Download Appendix B. ACEP CEDR QCDR Measure Information

Appendix B. ACEP CEDR QCDR Measure Information
Registry
CEDR
CEDR
CEDR
CEDR
CEDR
#
1
2
3
Measure Title/Description
Emergency Department
Utilization of CT for Minor Blunt
Head Trauma for Patients Aged
18 Years and Older
Emergency Department
Utilization of CT for Minor Blunt
Head Trauma for Patients Aged
2 Through 17 Years
Coagulation Studies in Patients
Presenting with Chest Pain with
No Coagulopathy or Bleeding
Numerator
Emergency department visits
for patients who have an
indication for a head CT
Emergency department visits
for patients who are classified
as low risk according to the
Pediatric Emergency Care
Applied Research Network
(PECARN) prediction rules for
traumatic brain injury
Emergency department visits
during which coagulation
studies (PT, PTT, or INR tests)
were ordered by an emergency
care provider
4
Appropriate Emergency
Department Utilization of CT for
Pulmonary Embolism
Emergency department visits
for patients with either:
1. Moderate or high pre-test
clinical probability for
pulmonary embolism
OR
2. Positive result or elevated Ddimer level
5
ED Median Time from ED arrival
to ED departure for discharged
ED patients – Overall Rate
Continuous Variable Statement:
Time (in minutes) from ED
arrival to ED departure for
discharged patients
Denominator
All emergency department visits
for patients aged 18 years and
older who presented within 24
hours of a minor blunt head
trauma with a Glasgow Coma
Scale (GCS) score of 15 and who
had a head CT for trauma
ordered by an emergency care
provider
Denominator Exclusions
Patients with any of the following:

Ventricular shunt

Brain tumor

Multisystem trauma

Pregnancy

Currently taking antiplatelet
medications
All emergency department visits
for patients aged 2 through 17
years who presented within 24
hours of a minor blunt head
trauma (non-penetrating
injuries) with a Glasgow Coma
Scale (GCS) score of 15 and who
had a head CT for trauma
ordered by an emergency care
provider
Patients with any of the following:
• Ventricular shunt
• Brain tumor
• Coagulopathy
• Thrombocytopenia
All emergency department visits
for patients aged 18 years and
older with an emergency
department discharge diagnosis
of chest pain
Patients with any of the following
clinical indications for ordering
coagulation studies:

End stage liver disease

Coagulopathy

Thrombocytopenia

Currently taking or newly
prescribed anticoagulant meds

Pregnancy

Pulmonary or gastrointestinal
hemorrhage

Atrial fibrillation

Inability to obtain medical
history
All emergency department visits
during which patients aged 18
years and older had a CT
pulmonary angiogram (CTPA)
ordered by an emergency care
provider, regardless of
discharge disposition
All ED encounters


