2025 Emergency & Acute Care Clinical Registry quality measures

Quality Id	Measure Name	High Priority	Measure Type	Measure Description
ECPR46	Avoidance of Opiate Prescriptions for Low Back Pain or Migraines	Yes	Process	Percentage of Patients with Low Back Pain and/or Migraines Who Were Not Prescribed an Opiate	View
ECPR51	Discharge Prescription of Naloxone after Opioid Poisoning or Overdose	Yes	Process	Percentage of Opioid Poisoning or Overdose Patients Presenting to An Acute Care Facility Who Were Prescribed Naloxone at Discharge.	View
ECPR52	Appropriate Treatment of Psychosis and Agitation in the Emergency Department	No	Process	Percentage of Adult Patients With Psychosis or Agitation Who Were Ordered an Oral Antipsychotic Medication in the Emergency Department.	View
ECPR55	Avoidance of Long-Acting (LA) or Extended-Release (ER) Opiate Prescriptions and Opiate Prescriptions for Greater Than 3 Days Duration for Acute Pain	Yes	Process	Percentage of Adult Patients Who Were Prescribed an Opiate Who Were Not Prescribed a Long-Acting (LA) or Extended-Release (ER) Formulation and for Whom the Prescription Duration Was Not Greater than 3 days for Acute Pain.	View
ECPR56	Opioid Withdrawal: Initiation of Medication-Assisted Treatment (MAT) and Referral to Outpatient Opioid Treatment	Yes	Process	Percentage of Patients Presenting with Opioid Withdrawal Who Were Given Medication-Assisted Treatment and Referred to Outpatient Opioid Treatment.	View
ECPR60	Avoidance of Advanced Imaging for Patients with Unprovoked, Generalized Seizur	Yes	Efficiency	Percentage of patients aged younger than 18 years with diagnosis of seizure that did not have a CT or MRI of the head ordered.	View
HCPR20	Clostridium Difficile- Risk Assessment and Plan of Care	Yes	Process	Percentage of Adult Patients Who Had a Risk Assessment for C. difficile Infection and, If High-Risk, Had a Plan of Care for C. difficile Completed on the Day Of or Day After Hospital Admission	View
HCPR23	Avoidance of Echocardiogram and Carotid Ultrasound for Syncope	Yes	Process	Percentage of Patients Presenting with Syncope Who Did Not Have an Echocardiogram or Carotid Ultrasound Ordered	View
HCPR24	Appropriate Utilization of Vancomycin for Cellulitis	Yes	Process	Percentage of Patients with Cellulitis Who Did Not Receive Vancomycin Unless MRSA Infection or Risk for MRSA Infection Was Identified	View
HCPR25	Physician’s Orders for Life-Sustaining Treatment (POLST) Form	Yes	Process	Percentage of Patients with Advanced Illness with Physician’s Orders for Life-Sustaining treatment (POLST) Forms Completed.	View
HCPR27	Point-of-Care Ultrasound: Evaluation for Pneumothorax after Central Venous Catheter (CVC) Placement	Yes	Process	Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge. Management strategies include one or more of the following: Cell salvage techniques employed intraoperatively Intraoperative antifibrinolytic therapy or tourniquet, if not contraindicated Preoperative iron supplementation, epoetin alpha Use of evidence-based preoperative anemia management algorithm supplemented with laboratory testing and/or multidisciplinary consult	View
HCPR28	Heart Failure (HF): SGLT-2 Inhibitor Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Yes	Process	Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) less than or equal to 40% who were prescribed SGLT-2 Inhibitors during their SNF stay or at the time of discharge.	View
HCPR29	Avoidance of DVT Ultrasound for Patients Diagnosed with Cellulitis	Yes	Process	Percentage of patients aged 18 years and older with diagnosis of cellulitis that did not have a DVT ultrasound ordered.	View
HCPR30	Avoidance of Sliding-Scale Insulin Monotherapy for Admitted Diabetic Patients	No	Process	Percentage of patients aged 18 years and older admitted to the hospital with diagnosis of diabetes mellitus that received order for basal insulin therapy	View
HCPR31	Point-of-Care Ultrasound for Evaluation and Management of Shock	No	Process	Percentage of patients aged 18 years and older with diagnosis of Shock that had Pointof-Care Ultrasound performed.	View
ECPR50	Door to Diagnostic Evaluation by a Provider Within 30 Minutes – Urgent Care Patients	Yes	Process	Percentage of patients, aged 18 years and older, undergoing elective total joint arthroplasty who were screened for anemia preoperatively AND, if positive, have documentation that one or more of the following management strategies were used prior to PACU discharge. Management strategies include one or more of the following: Cell salvage techniques employed intraoperatively Intraoperative antifibrinolytic therapy or tourniquet, if not contraindicated Preoperative iron supplementation, epoetin alpha Use of evidence-based preoperative anemia management algorithm supplemented with laboratory testing and/or multidisciplinary consult	View
