JCI International Library of Measures

Joint Commission Internationals
International Library of
Measures
Pre-Publication Copy

Joint Commission International
A division of Joint Commission Resources, Inc.

The mission of Joint Commission International (JCI) is to improve the safety and quality of care in the
international community through the provision of education, publications, consultation, and evaluation
services. Joint Commission Resources educational programs and publications support, but are separate
from, the accreditation activities of Joint Commission International. Attendees at Joint Commission
Resources educational programs and purchasers of Joint Commission Resources publications receive no
special consideration or treatment in, or confidential information about, the accreditation process.

2011 Joint Commission International

All rights reserved. No part of this publication may be reproduced in any form or by any means without
written permission from the publisher.

Requests for permission to make copies of any part of this work should be mailed to
Permissions Editor
Department of Publications
Joint Commission Resources
One Renaissance Boulevard
Oakbrook Terrace, Illinois 60181 U.S.A.
permissions@jcrinc.com

For more information about Joint Commission Resources, please visit
http://www.jcrinc.com.

For more information about Joint Commission International, please visit
http://www.jointcommissioninternational.org.
Last Updated: Version 1.2 January 2011

1

Foreword
Joint Commission International (JCI) is very pleased to present this first edition of the Joint
Commission International Library of Measures. The Library is an organized, descriptive
catalogue of 36 selected measures designed to assist health care organizations in choosing a
specific set of measures based on the needs of their populations. The Library will begin to
standardize measurement among organizations by standardizing the measures that are
collected and the details of how they are collected.
Measures provide healthcare professionals and organizations with valuable information about
their performance. Organizations can use this information to make comparisons with other
organizations or with themselves over time. Comparison helps organizations see where they
may be falling short and when processes may be breaking down; thus helping to facilitate
improved performance.
Accreditation programs around the world are moving toward more objective measurements of
quality and patient safety. Over time, the on-site evaluation process will be adjusted to reflect
priority evaluation issues gleaned from measurement data. Accreditation becomes continuous
when a flow of objective data comes to JCI between on-site evaluations. All of this requires
reduction in the variations between organizations in terms of what they collect and how they
collect it. The JCI International Library of Measures is a first step in a multi-year effort to bring
JCI accreditation to the next level. d>:/
improve the quality and safety of patient care around the world.

2

International Library of Measures
The 4th Edition International Standards for Hospitals (Effective 1 January 2011) require organizations to
select five (5) individual clinical measures from the JCI International Library of Measures (see QPS.3.1).
In addition, the Clinical Care Program Certification requirements include the need for programs to
choose at least two (2) of their four (4) measures from the JCI International Library of Measures. There
are a total of ten (10) measures sets, each containing from two (2) to eight (8) individual measures.
Measure Measure Description

Code
Acute Myocardial Infarction (AMI)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Aspirin received within 24 hours of arrival to the hospital for patients having an acute
I-AMI-1 myocardial infarction (AMI).
I-AMI-2 Aspirin prescribed at discharge for patients who had an acute myocardial infarction.
ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)

for patients who have LVSD (Left Ventricular Systolic Dysfunction) after having an
I-AMI-3 acute myocardial infarction.
Adult smoking cessation advice/counseling given to patients who had an acute

I-AMI-4 myocardial infarction.
Beta-blocker prescribed at discharge for patients who had an acute myocardial

I-AMI-5 infarction.
I-AMI-9 Acute myocardial infarction (AMI) patients who expire during the hospital stay
Heart Failure (HF)
Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival, during hospitalization, or is
I-HF-2 planned for after discharge

3


Code
I-HF-3 for heart failure patients who have LVSD (Left Ventricular Systolic Dysfunction)
I-HF-4 Adult smoking cessation advice/counseling given to heart failure patients
Stroke (STK)
I-STK-2 Patients with ischemic stroke prescribed antithrombotic therapy at discharge
I-STK-3 Patients with atrial fibrillation/flutter receiving anticoagulation therapy
I-STK-8 Stroke patients who were given stroke education during their hospital stay
I-STK-10 Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services

I-CAC-1 Pediatric asthma patients who received relievers during this hospitalization
I-CAC-2 Pediatric asthma patients who received systemic corticosteroids during hospitalization
Hospital-Based Inpatient Psychiatric Service (HBIPS)
Psychiatric patients who were placed in physical restraints during their inpatient
hospitalization. This measure will determine the total number of hours that patients
were maintained in physical restraints for those admitted to a hospital-based inpatient
I-HBIPS-2 psychiatric setting
Psychiatric patients who were placed in seclusion during their inpatient hospitalization.
This measure will determine the total number of hours that all patients were
maintained in seclusion for those admitted to a hospital-based inpatient psychiatric
I-HBIPS-3 setting.

4


Code
Nursing-Sensitive Care (NSC)
Originally developed by the National Quality Forum (NQF)

Patients that have hospital-acquired (nosocomial) pressure ulcer(s) (category/stage II)
on the day of the prevalence study. Note: Please see Appendix E for details on
I-NSC-2 how to collect this measure.
All documented falls with or without injury, experienced by patients in a calendar
I-NSC-4 month.
I-NSC-5 All documented falls by a patient with an injury level of minor (2) or greater.
Perinatal Care (PC)
Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39
I-PC-01 weeks of gestation completed
Nulliparous women with a term, singleton baby in a vertex position delivered by

I-PC-02 cesarean section
I-PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization
Pneumonia (PN)
Pneumonia patients, aged 65 and older, who were screened for pneumococcal vaccine
I-PN-2 status and were administered the vaccine prior to discharge, if indicated
Adult smoking cessation advice/counseling given to patients who smoke cigarettes and
I-PN-4 who are hospitalized for pneumonia

5


Code
Pneumonia patients, aged 50 and older, who during the flu season, were screened for
I-PN-7 influenza vaccine status and were vaccinated prior to discharge, if indicated
Surgical Care Improvement Project (SCIP)
Prophylactic antibiotics received one hour prior to surgical incision for hip arthroplasty
I-SCIP-Inf-1d patients
Prophylactic antibiotics received one hour prior to surgical incision for knee
I-SCIP-Inf-1e arthroplasty patients
Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent

I-SCIP-Inf-2d with current guidelines
Surgical patients (knee arthoplasty) who received prophylactic antibiotics consistent

I-SCIP-Inf-2e with current guidelines
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued

I-SCIP-Inf-3d within 24 hours after anesthesia end time
Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued

I-SCIP-Inf-3e within 24 hours after anesthesia end time
Surgical patients (hip/knee arthroplasty) with recommended venous

thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours
I-SCIP-VTE-1 after Anesthesia End Time
Surgical patients who received appropriate venous thromboembolism (VTE)

prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia
I-SCIP-VTE-2 end time

6


Code
Venous Thromboembolism (VTE)
Patients who received VTE prophylaxis (or reasons of why this was not done) on the
day of or day after hospital admission or surgery. Note: This measure applies to
I-VTE-1 medical and surgical cases that are not included in the SCIP measure population
ICU patients who received VTE prophylaxis (or reasons of why this was not done) on
the day of or day after hospital admission or surgery. Note: This measure applies
to all ICU cases except those included in the SCIP measure population (knee/hip
I-VTE-2 arthroplasty) who had surgery on the day of or the day after ICU admission or transfer

7

Acute Myocardial
Infarction (AMI)
Measure Set

8


Code
I-AMI-1 myocardial infarction (AMI).
I-AMI-2 Aspirin prescribed at discharge for patients who had an acute myocardial infarction.

for patients who have LVSD (Left Ventricular Systolic Dysfunction) after having an
I-AMI-3 acute myocardial infarction.
Adult smoking cessation advice/counseling given to patients who had an acute

I-AMI-4 myocardial infarction.
Beta-blocker prescribed at discharge for patients who had an acute myocardial

I-AMI-5 infarction.
I-AMI-9 Acute myocardial infarction (AMI) patients who expire during the hospital stay

9

I-AMI 1
Aspirin on Arrival
Measure Overview
I-AMI 1 Aspirin received within 24 hours of arrival to the hospital for patients
having an acute myocardial infarction.
Overview/Details:
myocardial infarction (AMI).
Rationale:
The early use of aspirin in patients with acute myocardial infarction results in a
significant reduction in adverse events and subsequent mortality.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Indicator Name: Aspirin on arrival
Numerator: AMI patients who received aspirin within 24 hours before

or after hospital arrival
Denominator: AMI patients who are age >= 18 years
Domains of Performance QPS Standards CCPC IPSG
Appropriateness QPS.3 patient assessments AMI *RDO

Availability
Continuity QPS.3 antibiotic and other
medication use
Effectiveness
Timeliness

10

I-AMI 1
Measure Details
Reasons and Implications: The benefits of aspirin therapy on mortality is

comparable to thrombolytic therapy. The combination provides additive benefit for
patients with ST-elevation myocardial infarction and aspirin is also effective in patients
with non-ST-elevation myocardial infarction. Clinical guidelines strongly recommend
aspirin for patients hospitalized with AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who received aspirin within 24 hours before or after hospital
arrival
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Aspirin received within 24 hours before or after hospital arrival
Denominator: AMI patients who are >= 18 years
Data elements:
x Admission Date
x Birthdate
x ICD Principal Diagnosis Code
x Reason for no aspirin on arrival
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1
Exclusions to the population:

x Patients less than 18 years of age
x Patients who left against medical advice or discontinued care on day of or day
after arrival
x Patients who expired on day of or day after arrival
x Patients with a documented Reason for No Aspirin on Arrival

11

I-AMI-1
References
x Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et
al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
x Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). 2004.
x Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et
al. ACC/AHA 2008 performance measures for adults with ST-elevation and
nonST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
x Randomized trial of intravenous streptokinase, oral aspirin, both or neither
among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2
(Second International Study of Infarct Survival) Collaborative Group. Lancet.
1988 Aug 13;2(8607):349w-60.
x Risk of myocardial infarction and death during treatment with low dose aspirin
and intravenous heparin in men with unstable coronary artery disease. The
RISC Group. Lancet. 1990;336(8719):827-830.
x Theroux P, Ouimet H, McCans J et al. Aspirin, heparin, or both to treat acute
unstable angina. N Engl J Med. 1988;319(17):1105-1111.

12

I-AMI 2
Aspirin Prescribed at Discharge
Measure Overview
I-AMI 2 Aspirin prescribed at discharge for patients who had an

acute myocardial infarction.
Overview/Details:
Aspirin prescribed at discharge for patients who had an acute myocardial
infarction (AMI).
Rationale:
Aspirin therapy in patients who have suffered an acute myocardial infarction reduces
the risk of adverse events and mortality.
Outcomes:
Readmissions within 30 days : Decreased
Indicator Name: Aspirin at discharge
Numerator: AMI patients who are prescribed aspirin at hospital discharge
Appropriateness QPS.3 patient AMI *RDO

assessments
Continuity
Effectiveness
QPS.3 antibiotic and other
Prevention/Early
medication use
Detection

13

I-AMI 2
Measure Details
Reasons and Implications: Studies have demonstrated that aspirin reduces the risk
of adverse events and mortality by 20%. Clinical guidelines strongly recommend long-
term aspirin for the secondary prevention of subsequent cardiovascular events in
eligible patients discharged after AMI.
Data Collection:
Numerator: AMI patients who are prescribed aspirin at hospital discharge
Data elements:
x Aspirin Prescribed at Discharge
Data elements:
x Birthdate
x Reason for no aspirin at discharge

x Patients who left against medical advice
x Patients who expired
x Patients with a documented Reason for No Aspirin at Discharge

14

I-AMI 2
References
x Antiplatelet Trialists' Collaboration. Collaborative overview of randomized trials of
antiplatelet therapy - I: prevention of death, myocardial infarction, and stroke by
prolonged antiplatelet therapy in various categories of patients. BMJ.
1994;308:81-106.
Infarction). 2004.
al. ACC/AHA 2008 performance measures for adults with ST-elevation and non
ST-elevation myocardial infarction: a report of the American College of
x Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC
guidelines for secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130
9. doi:10.1016/j.jacc.2006.04.026.

15

I-AMI 3
ACEI or ARB for LVSD
Measure Overview
I-AMI 3 ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin

receptor blocker) for patients who have LVSD (Left Ventricular Systolic
Dysfunction) after having an acute myocardial infarction.
Overview/Details:
ACEI or ARB prescribed at discharge for patients with LVSD after having an acute
myocardial infarction (AMI).
NOTE: For the purposes of this measure, LVSD is defined as chart documentation of a
left ventricular ejection fraction (LVEF) less than 40% or a narrative consistent with
moderate or severe systolic dysfunction.
Rationale:
ACEI inhibitors reduce mortality and morbidity in patients with left ventricular systolic
dysfunction (LVSD) after AMI. Clinical trials have also established ARB therapy as an
acceptable alternative to ACEI, especially in patients with heart failure and/or LVSD who
are ACEI intolerant.
Outcomes:
Patient Settings/Services: Medical/Surgical units

Indicator Name: ACEI or ARB for LVSD
Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge
Denominator: AMI patients with LVSD who are >= 18 years
Appropriateness QPS.3 patient assessments AMI Goal 1

Continuity QPS.3 radiology and
diagnostic imaging services
Effectiveness
medication use

16

I-AMI 3
Measure Details
Reasons and Implications: Clinical guidelines strongly recommend ACEI for patients
hospitalized with AMI who have either clinical heart failure or LVSD. Guideline
FRPPLWWHHVKDYHDOVRVXSSRUWHGWKHLQFOXVLRQRI$5%VLQSHUIRUPDQFHPHDVXUHVIRU
AMI.
Data Collection:
Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge
Data elements:
x ACEI Prescribed at Discharge
x ARB Prescribed at Discharge
Denominator: AMI patients with LVSD and who are >= 18 years
Data elements:
x Birthdate
x LVSD
x Reason for No ACEI and No ARB at Discharge
AMI as defined in Appendix A, Table 1.1 and chart documentation of LVEF less than
40% or a narrative description of LVS function consistent with moderate or severe
systolic dysfunction

x Patients with a documented Reason for No ACEI or ARB at Discharge

17

I-AMI 3
References
Infarction). 2004.
x Flather MD, Yusuf S, Kober L et al. Long-term ACE-inhibitor therapy in patients
with heart failure or left-ventricular dysfunction: a systematic overview of data
from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group.
Lancet. 2000;355(9215):1575-1581.
x Granger CB, McMurray JJ, Yusuf S et al. Effects of candesartan in patients with
chronic heart failure and reduced left-ventricular systolic function intolerant to
angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet.
2003;362:772-776.
x Pfeffer MA, Braunwald E, Moye LA, Basta L, Brown EJ, Jr., Cuddy TE, et al, for
the SAVE Investigators. Effect of captopril on mortality and morbidity in patients
with left ventricular dysfunction after myocardial infarction. Results of the Survival
and Ventricular Enlargement Trial. N Engl J Med. 1992;327:669-77.
x Pfeffer MA, McMurray JJ, Velazquez EJ et al. Valsartan, captopril, or both in
myocardial infarction complicated by heart failure, left ventricular dysfunction, or
both. N Engl J Med. 2003;349:1893-1906.

18

9. doi:10.1016/j.jacc.2006.04.026.
x Torp-Pedersen C, Kober L. Effect of ACE inhibitor trandolapril on life expectancy

of patients with reduced left-ventricular function after acute myocardial infarction.
TRACE Study Group. Trandolapril Cardiac Evaluation. Lancet.
1999;354(9172):9-12.
x Yusuf S, Pepine CJ, Garces C et al. Effect of enalapril on myocardial infarction
and unstable angina in patients with low ejection fractions. Lancet.
1992;340(8829):1173-1178.

19

I-AMI 4
Adult Smoking Counseling
Measure Overview
I-AMI 4 Adult smoking cessation advice/counseling given to patients who had

an acute myocardial infarction.
Overview/Details:
Smoking cessation advice/counseling given to patients (cigarette smokers) who had an
acute myocardial infarction (AMI).
NOTE: For the purposes of this measure, a smoker is defined as someone who has
smoked cigarettes anytime during the year prior to hospital arrival.
Rationale:
Smoking cessation reduces mortality and morbidity in all populations. Patients who
receive even brief smoking-cessation advice from their health care providers are more
likely to quit.
Outcomes:
Indicator Name: Adult smoking cessation advice/counseling
Numerator: AMI patients (cigarette smokers) who receive smoking cessation advice or
counseling during the hospital stay
Denominator: AMI patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival who are >= 18 years
Appropriateness QPS.3 patient AMI

assessments
Continuity
Effectiveness
Prevention/Early Detection

20

I-AMI - 4
Measure Details
Reasons and Implications: Smoking cessation reduces mortality and morbidity in all
populations. Patients who receive even brief smoking-cessation advice from their
health care providers are more likely to quit. Clinical guidelines strongly recommend
smoking cessation counseling for smokers hospitalized with AMI.
Data Collection:
Numerator: AMI patients (cigarette smokers) who receive smoking cessation advice or
counseling during the hospital stay
Data elements:
x Adult Smoking Counseling
Denominator: AMI patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival who are >= 18 years
Data elements:
x Adult Smoking History
x Birthdate
AMI as defined in Appendix A, Table 1.1 and a history of smoking cigarettes anytime
during the year prior to hospital arrival


21

I-AMI 4
References
Infarction). 2004.
x Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. May 2008.
9. doi:10.1016/j.jacc.2006.04.026.

22

I-AMI 5
Beta Blocker Prescribed at Discharge
Measure Overview
I-AMI 5 Beta-blocker prescribed at discharge for patients who had an acute

myocardial infarction.
Overview/Details:
Acute myocardial infarction (AMI) patients who are prescribed a beta-blocker at hospital
discharge
Rationale:
Long-term use of beta blockers for patients who have suffered an acute myocardial
infarction can reduce mortality and morbidity. Studies have demonstrated that the use
of beta-blockers is associated with a 20% reduction in this risk.
Outcomes:
Indicator Name: Beta-blocker prescribed at discharge
Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge

assessments
Continuity
Effectiveness
QPS.3 antibiotic and
Prevention/Early
other medication use
Detection

23

I-AMI - 5
Measure Details
Reasons and Implications: Studies have demonstrated that the use of beta-blockers
is associated with a 20% reduction in risk and there is evidence of effectiveness in
broad populations of patients. Clinical guidelines strongly recommend long-term beta-
blocker therapy for the secondary prevention of subsequent cardiovascular events in
patients discharged after AMI.
Data Collection:
Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge
Data elements:
x Beta-Blocker Prescribed at Discharge
Data elements:
x Birthdate
x Reason for no Beta-blocker at discharge

x Patients with a documented Reason for No Beta-Blocker at Discharge

24

I-AMI 5
References
Infarction). 2004.
x Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use
and effectiveness of E-blockers for the treatment of elderly patients after acute
myocardial infarction: National Cooperative Cardiovascular Project. JAMA.
1998;280:623-629.
9. doi:10.1016/j.jacc.2006.04.026.
x Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in
heart disease. I. Treatments following myocardial infarction. JAMA. 1988;
260(14):2088:2093.