Pregnant patients;
Medical reason for ordering a
CTPA without moderate or
high pre-test clinical
probability for PE AND no
positive result or elevated Ddimer level (eg, CT ordered for
aortic dissection)
Patients who expired in the
emergency department
Measure
Type
Process
Process
Process
Process
Outcome
Rationale
Evidence
Risk Adjustment or
Stratification
Notes
Efficiency & Cost
Reduction
About 2.5 million traumatic
brain injuries occur each year,
where 75% of these are
considered mild. 3 There is data
to suggest that 70% of head
injury patients receive a head
CT 4, and it is estimated that 1035% of head CTs obtained in
head injury patients do not
follow recognized guidelines 5
Some estimate that as many as
55,000-194,000 CT scans are
possibly avoidable annually. 6
Level A recommendations. A noncontrast head CT is indicated in
head trauma patients with loss of
consciousness or posttraumatic
amnesia only if one or more of the
following is present: headache,
vomiting, age greater than 60 years,
drug or alcohol intoxication, deficits
in short-term memory, physical
evidence of trauma above the
clavicle, posttraumatic seizure, GCS
score less than 15, focal neurologic
deficit, or coagulopathy (ACEP,
2008).1
N/A
NON-PQRS
ACEP Update NQF
#0668
Efficiency & Cost
Reduction
About 2.5 million traumatic
brain injuries occur each year,
where 75% of these are
considered mild. 2 There is data
to suggest that 70% of head
injury patients receive a head
CT 3, and it is estimated that 1035% of head CTs obtained in
head injury patients do not
follow recognized guidelines 4
Some estimate that as many as
55,000-194,000 CT scans are
possibly avoidable annually. 5
Pediatric Emergency Care Applied
Research Network (PECARN):
Suggested CT algorithm for children
younger than 2 years (A) and for
those aged 2 years and older (B)
with GCS scores of 14–15 after head
trauma
N/A
NON-PQRS
ACEP
Coagulation studies are often
ordered out of habit as part of a
blood panel with little value
added to the patient. Ensuring
that clinicians are purposefully
ordering these studies may lead
to significant reduction in
resource utilization without any
decrease in value of healthcare
provided to the patient.
In the United States, it is estimated
that $114 million are spent annually
on coagulation testing for patients
presenting with chest pain and
without any other indications in the
Emergency Department. 1 Across
laboratory testing overall 15% to
56% of tests are considered to have
been ordered inappropriately; in a
study of coagulation studies
specifically, it was found that 81%
of coagulation tests were ordered
inappropriately. 1
N/A
NON-PQRS
ACEP
Suspected non-high risk PE: Plasma
D-dimer measurement is
recommended in
emergency department patients to
reduce the need for unnecessary
imaging and
irradiation, preferably using a highly
sensitive assay (Class I Level A
recommendation)
N/A
NON-PQRS
ACEP Update NQF
#0667
ED crowding may result in delays in
the administration of medication
such as antibiotics for pneumonia
and has been associated with
ED volume, acuity mix,
trauma center level,
teaching status, patient
age, patient gender,
NQS Domain
Efficiency & Cost
Reduction
Efficiency & Cost
Reduction
Patient
Experience of
Care
The goal of this measure is to
reduce the inappropriate
ordering of CTPA for pulmonary
embolism based on pre-test
probability estimation. This
measure does not require
utilization of a structured
clinical prediction rule such as
the Wells Score or Geneva
Score, however the measure
aims to improve efficiency by
guiding clinical practice towards
use of initial d-dimer testing
rather than immediate CTPA in
low or intermediate probability
patients as indicated.
Reducing the time patients
remain in the emergency
department (ED) can improve
access to treatment and
NON-PQRS
NQF #0496
OP-18:
a. Overall Rate
Page 1
Appendix B. ACEP CEDR QCDR Measure Information
Registry
CEDR
#
6
CEDR
7
CEDR
8
CEDR
CEDR
CEDR
CEDR
9
10
11
12
Measure Title/Description
ED Median Time from ED arrival
to ED departure for discharged
ED patients – General Rate =
(Overall Rate – Psych Pts–
Transfer Pts)
ED Median Time from ED arrival
to ED departure for discharged
ED patients – Psych Mental
Health Patients
ED Median Time from ED arrival
to ED departure for discharged
ED patients – Transfer Patients
Door to Diagnostic Evaluation
by a Qualified Medical
Personnel
Anti-coagulation for Acute
Pulmonary Embolism Patients
Pregnancy Test for Female
Abdominal Pain Patients
Three day return rate ED
Numerator
Denominator
Denominator Exclusions
•
•
Transfers
Psychiatric and mental health
pts
Patients who expired in the
emergency department
Measure
Type
NQS Domain
Outcome
Patient
Experience of
Care
Time (in minutes) from ED
arrival to ED departure for
discharged patients
All ED encounters (excluding
psych and transfers)
Time (in minutes) from ED
arrival to ED departure for
discharged patients
All ED psychiatric and mental
health patients
Patients who expired in the
emergency department
Outcome
Patient
Experience of
Care
Time (in minutes) from ED
arrival to ED departure for
discharged patients
All ED patients transferred to
another hospital or facility
Patients who expired in the
emergency department
Outcome
Patient
Experience of
Care
•
Median time between patient
presentation to the ED and the
first moment the patient is seen
by a qualified medical person
for patient evaluation and
management.
All ED encounters
Patients who have orders for
anticoagulation
All patients, regardless of age,
presenting to the emergency
department (ED) with a
diagnosis of pulmonary embolus
Anticoagulation not ordered for
reasons documented by clinician
All female patients ages 14
through 50 years old who
present to the ED with a chief
complaint of abdominal pain.
Pregnancy test (urine or serum) not
