Process Measures Toolkit for 2016 Admissions
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1 Process Measures Toolkit for 2016 Admissions Collection Criterion #1 Collect on all patients The following data fields should be reported using the listed field value option(s), or relevant value, as indicated in the data definitions. Venous Thromboembolism Prophylaxis Type Venous Thromboembolism Prophylaxis Date Venous Thromboembolism Prophylaxis Time Transfusion Blood (4 Hours) Withdrawal of Care Withdrawal of Care Date Withdrawal of Care Time See Additional Information for critical instructions on proper use of null values.
2 Collection Criterion #2 Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival This is an example of how to complete TQIP process measures data fields for those patients who meet the collection criterion, as well as those patients who do not. The table below reflects a patient that meets the collection criterion. This center measures/reports blood products in units. The patient received: o 1 unit of packed red blood cells within 4hours ED/hospital arrival. Each unit contains 350cc o An addition unit of packed red blood cells 8 hours after ED/hospital arrival o 1 unit of plasma within 4 hours ED/hospital arrival. Each unit contains 250cc o 1 unit of platelets within 24 hours ED/ hospital arrival. Each unit contains 400cc o 0 units of cryoprecipitate Transfusion Blood** Units 350 Plasma Units 250 Platelets Units 400 Cryoprecipitate 0 0 N/A N/A
3 Continuation of data fields associated with Collection Criterion #2: Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival. The table below reflects a patient that meets the collection criterion. The center measures/reports blood products in CC s. The patient received: o 350cc of packed red blood cells within 4 hours ED/hospital arrival o A total of 700cc packed red blood cell within 24 hours ED/hospital arrival o 250cc of plasma within 4 hour ED/hospital arrival o 400cc of platelets within 24 hours of ED/hospital arrival Transfusion Blood** CC s N/A Plasma CC s N/A Platelets CC s N/A Cryoprecipitate 0 0 N/A N/A The table below reflects patients that did NOT meet the collection criteria. Transfusion Blood** 0 N/A N/A N/A Plasma N/A N/A N/A N/A Platelets N/A N/A N/A N/A Cryoprecipitate N/A N/A N/A N/A
4 Continuation of data fields associated with Collection Criterion #2: Collect on all patients with transfused packed red blood cells within first 4 hours after ED/hospital arrival. Data Field Meets Collection Criterion Does Not Meet Collection Criterion Lowest ED/Hospital Systolic Blood Pressure Angiography Field Value (Report one) 2. Angiogram only 3. Angiogram with embolization Embolization Site Field Value (Report all the apply) 1. Liver 2. Spleen 3. Kidneys 4. Pelvic (iliac, gluteal, obturator) 5. Retroperitoneum (lumbar, sacral) 6. Peripheral vascular (neck, extremities) 7. Aorta (thoracic or abdominal) 8. Other Angiography Date *If Angiography is Angiography Time *If Angiography is Surgery For Hemorrhage Control Type Field Value (Report one) 2. Laparotomy 3. Thoracotomy 4. Sternotomy 5. Extremity (peripheral vascular) 6. Neck 7. Mangled extremity/traumatic Amputation 8. Other soft/skin tissue Surgery For Hemorrhage Control Date *If Surgery For Hemorrhage Control is Surgery For Hemorrhage Control Time *If Surgery For Hemorrhage Control is *Conditional data field
5 Collection Criterion #3 Collect on all patients with at least one injury in AIS Head Region (AIS Head Region includes all injuries coded in AIS beginning with a 1 ) Data Field Meets Collection Criterion Does Not Meet Collection Criterion Highest GCS Total A value between 3-15 Highest GCS Motor GCS Assessment Qualifier Component of Highest GCS Total Initial ED/Hospital Pupillary Response Midline Shift Cerebral Monitor Cerebral Monitor Date *If Cerebral Monitor is 1. None Cerebral Monitor Time *If Cerebral Monitor is 1. None Pediatric (<2 years): Adult: 1. No motor response 1. No motor response 2. Extension to pain 2. Extension to pain 3. Flexion to pain 3. Flexion to pain 4. Withdrawal from pain 4. Withdrawal from pain 5. Localizing pain 5. Localizing pain 6. Appropriate response 6. Obeys commands to stimulation Field Values (Report all that apply) 1. Patient chemically sedated or paralyzed 2. Obstruction to the patient s eye 3. Patient intubated 4. Valid GCS: patient was not sedated, not intubated, and did not have obstruction to the eye 1. Both reactive 2. One reactive 3. Neither reactive 1. Yes 2. No 3. Not Imaged (e.g. CT Scan, MRI) Field Values (Report all that apply) 1. Intraventricular drain/catheter (e.g. ventriculostomy, external ventricular drain) 2. Intraparenchymal pressure monitor (e.g. Camino bolt, subarachnoid bolt, intraparenchymal catheter) 3. Intraparenchymal oxygen monitor (e.g. Licox) 4. Jugular venous bulb 5. None *Conditional data field
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