25

I-AMI 9
Inpatient AMI Mortality
Measure Overview
I-AMI 9 Acute myocardial infarction (AMI) patients who expire during hospital
stay
Overview/Details:
Acute myocardial infarction (AMI) patients who expired during the hospital stay
Rationale:
Mortality of patients with AMI represents a significant outcome potentially related to the
quality of care. This rate-based indicator identifies an undesirable outcome of care.
High rates over time may warrant investigation into the quality of care provided.
Outcomes:
Mortality: A decrease in the rate
Improvement noted as: Decrease in rate
Indicator Name: Inpatient mortality
Numerator: Inpatient mortality of AMI patients

Effectiveness AMI

26

I-AMI 9
Measure Details
Reasons and Implications: Mortality of patients with AMI represents a significant

outcome potentially related to the quality of care. This rate based indicator identifies an
undesirable outcome of care. High rates over time may warrant investigation into the
quality of care provided.
Data Collection:
Numerator: Inpatient mortality of AMI patients
Data elements:
x Discharge status
Data elements:
x Birthdate

Note: This measure population does not include deaths that occurred in the
emergency department

27

I-AMI 9
References
ACC/AHA guidelines for the management of patients with ST-elevation myocardial
infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Committee to Revise the 1999
Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
x Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al.
ACC/AHA 2008 performance measures for adults with ST-elevation and nonST-
elevation myocardial infarction: a report of the American College of
(Writing Committee to Develop Performance Measures for ST-Elevation and Non
ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
x Maggioni AP, et al: Age related increase in mortality among patients with first
myocardial infarctions treated with thrombolysis: the Investigators of the Gruppo
,WDOLDQRSHUOR6WXGLRGHOOD6RSUDYYLYHQ]DQHOO,QIDUWR0LRFDUGLFR*,66,-2). N Engl J
Med. 1993;329:1442-1448.

28

Appendix A
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries, ICD-8,
ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in the specific
code utilized by your country to correspond to the ICD-9-CM code description for the
following diagnoses.
Table 1.1 AMI
Acute Myocardial Infarction Codes
ICD-8 ICD-9 ICD-10 ICD-9-CM Shortened Description
Code Code Code Code
410.00 AMI ANTEROLATERAL,UNSPEC
410.01 AMI ANTEROLATERAL, INIT
410.10 AMI ANTERIOR WALL,UNSPEC
410.11 AMI ANTERIOR WALL, INIT
410.20 AMI INFEROLATERAL,UNSPEC
410.21 AMI INFEROLATERAL, INIT
410.30 AMI INFEROPOST, UNSPEC
410.31 AMI INFEROPOST, INITIAL
410.40 AMI INFERIOR WALL,UNSPEC
410.41 AMI INFERIOR WALL, INIT
410.50 AMI LATERAL NEC, UNSPEC
410.51 AMI LATERAL NEC, INITIAL
410.60 TRUE POST INFARCT,UNSPEC
410.61 TRUE POST INFARCT, INIT
410.70 SUBENDO INFARCT, UNSPEC
410.71 SUBENDO INFARCT, INITIAL
410.80 AMI NEC, UNSPECIFIED
410.81 AMI NEC, INITIAL
410.90 AMI NOS, UNSPECIFIED
410.91 AMI NOS, INITIAL

29

Heart Failure (HF)

Measure Set

30


Code
Heart Failure (HF)
Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival, during hospitalization, or is
I-HF-2 planned for after discharge

I-HF-3 for heart failure patients who have LVSD (Left Ventricular Systolic Dysfunction)
I-HF-4 Adult smoking cessation advice/counseling given to heart failure patients

31

I-HF 2
Evaluation of LVS Function
Measure Overview
I-HF 2 Heart failure patients with documentation in the hospital record that left
ventricular systolic (LVS) function was evaluated before arrival, during
hospitalization, or is planned for after discharge
Overview/Details:
Heart failure patients with LVS function evaluation
Rationale:
Appropriate selection of medications to reduce morbidity and mortality in heart failure

requires the identification of patients with impaired left ventricular systolic function.
Clinical guidelines advocate evaluation of left ventricular systolic function as the single
most important diagnostic test in the management of all patients with heart failure.
Outcomes:
Indicator Name: Evaluation of LVS function
Numerator: Heart failure patients with documentation in the hospital record that LVS
function was evaluated before arrival, during hospitalization, or is planned for after
discharge
Denominator: Heart failure patients who are >= 18 years

32

$SSURSULDWHQHVV QPS.3 patient +) *RDO

assessments
$YDLODELOLW\
QPS.3 radiology and
&RQWLQXLW\ diagnostic imaging
(IIHFWLYHQHVV services
7LPHOLQHVV

33

I-HF-2
Measure Details
Reasons and Implications:
Clinical guidelines advocate evaluation of left ventricular systolic function as the single
most important diagnostic test in the management of all patients with heart failure.
Data Collection:
Numerator: Heart failure patients with documentation in the hospital record that LVS
function was evaluated before arrival, during hospitalization, or is planned for after
discharge
Data elements:
x LVF Assessment
Denominator: Heart failure patients who are >= 18 years
Data elements:
x Birthdate
x LVF Assessment
Inclusions to the population: Patients with ICD principal diagnosis code for heart
failure as defined in Appendix A, Table 2.1

x Patients who had a left ventricular assistive device (LVAD) or heart transplant
procedure during hospital stay
x Patients with reasons documented for no LVS function evaluation

34

I-HF-2
References
x Bonow RO, Bennett S, Casey DE, Ganiats TG, Hlatky MA, Konstam MA, et al.
ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure: a
report of the American College of Cardiology/American Heart Association Task
Force on Performance Measures (Writing Committee to Develop Heart Failure
Clinical Performance Measures). J Am Coll Cardiol. 2005;46:114478. Available at
http://www.acc.org and http://www.americanheart.org.
x Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure
Practice Guideline. J Card Fail. 2006 Feb;12(1):e1-2.
x Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al,
writing on behalf of the 2005 Guideline Update for the Diagnosis and
Management of Chronic Heart Failure in the Adult Writing Committee. 2009
focused update: ACCF/AHA guidelines for the diagnosis and management of
heart failure in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2009;53:1343 82.


35

I-HF-3
ACEI or ARB for LVSD
Measure Overview
I-HF 3 ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin

receptor blocker) for heart failure patients who have LVSD (Left Ventricular
Systolic Dysfunction)
Overview/Details:
Heart failure patients with LVSD who are prescribed and ACEI or ARB at hospital
discharge
NOTE: For the purposes of this measure, LVSD is defined as chart documentation of a
left ventricular ejection fraction (LVEF) less than 40% or a narrative consistent with
moderate or severe systolic dysfunction.
Rationale:
ACEI inhibitors reduce mortality and morbidity in patients with heart failure and left
ventricular systolic dysfunction (LVSD) and are effective in a wide range of patients.
Clinical trials have also established ARB therapy as in acceptable alternative to ACEI,
especially in patients who are ACEI intolerant.
Outcomes:

Indicator Name: ACEI or ARB for LVSD
Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital
discharge
Denominator: Heart failure patients with LVSD who are >= 18 years

36


assessments
&RQWLQXLW\
QPS,3 radiology and
(IIHFWLYHQHVV diagnostic imaging
services

other med use

37

I-HF-3
Measure Details
Reasons and Implications: Clinical guidelines strongly recommend ACEI for patients
hospitalized with heart failure and left ventricular systolic dysfunction. Guideline
committees have also supported the inclusLRQRI$5%VLQSHUIRUPDnce measures for
heart failure.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital
discharge
Data elements:
x ACEI Prescribed at Discharge or

x ARB Prescribed at Discharge
Denominator: Heart failure patients with LVSD who are >= 18 years
Data elements:
x Birthdate
x LVSD
x Reason for No ACEI and No ARB at Discharge
Inclusions to the population: Patients with ICD principal diagnosis code for heart
failure as defined in Appendix A, Table 2.1 and chart documentation of LVEF less than
40% or a narrative description of LVS function consistent with moderate or severe
systolic dysfunction


38

procedure during the hospital stay
x Patients with a documented Reason for No ACEI or ARB at Discharge

39

I-HF-3
References
x Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al.
ACC/AHA 2007 guidelines for the management of patients with unstable angina/nonST-
elevation myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation
Myocardial Infarction): developed in collaboration with the American College of Emergency
Physicians, American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of Thoracic
Surgeons. J Am Coll Cardiol. 2007;50:e1157.
x Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA
guidelines for the management of patients with ST-elevation myocardial infarction: a report
of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With
Acute Myocardial Infarction). 2004.
x Flather MD, Yusuf S, Kober L et al. Long-term ACE-inhibitor therapy in patients with heart
failure or left-ventricular dysfunction: a systematic overview of data from individual patients.
ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet. 2000;355(9215):1575-
1581.
x Granger CB, McMurray JJ, Yusuf S et al. Effects of candesartan in patients with chronic
heart failure and reduced left-ventricular systolic function intolerant to angiotensin-
converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet. 2003;362:772-776.
x Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al.
ACC/AHA 2008 performance measures for adults with ST-elevation and nonST-elevation
myocardial infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Performance Measures (Writing Committee to Develop
Performance Measures for ST-Elevation and NonST-Elevation Myocardial Infarction).J
Am Coll Cardiol.2008;52:204699.
x Pfeffer MA, Braunwald E, Moye LA, Basta L, Brown EJ, Jr., Cuddy TE, et al, for the SAVE
Investigators. Effect of captopril on mortality and morbidity in patients with left ventricular
dysfunction after myocardial infarction. Results of the Survival and Ventricular Enlargement
Trial. N Engl J Med. 1992;327:669-77.
x Pfeffer MA, McMurray JJ, Velazquez EJ et al. Valsartan, captopril, or both in myocardial
infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med.
2003;349:1893-1906.
guidelines for secondary prevention for patients with coronary and other atherosclerotic
vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130 9.
doi:10.1016/j.jacc.2006.04.026.
x Torp-Pedersen C, Kober L. Effect of ACE inhibitor trandolapril on life expectancy of patients
with reduced left-ventricular function after acute myocardial infarction. TRACE Study
Group. Trandolapril Cardiac Evaluation. Lancet. 1999;354(9172):9-12.
x Yusuf S, Pepine CJ, Garces C et al. Effect of enalapril on myocardial infarction and
unstable angina in patients with low ejection fractions. Lancet. 1992;340(8829):1173-1178.

40

I-HF-4
Measure Overview
I-HF 4 Adult smoking cessation advice/counseling given to heart failure patients
Overview/Details:
Smoking cessation advice/counseling given to heart failure patients (cigarette smokers)
NOTE: For purposes of this measure, a smoker is defined as someone who has
Rationale:
likely to quit.
Outcomes:
Indicator Name: Adult smoking cessation advice/counseling
Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Denominator: Heart failure patients with a history of smoking cigarettes anytime during
the year prior to hospital arrival and who are >= 18 years.

41

$SSURSULDWHQHVV QPS.3 patient +)

assessments
&RQWLQXLW\ AMI
(IIHFWLYHQHVV Asthma
3UHYHQWLRQ(DUO\'HWHFWLRQ Primary Stroke
Cancer
COPD
Diabetes

42

I-HF-4
Measure Details
Reasons and Implications: Smoking cessation reduces mortality and morbidity in all
populations. Patients who receive even brief smoking-cessation advice from their health
care providers are more likely to quit. Clinical guidelines strongly recommend smoking
cessation counseling for cigarette smokers with cardiovascular disease, including heart
failure.
Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation
Data elements:
Denominator: Heart failure patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival and who are >= 18 years
Data elements:

x Birthdate
Inclusions to the population: Patients with ICD principal diagnosis code for HF as defined
in Appendix A, Table 2.1 and a history of smoking cigarettes anytime during the year prior
to hospital arrival

procedure during hospital stay

43

I- HF-4
References
x Bonow RO, Bennett S, Casey DE, Ganiats TG, Hlatky MA, Konstam MA, et al.
ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure:
a report of the American College of Cardiology/American Heart Association Task
Force on Performance Measures (Writing Committee to Develop Heart Failure
Clinical Performance Measures). J Am Coll Cardiol. 2005;46:114478. Available
at http://www.acc.org and http://www.americanheart.org.
x Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. May 2008.
x Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure
Practice Guideline. J Card Fail. 2006 Feb;12(1):e1-2.
x Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al,
writing on behalf of the 2005 Guideline Update for the Diagnosis and
Management of Chronic Heart Failure in the Adult Writing Committee. 2009
focused update: ACCF/AHA guidelines for the diagnosis and management of
heart failure in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2009;53:1343 82.


44

Appendix A
ICD Codes
Table 2.1
Heart Failure Codes
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description

CMCode
Code Code Code
402.01 MAL HYPERT HRT DIS W HF
402.11 BENIGN HYP HT DIS W HF
402.91 HYP HT DIS NOS W HT FAIL
404.01 MAL HYP HT/KD I-IV W HF
404.03 MAL HYP HT/KD STG V W HF
404.11 BEN HYP HT/KD I-IV W HF
404.13 BEN HYP HT/KD STG V W HF
404.91 HYP HT/KD NOS I-IV W HF
404.93 HYP HT/KD NOS ST V W HF
428.0 CHF NOS
428.1 LEFT HEART FAILURE
428.20 SYSTOLIC HRT FAILURE NOS
428.21 AC SYSTOLIC HRT FAILURE
428.22 CHR SYSTOLIC HRT FAILURE
428.23 AC ON CHR SYST HRT FAIL

45

CMCode
Code Code Code
428.30 DIASTOLC HRT FAILURE NOS

428.31 AC DIASTOLIC HRT FAILURE
428.32 CHR DIASTOLIC HRT FAIL
428.33 AC ON CHR DIAST HRT FAIL
428.40 SYST/DIAST HRT FAIL NOS
428.41 AC SYST/DIASTOL HRT FAIL
428.42 CHR SYST/DIASTL HRT FAIL
428.43 AC/CHR SYST/DIA HRT FAIL
428.9 HEART FAILURE NOS

Table 2.2
Left Ventricular Assistive Device (LVAD) and Heart Transplant
CMCode
Code Code Code
33.6 COMB HEART/LUNG TRANSPLA
37.51 HEART TRANSPLANTATION
37.52 IMP TOT INT BI HT RP SYS
37.53 REPL/REP THR UNT TOT HRT
37.54 REPL/REP OTH TOT HRT SYS
37.60 IMP BIVN EXT HRT AST SYS
37.62 INSRT NON-IMPL CIRC DEV
37.63 REPAIR HEART ASSIST SYS
37.65 IMP VENT EXT HRT AST SYS

46

CMCode
Code Code Code
37.66 IMPLANTABLE HRT ASSIST
37.68 PERCUTAN HRT ASSIST SYST

47

Stroke (STK)
Measure Set

48

Measure
Code Measure Description
Stroke (ST K )
Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)
Patients with ischemic stroke prescribed antithrombotic therapy at
I-STK-2 discharge
Patients with atrial fibrillation/flutter receiving anticoagulation
I-STK-3 therapy
Stroke patients who were given stroke education during their
I-STK-8 hospital stay
Ischemic or hemorrhagic stroke patients who were assessed for
I-STK-10 rehabilitation services

49

I-STK-2
Discharged on Antithrombotic Therapy
Measure Overview
I-STK 2 Patients with ischemic stroke prescribed antithrombotic therapy at

discharge
Overview/Details:
Patients prescribed antithrombotic therapy at discharge after having an ischemic stroke.
Rationale:
Data at this time suggest that antithrombotic therapy should be prescribed at discharge
following acute ischemic stroke to reduce stroke mortality and morbidity as long as no
contraindications exist.
Measure Related Outcomes:

Measure Name: Discharged on Antithrombotic Therapy
Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital

discharge
Denominator: Ischemic stroke patients who are >= 18 years.

Appropriateness QPS.3 patient Stroke Goal 1
assessments
Continuity
Effectiveness QPS.3 antibiotic and
Prevention/Early Detection other medication use
Timeliness

50

I-STK-2
Measure Details
Reasons and Implications: The effectiveness of antithrombotic agents in reducing

stroke mortality, stroke related morbidity and recurrence rates has been studied in
several large clinical trials. While the use of these agents for patients with acute
ischemic stroke and transient ischemic attacks continues to be the subject of study,
substantial evidence is available from completed studies. Data at this time suggest
that antithrombotic therapy should be prescribed at discharge following acute
ischemic stroke to reduce mortality and morbidity.
Data Collection:
Retrospective data sources for the required data elements include administrative
data and medical records.
Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital

discharge
Data elements:
x Antithrombotic therapy prescribed at discharge
Denominator: Ischemic stroke patients who are > = 18 years.
Data elements:
x Birthdate
x Elective Carotid Intervention
x ICD principal diagnosis code
x Reason for not prescribing antithrombotic therapy at discharge
Inclusions to the population: Patients with ICD principal diagnosis code for
ischemic stroke as defined in Appendix A, Table 8.1

x Patients admitted for the performance of elective carotid intervention

51

I-STK-2
References
x Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida
RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH,
Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic
Stroke: A Guideline From the American Heart Association/American Stroke Association
Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care
Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655-1711.
x Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the Early Management
of Patients With Ischemic Stroke: Guidelines Update A Scientific Statement From the
Stroke Council of the American Heart Association/American Stroke Association. Stroke
Vol. 36, 2005: 916:923.
x Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and
Thrombolytic Therapy for Ischemic Stroke. Chest Vol. 119, 2001: 300-320.
x Brott TG, Clark WM, Grotta JC, et al. Stroke the first hours. Guidelines for acute
treatment. Consensus Statement. National Stroke Association. 2000.
x Chen ZM, Sandercock P, Pan HC, et al. Indications for early aspirin use in acute
ischemic stroke: a combined analysis of 40,000 randomized patients from the Chinese
acute stroke trial and the international stroke trial. On behalf of the CAST and IST
collaborative groups, Stroke 2000;31:1240-1249.
x Coull BM, Williams LS, Goldstein LB, et al. Anticoagulants and Antiplatelet Agents in
Acute Ischemic Stroke. Report of the Joint Stroke Guideline Development Committee of
the American Academy of Neurology and the American Stroke Association (a Division
of the American Heart Association) Stroke. 2002;33:1934 -1942.
x Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in
Primary Care, Centre for Health Services Research University of Newcastle upon Tyne,
& Centre for Health Economics of York, 1998.
x Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB,
Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ,
Marks M, Schwamm LH, Tomsick T. Guidelines for Prevention of Stroke in Patients
With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare
Professionals From the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and
Intervention. Stroke. Vol. 37, 2006:577.

52

I-STK-3
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Measure Overview
I-STK 3 Patients with atrial fibrillation/flutter receiving anticoagulation therapy
Overview/Details:
Patients with ischemic stroke with atrial fibrillation/flutter discharged on anticoagulation
therapy.
Rationale:
A prior stroke or transient ischemic attack (TIA) are among a limited number of
predictors of high stroke risk within the population of patients with atrial fibrillation.

