International Hospital Inpatient Quality Measures
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1 I-Acute Myocardial Infarction (I-AMI) I-AMI-1 Aspirin at Arrival Aspirin received within 24 hours of arrival to the hospital for patients having an acute myocardial infarction (AMI). I-AMI-2 Aspirin Prescribed at Discharge Aspirin prescribed at discharge for patients who had an acute myocardial infarction. I-AMI-3 ACEI or ARB for LVSD ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) for patients who have LVSD (Left Ventricular Systolic Dysfunction) after having an acute myocardial infarction. I-AMI-4 Adult Smoking Cessation Advice/Counseling Adult smoking (cigarette) cessation advice/counseling given to patients who had an acute myocardial infarction. I-AMI-5 Beta Blocker Prescribed at Discharge Beta-blocker prescribed at discharge for patients who had an acute myocardial infarction. I-AMI-9 Inpatient Mortality Acute myocardial infarction (AMI) patients who expire during the hospital stay I-Heart Failure (I-HF) I-HF-2 Evaluation of LVS Function Heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival; during hospitalization, or is planned for after discharge I-HF-3 ACEI or ARB for LVSD ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) for heart failure 2011 Joint Commission International 1
2 I-HF-4 Adult Smoking Cessation Advice/Counseling patients who have LVSD (Left Ventricular Systolic Dysfunction) Adult smoking(cigarettes) cessation advice/counseling given to heart failure patients I-Pneumonia (I-PN) I-PN-2 Pneumococcal Vaccination Pneumonia patients, aged 65 and older, who were screened for pneumococcal vaccine status and were administered the vaccine prior to discharge, if indicated I-PN-4 Adult Smoking Cessation Advice/Counseling Adult smoking cessation advice/counseling given to patients who smoke cigarettes and who are hospitalized for pneumonia I-PN-7 Influenza Vaccination Pneumonia patients, aged 50 and older, who during the flu season, were screened for influenza vaccine status and were vaccinated prior to discharge, if indicated I-Surgical Care Improvement Project (I-SCIP) Measure I-SCIP-Inf-1d Measure Short Name Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision Hip Arthroplasty Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received Vancomycin or a Fluroquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for Vancomycin and 2011 Joint Commission International 2
3 I-SCIP-Inf-1e I-SCIP-Inf-2d I-SCIP-Inf-2e I-SCIP-Inf-3d Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision-Knee Arthroplasty Prophylactic Antibiotic Selection for Surgical Patients-Hip Arthroplasty Prophylactic Antibiotic Selection for Surgical Patients-Knee Arthroplasty Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time- Hip Arthroplasty Fluroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time. Surgical patients with prophylactic antibiotics initiated within one hour prior to surgical incision. Patients who received Vancomycin or a Flurooquinolone for prophylactic antibiotics should have the antibiotics initiated within two hours prior to surgical incision. Due to the longer infusion time required for Vancomycin and Fluroquinolone, it is acceptable to start these antibiotics within two hours prior to incision time. Surgical patients who received prophylactic antibiotics consistent with current Hip Arthroplasty guidelines, Appendix C, Table 3.2, Prophylactic Antibiotic Regimen Selection for Surgery Surgical patients who received prophylactic antibiotics consistent with current Knee Arthroplasty guidelines Appendix C, Table 3.2, Prophylactic Antibiotic Regimen Selection for Surgery Surgical patients, who had a Hip Arthroplasty, whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time 2011 Joint Commission International 3
4 I-SCIP-Inf-3e I-SCIP-VTE-1 I-SCIP-VTE-2 Prophylactic Antibiotics Discontinued Within 24 Hours After Surgery End Time Knee Arthroplasty Surgery Patients with Recommended Venous Thromboembolism Prophylaxis Ordered Surgery Patients Who Received Appropriate Venous Thromboembolism Prophylaxis Within 24 hours Prior to Surgery to 24 Hours After Surgery Surgical patients, who had a Knee Arthroplasty, whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time Surgery patients with recommended Venous Thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time, Surgery patients who received appropriate Venous Thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to 24 hours after Anesthesia End Time, I-Hospital Based Inpatient Psychiatric Care Services (I-HBIPS) I-HBIPS-2 Hours of physical restraint use The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were maintained in physical restraint I-HBIPS-3 Hours of seclusion use The total number of hours that all patients admitted to a hospital-based inpatient psychiatric setting were held in seclusion. I-Children s Asthma Care (I-CAC) I-CAC-1 Relievers for Inpatient Asthma Use of relievers in pediatric patients admitted for inpatient treatment of asthma I-CAC-2 Systemic Corticosteroids for Inpatient Asthma Use of systemic corticosteroids in pediatric patients admitted for impatient treatment of asthma 2011 Joint Commission International 4
5 I-Venous Thromboembolism (I-VTE) I-VTE-1 Venous Thromboembolism Prophylaxis This measure assesses the number of patients who received 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. I-VTE-2 Intensive Care Unit Venous Thromboembolism Prophylaxis This measure assesses the number of patients who received VTE prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after the initial admission (or transfer) to the Intensive Care Unit (ICU) or surgery end date for surgeries that start the day of or the day after ICU admission (or transfer). I-Stroke (I-STK) Measure I-STK-2 I-STK-3 Measure Short Name Discharged on Antithrombotic Therapy Anticoagulation Therapy for Atrial Fibrillation/Flutter Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge. Ischemic stroke patients with atrial fibrillation/flutter who are prescribed anticoagulation therapy at hospital discharge. I-STK-8 Stroke Education Ischemic or hemorrhagic stroke patients or their caregivers who were given educational material addressing ALL of the following: Activation of emergency medical system (if available in region), need for follow-up after discharge, medications prescribed at discharge, 2011 Joint Commission International 5
6 risk factors for stroke, and warning signs and symptoms of stroke. I-STK-10 Assessed for Rehabilitation Ischemic or hemorrhagic stroke patients who were assessed for or received rehabilitation services. I-Nursing- Sensitive Care (I-NSC) Measure I-NSC-2 Measure Short Name Pressure Ulcer Prevalence (Hospital- Acquired) Patients that have hospital-acquired (nosocomial) category/stage II or greater pressure ulcer(s) on the day of the prevalence study. I-NSC-4 Patient Falls All documented falls with or without injury, experienced by patients in a calendar month. I-NSC-5 Falls with Injury All documented falls by a patient with an injury level of minor (2) or greater. I-Perinatal Care (I-PC) I-PC-1 Elective Delivery Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed I-PC-2 Cesarean Section Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section I-PC-5 Exclusive Breast Feeding Exclusive breast milk feeding during the newborn's entire hospitalization 2011 Joint Commission International 6
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