Elements

• Decision to Admit Date
• Decision to Admit Time
• ED Departure Date
• ED Departure Time
• ED Patient
• ICD-10-CM Principal Diagnosis Code

Data Reported To

QNet

Measure Set

Emergency Department

Reporting Period

Quarterly

Improvement

Decrease in the median value

Data Collection Approach

Chart Abstracted

Cases to Submit

Global Initial Patient Population: All patients discharged from acute inpatient care with a length of stay less than or equal to 120 days.

Influenza Vaccination Coverage Among Health Care Personnel

Patient Safety/Inpatient

Percentage of health care workers given influenza vaccination

Importance

1 in 5 people in the U.S. get influenza each season. Combined with pneumonia, influenza is the 8th leading cause of death, with two-thirds of those attributed to patients hospitalized during the flu season.

Sample Size

No Sampling
Report all cases

Data Elements

3 categories (all with separate denominators) of HCP working in the facility at least one day b/w 10/1-3/31:
• employees on payroll
• licensed independent practitioners
• students, trainees and volunteers 18yo+

A fourth optional category is available for reporting other contract personnel
HCP workers who:
• Received vaccination at the facility
• Received vaccination outside of the facility
• Did not receive vaccination due to contraindication
• Did not receive vaccination due to declination

Data Reported To

NHSN

Measure Set

Web-Based (Preventive Care)

Reporting Period

Yearly

Improvement

Increase in rate (percent)

Data Collection Approach

Hospital Tracking

Cases to Submit

Each facility in a system needs to be registered separately and HCPs should be counted in the sample population for every facility at which s/he works. Facilities must complete a monthly reporting plan for each year or data reporting period. All data reporting is aggregate (whether monthly, once a season, or at a different interval).

Additional Measures

Care Transitions Outpatient Patient Engagement Patient Safety/Inpatient
Discharge Planning § (formerly OP-4)
Aspirin at Arrival §
Emergency Department Patient Experience Survey § CLABSI
Central Line-Associated Bloodstream Infection
Medical Reconciliation § (formerly OP-5)
Median Time to EDG §
CAUTI
Catheter-Associated Urinary Tract Infection
Swing Bed Care § (formerly OP-20)
Door to Diagnostic Evaluation by a Qualified Medical Professional §
CDI
Clostridioides Difficile Infection
Claims-Based Measures
Measures are automatically calculated for hospitals using Medicare Administrative Claims Data
MRSA
Methicillin-resistant Staphylococcus Aureus
SSIs
Surgical Site Infections Colon or Hysterectomy
PC-01
Elective Delivery
Falls §
Adverse Drug Events (ADE) §
Patient Safety Culture Survey
(formerly IMM-2)
Inpatient Influenza Vaccination §

§No nationally standardized or standardly reported measure currently available, however, Flex programs can propose work on these measures if there is a data collection mechanism in place.

Archived Measures

Care Transitions Outpatient Patient Engagement Patient Safety/Inpatient
OP-1
Median Time to Fibrinolysis
ED-1
Median Time from ED Arrival to ED Departure for Admitted ED Patients
OP-21
Median Time to Pain Management for Long Bone Fracture
ED-2
Admit Decision Time to ED Departure Time for Admitted Patients