Measure Name: Anticoagulation therapy for Atrial Fibrillation/Flutter
Numerator: Ischemic stroke patients prescribed anticoagulation therapy at hospital

discharge
Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter who

are > = 18 years.
Domains of Performance QPS CCPC IPSG

Standards
Appropriateness Stroke Goal 1
Continuity
Effectiveness

53

I-STK-3
Measure Details
Reasons and Implications: Analysis of multiple controlled clinical trials investigating

the efficacy of warfarin in the primary prevention of thromboembolic stroke, found the
relative risk of thromboembolic stroke was reduced by 68% for atrial fibrillation patients
treated with warfarin. The administration of anticoagulation therapy, unless there are
contraindications, is an established effective strategy in preventing recurrent stroke in
high stroke risk-atrial fibrillation patients with TIA or prior stroke.
Data Collection:
Numerator: Ischemic stroke patients prescribed anticoagulation therapy at discharge
Data elements:
x Anticoagulation therapy prescribed at discharge
Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter who

are >= 18 years
Data elements:
x Atrial Fibrillation/Flutter
x Birthdate
x Reason for Not Prescribing Anticoagulation Therapy
Inclusions to the population: Patients with ICD principal diagnosis code for ischemic
stroke as defined in Appendix A, Table 8.1.

x Patients admitted for the performance of elective carotid intervention

54

I- STK-3
References
x Kearon C, Kahn, SR, Agnelli G, Goldhaber S, Raskob, GE, Comerota AJ.

Antithrombotic therapy for venous thromboembolic disease. The Eighth ACCP
Conference on antithrombotic and thrombolytic therapy. Chest. 2008;133: 454S-
545S.
x Sallah S, Thomas DP, Roberts HR. Warfarin and heparin-induced skin necrosis
and the purple toe syndrome: infrequent complications of anticoagulant
treatment. Thromb Haemost. 1997; 78(2): 785-90.
x Gallus A, Jackaman J, Tillet J et al. Safety and efficacy of warfarin started early
after submassive venous thrombosis or pulmonary embolism. Lancet. 1986 Dec
6;2(8519):1293-6.
x Buller HR, Davidson BL, Decousus DL et al. Subcutaneous fondaparinux versus
intravenous unfractionated heparin in the initial treatment of pulmonary
embolism. N Engl J Med. 2003 Oct 30;349 (18):1695-702.
x Buller HR, Davidson BL, Decousas DL et al. Fondaparinux or enoxaparin for the
initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann
Intern Med. 2004 Jun 1;140(11):867-73.
x Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology
and management of the vitamin K antagonists: The Eighth ACCP Conference on
Antithrombotic and Thrombolytic Therapy. Chest. 2008 133:160S-198S.
x Caprini JA, Tapson VF, Hyers TM et al. NABOR Steering Committee. Treatment
of venous thromboembolism: adherence to guidelines and impact of physician
knowledge, attitudes, and beliefs. J of Vasc Surg. 2005 Oct;42(4):726-33.

55

I-STK-8 Stroke Education
Measure Overview
I-STK 8 Stroke patients who were given stroke education during their hospital
stay
Overview/Details:
Patients with ischemic stroke or hemorrhagic stroke who are given educational
materials on all of the following; activation of emergency medical system, need for
follow-up after discharge, medications prescribed at discharge, risk factors for stroke,
and warning signs and symptoms of stroke.
Rationale:
Clinical practice guidelines include recommendations for patient and family education
during hospitalization as well as information about resources for social support services.
Some clinical trials have shown measurable benefits in patient and caregiver outcomes
with the application of education and support strategies. The type of stroke experienced
and the resulting outcomes will play a large role in determining not only the course of
treatment but also what education will be required.

Measure Name: Stroke education
Numerator: Ischemic or hemorrhagic stroke patients with documentation that they or

their caregivers were given educational material addressing all of the following:
1. Activation of emergency medical system
2. Follow-up after discharge
3. Medications prescribed at discharge
4. Risk factors for stroke
5. Warning signs and symptoms of stroke
Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home

who are >= 18 years

56


Appropriateness QPS.3 clinical assessments Stroke
Continuity
Effectiveness
Prevention/Early
Detection

57

I-STK-8
Measure Details
Reasons and Implications: Clinical practice guidelines include recommendations for

patient and family education during hospitalization as well as information about
resources for social support services. Some clinical trials have shown measurable
benefits in patient and caregiver outcomes with the application of education and
support strategies. The type of stroke experienced and the resulting outcomes will
play a large role in determining not only the course of treatment but also what
education will be required. Patient education should include information about the
event, the role of various medications or strategies, as well as desirable lifestyle
modifications to reduce risk or improve outcomes.
Data Collection:
Numerator: Ischemic or hemorrhagic stroke patients with documentation that they or

their caregivers were given educational material addressing all of the following:
1. Activation of emergency medical system
2. Follow-up after discharge
3. Medications prescribed at discharge
4. Risk factors for stroke
5. Warning signs and symptoms of stroke
Data elements:
x Education Addresses Activation of Emergency Medical System
x Education Addresses Follow-up after Discharge
x Education Addresses Medications Prescribed at Discharge
x Education Addresses Risk Factors for Stroke
x Education Addresses Warning Signs and Symptoms of Stroke
Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home who

are >= 18 years.

58

Data elements:
x Birthdate
stroke as defined in Appendix A, Table 8.1, or Table 8.2 and who are discharged to
home or home care.

x Patients admitted for elective carotid intervention

59

I-STK-8
References
x Duncan et al, Stroke Rehabilitation Clinical Practice Guidelines Stroke.

2005;36:e100-e143.
x Evans RL, Matlock AL, Bishop DS, Stranahan S, Pederson C. Family
intervention after stroke: Does counseling or education help?, Stroke
1988;19:1243-1249.
x Kaiser Permanente Clinical Practice Guidelines for Acute Stroke, Kaiser
Permanente Medical Group, 1998.
x Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic
disease self-management program can improve health status while reducing
hospitalization: A randomized trial. Medical Care 1999;37:5-14.
x Post Stroke Rehabilitation, Clinical Practice Guideline No.16, Agency for Health
Care Policy and Research (now known as Agency for Healthcare Research and
Quality), 1995.

60

I-STK-10 Assessed for Rehabilitation
Measure Overview
I-STK 10 Ischemic or hemorrhagic stroke patients who were assessed for

rehabilitation services
Overview/Details:
Each year hundreds of thousands of people experience a new or recurrent stroke.
Approximately two thirds of these individuals survive and require rehabilitation. Stroke
is a leading course of serious long-term disability in all countries. Many of these
patients are left with moderate functional impairment and some with severe disability.
More than half of patients who have experienced a stroke, or serious injury, have never
received rehabilitation.
Rationale:
Stroke rehabilitation should begin as soon as the diagnosis of stroke is established and
life-threatening problems are under control. Among high priorities for stroke patients
are to mobilize the patient and encourage resumption of self-care activities as soon as
possible. A considerable body of evidence indicates better clinical outcomes when
patients with stroke are treated in a setting that provides coordinated, multidisciplinary
stroke-related evaluation and services.
Outcomes:
Measure Name: Assessed for Rehabilitation
Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received

rehabilitation
Denominator: Ischemic stroke or hemorrhagic stroke patients who are >= 18 years.

61


Appropriateness QPS.3 patient assessments Stroke Goal 1
Availability
Continuity
Effectiveness
Timeliness

62

I-STK-10
Measure Details
Reasons and Implications: A considerable body of evidence indicates better clinical

outcomes when patients with stroke are treated in a setting that provides a coordinated,
multidisciplinary stroke-related evaluation and services. Effective rehabilitation
interventions initiated early following stroke care enhance the recovery process and
minimize functional disability. The primary goal of rehabilitation is to prevent
complications, minimize impairments, and maximize function.
Data Collection:
Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received

rehabilitation services.
Data elements:
Assessed for Rehabilitation Services
Denominator: Ischemic stroke or hemorrhagic stroke patients who are > = 18 years
Data elements:
x Birthdate
stroke or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2.

x Patients admitted for elective carotid intervention

63

STK-10
References
x American Academy of Physical Medicine and Rehabilitation. Rehabilitation Helps

Stroke Patients Recover Skills. AAPM&R Chicago, IL Office: Author.
x American Academy of Physical Medicine and Rehabilitation. Urgency Key But
Perseverance Pays Off. AAPM&R Chicago, IL Office: Author.
x Bates B, Choi JY, Duncan PW, Glasberg JJ, Graham GD, Katz RC, Lamberty K,
Recker D, Zorowitz R. American Heart Association/American Stroke Association-
endorsed practice guideline. Veterans Affairs/Department of Defense clinical
practice guideline for the management of adult stroke rehabilitation care. Stroke.
2005;36:2049. Retrieved August 2, 2007 from World Wide Web.
http://stroke.ahajournals.org/cgi/content/full/36/9/2049.
x Management of patients with stroke. Rehabilitation, prevention and management
of complications, and discharge planning, Scottish Intercollegiate network
Guidelines Network (SIGN), 2002.
x National Institute of Neurological Disorders. Post-Stroke Rehabilitation Fact
Sheet. National Institute of Neurological Disorders Bethesda, MD Office: Author.
x Post Stroke Rehabilitation, Clinical Practice Guideline No.16, Agency for Health
Care Policy and Research (now known as Agency for Healthcare Research and
Quality), 1995.
x VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation
in the Primary Care Setting, 2003.
x Zorowitz RD, et al, the Post-Stroke Rehabilitation Outcomes Project (PSROP),
Top Stroke Rehabil. 2005 Fall;12(4).

64

Appendix A
ICD Code Tables
Stroke Measures
Please Note : Due to the various ICD Code versions used by different countries,
ICD-8, ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in
the specific code utilized by your country to correspond to the ICD-9-CM code
description for the following diagnoses.
Table 8.1
Ischemic Stroke (STK)
CM
Code Code Code
Code
433.01 OCL BSLR ART W INFRCT

433.10 OCL CRTD ART WO INFRCT
433.11 OCL CRTD ART W INFRCT
433.21 OCL VRTB ART W INFRCT
433.31 OCL MLT BI ART W INFRCT
433.81 OCL SPCF ART W INFRCT
433.91 OCL ART NOS W INFRCT
434.00 CRBL THRMBS WO INFRCT
434.01 CRBL THRMBS W INFRCT
434.11 CRBL EMBLSM W INFRCT
434.91 CRBL ART OCL NOS W INFRC
436 CVA

65

Table 8.2
Hemorrhagic Stroke (STK)
Code Code Code CM
Code
430 SUBARACHNOID HEMORRHAGE
431 INTRACEREBRAL HEMORRHAGE

66

&KLOGUHQV$VWKPD
Care (CAC)
Measure Set

67

Measure

Pediatric asthma patients who received relievers during this
I-CAC-1 hospitalization
Pediatric asthma patients who received systemic corticosteroids during

I-CAC-2 hospitalization

68

I-CAC-1
5HOLHYHUVIRU&KLOGUHQV,QSDWLHQW$VWKPD
Measure Overview
I-CAC-1 5HOLHYHUVIRU&KLOGUHQV,QSDWLHQW$VWKPD
Overview/Details:
Use of relievers in pediatric patients admitted for inpatient treatment of asthma
Rationale:
Asthma is the most common chronic disease in children and a major cause of morbidity
and increased health care expenditures. For children, asthma is one of the most
frequent reasons for admission to hospitals. Under-treatment and/or inappropriate
treatment of asthma are recognized as major contributors to asthma morbidity and
mortality. Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of relievers to gain control of acute asthma exacerbation and
reduce severity as quickly as possible, with step down medication to the least
medication necessary to maintain control.

Pediatric units
Medical/Surgical units (serving pediatric patients)
Free-standing Pediatric hospitals
Measure Name: 5HOLHYHUVIRU&KLOGUHQV,QSDWLHnt Asthma
Numerator: Pediatric asthma inpatients who received relievers during this
hospitalization.
Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were
discharged with a principal diagnosis of asthma

69

$SSURSULDWHQHVV QPS.3 patient $VWKPD *RDO

assessments
$YDLODELOLW\
&RQWLQXLW\
(IIHFWLYHQHVV medication use
3UHYHQWLRQ(DUO\'HWHFWLRQ
7LPHOLQHVV

70

I-CAC-1
Measure Details

Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of relievers to gain control of acute asthma exacerbation and
reduce severity as quickly as possible, with step down medication to the least
medication necessary to maintain control.
Data Collection:
Numerator: Pediatric asthma inpatients who received relievers during this

hospitalization.
Inclusions to the population: Patients who were administered relievers during this
hospitalization.
Data elements:
x Relievers Administered
Data elements:
x Birthdate
x ICD Principal Diagnosis code
x Reason for Not Administering Relievers
Inclusions to the population: Discharges with:

x Patients with ICD principal diagnosis code of asthma as defined in Appendix A,
Table 6.1
x An age of 2 through 17 years

x Patients less than 2 years of age or greater than 18 years of age
x Patients with a documented Reason for Not Administering Relievers

71

I-CAC-1
References
x Adams RJ, Fuhlbrigge A, Finkelstein JA, Lozano P, Livingston JM, Weiss KB, and
Weiss ST (2001). Use of Inhaled Anti-inflammatory Medication in Children with
Asthma in Managed Care Settings. Archives of Pediatrics and Adolescent
Medicine, 155, 501-507.
x Clinical Practice Guidelines of the American Academy of Pediatrics: A Compendium
of Evidence-Based Research for Pediatric Practice. American Academy of
Pediatrics, 1999.
x Crain EF, Weiss KB and Fagan MJ (1995). Pediatric Asthma Care in U.S. Emergency
Departments. Archives of Pediatric and Adolescent Medicine. 149, 893-901.
x Gross KM, Ponte CD (1998). New Strategies in the Medical Management of Asthma.
American Family Physician. 58:1
x McCormick MC, Kass B, Elixhauser A, Thompson J and Simpson L (2000). Annual
Report on Access to and Utilization of Health Care for Children and Youth in the
United States 1999. Pediatrics, 105:1, 219-230.
x Silber JH, Rosenbaum PR, Even-Shoshan O, Shabbout M, Zhang X, Bradlow ET,
and Marsh RR (2003). Length of Stay, Conditional Length of Stay, and Prolonged
Stay in Pediatric Asthma. Health Services Research, 38: 3, 867-886.
x Guidelines for the Diagnosis and Management of Asthma (EPR-3) (2007).
http://www.nhlbi.nih.gov
x Asthma Management Model System, http://www.nhlbi.nih.gov
x National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov

72

I-CAC-2
Systemic Corticosteroids for Children Inpatient Asthma
Measure Overview
I-CAC 2 Systemic Corticosteroids for Children Inpatient Asthma
Overview/Details: Use of systemic corticosteroids in pediatric patients admitted for

inpatient treatment of asthma
Rationale:
Asthma is the most common chronic disease in children and a major cause of morbidity
and increased health care expenditures nationally. For children, asthma is one of the
most frequent reasons for admission to hospitals. Under-treatment and/or inappropriate
treatment of asthma are recognized as major contributors to asthma morbidity and
mortality. Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of systemic corticosteroids to gain control of acute asthma
exacerbation and reduce severity as quickly as possible, with step down medication to
the least medication necessary to maintain control.

Pediatric units
Medical/Surgical units (serving pediatric patients)
Free standing Pediatric hospitals
Measure Name: 6\VWHPLFFRUWLFRVWHURLGVIRU&KLOGUHQV,QSDWLHQW$VWKPD
Numerator: Pediatric asthma inpatients who received systemic corticosteroids during

hospitalization.

73

$SSURSULDWHQHVV QPS.3 patient $VWKPD *RDO

assessments
$YDLODELOLW\
&RQWLQXLW\
(IIHFWLYHQHVV other medication use
7LPHOLQHVV

74

I-CAC-2
Measure Details
Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of systemic corticosteroids to gain control of acute asthma
exacerbation and reduce severity as quickly as possible, with step down medication to
the least medication necessary to maintain control.
Data Collection:
Numerator: Pediatric asthma inpatients who received systemic corticosteroids during
hospitalization.
Inclusions to the population: Patients who were administered systemic corticosteroids
during this hospitalization.
Data elements:
x Systemic Corticosteroids Administered
Data elements:
x Birthdate
x ICD Principal Diagnosis code
x Reason for Not Administering Systemic Corticosteroids
Inclusions to the population: Discharges with:

x Patients with ICD principal diagnosis code of asthma as defined in Appendix A,
Table 6.1
x An age of 2 years through 17 years

x Patients less than 2 years of age or greater than 18 years of age
x 3DWLHQWVZLWKDGRFXPHQWHG5HDVRQIRU1RW$GPLQLVWHULQJV\VWHPLF
corticosteroids

75

I-CAC-2
References
x Adams RJ, Fuhlbrigge A, Finkelstein JA, Lozano P, Livingston JM, Weiss KB, and
Weiss ST (2001). Use of Inhaled Anti-inflammatory Medication in Children with
Asthma in Managed Care Settings. Archives of Pediatrics and Adolescent
Medicine, 155, 501-507.
x Clinical Practice Guidelines of the American Academy of Pediatrics: A Compendium
of Evidence-Based Research for Pediatric Practice. American Academy of
Pediatrics, 1999.
x Crain EF, Weiss KB and Fagan MJ (1995). Pediatric Asthma Care in U.S. Emergency
Departments. Archives of Pediatric and Adolescent Medicine. 149, 893-901.
x Gross KM, Ponte CD (1998). New Strategies in the Medical Management of Asthma.
American Family Physician. 58:1
x McCormick MC, Kass B, Elixhauser A, Thompson J and Simpson L (2000). Annual
Report on Access to and Utilization of Health Care for Children and Youth in the
United States 1999. Pediatrics, 105:1, 219-230.
x Silber JH, Rosenbaum PR, Even-Shoshan O, Shabbout M, Zhang X, Bradlow ET,
and Marsh RR (2003). Length of Stay, Conditional Length of Stay, and Prolonged
Stay in Pediatric Asthma. Health Services Research, 38: 3, 867-886.
x Guidelines for the Diagnosis and Management of Asthma (EPR-3) (2007).
http://www.nhlbi.nih.gov
x Asthma Management Model System, http://www.nhlbi.nih.gov
x National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov

76

Appendix A
ICD Codes
ICD-8, ICD-9,and ICD-10 spaces have been left intentionally blank. Please fill in
Table 6.1
Asthma Codes

CM Code
Code Code Code
493.00 EXTRINSIC ASTHMA NOS
493.01 EXT ASTHMA W STATUS ASTH
493.02 EXT ASTHMA W(ACUTE) EXAC
493.10 INTRINSIC ASTHMA NOS
493.11 INT ASTHMA W STATUS ASTH
493.12 INT ASTHMA W (AC) EXAC
493.81 EXERCSE IND BRONCHOSPASM
493.82 COUGH VARIANT ASTHMA
493.90 ASTHMA NOS
493.91 ASTHMA W STATUS ASTHMAT
493.92 ASTHMA NOS W (AC) EXAC

77

Hospital Based
Inpatient Psychiatric
Services (HBIPS)
Measure Sets

78

Measure
Hospital-Based Inpatient Psychiatric Service (HBIPS)

Psychiatric patients who were placed in physical restraints during their
inpatient hospitalization. This measure will determine the total number
of hours that patients were maintained in physical restraints for those
I-HBIPS-2 admitted to a hospital-based inpatient psychiatric setting
Psychiatric patients who were placed in seclusion during their inpatient
hospitalization. This measure will determine the total number of hours
that all patients were maintained in seclusion for those admitted to a
I-HBIPS-3 hospital-based inpatient psychiatric setting.

