Quality Measure: Nausea Management
Quality Indicator Data Collection, Recording and Calculation Protocol
Name of the Quality Indicator
Brief description or definition:
For patients who were assessed positive for nausea
and/or vomiting, the percent of patients who received
treatment and self-reported improvement within 1 day
of initial hospice assessment.
Percentages of patients that had improvement of their
nausea/vomiting status within one day after initial
hospice assessment.
Quality Area:
Patient/Family Outcomes
Quality Domain:
Physical Aspects of Care
How often collected:
To be collected on all new admissions, to be abstracted
by the QAPI department on a monthly basis
How often reported:
Quarterly
Data Elements:

Benchmark or Target:
Numerator: All patients with nausea and/or vomiting
on initial hospice assessment who received
treatment and self-reported improvement within 1
day of initial hospice assessment.
 Denominator: Total number of patients who
assessed positive for nausea or vomiting at the first
nausea assessment
 Formula: Numerator/Denominator x 100%
 See below for individual calculations
No benchmarks available
Target to be determined based on first year data
Population included in the measure:
Inclusions:
Patients on service who are 18 years of age or older with nausea present on the
initial hospice assessment.
Exclusions:
All pediatric patients and adults without nausea on initial hospice assessment.
Data collection and recording procedures:
1.
All admitting RN’s are responsible for obtaining the date on their admission
documentation.
2.
All admitting RN’s are to report the positive screenings for Nausea/vomiting to the
(each hospice agency to determine) to ensure follow-up within one day of initial
hospice assessment.
Data Variables – Categorical
Variable Name
1. Assessed for nausea (1)
Allowable values:
Variable Question
Was patient assessed for nausea on admission?
Y
N
Not documented
2. Date of first assessment
MM/DD/YYYY
3. Was patient nauseous?
Allowable values:
Did the assessment indicate the patient had nausea?
Y
No, the patient did not have nausea
Not documented
4. Nausea Treatment
Allowable values:
Was nausea treatment initiated?
Y
N
Not documented
5. Date nausea
treatment initiated
MM/DD/YYYY
6. Reassessed for nausea (2)
Was a second assessment of nausea done if the first
assessment was positive?
Y
N
Not documented
Allowable values:
7. Date of second assessment
MM/DD/YYYY
8. Nausea improved
Allowable values:
Was nausea improved at the second assessment?
Y
No, the nausea was not improved
Not documented—indicate reason; i.e.
 Discharged due to death
 Discharged alive
 Can no longer speak due to disease process
Calculation of the quality indicators



Numerator: All patients who self-report nausea on the initial hospice assessment whose
nausea was documented as improved at the second nausea assessment; the time interval
between the first and second nausea assessment was one day.
Denominator: Total number of patients who had nausea at rest at the first assessment.
Formula: Numerator/Denominator x 100%
Notes for abstraction: Treatment can be with pharmacological or with nonpharmacological
interventions. Medications can be scheduled or PRN/as needed.
www.VNAA.org
NauseaMeasure.Aug.29, 2012