ordered for reasons documented by
clinician (e.g., documentation of
pregnancy or status post
hysterectomy)
Patients who have had a
pregnancy test (urine or serum)
ordered
All patients who incurred a
repeat ED encounter within 3
calendar days
All ED Encounters
Patients who expired in the
emergency department
None
Outcome
Process
Process
Outcome
Rationale
Evidence
increase quality of care.
Reducing this time potentially
improves access to care specific
to the patient condition and
increases the capability to
provide additional treatment.
perceptions of compromised
emergency care. For patients with
non-ST-segment-elevation
myocardial infarction, long ED stays
were associated with decreased use
of guideline-recommended
therapies and a higher risk of
recurrent myocardial infarction.
When EDs are overwhelmed, their
ability to respond to community
emergencies and disasters may be
compromised
Patient Safety
Reducing the time patients
remain in the emergency
department (ED) can improve
access to treatment and
increase quality of care.
Reducing this time potentially
improves access to care specific
to the patient condition and
increases the capability to
provide additional treatment.
Patient Safety
ED patients who have delayed
anticoagulation (either on the
floor and/or as measured by a
delayed therapeutic aPTT) have
higher mortality
Patient Safety
Use of the measure can
eliminate the risk of the
physician failing to diagnose a
patient is pregnancy, thereby
reducing the possibility that a
patient with ectopic pregnancy
is not identified
Communication
and Care
Coordination
Hospitalizations occurring
shortly after emergency
department (ED) discharge, or
bounce-back admissions, may
signal missed diagnoses of
serious illness, incomplete ED
care, or insufficient outpatient
follow-up after discharge.
ED crowding may result in delays in
the administration of medication
such as antibiotics for pneumonia
and has been associated with
perceptions of compromised
emergency care. For patients with
non-ST-segment-elevation
myocardial infarction, long ED stays
were associated with decreased use
of guideline-recommended
therapies and a higher risk of
recurrent myocardial infarction.
When EDs are overwhelmed, their
ability to respond to community
emergencies and disasters may be
compromised
Several studies demonstrate the
importance of timely treatment of
pulmonary embolism in the ED.
Data from AHRQ’s National
Inpatient Sample suggests that
about 158,000 patients are
admitted to US hospitals with a
diagnosis of PE each year, and that
72% of these patients were
diagnosed as having a PE in the ED
suggesting that the emergency
department is an appropriate
setting for measurement of this
important clinical condition
Pregnancy testing is recommended
in the Emergency Department for
females who might be pregnant
because clinical history is unreliable
(Ann Emerg Med 1989). The
importance of pregnancy diagnosis
is particularly true in patients with
abdominal pain and/or prior to
radiologic procedures where failure
to diagnose pregnancy is a risk to
the woman and her unborn child.
A review of the literature suggests
that the rate of return visits to EDs
ranges from 0.39% to 5.8% in
adults. Reported risk factors for
return admissions include older age,
living alone, insurance status, and
certain diagnoses such as mental
disorders, genitourinary disorders,
Risk Adjustment or
Stratification
payer, hospital case mix
adjustment factor of
the hospital where the
service was provided (if
provided in a hospital
vs. free-standing
facility)
ED volume, teaching
status, acuity mix,
trauma center level,
patient age, patient
gender, payer, hospital
case mix adjustment
factor of the hospital
Notes
b. Reporting
Measure
c. Psych Pts
d. Transfer Pts
NON-PQRS
OP-20
NQF #0498
N/A
Former PQRS
#252; Former NQF
#0503
N/A
Former PQRS
#253; Former NQF
#0502
ED volume, acuity mix,
trauma center level,
teaching status, patient
age, patient gender,
payer mix, hospital case
mix adjustment factor
of the hospital
Adapted 72 hour
return rate
Page 2
Appendix B. ACEP CEDR QCDR Measure Information
Registry
#
Measure Title/Description
Numerator
Denominator
Denominator Exclusions
Measure
Type
NQS Domain
Rationale
Understanding the factors
associated with return visits
may inform the design of ED
quality improvement
interventions for improved care
coordination.
CEDR
CEDR
CEDR
CEDR
CEDR
13
Three day return rate UC
14
tPA Considered:
Percentage of patients aged 18
years and older with a diagnosis
of ischemic stroke whose time
from symptom onset to arrival
is less than 3 hours who were
considered for t-PA
administration
15
16
17
Tobacco Screening and
Cessation Intervention:
Percentage of asthma and COPD
patients aged 18 years and
older who were screened for
tobacco use AND who received
cessation counseling
intervention if identified as a
tobacco user.
Antibiotic Prescribed for Adult
Acute Sinusitis: Percentage of
patients, aged 18 years and
older, with acute sinusitis for
less than 10 days who were
prescribed an antibiotic
Adult Sinusitis: Appropriate
Choice of Antibiotic: Amoxicillin
Prescribed for Patients with
Acute Bacterial Sinusitis
All patients who incurred a
repeat UC encounter within 3
calendar days
Patients who were considered
for t-PA administration
Patients who were screened for
tobacco use during the ED
encounter AND who received
tobacco cessation counseling
intervention if identified as a
tobacco user
Antibiotic regimen prescribed
within 10 days of onset of
symptoms
Patients who were prescribed
amoxicillin, with or without
clavulanate, as a first line
antibiotic at the time of
diagnosis
All UC Encounters
None
All patients aged 18 years and
older with the diagnosis of
ischemic stroke whose time
from symptom onset to arrival
is less than 3 hours

