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  2. CQM-437

PN6 Denominator1 logic flaw in check for CT for a patient with direct admission to ICU

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    • Icon: EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals EH/CAH eCQMs - Eligible Hospitals/Critical Access Hospitals
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    • Tamara Bailey
    • 520.750.4324
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      Thank you for your question. This logic is used to establish that the patient was directly admitted to the ICU. To do this, the two “AND NOT” statements endure that the patient did not present at the ED <=24 hours before admit to Non ICU nor direct admit to the NonICU before the ICU. Population-ICU walks through four scenarios using location of ED, NonICU, and ICU as location time stamps to ensure that the patient was ultimately admitted to the ICU. Population 2-NonICU walks through two scenarios to ensure the patient was ultimately admitted to the NonICU. No logic changes are required.
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      Thank you for your question. This logic is used to establish that the patient was directly admitted to the ICU. To do this, the two “AND NOT” statements endure that the patient did not present at the ED <=24 hours before admit to Non ICU nor direct admit to the NonICU before the ICU. Population-ICU walks through four scenarios using location of ED, NonICU, and ICU as location time stamps to ensure that the patient was ultimately admitted to the ICU. Population 2-NonICU walks through two scenarios to ensure the patient was ultimately admitted to the NonICU. No logic changes are required.
    • CMS188v1/NQF0147

      In the denominator of PN6 where it is attempting to determine if a patient who was a direct admit to ICU got a CT Scan with finding of Pneumonia, the first "AND NOT" statement checks ED encounter that starts <=24 hour(s) before their admittance to a Non-ICU location.

      ■OR:
      ■AND NOT: "Occurrence A of Encounter, Performed: Hospital Measures-Encounter ED (facility location arrival datetime)" <= 24 hour(s) starts before start of "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Hospital Measures-Non-ICU Locations')"
      ■AND NOT: "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Hospital Measures-Non-ICU Locations', facility location arrival datetime)" starts before start of "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location: 'Hospital Measures-ICU Locations', facility location arrival datetime)"
      ■AND:
      ■OR: "Diagnostic Study, Result: Hospital Measures-CT scan including chest (result: 'Hospital Measures-Radiological findings consistent with pneumonia')" <= 24 hour(s) starts before start of "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location arrival datetime, facility location: 'Hospital Measures-ICU Locations')"
      ■OR: "Diagnostic Study, Result: Hospital Measures-CT scan including chest (result: 'Hospital Measures-Radiological findings consistent with pneumonia')" during "Occurrence A of Encounter, Performed: Encounter Inpatient (facility location arrival datetime, facility location: 'Hospital Measures-ICU Locations')"

      Per other examples in this measure, this should be checking for an ED encounter that starts <=24 hour(s) before their admittance to a ICU location.

            abt.associate Abt Associate (Inactive)
            tamarabailey Tamara Bailey (Inactive)
            Deborah Krauss (Inactive)
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