79

I-HBIPS-2
Hours of physical restraint use
Measure Overview
I-HBIPS 2 Psychiatric patients who were placed in physical restraints during

their inpatient hospitalization. NOTE: This measure will determine the total
number of hours that patients were maintained in physical restraints for those
admitted to a hospital-based inpatient psychiatric setting.
Overview/Details:
Patients who are placed in physical restraint while admitted to a hospital-based inpatient
psychiatric setting.
Rationale:
The use of seclusion and restraint is limited to situations that may present imminent
danger to either the patient and/or staff. The use of restraint is rigorously monitored and
analyzed to prevent future restraint use and to prevent harm.
Psychiatric units
Measure Name: Hours of physical restraint use
Numerator: The total number of hours that all psychiatric inpatients were maintained in
physical restraints.
Denominator: Number of psychiatric inpatient days

80

$SSURSULDWHQHVV *RDO
(IIHFWLYHQHVV QPS.3 patient assessments
6DIHW\

81

I-HBIPS-2
Measure Details
Reasons and Implications: The use of restraint is limited to situations that may present
imminent danger to either the patient and/or staff. The use of restraint is rigorously
monitored and analyzed to prevent future restraint use and to prevent harm. Providers also
seek to prevent violence or aggression from occurring in their treatment environments by
focusing their attention on prevention activities that have a growing evidence base.
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Numerator: The total number of hours that all psychiatric inpatients were maintained in
physical restraints.
Inclusions to the population: Patients for whom at least one physical restraint event is
reported during the month.
Data elements:
x Event Date
x Event Type
x Minutes of Physical Restraint
Denominator Basis: Per 1,000 hours (psychiatric inpatient)
Data elements:
x Admission Date
x Birthdate
x Psychiatric Care Setting
x Psychiatric Inpatient days
Inclusions to the population: All psychiatric inpatient days

x None

82

I-HBIPS-2
References
x Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of

seclusion and restraint at a public psychiatric hospital. Psychiatric Services.
54(8): 1119-1123.
x Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction
programs and their application in a large, urban, state psychiatric hospital.
Journal of Psychiatric Practice, 9(1), 7-15.
x Huckshorn, K.A. (2004/September). Reducing seclusion and restraint use in
mental health settings: Core strategies for prevention. Journal of Psychosocial
Nursing and Mental Health Services. 42(9). Pp. 22-31.
x Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the
use of restraints with children. Journal of Child and Adolescent Psychiatric
Nursing, 14(3), 141- 151.
x Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services,
56 (9), 1104-1142.
x Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A
compendium of strategies created by the American Psychiatric Association
(APA), the American Psychiatric Nurses Association (APNA), the National
Association of Psychiatric Health Systems (NAPHS), and the American Hospital
Association Section for Psychiatric and Substance Abuse Services (AHA).
Retrieved from the Internet on February 10, 2010 at http://www.naphs.org

83

I-HBIPS-3
Hours of seclusion use
Measure Overview
I-HBIPS 3 Psychiatric patients who were placed in seclusion during their

inpatient hospitalization.
NOTE: This measure will determine the total number of hours that all patients were
maintained in seclusion for those admitted to a hospital-based inpatient psychiatric
setting.
Overview/Details:
Patients who are placed in seclusion while admitted to a hospital-based inpatient

psychiatric setting.
Rationale:
The use of seclusion and restraint is limited to situations that may present imminent
danger to either the patient and/or staff. The use of seclusion is rigorously monitored
and analyzed to prevent future restraint/seclusion use and to prevent harm.
Psychiatric units
Measure Name: Hours of seclusion
Numerator: The total number of hours that all psychiatric inpatients were held in
seclusion.

84

$SSURSULDWHQHVV QPS.3 patient *RDO

assessments
(IIHFWLYHQHVV
6DIHW\

85

I-HBIPS-3
Measure Details
Reasons and Implications: The use of seclusion and restraint is limited to situations
that may present imminent danger to either the patient and/or staff. The use of either
restraint or seclusion is rigorously monitored and analyzed to prevent future restraint
use and to prevent harm. Providers also seek to prevent violence or aggression from
occurring in their treatment environments by focusing their attention on prevention
activities that have a growing evidence base.
Numerator: The total number of hours that all psychiatric inpatients were held in
seclusion.
Inclusions to the population: Patients for whom at least one seclusion event is
reported during the month.
Data elements:
x Event Date
x Event Type
x Minutes of Seclusion
Denominator Basis: Per 1,000 hours (psychiatric inpatient)
Data elements:
x Admission Date
x Birthdate
x Psychiatric Care Setting
x Psychiatric Inpatient days
Inclusions to the population: All psychiatric inpatient days

86

I-HBIPS-3
References
x Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of

seclusion and restraint at a public psychiatric hospital. Psychiatric Services.
54(8): 1119-1123.
x Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction
programs and their application in a large, urban, state psychiatric hospital.
Journal of Psychiatric Practice, 9(1), 7-15.
x Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the
use of restraints with children. Journal of Child and Adolescent Psychiatric
Nursing, 14(3), 141- 151.
x Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services,
56 (9), 1104-1142.
x Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A
compendium of strategies created by the American Psychiatric Association
(APA), the American Psychiatric Nurses Association (APNA), the National
Association of Psychiatric Health Systems (NAPHS), and the American Hospital
Association Section for Psychiatric and Substance Abuse Services (AHA).
Retrieved from the Internet on February 10, 2010 at http://www.naphs.org


87

Appendix A
ICD Codes
Table 10.01
Mental Disorders
CMCode
Code Code Code
290.0 SENILE DEMENTIA UNCOMP
290.10 PRESENILE DEMENTIA
290.11 PRESENILE DELIRIUM
290.12 PRESENILE DELUSION
290.13 PRESENILE DEPRESSION
290.20 SENILE DELUSION
290.21 SENILE DEPRESSIVE
290.3 SENILE DELIRIUM
290.40 VASCULAR DEMENTIA,UNCOMP
290.41 VASC DEMENTIA W DELIRIUM
290.42 VASC DEMENTIA W DELUSION
290.43 VASC DEMENTIA W DEPRESSN
290.8 SENILE PSYCHOSIS NEC
290.9 SENILE PSYCHOT COND NOS
291.0 DELIRIUM TREMENS

88

CMCode
Code Code Code
291.1 ALCOHOL AMNESTIC DISORDR
291.2 ALCOHOL PERSIST DEMENTIA
291.3 ALCOH PSY DIS W HALLUCIN
291.4 PATHOLOGIC ALCOHOL INTOX
291.5 ALCOH PSYCH DIS W DELUS
291.81 ALCOHOL WITHDRAWAL
291.82 ALCOH INDUCE SLEEP DISOR
291.89 ALCOHOL MENTAL DISOR NEC
291.9 ALCOHOL MENTAL DISOR NOS
292.0 DRUG WITHDRAWAL
292.11 DRUG PSYCH DISOR W DELUS
292.12 DRUG PSY DIS W HALLUCIN
292.2 PATHOLOGIC DRUG INTOX
292.81 DRUG-INDUCED DELIRIUM
292.82 DRUG PERSISTING DEMENTIA
292.83 DRUG PERSIST AMNESTC DIS
292.84 DRUG-INDUCED MOOD DISORD
292.85 DRUG INDUCED SLEEP DISOR
292.89 DRUG MENTAL DISORDER NEC
292.9 DRUG MENTAL DISORDER NOS
293.0 DELIRIUM D/T OTHER COND
293.1 SUBACUTE DELIRIUM

89

CMCode
Code Code Code
293.81 PSY DIS W DELUS OTH DIS
293.82 PSY DIS W HALLUC OTH DIS
293.83 MOOD DISORDER OTHER DIS
293.84 ANXIETY DISORDER OTH DIS
293.89 TRANSIENT MENTAL DIS NEC
293.9 TRANSIENT MENTAL DIS NOS
294.0 AMNESTIC DISORD OTH DIS
294.10 DEMENTIA W/O BEHAV DIST
294.11 DEMENTIA W BEHAVIOR DIST
294.8 MENTAL DISOR NEC OTH DIS
294.9 MENTAL DISOR NOS OTH DIS
295.00 SIMPL SCHIZOPHREN-UNSPEC
295.01 SIMPL SCHIZOPHREN-SUBCHR
295.02 SIMPLE SCHIZOPHREN-CHR
295.03 SIMP SCHIZ-SUBCHR/EXACER
295.04 SIMPL SCHIZO-CHR/EXACERB
295.05 SIMPL SCHIZOPHREN-REMISS
295.10 HEBEPHRENIA-UNSPEC
295.11 HEBEPHRENIA-SUBCHRONIC
295.12 HEBEPHRENIA-CHRONIC
295.13 HEBEPHREN-SUBCHR/EXACERB
295.14 HEBEPHRENIA-CHR/EXACERB

90

CMCode
Code Code Code
295.15 HEBEPHRENIA-REMISSION
295.20 CATATONIA-UNSPEC
295.21 CATATONIA-SUBCHRONIC
295.22 CATATONIA-CHRONIC
295.23 CATATONIA-SUBCHR/EXACERB
295.24 CATATONIA-CHR/EXACERB
295.25 CATATONIA-REMISSION
295.30 PARANOID SCHIZO-UNSPEC
295.31 PARANOID SCHIZO-SUBCHR
295.32 PARANOID SCHIZO-CHRONIC
295.33 PARAN SCHIZO-SUBCHR/EXAC
295.34 PARAN SCHIZO-CHR/EXACERB
295.35 PARANOID SCHIZO-REMISS
295.40 SCHIZOPHRENIFORM DIS NOS
295.41 SCHIZOPHRENIC DIS-SUBCHR
295.42 SCHIZOPHREN DIS-CHRONIC
295.43 SCHIZO DIS-SUBCHR/EXACER
295.44 SCHIZOPHR DIS-CHR/EXACER
295.45 SCHIZOPHRENIC DIS-REMISS
295.50 LATENT SCHIZOPHREN-UNSP
295.51 LAT SCHIZOPHREN-SUBCHR
295.52 LATENT SCHIZOPHREN-CHR

91

CMCode
Code Code Code
295.53 LAT SCHIZO-SUBCHR/EXACER
295.54 LATENT SCHIZO-CHR/EXACER
295.55 LAT SCHIZOPHREN-REMISS
295.60 SCHIZOPHR DIS RESID NOS
295.61 SCHIZOPH DIS RESID-SUBCH
295.62 SCHIZOPHR DIS RESID-CHR
295.63 SCHIZO RESID SUBCHR/EXAC
295.64 SCHIZOPH RESID-CHRO/EXAC
295.65 SCHIZOPH DIS RESID-REMIS
295.70 SCHIZOAFFECTIVE DIS NOS
295.71 SCHIZOAFFECTV DIS-SUBCHR
295.72 SCHIZOAFFECTIVE DIS-CHR
295.73 SCHIZOAFF DIS-SUBCH/EXAC
295.74 SCHIZOAFFTV DIS-CHR/EXAC
295.75 SCHIZOAFFECTVE DIS-REMIS
295.80 SCHIZOPHRENIA NEC-UNSPEC
295.81 SCHIZOPHRENIA NEC-SUBCHR
295.82 SCHIZOPHRENIA NEC-CHR
295.83 SCHIZO NEC-SUBCHR/EXACER
295.84 SCHIZO NEC-CHR/EXACERB
295.85 SCHIZOPHRENIA NEC-REMISS
295.90 SCHIZOPHRENIA NOS-UNSPEC

92

CMCode
Code Code Code
295.91 SCHIZOPHRENIA NOS-SUBCHR
295.92 SCHIZOPHRENIA NOS-CHR
295.93 SCHIZO NOS-SUBCHR/EXACER
295.94 SCHIZO NOS-CHR/EXACERB
295.95 SCHIZOPHRENIA NOS-REMISS
296.00 BIPOL I SINGLE MANIC NOS
296.01 BIPOL I SINGLE MANC-MILD
296.02 BIPOL I SINGLE MANIC-MOD
296.03 BIPOL I SING-SEV W/O PSY
296.04 BIPO I SIN MAN-SEV W PSY
296.05 BIPOL I SING MAN REM NOS
296.06 BIPOL I SINGLE MANIC REM
296.10 RECUR MANIC DIS-UNSPEC
296.11 RECUR MANIC DIS-MILD
296.12 RECUR MANIC DIS-MOD
296.13 RECUR MANIC DIS-SEVERE
296.14 RECUR MANIC-SEV W PSYCHO
296.15 RECUR MANIC-PART REMISS
296.16 RECUR MANIC-FULL REMISS
296.20 DEPRESS PSYCHOSIS-UNSPEC
296.21 DEPRESS PSYCHOSIS-MILD
296.22 DEPRESSIVE PSYCHOSIS-MOD

93

CMCode
Code Code Code
296.23 DEPRESS PSYCHOSIS-SEVERE
296.24 DEPR PSYCHOS-SEV W PSYCH
296.25 DEPR PSYCHOS-PART REMISS
296.26 DEPR PSYCHOS-FULL REMISS
296.30 RECURR DEPR PSYCHOS-UNSP
296.31 RECURR DEPR PSYCHOS-MILD
296.32 RECURR DEPR PSYCHOS-MOD
296.33 RECUR DEPR PSYCH-SEVERE
296.34 REC DEPR PSYCH-PSYCHOTIC
296.35 RECUR DEPR PSYC-PART REM
296.36 RECUR DEPR PSYC-FULL REM
296.40 BIPOL I CURRNT MANIC NOS
296.41 BIPOL I CURNT MANIC-MILD
296.42 BIPOL I CURRNT MANIC-MOD
296.43 BIPOL I MANC-SEV W/O PSY
296.44 BIPOL I MANIC-SEV W PSY
296.45 BIPOL I CUR MAN PART REM
296.46 BIPOL I CUR MAN FULL REM
296.50 BIPOL I CUR DEPRES NOS
296.51 BIPOL I CUR DEPRESS-MILD
296.52 BIPOL I CUR DEPRESS-MOD
296.53 BIPOL I CURR DEP W/O PSY

94

CMCode
Code Code Code
296.54 BIPOL I CURRNT DEP W PSY
296.55 BIPOL I CUR DEP REM NOS
296.56 BIPOL I CURRNT DEP REMIS
296.60 BIPOL I CURRNT MIXED NOS
296.61 BIPOL I CURRNT MIX-MILD
296.62 BIPOL I CURRNT MIXED-MOD
296.63 BIPOL I CUR MIX W/O PSY
296.64 BIPOL I CUR MIXED W PSY
296.65 BIPOL I CUR MIX-PART REM
296.66 BIPOL I CUR MIXED REMISS
296.7 BIPOLOR I CURRENT NOS
296.80 BIPOLAR DISORDER NOS
296.81 ATYPICAL MANIC DISORDER
296.82 ATYPICAL DEPRESSIVE DIS
296.89 BIPOLAR DISORDER NEC
296.90 EPISODIC MOOD DISORD NOS
296.99 EPISODIC MOOD DISORD NEC
297.0 PARANOID STATE, SIMPLE
297.1 DELUSIONAL DISORDER
297.2 PARAPHRENIA
297.3 SHARED PSYCHOTIC DISORD
297.8 PARANOID STATES NEC

95

CMCode
Code Code Code
297.9 PARANOID STATE NOS
298.0 REACT DEPRESS PSYCHOSIS
298.1 EXCITATIV TYPE PSYCHOSIS
298.2 REACTIVE CONFUSION
298.3 ACUTE PARANOID REACTION
298.4 PSYCHOGEN PARANOID PSYCH
298.8 REACT PSYCHOSIS NEC/NOS
298.9 PSYCHOSIS NOS
299.00 AUTISTIC DISORD-CURRENT
299.01 AUTISTIC DISORD-RESIDUAL
299.10 CHILDHD DISINTEGR-ACTIVE
299.11 CHILDHD DISINTEGR-RESID
299.80 PERVASV DEV DIS-CUR NEC
299.81 PERVASV DEV DIS-RES NEC
299.90 PERVASV DEV DIS-CUR NOS
299.91 PERVASV DEV DIS-RES NOS
300.00 ANXIETY STATE NOS
300.01 PANIC DIS W/O AGORPHOBIA
300.02 GENERALIZED ANXIETY DIS
300.09 ANXIETY STATE NEC
300.10 HYSTERIA NOS
300.11 CONVERSION DISORDER

96

CMCode
Code Code Code
300.12 DISSOCIATIVE AMNESIA
300.13 DISSOCIATIVE FUGUE
300.14 DISSOCIATVE IDENTITY DIS
300.15 DISSOCIATIVE REACT NOS
300.16 FACTITIOUS DIS W SYMPTOM
300.19 FACTITIOUS ILL NEC/NOS
300.20 PHOBIA NOS
300.21 AGORAPHOBIA W PANIC DIS
300.22 AGORAPHOBIA W/O PANIC
300.23 SOCIAL PHOBIA
300.29 ISOLATED/SPEC PHOBIA NEC
300.3 OBSESSIVE-COMPULSIVE DIS
300.4 DYSTHYMIC DISORDER
300.5 NEURASTHENIA
300.6 DEPERSONALIZATION DISORD
300.7 HYPOCHONDRIASIS
300.81 SOMATIZATION DISORDER
300.82 UNDIFF SOMATOFORM DISRDR
300.89 SOMATOFORM DISORDERS NEC
300.9 NONPSYCHOTIC DISORD NOS
301.0 PARANOID PERSONALITY
301.10 AFFECTIV PERSONALITY NOS

97

CMCode
Code Code Code
301.11 CHRONIC HYPOMANIC PERSON
301.12 CHR DEPRESSIVE PERSON
301.13 CYCLOTHYMIC DISORDER
301.20 SCHIZOID PERSONALITY NOS
301.21 INTROVERTED PERSONALITY
301.22 SCHIZOTYPAL PERSON DIS
301.3 EXPLOSIVE PERSONALITY
301.4 OBSESSIVE-COMPULSIVE DIS
301.50 HISTRIONIC PERSON NOS
301.51 CHR FACTITIOUS ILLNESS
301.59 HISTRIONIC PERSON NEC
301.6 DEPENDENT PERSONALITY
301.7 ANTISOCIAL PERSONALITY
301.81 NARCISSISTIC PERSONALITY
301.82 AVOIDANT PERSONALITY DIS
301.83 BORDERLINE PERSONALITY
301.84 PASSIVE-AGGRESSIV PERSON
301.89 PERSONALITY DISORDER NEC
301.9 PERSONALITY DISORDER NOS
302.0 EGO-DYSTONIC SEX ORIENT
302.1 ZOOPHILIA
302.2 PEDOPHILIA

98

CMCode
Code Code Code
302.3 TRANSVESTIC FETISHISM
302.4 EXHIBITIONISM
302.50 TRANS-SEXUALISM NOS
302.51 TRANS-SEXUALISM, ASEXUAL
302.52 TRANS-SEXUAL, HOMOSEXUAL
302.53 TRANS-SEX, HETEROSEXUAL
302.6 GENDR IDENTITY DIS-CHILD
302.70 PSYCHOSEXUAL DYSFUNC NOS
302.71 HYPOACTIVE SEX DESIRE
302.72 INHIBITED SEX EXCITEMENT
302.73 FEMALE ORGASMIC DISORDER
302.74 MALE ORGASMIC DISORDER
302.75 PREMATURE EJACULATION
302.76 DYSPAREUNIA, PSYCHOGENIC
302.79 PSYCHOSEXUAL DYSFUNC NEC
302.81 FETISHISM
302.82 VOYEURISM
302.83 SEXUAL MASOCHISM
302.84 SEXUAL SADISM
302.85 GEND IDEN DIS, ADOL/ADULT
302.89 PSYCHOSEXUAL DIS NEC
302.9 PSYCHOSEXUAL DIS NOS