EACCR1	Early Tracheostomy Goals of Care Discussion	Yes	Process	Patients with > 96 hours of intubation and mechanical ventilation expected to require prolonged mechanical ventilation and/or their POA or families should engage in conversations clarifying goals of care prior to the 5th day of mechanical ventilation, to avoid late decisions regarding tracheostomy or comfort care.	View
EACCR2	Delirium Management; Early mobility; and Family Engagement in ICU patients	Yes	Process	Patients admitted to the intensive care unit (ICU) for > or = 3 days should be included in the 'DEF' portion of the ABCDEF bundle, including Delirium Assessment, Prevention, and Management; Early mobility; and Family Engagement and Empowerment.	View
ACQR16	COPD Exacerbation or CHF Exacerbation requiring Hospital Admission: Palliative Care Evaluation	Yes	Efficiency	Patients admitted with 2 or more COPD exacerbations in 12 months or a single admission for COPD with hypercapnic respiratory failure, or being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available; and patients admitted with AHA Class D heart failure and/or patients admitted with Congestive Heart Failure (any class) being discharged to a SNF or LTACH should receive an evaluation from a palliative care professional, if available	View
EACCR3	ABC Portion of [ABCDEF ICU Liberation Bundle] - Pain, Sedation, and Breathing management	Yes	Process	Patients admitted to the intensive care unit (ICU) for > or = 3 days that are intubated and have acute respiratory failure should be included in the 'ABC' of the ABCDEF bundle, including Assessment, Prevention and Management of Pain; Spontaneous Awakening/Breathing Trials, and Choice of Anesthesia and Sedation.	View
PQRANES1	Use of Peripheral Nerve Block within the Emergency Department in Patients Admitted with Low Energy Hip Fracture	Yes	Process	Percentage of patients aged 65 years and older that receive a peripheral nerve block for analgesia following diagnosis of isolated hip fracture within the Emergency Department	View
PQRANES3	Reporting of Incidental Carotid Artery Calcification (ICAC) on CT Scans.	Yes	Process	This measure calculates the percentage of final reports for non-arterial CT of the neck region that document the presence or absence of incidental carotid artery calcification.	View
PQRANES4	Limiting use of Desflurane-Based Inhalation Anesthesia.	Yes	Process	This measure quantifies the use of desflurane during general inhalation anesthesia.	View
THEPQR1	High Intensity Statin Prescribed for Acute and Subacute Ischemic Stroke and Transient Ischemic Attack (TIA)	No	Process	Acute and subacute ischemic stroke and confirmed Transient Ischemic Attack (TIA) patients prescribed or continuing to take a high intensity statin at time of hospital discharge	View
THEPQR2	Discontinuation of Proton Pump Inhibitors for patients who do not meet criteria for long-term utilization.	Yes	Process	The percentage of patients on a Proton Pump Inhibitor with an appropriately documented indication or an order for discontinuation for not meeting criteria for long-term utilization.	View
THEPQR4	Consultation to Palliative Care for Patients with End Stage Conditions	Yes	Process	The measure will identify patients with end stage diagnoses who meet any of the listed criteria for a palliative care consult	View
THEPQR5	Avoidance of Head CT Scans in Recurrent Seizure Episodes Without New Head Injury.	Yes	Efficiency	This quality measure aims to minimize the use of head computed tomography (CT) scans in both the Emergency Department (ED) and Hospital Medicine (HM) settings for patients presenting with seizures when they have a known history of seizure disorder and there is no new clinical evidence of head injury.	View
THEPQR6	Timely and Effective Management of Pediatric Asthma Exacerbations in the Emergency Department	No	Process	This measure evaluates the timely administration of both Short-Acting Beta Agonists (SABAs) and corticosteroids within 60 minutes of ED presentation in pediatric patients aged 2 to 18 years experiencing moderate to severe asthma exacerbations. It specifically assesses the prompt delivery of SABAs in conjunction with oral, intramuscular (IM), or intravenous (IV) corticosteroids to ensure effective management of asthma symptoms.	View
THEPQR7	Optimization of Short-term Dual Antiplatelet Therapy for High-risk Cerebrovascular Events	No	Process	This measure assesses the proportion of adult patients who are prescribed short-term dual antiplatelet therapy upon discharge following a diagnosis of high-risk transient ischemic attack (TIA), minor non-embolic ischemic stroke, or intracranial large artery atherosclerosis. It encourages the use of evidence-based protocols to reduce the risk of recurrent stroke.	View

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