All asthma and COPD patients
aged 18 years and older




All patients aged 18 years and
older with a diagnosis of acute
sinusitis
All patients aged 18 years and
older with a diagnosis of acute
bacterial sinusitis

Ischemic stroke symptom
onset ≥ 3 hours prior to arrival
at emergency department
Other medical reason
documented
Current tobacco non-user
Documented medical reason(s)
for not screening for tobacco
use (eg, limited life expectancy,
other medical reasons)
Patients who present with
sinusitis which has lasted
greater than 10 days
Patients without assurance of
follow-up
Documented medical reason (e.g.,
cystic fibrosis, immotile cilia
disorders, ciliary dyskinesia,
immune deficiency, prior history of
sinus surgery within the past 12
months, and anatomic
abnormalities, such as deviated
nasal septum, resistant organisms,
allergy to medication, recurrent
sinusitis, chronic sinusitis, or other
reasons)
Outcome
Process
Process
Process
Process
Evidence
Risk Adjustment or
Stratification
Notes
Acuity mix, patient age,
patient gender, payer
mix
Adapted 72 hour
return rate
N/A
Formerly
PQRS #34
NQF# 0242
N/A
NON-PQRS
Adapted
PQRS # 226
NQF #0028
symptom based diagnoses such as
abdominal pain and chest pain,
dehydration, and septicemia.
Monitoring unscheduled return
visits is important for quality
assurance in the Emergency
Department (ED).
Communication
and Care
Coordination
Understanding the factors
associated with return visits
may inform the quality
improvement interventions for
improved care coordination.
Monitoring unscheduled return
visits is important for quality
assurance and care coordination.
Effective Clinical
Care
Patients who arrive at the
hospital within 3 hours of stroke
symptom onset should be
considered for t-PA therapy.
Intravenous rtPA (0.9 mg/kg,
maximum dose 90 mg) is strongly
recommended for carefully selected
patients who can be treated within
3 hours of onset of ischemic stroke.
(Adams, ASA, 2003) (Grade A)
CommunityPopulation
Health
There is good evidence that
tobacco screening and brief
cessation intervention
(including counseling and/or
pharmacotherapy) is successful
in helping high-risk tobacco
users quit. Tobacco users who
are able to stop smoking lower
their risk for acute
exacerbations of their lung
disease.
The USPSTF recommends that
clinicians ask adults about tobacco
use and provide tobacco cessation
interventions for those who use
tobacco products. (A
Recommendation) (U.S. Preventive
Services Task Force, 2009)
Efficiency & Cost
Reduction
Antibiotic treatment for
Sinusitis is indicated for some
patients, but overtreatment of
acute sinusitis with antibiotics is
common and often not
indicated. Further, treatment
with antibiotics may increase
patient harm and can lead to
antibiotic resistance.
AAO-HNS Sinusitis Guideline (2007):