99

CMCode
Code Code Code
306.0 PSYCHOGEN MUSCULSKEL DIS
306.1 PSYCHOGENIC RESPIR DIS
306.2 PSYCHOGEN CARDIOVASC DIS
306.3 PSYCHOGENIC SKIN DISEASE
306.4 PSYCHOGENIC GI DISEASE
306.50 PSYCHOGENIC GU DIS NOS
306.51 PSYCHOGENIC VAGINISMUS
306.52 PSYCHOGENIC DYSMENORRHEA
306.53 PSYCHOGENIC DYSURIA
306.59 PSYCHOGENIC GU DIS NEC
306.6 PSYCHOGEN ENDOCRINE DIS
306.7 PSYCHOGENIC SENSORY DIS
306.8 PSYCHOGENIC DISORDER NEC
306.9 PSYCHOGENIC DISORDER NOS
307.0 STUTTERING
307.1 ANOREXIA NERVOSA
307.20 TIC DISORDER NOS
307.21 TRANSIENT TIC DISORDER
307.22 CHR MOTOR/VOCAL TIC DIS
307.23 TOURETTE'S DISORDER
307.3 STEREOTYPIC MOVEMENT DIS
307.40 NONORGANIC SLEEP DIS NOS

100

CMCode
Code Code Code
307.41 TRANSIENT INSOMNIA
307.42 PERSISTENT INSOMNIA
307.43 TRANSIENT HYPERSOMNIA
307.44 PERSISTENT HYPERSOMNIA
307.45 NONORGANIC CIRCADIAN RHY
307.46 SLEEP AROUSAL DISORDER
307.47 SLEEP STAGE DYSFUNC NEC
307.48 REPETIT SLEEP INTRUSION
307.49 NONORGANIC SLEEP DIS NEC
307.50 EATING DISORDER NOS
307.51 BULIMIA NERVOSA
307.52 PICA
307.53 RUMINATION DISORDER
307.54 PSYCHOGENIC VOMITING
307.59 EATING DISORDER NEC
307.6 ENURESIS
307.7 ENCOPRESIS
307.80 PSYCHOGENIC PAIN NOS
307.81 TENSION HEADACHE
307.89 PSYCHOGENIC PAIN NEC
307.9 SPECIAL SYMPTOM NEC/NOS
308.0 STRESS REACT, EMOTIONAL

101

CMCode
Code Code Code
308.1 STRESS REACTION, FUGUE
308.2 STRESS REACT, PSYCHOMOT
308.3 ACUTE STRESS REACT NEC
308.4 STRESS REACT, MIXED DIS
308.9 ACUTE STRESS REACT NOS
309.0 ADJUSTMNT DIS W DEPRESSN
309.1 PROLONG DEPRESSIVE REACT
309.21 SEPARATION ANXIETY
309.22 EMANCIPATION DISORDER
309.23 ACADEMIC/WORK INHIBITION
309.24 ADJUSTMENT DIS W ANXIETY
309.28 ADJUST DIS W ANXIETY/DEP
309.29 ADJ REACT-EMOTION NEC
309.3 ADJUST DISOR/DIS CONDUCT
309.4 ADJ DIS-EMOTION/CONDUCT
309.81 POSTTRAUMATIC STRESS DIS
309.82 ADJUST REACT-PHYS SYMPT
309.83 ADJUST REACT-WITHDRAWAL
309.89 ADJUSTMENT REACTION NEC
309.9 ADJUSTMENT REACTION NOS
310.0 FRONTAL LOBE SYNDROME
310.1 PERSONALITY CHG OTH DIS

102

CMCode
Code Code Code
310.2 POSTCONCUSSION SYNDROME
310.8 NONPSYCHOT BRAIN SYN NEC
310.9 NONPSYCHOT BRAIN SYN NOS
311 DEPRESSIVE DISORDER NEC
312.00 UNSOCIAL AGGRESS-UNSPEC
312.01 UNSOCIAL AGGRESSION-MILD
312.02 UNSOCIAL AGGRESSION-MOD
312.03 UNSOCIAL AGGRESS-SEVERE
312.10 UNSOCIAL UNAGGRESS-UNSP
312.11 UNSOCIAL UNAGGRESS-MILD
312.12 UNSOCIAL UNAGGRESS-MOD
312.13 UNSOCIAL UNAGGR-SEVERE
312.20 SOCIAL CONDUCT DIS-UNSP
312.21 SOCIAL CONDUCT DIS-MILD
312.22 SOCIAL CONDUCT DIS-MOD
312.23 SOCIAL CONDUCT DIS-SEV
312.30 IMPULSE CONTROL DIS NOS
312.31 PATHOLOGICAL GAMBLING
312.32 KLEPTOMANIA
312.33 PYROMANIA
312.34 INTERMITT EXPLOSIVE DIS
312.35 ISOLATED EXPLOSIVE DIS

103

CMCode
Code Code Code
312.39 IMPULSE CONTROL DIS NEC
312.4 MIX DIS CONDUCT/EMOTION
312.81 CNDCT DSRDR CHLDHD ONST
312.82 CNDCT DSRDR ADLSCNT ONST
312.89 OTHER CONDUCT DISORDER
312.9 CONDUCT DISTURBANCE NOS
313.0 OVERANXIOUS DISORDER
313.1 MISERY & UNHAPPINESS DIS
313.21 SHYNESS DISORDER-CHILD
313.22 INTROVERTED DIS-CHILD
313.23 SELECTIVE MUTISM
313.3 RELATIONSHIP PROBLEMS
313.81 OPPOSITION DEFIANT DISOR
313.82 IDENTITY DISORDER
313.83 ACADEMIC UNDERACHIEVMENT
313.89 EMOTIONAL DIS CHILD NEC
313.9 EMOTIONAL DIS CHILD NOS
314.00 ATTN DEFIC NONHYPERACT
314.01 ATTN DEFICIT W HYPERACT
314.1 HYPERKINET W DEVEL DELAY
314.2 HYPERKINETIC CONDUCT DIS
314.8 OTHER HYPERKINETIC SYND

104

CMCode
Code Code Code
314.9 HYPERKINETIC SYND NOS
315.00 READING DISORDER NOS
315.01 ALEXIA
315.02 DEVELOPMENTAL DYSLEXIA
315.09 READING DISORDER NEC
315.1 MATHEMATICS DISORDER
315.2 OTH LEARNING DIFFICULTY
315.31 EXPRESSIVE LANGUAGE DIS
315.32 RECP-EXPRES LANGUAGE DIS
315.34 SPEECHDEL D/T HEAR LOSS
315.39 SPEECH/LANGUAGE DIS NEC
315.4 DEVEL COORDINATION DIS
315.5 MIXED DEVELOPMENT DIS
315.8 DEVELOPMENT DELAYS NEC
315.9 DEVELOPMENT DELAY NOS
316 PSYCHIC FACTOR W OTH DIS
317 MILD MENTAL RETARDATION
318.0 MOD MENTAL RETARDATION
318.1 SEVERE MENTAL RETARDAT
318.2 PROFOUND MENTAL RETARDAT
319 MENTAL RETARDATION NOS

105

Nursing Sensitive
Care (NSC)
Measure Set

106

Measure
Nursing-Sensitive Care (NSC)
Originally developed by the National Quality Forum (NQF)

Patients that have hospital-acquired (nosocomial) pressure ulcer(s)
(category/stage II) on the day of the prevalence study. Note: Please
I-NSC-2 see Appendix E for details on how to collect this measure.
All documented falls with or without injury, experienced by patients in
I-NSC-4 a calendar month.
All documented falls by a patient with an injury level of minor (2) or
I-NSC-5 greater.

107

I-NSC-2
Pressure Ulcer Prevalence (Hospital-Acquired)
Measure Overview
I-NSC 2 Patients that have hospital-acquired (nosocomial) pressure ulcer(s)

(category/stage II) on the day of the prevalence study.
Overview/Details:
The total number of patients that have hospital-acquired (nosocomial) category/stage II

or greater pressure ulcer(s) on the day of the prevalence study.
Note: Please see Attachment E for details on how to collect this measure.
Rationale: The incidence of hospitalized patients developing pressure ulcers has been
reported to range from 2.7 percent to 29.5 percent in various clinical studies. Certain
circumstances (e.g., immobility, incontinence, impaired nutritional status ,critical illness,
etc.) further increase the risk for selected patients. The development of hospital
acquired pressure ulcers (HAPU) places the patient at risk for other adverse events and
may lead to increased lengths of stay. HAPUs also increase resource consumption and
costs. In most vulnerable patients, reducing risk factors and implementing
preventive/treatment measures will reduce the incidence of new pressure ulcer
development and prevent the worsening of existing ulcers. Recommendations from the
clinical guidelines include the individuals at risk and early intervention with a goal of
maintaining and improving tissue tolerance in order to prevent injury. In most vulnerable
patients, reducing risk factors and implementing preventive/treatment measures will
reduce the incidence of new pressure ulcer development and prevent the worsening of
existing ulcers. Nurses and nursing-care interventions play an important role in
pressure ulcer prevention and management. The use of this prevalence measure allows
organizations to monitor this important patient outcome at points in time and examine
institutional processes.

Improvement noted as: A decrease in rate

108

Patient Settings/Services:
Medical/surgical units
Intensive Care units/Critical care units
Measure Name: Pressure Ulcer Prevalence (Hospital-Acquired)
Numerator: Patients that have at least one category/stage II or greater

hospital-acquired pressure ulcer(s) on the day of the prevalence study.
Denominator: All patients surveyed for the study who are > = 18 years.

assessments
&RQWLQXLW\ 6WURNH
(IIHFWLYHQHVV &.'
QPS.3 infection,
3UHYHQWLRQ(DUO\ Detection prevention and 'LDEHWHV7\SH,,,
7LPHOLQHVV control, surveillance (65'

and reporting
7Uaumatic Brain Injury
+,9$,'6
&DQFHU
&23'

109

I-NSC-2
Measure Details
Reasons and Implications: Certain circumstances (e.g., immobility, incontinence,

impaired nutritional status, critical illness, etc.) further increase the risk for selected
patients. The development of hospital acquired pressure ulcers (HAPU) places the
patient at risk for other adverse events and may lead to increased lengths of stay. In
most vulnerable patients, reducing risk factors and implementing preventive/treatment
measures will reduce the incidence of new pressure ulcer development and prevent the
worsening of existing ulcers. Recommendations from the clinical guidelines include
identifying the individuals at risk and early intervention with a goal of maintaining and
improving tissue tolerance in order to prevent injury. In most vulnerable patients,
reducing risk factors and implementing preventive/ treatment measures will reduce the
incidence of new pressure ulcer development and prevent the worsening of existing
ulcers. Nurses and nursing-care interventions play an important role in pressure ulcer
prevention and management. The use of this prevalence measure allows organizations
to monitor this important patient outcome at points in time and examine institutional
processes.
Data Collection:
Concurrent for observed data elements (pressure ulcer).
Numerator: Patients that have at least one category/stage II or greater

hospital-acquired pressure ulcer(s) on the day of the prevalence study.
Inclusions to the population: Hospital-acquired pressure ulcers (ulcers discovered or

documented after the first 24 hours from the time of inpatient admission)
x Category/stage II or greater pressure ulcers

x Unstageable/unclassified pressure ulcers
x Suspected deep tissue injury
Data elements:
x Observed Pressure Ulcer

x Observed Pressure Ulcer Hospital-Acquired
x Observed Pressure Ulcer Category/stage

110

Denominator: All patients surveyed for the study who are > = 18 years.
Data elements:
x Admission Date
x Birthdate
x Sex
x Type of unit

x Patients who refuse to be assessed
x Patients who are off the unit at the time of the prevalence study, i.e.
surgery, x-ray, physical therapy, etc.
x Patients who are medically unstable at the time of the study for whom
assessment would be contraindicated at the time of the study, i.e., unstable
blood pressure, uncontrolled pain, or fracture waiting repair.
x Patients who are actively dying and pressure ulcer prevention is no longer a
treatment goal.

111

I-NSC-2
References
x AHRQ, Agency for Healthcare Quality and Research (2006). Numbers of patients
with pressure sores increasing. ttp://hcup.ahrq.gov/HCUPnet.asp
x Allman, R. (1997). Pressure ulcer prelavence, incidence and risk factors and
impact. Clinics in Geriatric Medicine, 13(3), 421-436.
x Allman, R. (2001). Pressure ulcers: Using what we know to improve quality of
care. Journal of the American Geriatric Society, 49, 996-997.
x Allman, R., Goode, P., Burst, N., Bartolucci, A., & Thomas, D. (1999) Pressure
ulcer, hospital complications, and disease severity: Impact on hospital costs and
length of stay. Advances in Wound Care, 12(1), 22-30.
x Anderson, C. & Rappl, L. (2004). Lateral rotation mattresses for wound healing.
Ostomy/Wound Management, 50(4), 50-62.
x Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B,
Holmes JH, Abbuhl SB, Kavesh W, Ruffin A. Pressure ulcers among elderly
patients early in the hospital stay. J Gerontol A Biol Sci Med Sci. 2006
Jul;61(7):749-54.
x Black J, Baharestani M, Cuddigan J, Dorner B, Edsberg L, Langemo D,
Posthauer ME, Ratliff C, Taler G; National Pressure Ulcer Advisory
Panel.National Pressure Ulcer Advisory Panel's updated pressure ulcer
staging/categorizing system. Dermatol Nurs. 2007 Aug;19(4):343-9; quiz 350.
x Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: An
update on this easy-to-XVHWRROWKDWDVVHVVHVDSDWLHQWVULVN$P-1XUV
2005;105:70-72.
x Dale, M.C., Burns, A., Panter, L., & Morris, J. (2001). Factors affecting survival of
elderly nursing home residents. Internal Journal of Geriatric Psychiatry. 16, 70-
76.
x European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel. Prevention and treatment of pressure ulcers: quick reference guide.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.
x Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk
factors for pressure ulcers in acute care hospitals. Wound Repair Regen. 2008
Jan- Feb;16(1):11-8.
x Hart S, Bergquist S, Gajewski B, Dunton N. Reliability testing of the National
Database of Nursing Quality Indicators pressure ulcer indicator. J Nurs Care
Qual. 2006 Jul-Sep;21(3):256-65.
x Hopkins, A., Dealey, C., Bale, S., Defloor, T., & Worboys, F. (2006). Patient
stories of living with a pressure ulcer. Journal of Advanced Nursing, 56(4), 345-
353.

112

x Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, Cook AS,
Sharkey SS, Voss AC. The National Pressure Ulcer Long-Term Care
Study:pressure ulcer development in long-term care residents. J Am Geriatr Soc.
2004 Mar;52(3):359-67.
x IOM (Institute of Medicine) (1999). To error is human: Building a safer health
system. Washington D.C: National Academy of Sciences.
x Kottner J, Tannen A, Halfens R, Dassen T.Does the number of raters influence
the pressure ulcer prevalence rate? Appl Nurs Res. 2009 Feb;22(1):68-72.
x Langemo, K.K., Melland, H., Hanson, K., Olson, B., & Hunter, S. (2000). The
lived experience of having a pressure ulcer: A qualitative analysis. Advances in
Skin and Wound Care, 13(5), 225-235.
x Maklebust, J. (2005). Pressure ulcers: The great insult. Nursing Clinics of North
America, 40, 365-389.
x Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C.
Risk assessment scales for pressure ulcer prevention: a systematic review. J
Adv Nurs. 2006 Apr;54(1):94-110.
x Pressure Ulcers in Adults: Prediction and Prevention (AHCPR, 1992). URL:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409
x Adults: Prediction and Prevention. Clinical Practice
Guideline Number 3. AHCPR Pub. No. 92-0047:May 1992
x Rastinehad, D. (2006). Pressure ulcer pain. Journal of Wound, Ostomy &
Continence Nursing, 33, 252-257.
x Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA.Treatment of
pressure ulcers: a systematic review. JAMA. 2008 Dec 10;300(22):2647-62.
x Redelings, M.D., Lee, N.E., Sorvillo, F. (2005). Pressure ulcers: More lethal than
we thought? Advances in Skin and Wound Care, 18, 367-372.
x Stechmiller JK, Cowan L, Whitney JD, Phillips L, Aslam R, Barbul A, Gottrup
F,Gould L, Robson MC, Rodeheaver G, Thomas D, Stotts N. Guidelines for the
prevention of pressure ulcers. Wound Repair Regen. 2008 Mar-Apr;16(2):151-
68.
x Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, Robson
x MC,Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pressure
ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):663-79.
x Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year
sequential acute care data. Adv Skin Wound Care. 2004 Nov-Dec;17(9):490-4
x Wound, Ostomy and Continence Nurses Society. (2003) Guideline for Prevention
and Management of Pressure Ulcers. WOCN: Glenview, IL
x Zulkowski, K., Langemo, D., Posthauer, M.E., & the National Pressure Ulcer
Advisory Panel. (2005). Coming to consensus on deep tissue injury. Advances in
Skin & Wound Care, 18(1), 28-29.

113

I-NSC-4
Patient Falls
Measure Overview
I-NSC 4 All documented falls with or without injury, experienced by patients in a

calendar month.
Overview/Details:
All documented falls with or without injury, experienced by patients in a calendar month.
Rationale: Patient falls occurring during hospitalization can result in serious and even
potentially life threatening consequences for many patients. Efforts to reduce this
adverse event have included the development of tools to assess and identify patients at
risk of falling and the implementation of fall prevention protocols. More recently,
research has suggested that staffing on patient care units, specifically the number of
professional nurses, may impact the incidence of this patient outcome. Nurses are
responsible for identifying patients who are at risk for falls and for developing a plan of
care to minimize that risk. High performance measure rates may suggest the need to
examine clinical and organizational processes related to the identification of, and care
for, patients at risk of falling, and possibly staffing effectiveness on the unit.

Measure Name: Patient Falls
Numerator: Total number of patient falls (with or without injury to the

patient) during the calendar month.
Denominator: Patient days by Type of Unit during the calendar month.


