#426: Post-Anesthetic Transfer of Care Measure: Procedure Room to a Post Anesthesia Care Unit (PACU)

Quality ID

426

High Priority Measure

Yes

Specifications

Registry

Measure Type

Process

Specialty

Anesthesiology

Measure Description

Percentage of patients, regardless of age, who are under the care of an anesthesia practitioner and are admitted to a PACU or other non-ICU location in which a post-anesthetic formal transfer of care protocol or checklist which includes the key transfer of care elements is utilized

 

Instructions

This measure is to be submitted each time a procedure including surgical, therapeutic or diagnostic is performed under anesthesia during the performance period and patients are admitted to a PACU or other non-ICU location. There is no diagnosis associated with this measure. It is anticipated that eligible clinicians who provide the listed anesthesia services as specified in the denominator coding will submit this measure.

Measure Submission:

The listed denominator criteria are used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.

 

Denominator

All patients, regardless of age, who are cared for by an anesthesia practitioner and transferred directly from the anesthetizing location to PACU or other non-ICU location.

DENOMINATOR NOTE: In order to meet the denominator criteria of the measure, a patient would need to be directly transferred from the anesthetizing location to PACU or other non-ICU location after the procedure where a transfer of care occurs. A patient that does not transfer directly to these locations is not included within the denominator.

Denominator Criteria (Eligible Cases):

All patients, regardless of age

AND

Patient procedure during the performance period (CPT): 00100, 00102, 00103, 00104, 00120, 00124, 00126, 00140, 00142, 00144, 00145, 00147, 00148, 00160, 00162, 00164, 00170, 00172, 00174, 00176, 00190, 00192, 00210, 00211, 00212, 00214, 00215, 00216, 00218, 00220, 00222, 00300, 00320, 00322, 00326, 00350, 00352, 00400, 00402, 00404, 00406, 00410, 00450, 00454, 00470, 00472, 00474, 00500, 00520, 00522, 00524, 00528, 00529, 00530, 00532, 00534, 00537, 00539, 00540, 00541, 00542, 00546, 00548, 00550, 00560, 00566, 00600, 00604, 00620, 00625, 00626, 00630, 00632, 00635, 00640, 00670, 00700, 00702, 00730, 00731, 00732, 00750, 00752, 00754, 00756, 00770, 00790, 00792, 00794, 00796, 00797, 00800, 00802, 00811, 00812, 00813, 00820, 00830, 00832, 00834, 00836, 00840, 00842, 00844, 00846, 00848, 00851, 00860, 00862, 00864, 00865, 00866, 00868, 00870, 00872, 00873, 00880, 00882, 00902, 00904, 00906, 00908, 00910, 00912, 00914, 00916, 00918, 00920, 00921, 00922, 00924, 00926, 00928, 00930, 00932, 00934, 00936, 00938, 00940, 00942, 00944, 00948, 00950, 00952, 01112, 01120, 01130, 01140, 01150, 01160, 01170, 01173, 01200, 01202, 01210, 01212, 01214, 01215, 01220, 01230, 01232, 01234, 01250, 01260, 01270, 01272, 01274, 01320, 01340, 01360, 01380, 01382, 01390, 01392, 01400, 01402, 01404, 01420, 01430, 01432, 01440, 01442, 01444, 01462, 01464, 01470, 01472, 01474, 01480, 01482, 01484, 01486, 01490, 01500, 01502, 01520, 01522, 01610, 01620, 01622, 01630, 01634, 01636, 01638, 01650, 01652, 01654, 01656, 01670, 01680, 01710, 01712, 01714, 01716, 01730, 01732, 01740, 01742, 01744, 01756, 01758, 01760, 01770, 01772, 01780, 01782, 01810, 01820, 01829, 01830, 01832, 01840, 01842, 01844, 01850, 01852, 01860, 01922, 01924, 01925, 01926, 01930, 01931, 01932, 01933, 01935, 01936, 01951, 01952, 01958, 01960, 01961, 01962, 01963, 01965, 01966

AND

Patient transferred directly from anesthetizing location to PACU or other non-ICU location: G9656

 

Numerator

Patients transferred directly from the procedure room to post-anesthesia care unit (PACU) for post-procedure care for whom a checklist or protocol which includes the key transfer of care elements is utilized

Definitions:

Checklist or Protocol - The key handoff elements that must be included in the transition of care include:

1. Identification of patient
2. Identification of responsible practitioner (PACU nurse or advanced practitioner)
3. Discussion of pertinent medical history
4. Discussion of the surgical/procedure course (procedure, reason for surgery, procedure performed)
5. Intraoperative anesthetic management and issues/concerns.
6. Expectations/Plans for the early post-procedure period.
7. Opportunity for questions and acknowledgement of understanding of report from the receiving PACU team

Identification of patient – In the instance the identity of the patient is unable to be confirmed, identification provided by the clinical facility would suffice toward meeting performance of the measure

Numerator Options:

Performance Met: A transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is used (G9655)

OR

Performance Not Met: A transfer of care protocol or handoff tool/checklist that includes the required key handoff elements is not used (G9658)

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