Observation without use of
antibiotics is an option for
selected adults with
uncomplicated ABRS who have
mild illness (mild pain and
temperature < 38.3°C or 101°F)
and assurance of follow-up
(based on double-blind
randomized controlled trials).

Antibiotics are not
recommended for treating viral
rhinosinusitis (VRS) because
they are ineffective and do not
relieve symptoms directly.
Efficiency & Cost
Reduction
The use of broad-spectrum
antibiotics as first line
treatment has contributed to
the rising incidence of drugresistant strains of bacteria and
to increased costs. Once
antibiotics therapy is initiated,
the goal is to choose a first-line
antibiotic treatment that is
efficacious, cost-effective and
results in minimal side effects.
Amoxicillin is first-line therapy
for most patients with ABRS
relates to its favorable adverse
effect profile, efficacy, low cost,
AAO-HNS Sinusitis Guideline (2007)
If a decision is made to treat ABRS
with an antibiotic agent, the
clinician should prescribe
amoxicillin as first-line therapy for
most adults (based on RCTs).
N/A
N/A
NON-PQRS
Adapted
PQRS # 331
NON-PQRS
Adapted
PQRS # 332
Page 3
Appendix B. ACEP CEDR QCDR Measure Information
Registry
#
Measure Title/Description
Numerator
Denominator
Denominator Exclusions
Measure
Type
NQS Domain
Rationale
Evidence
Risk Adjustment or
Stratification
Notes
Clinical guidelines do not support
antibiotic treatment of otherwise
healthy adults with acute bronchitis
due to the viral origin of acute
bronchitis. Patients with chronic
bronchitis, COPD or other chronic
comorbidity may be treated with
antibiotics and are therefore
excluded from the measure
denominator. (Gonzales R., D.C.
Malone, J.H. Maselli, et al, 2001)
N/A
Adapted
PQRS# 116
NQF #0058
and narrow microbiologic
spectrum.

CEDR
18
Avoidance of Antibiotic
Treatment in Adults With Acute
Bronchitis: Percentage of adults
18 through 64 years of age with
a diagnosis of acute bronchitis
who were not prescribed an
antibiotic prescription within 3
days of onset of symptoms

Patients who were not
prescribed or dispensed
antibiotics on or within 3 days
of the onset of symptoms.
All patients aged 18 through 64
years of age with an outpatient
or emergency department (ED)
visit with a diagnosis of acute
bronchitis at the visit
Patients who presented with
symptoms of bronchitis for
more than 3 days
Documentation of medical
reason(s) for prescribing or
dispensing antibiotic (another
infection), cystic fibrosis,
disorders of the immune
system, malignancy, lung
diseases (asthma, COPD,
chronic bronchitis), other
diseases of the respiratory
system, and tuberculosis
Process
Efficiency & Cost
Reduction
Antibiotics are commonly
misused and overused for a
number of viral respiratory
conditions where antibiotic
treatment is not clinically
indicated. In adults, antibiotics
are most often (65–80 percent)
prescribed for acute bronchitis,
despite its viral origin. The
misuse and overuse of
antibiotics contributes to
antibiotic drug resistance, which
is of public health concern due
to the diminished efficacy of
antibiotics against bacterial
infections, particularly in sick
patients and the elderly.
Legend: NQS Domains
Clinical Effectiveness
Efficiency & Cost Reduction
Patient Safety
Community-Population Health
Communication and Care Coordination
Patient Experience of Care
Page 4