114

Domains of QPS CCPC IPSG

Performance
Standards

assessments
&RQWLQXLW\ 6WURNH
(IIHFWLYHQHVV &.'
3UHYHQWLRQ(DUO\ 'LDEHWHV7\SH,,,

Detection
(65'
6DIHW\
7UDXPDWLF%UDLQ,QMXU\
+,9$,'6
&DQFHU
&23'

115

I-NSC-4
Measure Details
Reasons and Implications: Patient falls occurring during hospitalization can result in
serious and even potentially life threatening consequences for many patients. Efforts to
reduce this adverse event have included the development of tools to assess and identify
patients at risk of falling and the implementation of fall prevention protocols. More
recently, research has suggested that staffing on patient care units, specifically the
number of professional nurses, may impact the incidence of this patient outcome.
Nurses are responsible for identifying patients who are at risk for falls and for developing
a plan of care to minimize that risk. High performance measure rates may suggest the
need to examine clinical and organizational processes related to the identification of, and
care for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Numerator: Total number of patient falls (with or without injury to the (patient) during the
calendar month.
Inclusions to the population:

x Patient falls occurring while on an eligible reporting unit
x Assisted falls
x Repeat falls
Exclusions to the population: Falls by:

x Visitors
x Students
x Staff members
x Patients from eligible reporting units, however patient was not on unit at
time of fall (e.g., patients falls in radiology department)
x Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)
Data elements:
x Month
x Number of Injury Falls
x Type of Unit
x Year

116

Denominator Statement: Patient days by Type of Unit during the calendar month.
Included Populations:
x Inpatients, short stay patients, observation patients and same day surgery
patients who receive care on eligible in-patient units for all or part of a day.
x Adult critical care, step-down, medical, surgical, medical-surgical
combined, and mixed acuity units.
x Any age patient on an eligible reporting unit is included in the patient day count.
Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc)
Data Elements:
x Month
x Patient Days
x Type of Unit
x Year

117

I-NSC-4
References
x American Nurses Association. National Database of Nursing Quality Indicators.

(NDNQI) ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington, DC. American Nurses Publishing. 1996.
x Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic
Value of Professional Nursing. Medical Care 47(1): 97-104.
x Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on
acute care hospital units. Nursing Outlook. 2004; 53:53-59.
x Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality
of care on nursing units. Nursing Management.
x Dunton, N., Gajewski, B., Klaus, S., Pierson, B. (2007). The relationship of
nursing workforce characteristics to patient outcomes. OJIN: Online Journal of
Issues in Nursing, 12(3), Manuscript 4.
x Hendrich, A.L., Bender, P.S. & Myhuis, A. Validation of the Hendrich II fall risk
model: a large concurrent case/control study of hospitalized patients. Applied
Nursing Research. 2005 (16(1)): 9-12.
x McCollam, M.E. Evaluation and Implementation of a research-based falls
assessment innovation. Nursing Clinics of North America. 1995;30(3):507-514.
x Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone
patient. Canadian Journal of Aging. 1989; (8):366-377.
x Savitz, Lucy A., Jones, Cheryl B., Bernard, Shulamit. Advances in Patient Safety:
From Research to Implementation Advances in Patient Safety: From Research to
Implementation Volume 4. Programs, Tools, and Products Quality Indicators
Sensitive to Nurse Staffing in Acute Care Settings. 2005.
x Schmid, N. A. 1989 Federal Nursing Service Award Winner. Reducing patient
falls: a research-based comprehensive fall prevention program. Military Medicine.
1990; 155(5):202-207.
x Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care.
2003; 41(1):142-152.
x Yang KP. Relationships between nurse staffing and patient outcomes. Journal of
Nursing Research. 2003; 11(3):149-158.

118

I-NSC-5
Patient Falls with Injury
Measure Overview
I-NSC 5 All documented falls by a patient with an injury level of minor (2) or
greater.
Overview/Details:
All documented falls with a minor (2) or greater injury level
1. None - patient had no injuries

2. Minor - resulted in application of a dressing, ice, cleaning of a wound, limb
elevation, topical medication, bruise or abrasion
3. Moderate - resulted in suturing, application of steristrips/skin glue, splinting,
or muscle or joint strain
4. Major - resulted in surgery, casting, traction, fracture, or required consultation
for neurological or internal injury
5. Death - the patient died as a result of injuries sustained from the fall
6. UTD Unable to Determine from the documentation
Rationale: Patient falls occurring during hospitalization can result in serious and even
potentially life threatening consequences for many patients. Nurses are responsible for
identifying patients who are at risk for falls and for developing a plan of care to minimize
that risk. Short staffing, nurse inexperience and inadequate nurse knowledge could
place patients at risk for injury. High performance measure rates may suggest the need
to examine clinical and organizational processes related to the identification of, and care
for, patients at risk of falling, and possibly staffing effectiveness on the unit.


119

Measure Name: Patient Falls with injury
Numerator: Number of patient falls with an injury level of minor or greater during the
calendar month.
Denominator: Patient days by Type of Unit during the calendar month.
Domains of QPS Standards CCPC IPSG

Performance
$SSURSULDWHQHVV QPS.3 patient +) Goal 6

assessments
&RQWLQXLW\ 6WURNH
(IIHFWLYHQHVV &.'

Detection
(65'
6DIHW\
+,9$,'6
&DQFHU
&23'

120

I-NSC-5
Measure Details
Reasons and Implications: Patient falls occurring during hospitalization can result in
serious and even potentially life threatening consequences for many patients. Nurses are
responsible for identifying patients who are at risk for falls and for developing a plan of care
to minimize that risk. Short staffing, nurse inexperience and inadequate nurse knowledge
could place patients at risk for injury. High performance measure rates may suggest the
need to examine clinical and organizational processes related to the identification of, and
care for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Numerator: Number of patient falls with an injury level of minor or greater during the
calendar month
Inclusions to the population:
x Patient falls occurring while on an eligible reporting unit

x Falls with Fall Injury Level RIPLQRU
1. None - patient had no injuries

2. Minor - resulted in application of a dressing, ice, cleaning of a wound, limb
elevation, topical medication, bruise or abrasion
3. Moderate - resulted in suturing, application of steristrips/skin glue,
splinting, or muscle or joint strain
4. Major - resulted in surgery, casting, traction, fracture, or
required consultation for neurological or internal injury
5. Death - the patient died as a result of injuries sustained from the fall
6. UTD Unable to Determine from the documentation
Exclusions to the population: Falls by:
x Visitors
x Students
x Staff members

121

x Patients from eligible reporting units, however patient was not on unit at
time of fall (e.g., patients falls in radiology department)
x Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)
x Falls with Fall Injury Level RIQRQH
Data elements:
x Number of Injury Falls

x Type of Unit
Denominator Statement: Patient days by Type of Unit during the calendar month.
Included Populations:
x Inpatients, short stay patients, observation patients and same day surgery patients
who receive care on eligible in-patient units for all or part of a day.
x Adult critical care, step-down, medical, surgical, medical-surgical
combined, and mixed acuity units.
Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, and the like)
Data Elements:
x Month
x Patient Days
x Type of Unit
x Year
Data Accuracy:
x ,QMXU\OHYHO-when the initial fall report is written by the nursing staff, the extent of
the injury may not yet be known. A method to follow-XSRQWKHSDWLHQWVFRQGLWLRQDW
least 24 hours later should be established.
x A fall injury level of level of death may be selected only if the fall caused the death of
the patient, not if dying caused the fall.
x Eligible reporting unit(s) will calculate and report fall data by calendar month. In
addition, each unit that reports fall data must also collect patient day data for the
same month in order to calculate fall with injury rates.
x Fall rate is calculated by multiplying the numerator by 1,000 and then dividing by the
denominator.

122

I-NSC-5
References
x American Nurses Association. National Database of Nursing Quality Indicators.

(NDNQI) ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington, DC. American Nurses Publishing. 1996.
x Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic
Value of Professional Nursing. Medical Care 47(1): 97-104.
x Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on
acute care hospital units. Nursing Outlook. 2004; 53:53-59.
x Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality
of care on nursing units. Nursing Management.
x Dunton, N., Gajewski, B., Klaus, S., Pierson, B. (2007). The relationship of
nursing workforce characteristics to patient outcomes. OJIN: Online Journal of
Issues in Nursing, 12(3), Manuscript 4.
x Hendrich, A.L., Bender, P.S. & Myhuis, A. Validation of the Hendrich II fall risk
model: a large concurrent case/control study of hospitalized patients. Applied
Nursing Research. 2005 (16(1)): 9-12.
x McCollam, M.E. Evaluation and Implementation of a research-based falls
assessment innovation. Nursing Clinics of North America. 1995;30(3):507-514.
x Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone
patient. Canadian Journal of Aging. 1989; (8):366-377.
x Savitz, Lucy A., Jones, Cheryl B., Bernard, Shulamit. Advances in Patient Safety:
From Research to Implementation Advances in Patient Safety: From Research to
Implementation Volume 4. Programs, Tools, and Products Quality Indicators
Sensitive to Nurse Staffing in Acute Care Settings. 2005.
x Schmid, N. A. 1989 Federal Nursing Service Award Winner. Reducing patient
falls: a research-based comprehensive fall prevention program. Military Medicine.
1990; 155(5):202-207.
x Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care.
2003; 41(1):142-152.
x Yang KP. Relationships between nurse staffing and patient outcomes. Journal of
Nursing Research. 2003; 11(3):149-158.

123

Appendix E
Nursing Sensitive Care
Prevalence Study Methodology
General Information
The time and staff required to do a prevalence study depends on the size of the hospital
DQGWKHXQLWVDVZHOODVWKHVWXG\WHDPVH[SHULHQFHLQ conducting the observation,
extracting required data elements from the clinical record and documenting the
information. Experienced sites have indicated that the prevalence study process
requires some learning at first and benefits from a core group of staff that is very skilled
in the study area. This greatly improves the validity and reliability of the data. Other
suggestions include the pairing of less experienced staff with experts, in teams, to
provide a rich teaching/learning experience and as a valuable competency development
strategy. It is also important that the study team(s) has (have) at least one
planning/training session prior to the day on which the study is conducted.
For those organizations that are members of a multi-hospital system, it may be

beneficial to consider the development of an expert team to travel between hospitals. In
this way, the expertise and efficiency of the prevalence study is maximized. Another
suggestion is to have sites mentor one another so if this is your organizatLRQVILUVW
prevalence study, consider observing, first hand, another site conduct their prevalence
study. The insight and experience gained can then be applied as your organization
plans and conducts its own first study. Finally, some hospitals have found it convenient
to conduct the pressure ulcer and restraint prevalence studies at the same time.
Prevalence Study Procedures
1) Assign a coordinator
A coordinator should be selected who has organizational, problem-solving and

leadership skills. Responsibilities of the coordinator include communications,
selecting the study date, finalizing the data collection tool, training the data
collectors, managing questions/concerns, and assuring the data are collated. The
coordinator should ensure that all observers are trained in the study methodology
and observation techniques. The coordinator should also monitor Inter-rater
(interobserver) reliability as an important component of data quality assessment.

124

2) Determine Who Will Conduct the Study
a. Pressure Ulcer Prevalence: A combination of exempt nurses with current

clinical skills (e.g., ET nurses, clinical nurse specialists, educators, and unit
managers) and staff nurse experts should be considered for the inspection team.
Chart review may be conducted concurrently by other staff with skill in reading
GRFXPHQWDWLRQ8VLQJDWHDPIRUWKHREVHUYDWLRQSRUWLRQRIWKHVWXG\PD\EH
helpful for conducting skin inspection (e.g., to help turn immobile patients for
inspection). To help decrease the likelihood of bias in observation, consider
assigning observation team members to study units other than their regularly
assigned work unit. Resources required will vary based on the efficiency of the
teams and the amount of data desired by the facility.
b. Restraint Use Prevalence: To help decrease the likelihood of bias in

observation, consider assigning observation team members to study units other
than their regularly assigned work unit. Resources required will vary based on
the efficiency of the teams and the amount of data desired by the facility.
3) Train Those Who Will Conduct the Study
a. Pressure Ulcer Prevalence: Training in skin inspection and pressure ulcer

staging/categorization is required prior to study participation. One option would
be to have an ET nurse or clinical expert organize a training session on the
EPUAP/NPUAP Pressure Ulcer Guidelines.
b. Restraint Use Prevalence: Not applicable.
4) Observation
a. Pressure Ulcer Prevalence: Inspect all bony prominences including the

traditional areas such as the coccyx but also areas such as heels, elbows, ears,
and posterior cranium on bedridden patients. If using teams, be sure one person
is a skin expert. Any pressure ulcers found are staged/categorized and recorded
on the data collection tool. Facilities may opt to also measure/photograph ulcers
for their quality programs.
b. Restraint Use Prevalence: Each patient on the assigned unit is observed (i.e.,
observations are not to be referred by staff for those patients thought to be
restrained).

125

5) Chart Review
a. Pressure Ulcer Prevalence: (DFKSDWLHQWVFKDUWLVDOVRUHYLHZHGIRU

demographic data, documentation relative to risk assessment and, if the Braden
Scale is used, Total and Subscale Scores on admission for all patients with
stage/category I or greater ulcers. Sites may also decide to inspect
documentation related to skin care or other standards. Various other quality
management studies may be combined with the prevalence study and data
specific to those may also be included in the chart review.
b. Restraint Use Prevalence: (DFKSDWLHQWVFKDUWLVDOVRUHYLHZHGIRU

documentation relative to the clinical justification for use of a restraint or sitter.
$GGLWLRQDOLQIRUPDWLRQVXFKDVRWKHULQWHUYHQWLRQVSDWLHQWVFRQGLWLRQDQGOHQJWK
of time in restraints may be useful to collect for additional analysis.
6) Data Collection Tools
a. Pressure Ulcer Prevalence: Data should be recorded (whether or not pressure

ulcers were noted) for each patient whose skin is observed during the prevalence
study. These data include both the patient observation findings and the chart
review findings. If different team members are doing the observing and chart
review, it is helpful to have the data collection tool divided into distinct portions
(each with a patient identifier) and two systems for tracking which patients have
been completed (observers and chart reviewers proceed at different paces).
b. Restraint Use Prevalence: Data should be recorded (whether or not restraints

were noted) for each patient. These data include both the observation findings
and chart review findings. If different team members are doing the observing and
chart review, it is helpful to have the data collection tool divided into distinct
portions (each with a patient identifier) and two systems for tracking which
patients have been completed (observers and chart reviewers proceed at
different paces).
7) Data Submission
a. Pressure Ulcer Prevalence: After the chart review and patient observation
have been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure for internal analysis or following procedures as defined for external
data submission.

126

b. Restraint Use Prevalence: After the chart review and patient observation have
been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure developed for internal analysis or following procedures as defined for
external data submission.
8) Important Notes
a. Definition: A pressure ulcer is localized injury to the skin and/or underlying

tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction. (National Pressure Ulcer Advisory Panel,
NPUAP, 2009)
b. Hospital-acquired pressure ulcers are ulcers discovered or documented after

the first 24 hours from the time of inpatient admission.
c. Skin breakdown due to arterial occlusion, venous insufficiency, diabetes

related neuropathy or incontinence dermatitis are not pressure ulcers and should
not be reported in the prevalence study.
d. Healing/Closed or Healed Pressure Ulcers: Pressure ulcers that are healing

should not be reverse staged; rather they should be staged based on the
maximum anatomic depth of tissue damage that was recorded LQWKHSDWLHQWV
record. Pressure ulcers that have closed/healed are not counted as pressure
ulcers.
e. Patient consent NOT required: A prevalence study is NOT a research study

for which you must obtain patient consent. It is a Quality Improvement activity like
many others in your facility. The examination is the same as the mandatory skin
examinations your nurses perform on a regular basis. Thus all your nurses need
to do is let patients know that you are examining all patients as part of your
quality procedures. Of course, if they absolutely refuse, you do exclude them.
f. Actively dying and medically unstable patients: 7KHWHUPVDFWLYHO\G\LQJ

DQGPHGLFDOO\XQVWDEOHDUHWHUPVXVHGWRFKDUDFWHUL]HSDWLHQWVZho cannot
safely be turned for physiological reasons. Active dying is considered the last few
days of life when blood flow to organs (e.g., brain, heart, kidneys) is decreasing,
respiratory distress is increasing, and physiological instability is apparent, making
WXUQLQJXQUHDOLVWLF0HGLFDOO\XQVWDEOHSHRSOHPD\KDYHSRRUKHPRG\QDPLF
profiles or distress so severe that they cannot safely be turned for examination of
the back, sacrum scapula, ischea, back of head, etc. The nature of the instability

127

will vary e.g., some will require upright position to breathe, others cannot tolerate
movement because of changes in hemodynamics (reduction) or intracranial
pressure (increase).
g. A patient with a very long length of stay, who was surveyed previously, should
be counted and surveyed again as long as they remain a patient in your facility.
h. Mucous membrane ulcers are tissue disruption on mucous membranes due to

ischemic pressure from medical devices. Mucous membranes do not have skin
on them so the staging system for pressure ulcers cannot be used to stage
mucosal pressure ulcers. Do NOT report mucous membrane ulcers.
Source: Collaborative Alliance for Nursing Outcomes (CALNOC)

128

Perinatal Care (PC)

Measure Set

129

Measure
Perinatal Care (PC)

Patients with elective vaginal deliveries or elective cesarean sections at
I-PC-01 >= 37 and < 39 weeks of gestation completed
Nulliparous women with a term, singleton baby in a vertex position

I-PC-02 delivered by cesarean section
Exclusive breast milk feeding during the newborn's entire

I-PC-05 hospitalization

130

I-PC-01
Elective Delivery
Measure Overview
I-PC 01 Patients with elective vaginal deliveries or elective cesarean sections at

>= 37 and < 39 weeks of gestation completed
Overview/Details:
Patients who had an elective vaginal delivery or elective cesarean section performed
at greater than or equal to 37 weeks and less than 39 weeks gestation completed.
Rationale:
Clinical guidelines have had in place a standard requiring 39 completed weeks
gestation prior to ELECTIVE delivery, either vaginal or operative. Studies have
determined that elective delivery or elective cesarean section prior to the gestational
age of 39 weeks may result in significant short term neonatal morbidity (neonatal
intensive care unit admission rates of 13-21%).

Improvement Noted: Decrease in rate
Obstetric/Maternal units
Measure Name: Elective Delivery
Numerator: Patients with elective deliveries
Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation
completed
Appropriateness QPS.3 patient Goal 1

assessments
Effectiveness Goal 4
QPS.3 surgical
procedure
Timeliness

131

I-PC-01
Measure Details
Clinical guidelines have had in place a standard requiring 39 completed weeks

gestation prior to ELECTIVE delivery, either vaginal or operative. Studies have
determined that elective delivery or elective cesarean section prior to the
gestational age of 39 weeks may result in significant short term neonatal
morbidity (neonatal intensive care unit admission rates of 13-21%).
Numerator: Patients with elective deliveries
Inclusions to the population: ICD principal code for one or more of the following:
x Medical induction of labor (Appendix A Table 11.05)
x Cesarean section as defined in Appendix A, Table 11.06 while not in active labor,
or experiencing spontaneous rupture of membranes
Data elements:
x Active Labor
x ICD Principal/Other Procedure code
x Spontaneous Rupture of Membranes
Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation
completed
Data elements:
x Admission Date
x Birthdate
x Gestational age
x ICD principal/other diagnosis code
Inclusions to the population: Not applicable

x ICD Principal Diagnosis code for conditions possibly justifying elective delivery
prior to 39 weeks gestation as defined in Appendix A, Table 11.07
x Patients greater than or equal to 65 years of age

132

I-PC-01
References
x American Academy of Family Physicians. (2000). Tips from Other Journals:

Elective induction doubles cesarean delivery rate, 61, 4.Retrieved December 29,
2008 at: http://www.aafp.org/afp/20000215/tips/39.html.
x American College of Obstetricians and Gynecologists. (November 1996). ACOG
Educational Bulletin.
x Clark, S., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal
and maternal outcomes associated with elective delivery. [Electronic Version].
Am J Obstet Gynecol. 200:156.e1-156.e4.
x Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and
outcomes. [Electronic Version]. J Reprod Med. 50(4):235-40.
x Tita, A., Landon, M., Spong, C., Lai, Y., Leveno, K., Varner, M, et al. (2009).
Timing of elective repeat cesarean delivery at term and neonatal outcomes.
[Electronic Version]. NEJM. 360:2, 111-120.

133

I-PC-02
Cesarean Section
Measure Overview
I-PC 02 Nulliparous women with a term, singleton baby in a vertex position

delivered by cesarean section
Overview/Details:
Patients, during their first pregnancy who presented with a single fetus in a normal
(vertex position) who were delivered by cesarean section at 37 or more weeks of
gestation completed.
Rationale:
Studies have demonstrated that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor admission rates.
Clinical studies have shown if labor was forced when the cervix was not ready, the
outcomes were poorer. Studies have also shown the use of that labor and delivery
guidelines can make a difference in labor outcomes.

Improvement noted: Decrease in rate
Labor and Delivery units
Measure Name: Cesarean Section
Numerator: Patients with cesarean sections
Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex

presentation
Appropriateness QPS.3 patient Goal 1

assessments
Effectiveness Goal 4
Prevention/Early Detection QPS.3 surgical
procedures
Timeliness

134

I-PC-02
Measure Details
Clinical studies found that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor admission
rates. The results have shown if labor was forced when the cervix was not ready,
the outcomes were poorer. Many authors have shown that physician factors,
rather than patient characteristics or obstetric diagnoses are the major driver for
the difference in rates within a hospital.
Data Collection:
Numerator: Patients with cesarean sections
Inclusions to the population: ICD Principal Procedure Code or ICD Other Procedure
Codes for cesarean section as defined in Appendix A, Table 11.06
Data elements:
x ICD principal/other procedure Code
Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex

presentation.
Data elements:
x Admission Date
x Birthdate
x Gestational age
x ICD other diagnosis code
x ICD other procedure code
x ICD procedure code
x Parity

135

Inclusions to the population: Nulliparous patients with ICD Principal Diagnosis Code
or ICD Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table
11.08 and with a delivery of a newborn with 37 weeks or more of gestation completed

x ICD Principal Diagnosis Code or ICD Other Diagnosis Codes, for
contraindications to vaginal delivery as defined in Appendix A, Table 11.09
x Patients greater than or equal to 65 years of age

136

I-PC-02
References
x Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators
Guide to Inpatient Quality Indicators: Quality of Care in HospitalsVolume,
Mortality, and Utilization. Revision 4 (December 22, 2004). AHRQ Pub. No. 02-
RO204.
x Alfirevic, Z., Edwards, G., & Platt, M.J. (2004). The impact of delivery suite
JXLGHOLQHVRQLQWUDSDUWXPFDUHLQVWDQGDUGSULPLJUDYLGD(XU-2EVWHW*\QHFRO
Reprod Biol.115:28-31.
x American College of Obstetricians and Gynecologists. (2000). Task Force on
Cesarean Delivery Rates. Evaluation of Cesarean Delivery. (Developed under
the direction of the Task Force on Cesarean Delivery Rates, Roger K. Freeman,
MD, Chair, Arnold W. Cohen, MD, Richard Depp III, MD, Fredric D. Frigoletto Jr,
MD, Gary D.V. Hankins, MD, Ellice Lieberman, MD, DrPH, M. Kathryn Menard,
MD, David A. Nagey, MD, Carol W. Saffold, MD, Lisa Sams, RNC, MSN and
ACOG Staff: Stanley Zinberg, MD, MS, Debra A. Hawks, MPH, and Elizabeth
Steele).
x Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C. (2002).
Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes.
Am J Obstet Gynecol. 187(3):721-7.
x Bailit, J. & Garrett, J. (2003). Comparison of risk-adjustment methodologies. Am
J Obstet Gynecol.102:45-51. * Bailit, J.L., Love, T.E., & Dawson, N.V. (2006).
Quality of obstetric care and risk-adjusted primary cesarean delivery rates. Am J
Obstet Gynecol.194:402.
x Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob Gyn Sur.
62:207-213.
x Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician
characteristics on the cesarean birth rate. Am J Obstet Gynecol. 161:146-9.
x California Office of Statewide Hospital Planning and Development. (2006).
Utilization Rates for Selected Medical Procedures in California Hospitals,
Retrieved from the Internet on February 11, 2010 at:
http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hos
pIPQualInd/Vol-Util_IndicatorsRpt/2007Util.pdf
x Cleary, R., Beard, R.W., Chapple, J., Coles, J., Griffin, M., & Joffe, M. (1996).
The standard primipara as a basis for inter-unit comparisons of maternity care. Br
J Obstet Gynecol. 103:223-9.
x Coonrod, D.V., Drachman, D., Hobson, P., & Manriquez, M. (2008). Nulliparous
term singleton vertex cesarean delivery rates: institutional and individual level
predictors. Am J Obstet Gynecol. 694-696.

137

x DiGiuseppe, D.L., Aron, D.C., Payne, S.M., Snow, R.J., Dieker, L., & Rosenthal,
G.E. (2001). Risk adjusting cesarean delivery rates: a comparison of hospital
profiles based on medical record and birth certificate data. Health Serv
Res.36:959-77.
x Gould, J., Danielson, B., Korst, L., Phibbs, R., Chance, K.,& Main, E.K., et al.
(2004). Cesarean delivery rate and neonatal morbidity in a low-risk population.
Am J Obstet Gynecol, 104:11-19.
x Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor
in cesarean birth rates. N Engl J Med.320:706-9.
x Le Ray, C., Carayol, M., Zeitlin, J., Berat, G., & Goffinet, F. (2006). Level of
perinatal care of the maternity unit and rate of cesarean in low-risk nulliparas. Am
J Obstet Gynecol. 107:1269-77.
x Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003). Physician
contribution to a cesarean delivery risk model. Am J Obstet Gynecol.188:1579-
85.
x Main, E.K. (1999). Reducing cesarean birth rates with data-driven quality
improvement activities. Peds. 103: 374-383.
x Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale
obstetric quality-improvement program that focused on the nulliparous patient at
term. Am J Obstet Gynecol.190:1747-58.
x Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams, C., et
al., (2006). Is there a useful cesarean birth measure? Assessment of the
nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality
improvement. Am J Obstet Gynecol. 194:1644-51.
x Menacker, F. (2005).Trends in cesarean rates for first births and repeat cesarean
rates for low-risk women: United States, 1990-2003. Nat Vital Stat Rep. 54(4): 1-
5.
x Romano, P.S., Yasmeen, S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M.
(2005). Coding of perineal lacerations and other complications of obstetric care in
hospital discharge data. Am J Obstet Gynecol.106:717-25.
x U.S. Department of Health and Human Services. (2000). Healthy People 2010:
Understanding and Improving Health. 2nd ed. Washington, DC: U.S.
Government Printing Office. Measure 16-9.
x Yasmeen, S., Romano, P.S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M.
(2006). Accuracy of obstetric diagnoses and procedures in hospital discharge
data. Am J Obstet Gynecol. 194:992-1001.

138

I-PC-05
Exclusive Breast Milk Feeding
Measure Overview
I-PC 05 Exclusive breast milk feeding during the newborn's entire

hospitalization
Overview/Details:
([FOXVLYHEUHDVWPLONIHHGLQJGXULQJWKHQHZERUQVHQWLUHKRVSLWDOL]DWLRQ
Rationale:
Exclusive breast milk feeding for the first 6 months of neonatal life has long been the
expressed goal of World Health Organization (WHO) and other authorities of women
and child health care. A recent study substantiates the benefits of exclusively feeding a
newborn infant breast milk.

Labor and Delivery units
Measure Name: Exclusive Breast Milk Feeding
Numerator: Newborns that were fed breast milk only since birth
Denominator: Term newborns discharged from the hospital

Standards
Appropriateness
Prevention/Early
Detection
Timeliness

139

I-PC-05
Measure Details
Exclusive breast milk feeding for the first 6 months of neonatal life has long been the
expressed goal of World Health Organization (WHO) and other authorities of women and
child health care. A recent study substantiates the benefits of exclusively feeding
QHZERUQLQIDQWVEUHDVWPLON
Data Collection:
Numerator: Newborns that were fed breast milk only since birth
Data elements:
x Exclusive Breast Milk Feeding
Denominator: Term newborns discharged from the hospital

.
Data elements:
x Admission Date
x Birthdate
x ICD other diagnosis code
x ICD other procedure code
x ICD procedure code
x Reason for Not Exclusively Feeding Breast Milk
Inclusions to the population: Live-born newborns

x Infants admitted to the Neonatal Intensive Care Unit (NICU) during this
hospitalization
x ICD Principal Diagnosis Code or ICD Other Diagnosis Codes, for galactosemia
Table Appendix A, Table 11.21
x ICD Principal Procedure Code or ICD Other Procedure Codes for parenteral
infusion as defined in Appendix A, Table 11.22
x Newborns who die at birth
x Documented reason for Not Exclusively Feeding Breast Milk

140

I-PC-05
References
x American Academy of Pediatrics. (2005). Section on Breastfeeding. Policy
Statement: Breastfeeding and the Use of Human Milk. Pediatrics.115:496 506.
x American College of Obstetricians and Gynecologists. (Feb. 2007). Committee
on Obstetric Practice and Committee on Health Care for Underserved
Women.Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion
361.
x California Department of Public Health. (2006). Genetic Disease Branch.
California In-Hospital Breastfeeding as Indicated on the Newborn Screening Test
Form, Statewide, County and Hospital of Occurrence: Available at:
http://www.cdph.ca.gov/data/statistics/Pages/BreastfeedingStatistics.aspx.
x Centers for Disease Control and Prevention. (Aug 3, 2007). Breastfeeding trends
and updated national health objectives for exclusive breastfeeding--United States
birth years 2000-2004. MMWR - Morbidity & Mortality Weekly Report.
56(30):760-3.
x Centers for Disease Control and Prevention. (2007). Division of Nutrition,
Physical Activity and Obesity. Breastfeeding Report Card. Available at:
http://www.cdc.gov/breastfeeding/data/report_card2.htm.
x Ip, S., Chung, M., Raman, G., et al. (2007). Breastfeeding and maternal and
infant health outcomes in developed countries. Rockville, MD: US Department of
Health and Human Services. Available at:
http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
x Kramer, M.S. & Kakuma, R. (2002).Optimal duration of exclusive breastfeeding.
[107 refs] Cochrane Database of Systematic Reviews. (1):CD003517.
x Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and one-
month exclusive breastfeeding in association with the in-hospital feeding
modality. Breastfeeding Medicine. 2(2):92-8.
x Shealy, K.R., Li, R., Benton-Davis, S., & Grummer-Strawn, L.M. (2005).The CDC
guide to breastfeeding interventions. Atlanta, GA: US Department of Health and
Human Services, CDC. Available at:
http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf.
x Taveras, E.M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego,
V.H., Miroshnik, I., & Lieu, T.A. (2004). Opinions and practices of clinicians
associated with continuation of exclusive breastfeeding. Pediatrics. 113(4):e283-
90.
x US Department of Health and Human Services. (2007). Healthy People 2010
Midcourse Review. Washington, DC: US Department of Health and Human
Services. Available at: http://www.healthypeople.gov/data/midcourse.
x World Health Organization. (1991). Indicators for assessing breastfeeding
practices. Geneva, Switzerland: World Health Organization. Available at:
http://www.who.int/childadolescenthealth/new_publications/nutrition/who_cdd_se
r_91.14.pdf.

141

Appendix A
Perinatal Care ICD Code Tables
ICD Codes
ICD-8, ICD-9,and ICD-10 spaces have been left intentionally blank. Please fill in
Table 11.05
Medical Induction of Labor Codes
Code Code Code CMCode
73.01 INDUCT LABOR-RUPT MEMB
73.1 SURG INDUCT LABOR NEC
73.4 MEDICAL INDUCTION LABOR
Table 11.06
Cesarean Section
74.0 CLASSICAL C-SECTION
74.1 LOW CERVICAL SECTION
74.2 EXTRAPERITONEAL C-SECTION
74.4 CESAREAN SECTION NEC
74.99 CESAREAN SECTION NOS
Table 11.07
Conditions Justifying Elective Delivery
641.01 PLACENTA PREVIA-DELIVER
641.11 PLACENTA PREV HEM-DELIV
641.21 PREM SEPAR PLACEN-DELIV
641.31 COAG DEF HEMORR-DELIVER
641.81 ANTEPARTUM HEM NEC-DELIV

142

641.91 ANTEPARTUM HEM NOS-DELIV
642.01 ESSEN HYPERTEN-DELIVERED
642.02 ESSEN HYPERTEN-DEL W P/P
642.11 RENAL HYPERTEN PG-DELIV
642.12 RENAL HYPERTEN-DEL P/P
642.21 OLD HYPERTEN NEC-DELIVER
642.22 OLD HYPERTEN-DELIV W P/P
642.31 TRANS HYPERTEN-DELIVERED
642.32 TRANS HYPERTEN-DEL W P/P
642.41 MILD/NOS PREECLAMP-DELIV
642.42 MILD PREECLAMP-DEL W P/P
642.51 SEVERE PREECLAMP-DELIVER
642.52 SEV PREECLAMP-DEL W P/P
642.61 ECLAMPSIA-DELIVERED
642.62 ECLAMPSIA-DELIV W P/P
642.71 TOX W OLD HYPERTEN-DELIV
642.72 TOX W OLD HYP-DEL W P/P
642.91 TOX W OLD HYP-DEL W P/P
642.92 HYPERTENS NOS-DEL W P/P
645.11 POST TERM PREG-DEL
645.21 PROLONGED PREG-DEL
646.21 RENAL DIS NOS-DELIVERED
646.22 RENAL DIS NOS-DEL W P/P
646.71 LIVER DISORDER-DELIVERED
648.02 DIABETES-DELIVERED W P/P
648.51 CONGEN CV DIS-DELIVERED
648.52 CONGEN CV DIS-DEL W P/P
648.61 CV DIS NEC PREG-DELIVER

143

648.62 CV DIS NEC-DELIVER W P/P
648.81 ABN GLUCOSE TOLER-DELIV
648.82 ABN GLUCOSE-DELIV W P/P
649.31 COAGULATION DEF-DELIV
649.32 COAGULATN DEF-DEL W P/P
649.73 CERVICAL SHORTENING-ANTE
651.01 TWIN PREGNANCY-DELIVERED
651.11 TRIPLET PREGNANCY-DELIV
651.21 QUADRUPLET PREG-DELIVER
651.31 TWINS W FETAL LOSS-DEL
651.41 TRIPLETS W FET LOSS-DEL
651.51 QUADS W FETAL LOSS-DEL
651.61 MULT GES W FET LOSS-DEL
651.71 MULT GEST-FET REDUCT DEL
651.81 MULTI GESTAT NEC-DELIVER
651.91 MULT GESTATION NOS-DELIV
652.01 UNSTABLE LIE-DELIVERED
652.11 CEPHALIC VERS NOS-DELIV
652.21 BREECH PRESENTAT-DELIVER
652.31 TRANSVER/OBLIQ LIE-DELIV
652.41 FACE/BROW PRESENT-DELIV
652.51 HIGH HEAD AT TERM-DELIV
652.61 MULT GEST MALPRES-DELIV
654.31 RETROVERT UTERUS-DELIVER
654.32 RETROVERT UTER-DEL W P/P
655.01 FETAL CNS MALFORM-DELIV
655.11 FETAL CHROMOSO ABN-DELIV
655.31 FET DAMG D/T VIRUS-DELIV

144

655.41 FET DAMG D/T DIS-DELIVER
655.51 FET DAMAG D/T DRUG-DELIV
656.61 EXCESS FETAL GRTH-DELIV
656.01 FETAL-MATERNAL HEM-DELIV
656.11 RH ISOIMMUNIZAT-DELIV
656.21 ABO ISOIMMUNIZAT-DELIV
656.41 INTRAUTER DEATH-DELIV
656.51 POOR FETAL GROWTH-DELIV
657.01 POLYHYDRAMNIOS-DELIV
658.01 OLIGOHYDRAMNIOS-DELIV
658.11 PREM RUPT MEMBRAN-DELIV
658.21 PROLONG RUPT MEMB-DELIV
V27.1 DELIVER- SINGLE-STILLBORN
Table 11.08 Outcome of Delivery

V27.0 DELIVER-SINGLE LIVEBORN
Table 11.09 Contraindications to Vaginal Delivery

644.20 EARLY ONSET DELIV-UNSPEC
644.21 EARLY ONSET DELIVERY-DEL
651.00 TWIN PREGNANCY-UNSPEC
651.01 TWIN PREGNANCY-DELIVERED
651.03 TWIN PREGNANCY-ANTEPART
651.10 TRIPLET PREGNANCY-UNSPEC
651.11 TRIPLET PREGNANCY-DELIV

145

651.13 TRIPLET PREG-ANTEPARTUM
651.20 QUADRUPLET PREG-UNSPEC
651.21 QUADRUPLET PREG-DELIVER
651.23 QUADRUPLET PREG-ANTEPART
651.30 TWINS W FETAL LOSS-UNSP
651.31 TWINS W FETAL LOSS-DEL
651.33 TWINS W FETAL LOSS-ANTE
651.40 TRIPLETS W FET LOSS-UNSP
651.41 TRIPLETS W FET LOSS-DEL
651.43 TRIPLETS W FET LOSS-ANTE
651.50 QUADS W FETAL LOSS-UNSP
651.51 QUADS W FETAL LOSS-DEL
651.53 QUADS W FETAL LOSS-ANTE
651.60 MULT GES W FET LOSS-UNSP
651.61 MULT GES W FET LOSS-DEL
651.63 MULT GES W FET LOSS-ANTE
651.80 MULTI GESTAT NEC-UNSPEC
651.81 MULTI GESTAT NEC-DELIVER
651.83 MULTI GEST NEC-ANTEPART
651.90 MULTI GESTAT NOS-UNSPEC
651.91 MULT GESTATION NOS-DELIV
651.93 MULTI GEST NOS-ANTEPART
652.20 BREECH PRESENTAT-UNSPEC
652.21 BREECH PRESENTAT-DELIVER
652.23 BREECH PRESENT-ANTEPART
652.30 TRANSV/OBLIQ LIE-UNSPEC
652.31 TRANSVER/OBLIQ LIE-DELIV

146

652.33 TRANSV/OBLIQ LIE-ANTEPAR
652.40 FACE/BROW PRESENT-UNSPEC
652.41 FACE/BROW PRESENT-DELIV
652.43 FACE/BROW PRES-ANTEPART
652.60 MULT GEST MALPRESEN-UNSP
652.61 MULT GEST MALPRES-DELIV
652.63 MULT GES MALPRES-ANTEPAR
654.20 PREV C-DELIVERY UNSPEC
654.21 PREV C-DELIVERY-DELIVRD
654.23 PREV C-DELIVERY-ANTEPART
656.40 INTRAUTERINE DEATH-UNSPEC
656.41 INTRAUTER DEATH-DELIV
656.43 INTRAUTER DEATH-ANTEPART
660.50 LOCKED TWINS-UNSPECIFIED
660.51 LOCKED TWINS-DELIVERED
660.53 LOCKED TWINS-ANTEPARTUM
662.30 DELAY DEL 2ND TWIN-UNSP
662.31 DELAY DEL 2ND TWIN-DELIV
662.33 DELAY DEL 2 TWIN-ANTEPAR
669.60 BREECH EXTR NOS-UNSPEC
669.61 BREECH EXTR NOS-DELIVER
761.5 MULT PREGNANCY AFF NB
V27.1 DELIVER SINGLE-STILLBORN
V27.2 DELIVER-TWINS, BOTH LIVE
V27.3 DEL-TWINS, 1 NB, 1 SB
V27.4 DELIVER-TWINS, BOTH SB
V27.5 DEL-MULT BIRTH, ALL LIVE

147

V27.6 DEL-MULT BIRTH, SOME LIVE
V27.7 DEL-MULT BIRTH, ALL SB
Table 11.20.1 Term Gestation

765.29 37+ Comp WKS GESTATION
Table 11.21 Galactosemia

271.1 GALACTOSEMIA
Table 11.22 Parenteral Infusion

99.15 PARENT INFUS NUTRIT SUB

148

Pneumonia (PN)
Measure Set

149

Measure
Pneumonia (PN)
Pneumonia patients, aged 65 and older, who were screened for
pneumococcal vaccine status and were administered the vaccine prior
I-PN-2 to discharge, if indicated
Adult smoking cessation advice/counseling given to patients who

I-PN-4 smoke cigarettes and who are hospitalized for pneumonia
Pneumonia patients, aged 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to
I-PN-7 discharge, if indicated

150

I-PN-2
Pneumococcal Vaccination
Measure Overview
I-PN 2 Pneumonia patients, aged 65 and older, who were screened for
pneumococcal vaccine status and were administered the vaccine prior to
discharge, if indicated
Overview/Details:
Patients (aged 65 and older) who were diagnosed with pneumonia, and who received
pneumococcal vaccine prior to discharge from the hospital.
Rationale:
Pneumococcal vaccination is indicated for persons 65 years of age and older because it
is up to 75% effective in preventing pneumococcal bacteremia and meningitis. It is also
an important vaccine due to increasing antibiotic resistance among pneumocci.

Measure Name: Pneumococcal Vaccination
Numerator: Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if indicated.
Denominator: Pneumonia patients 65 years of age and older.

151


Performance Standards
Appropriateness QPS.3 patient AMI Goal 1
assessments
Availability HF
Continuity Stroke
QPS.3 infection
Effectiveness Diabetes (Type I/II)
prevention and control,
Prevention/Early surveillance and ESRD
Detection reporting Traumatic
Timeliness Brain Injury
HIV/AIDS
Asthma
COPD

152

I-PN-2
Measure Details
Reasons and Implications: Pneumococcal vaccination is indicated for persons 65

years of age and older because it is up to 75% effective in preventing pneumococcal
bacteremia and meningitis. It is also an important vaccine due to increasing
antibiotic resistance for pneumococcal infection. Inpatient vaccine screening and
administration are recommended, and hospitalization is an underutilized opportunity
for adult vaccination.
Data Collection:
Numerator: Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if indicated.
Data elements:
x Pneumococcal Vaccination Status
Denominator: Pneumonia patients 65 years of age and older.
Data elements:
x Admission Date
x Birthdate
x Chest X-ray
x ICD principal or other diagnosis code
Inclusions to the population: Patients with ICD principal diagnosis code of

pneumonia as defined in Appendix A, Table 3.1 or an other diagnosis code of
pneumonia (Appendix A, Table 3.1)

x Patients who had no chest x-ray or CT scan that indicated abnormal findings
within 24 hours prior to or during this hospital stay

153

I-PN-2
References
x Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare

inpatients: a missed opportunity. Arch Intern Med 2002;162:2349-
2356.
x Centers for Disease Control and Prevention. General
recommendations on immunization. Recommendations of the Advisory
Committee on Immunization Practices (ACIP) and the American
Academy of Family Physicians (AAFP). MMWR. 2002;51(RR02):1-36.
x Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and
SQHXPRFRFFDOYDFFLQDWLRQ6XWWRQV/DZDSSOLHGWRSUHYHQWLRQInfect
Control Hosp Epi. 2000;21:692-699.
x Fine MF, Smith MAA, Carson CA, Meffe P, Sankery SS, Weissfeld LA,
Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in
adults: a meta-analysis of randomized controlled trials. Arch Intern
Med. 1994(December); 154:2666-2677.
x Kissam S, Gifford DR, Patry G, et al. Is signed consent for influenza or
pneumococcal polysaccharide vaccination required? Arch Intern Med
2004; 164:13-16.
x Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious
Diseases Society of America; American Thoracic Society. Infectious
Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
x Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of
vaccination against pneumococcal bacteremia among elderly people.
JAMA, 1997; 278:1333-1339.

154

I-PN 4
Measure Overview
I-PN 04 Adult smoking cessation advice/counseling given to patients who

smoke cigarettes and who are hospitalized for pneumonia.
Overview/Details:
Smoking cessation advice/counseling given to patients who had pneumonia.
NOTE: For the purposes of this measure, a smoker is defined as someone who has
Rationale:
likely to quit than those who receive no counseling whatsoever.

Improvement Noted as: An increase in the rate
Patient Settings/Services: Medical/Surgical units
Measure Name: Adult smoking cessation advice/counseling
Numerator: Pneumonia patients (cigarette smokers) who receive smoking cessation

Denominator: Pneumonia patients 18 years of age and older with a history of smoking
cigarettes anytime during the year prior to hospital arrival

Appropriateness QPS.3 patient HF
assessments
Continuity Stroke
Effectiveness Diabetes
Prevention/Early Detection Traumatic Brain Injury
Asthma
COPD

155

I-PN 4
Measure Details
Reasons and Implications: Smoking cessation may reduce mortality and morbidity in
all populations. Patients who receive even brief smoking-cessation advice from their
health care providers are more likely to quit. Clinical guidelines strongly recommend
smoking cessation counseling for smokers. Hospitalization can be an ideal opportunity
IRUDSDWLHQWWRVWRSVPRNLQJDQGVPRNLQJFHVVDWLRQPD\SURPRWHWKHSDWLHQWV
medical recovery.
Data Collection:
Numerator: Pneumonia patients (cigarette smokers) who receive smoking cessation

Data elements:
Denominator: Pneumonia patients 18 years of age and older with a history of

smoking cigarettes anytime during the year prior to hospital arrival
Data elements:
x Birthdate
x ICD Principal Diagnosis Code or Other
x Chest X-ray
Inclusions to the population: Patients with ICD principal diagnosis code for
pneumonia as defined in Appendix A, Table 3.1 and a history of smoking cigarettes
anytime during the year prior to hospital arrival


156

I-PN-4
References
x Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and
Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD:
U.S. Department of Health and Human Services. Public Health
Service. May 2008.
x HXGPRQ.6+HPEHUJHU..&RUHOOL5/HWDO7KHSKDUPDFLVWVUROHLQ
smoking cessation counseling: perceptions of users of nonprescription
nicotine replacement therapy. J Am Pharm Assoc 2003; 43(5):573-
582.
x Kikano GE, et al: The value of brief, targeted smoking-cessation
advice. Family Practice Management. pp. 50-2000.
x Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious
Diseases Society of America; American Thoracic Society. Infectious
Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
x Sheahan SL. How to help older adults quit smoking. Nurse Pract 2002;
27:27-33.
x The Smoking Cessation Clinical Practice Guideline Panel and Staff:
The Agency for Health Care Policy and Research. Smoking Cessation
Clinical Practice Guideline. JAMA, 275:1270-1280, 1996.

157

I-PN 7
Influenza Vaccination
Measure Overview
I-PN 07 Pneumonia patients, aged 50 and older, who during the flu season, were
screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated
Overview/Details:
Patients (aged 50 and older) who were diagnosed with pneumonia (during the flu
season), and who received influenza vaccine prior to discharge from the hospital.
Rationale:
Pneumococcal vaccination is indicated for persons 50 years of age and older because it
is highly effective in preventing influenza-related pneumonia.

Improvement Noted as: An increase in rate/score/number of occurrences
Measure Name: Influenza Vaccination
Numerator: Patients with pneumonia, age 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated.
Denominator: Pneumonia patients 50 years and older (during the flu season)

158


assessments
Availability HF
Continuity Stroke
QPS.3 infection
Effectiveness Diabetes (Type I/II)
prevention and
Prevention/Early Detection control, surveillance, Traumatic Brain Injury
Timeliness and reporting Asthma
COPD

159

I-PN 7
Measure Details
Reasons and Implications: Influenza vaccination is indicated for persons 50 years of

age and older because it is highly effective in preventing influenza related pneumonia,
hospitalization and death. Inpatient vaccine screening and administration are
recommended especially during the flu season, and hospitalization is an underutilized
opportunity to provide vaccination to adults.
Data Collection:
Numerator: Patients with pneumonia, age 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated.
Data elements:
x Influenza Vaccination Status
Denominator: Pneumonia patients 50 years of age and older (during the flu season)
Data elements:
x Admission Date
x Birthdate
x Chest X-ray
x ICD principal or other diagnosis code
Inclusions to the population: Patients with ICD principal diagnosis code of pneumonia
as defined in Appendix A, Table 3.1 or an other diagnosis code of pneumonia
(Appendix A, Table 3.1)

x Patients with a secondary diagnosis of influenza pneumonia

160

I-PN - 7
References
x Centers for Disease Control. Prevention of Influenza. Recommendations of the

Advisory Committee on Immunization Practices (ACIP). MMWR. April
2002;51(No.RR-02):1-36.
x Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and pneumococcal
YDFFLQDWLRQ6XWWRQV/DZDSSOLHGWRSUHYHQWLRQInfect Control Hosp Epi.
2000;21:692-699.
x Kissam S, Gifford DR, Patry G, et al. Is signed consent for influenza or
pneumococcal polysaccharide vaccination required? Arch Intern Med 2004; 164:13-
16.
x Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of
America; American Thoracic Society. Infectious Diseases Society of
America/American Thoracic Society consensus guidelines on the management of
community-acquired pneumonia in adults. Clin Infect Dis. 2007 March 1;44 Suppl
2:S27-72.

161

Appendix A
ICD Codes
Please Note: Due to the various ICD Code versions used by different countries, ICD-8,
Table 3.1
Pneumonia (PN)
481 PNEUMOCOCCAL PNEUMONIA
482.0 K. PNEUMONIAE PNEUMONIA
482.1 PSEUDOMONAL PNEUMONIA
482.2 H.INFLUENZAE PNEUMONIA
482.30 STREPTOCOCCAL PNEUMN NOS
482.31 PNEUMONIA STRPTOCOCCUS A
482.32 PNEUMONIA STRPTOCOCCUS B
482.39 PNEUMONIA OTH STREP
482.40 STAPHYLOCOCCAL PNEU NOS
482.41 METH SUS PNEUM D/T STAPH
482.42 METH RES PNEU D/T STAPH
482.49 STAPH PNEUMONIA NEC
482.82 PNEUMONIA E COLI
482.83 PNEUMO OTH GRM-NEG BACT
482.84 LEGIONNAIRES' DISEASE
482.89 PNEUMONIA OTH SPCF BACT
482.9 BACTERIAL PNEUMONIA NOS
483.0 PNEU MYCPLSM PNEUMONIAE
483.1 PNEUMONIA D/T CHLAMYDIA
483.8 PNEUMON OTH SPEC ORGNSM
485 BRONCHOPNEUMONIA ORG NOS
486 PNEUMONIA, ORGANISM NOS

162

Surgical Care
Improvement Project
(SCIP)
Measure Set

163

Measure
Prophylactic antibiotics received one hour prior to surgical incision for

I-SCIP-Inf-1d hip arthroplasty patients
Prophylactic antibiotics received one hour prior to surgical incision for

I-SCIP-Inf-1e knee arthroplasty patients
Surgical patients (hip arthroplasty) who received prophylactic

I-SCIP-Inf-2d antibiotics consistent with current guidelines
Surgical patients (knee arthoplasty) who received prophylactic

I-SCIP-Inf-2e antibiotics consistent with current guidelines
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were

I-SCIP-Inf-3d discontinued within 24 hours after anesthesia end time
Surgical patients (knee arthroplasty) whose prophylactic antibiotics

I-SCIP-Inf-3e were discontinued within 24 hours after anesthesia end time
Surgical patients (hip/knee arthroplasty) with recommended venous

thromboembolism (VTE) prophylaxis ordered anytime from hospital
I-SCIP-VTE-1 arrival to 24 hours after Anesthesia End Time
Surgical patients who received appropriate venous thromboembolism

(VTE) prophylaxis within 24 hours prior to anesthesia start time to 24
I-SCIP-VTE-2 hours after anesthesia end time

164

I-SCIP-Inf-1d
Prophylactic Antibiotic Received
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 1d Prophylactic antibiotics received within one hour prior to surgical
incision for hip arthroplasty patients.
Overview/Details:
Surgical patients (hip arthroplasty) with prophylactic antibiotics initiated within one hour
prior to surgical incision.
Note: Patients who received vancomycin or a fluroquinolone for prophylactic antibiotics should
have the antibiotics initiated within two hours prior to a surgical incision. Due to the longer
infusion time required for vancomycin or a fluroquinolone, it is acceptable to start these
antibiotics within two hours prior to incision time.
Rationale:
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels
at the time of skin incision. Clinical studies have demonstrated that a common reason
for failure of prophylaxis was delay of antibiotic administration until after the operation.
In a comprehensive study, it was found that the lowest incidence of post-operative
infection was associated with antibiotic administration during the one hour prior to
surgery. The risk of infection increased progressively with greater time intervals
between administration and skin incision. Therefore, opportunities to improve care have
been demonstrated and timely administration has been recommended.

Improvement noted as: An increase in rate
Measure Name: Prophylactic antibiotic received within one hour prior to surgical
incision for hip arthroplasty.
Numerator: Number of surgical patients (hip arthroplasty) with prophylactic antibiotics

initiated within one hour prior to surgical incision
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection and who are > = 18 years.

165


Standards
Appropriateness QPS.3 surgical Joint *RDO
procedures Replacement
Availability Goal 4
Continuity Goal 5
QPS.3 antibiotics and
Effectiveness
other mediation use
Prevention/Early
Detection
QPS.3 infection,
Timeliness prevention and control,
surveillance and reporting

166

I-SCIP-Inf-1d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to establish bactericidal

tissue and serum levels at the time of skin incision. Clinical studies have demonstrated that
a common reason for failure of prophylaxis was delay of antibiotic administration until after
the operation. In a comprehensive study, it was found that the lowest incidence of post-
operative infection was associated with antibiotic administration during the one hour prior to
surgery. The risk of infection increased progressively with greater time intervals between
administration and skin incision. Therefore, opportunities to improve care have been
demonstrated and timely administration has been recommended.
Data Collection:
medical records.
Numerator: Number of surgical patients (hip arthroplasty) with prophylactic antibiotics

Data elements:
x Anesthesia start date
x Antibiotic administration date
x Antibiotic administration time
x Surgical incision time
infection and who are >= 18 years.
Data elements:
x Admission date
x Antibiotic name
x Antibiotic received
x Antibiotic administration route
x Birthdate
x ICD principal procedure Code
x Infection prior to anesthesia
x Other surgeries

167

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04).

x Patients who had a previous diagnosis suggestive of preoperative infectious disease
(as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to the surgical procedure of interest (hip
arthroplasty)
x Patients who had other procedures requiring general or spinal anesthesia that
occurred within 3 days prior to or after the procedure of interest (during separate
surgical episodes) during this hospital stay
x Patients who were receiving antibiotics within 24 hours prior to arrival
x Patients who were receiving antibiotics more than 24 hours prior to surgery

168

I-SCIP-Inf-1d
References
x Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):1706-
1715.
x Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
x Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in
selected inpatient surgical procedures. Am J Surg. 1996;171:548-552.
x Larsen RA, Evans RS, Burke JP, et al. Improved perioperative antibiotic use and
reduced surgical wound infections through use of computer decision analysis.
Infect Control Hosp Epidemiol. 1989;10:316-320.
x Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic
prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097.
x Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care:
administration of preoperative antibiotics in the operating room. Am Surg.
1997;63:500-503.
x Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients
undergoing common surgical procedures in a community teaching hospital: the
chaos continues. World J Surg. 1999;23:429-432.
x Bernard HR, Cole WR. The prophylaxis of surgical infections: the effect of
prophylactic antimicrobial drugs on the incidence of infection following potentially
contaminated operations. Surgery. 1964;56:151-157.
x Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of
determinant factors and prevention. Surgery. 1969;66:97-103.
x Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary,
and colonic surgery. Ann Surg. 1976;184:443-452.
x American College of Obstetricians and Gynecologists (ACOG) Committee on
Practice Bulletins ACOG Practice Bulletin No 104 Antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol May 2009; 113(5) : 1180-1189.

169

I-SCIP-Inf-1e
Prophylactic Antibiotics Received
(Knee arthroplasty)
Measure Overview
I-SCIP-Inf 1e Prophylactic antibiotics received within one hour prior to surgical

incision for knee arthroplasty patients.
Overview/Details:
Surgical patients (knee arthroplasty) with prophylactic antibiotics initiated within one
hour prior to surgical incision.
Note: Patients who received vancomycin or a fluroquinolone for prophylactic antibiotics should
have the antibiotics initiated within two hours prior to a surgical incision. Due to the longer
infusion time required for vancomycin or a fluroquinolone, it is acceptable to start these
antibiotics within two hours prior to incision time.
Rationale:
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels
at the time of skin incision.

Measure Name: Prophylactic antibiotic received within one hour prior to surgical
incision.
Numerator: Number of surgical patients (knee arthroplasty) with prophylactic antibiotics

Denominator: All selected surgical patients (knee arthroplasty) with no evidence of

prior infection and > = 18 years.

170

Appropriateness QPS.3 surgical procedures Joint *RDO
Replacement
Availability Goal 4
Continuity QPS.3 antibiotics and other Goal 5
mediation use
Effectiveness
Prevention/Early
QPS.3 infection, prevention
Detection
and control, surveillance and
Timeliness reporting

171

I-SCIP-Inf-1e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to establish

bactericidal tissue and serum levels at the time of skin incision. Clinical studies have
demonstrated that a common reason for failure of prophylaxis was delay of antibiotic
administration until after the operation. In a comprehensive study, it was found that the
lowest incidence of post-operative infection was associated with antibiotic administration
during the one hour prior to surgery. The risk of infection increased progressively with
greater time intervals between administration and skin incision. Therefore, opportunities to
improve care have been demonstrated and timely administration has been recommended.
Data Collection:
medical records.
Numerator: Number of surgical patients (knee arthroplasty) with prophylactic antibiotics

Data elements:
Denominator: All selected surgical patients (knee arthoplasty) with no evidence of prior
Data elements:
x Admission date
x Antibiotic name
x Birthdate
x ICD principal procedure code
x Other surgeries

172

defined in Appendix A, Table 5.05).

x Patients with a documented infection prior to surgical procedure of interest (knee
arthroplasty)
x Patients who were receiving antibiotics within 24 hours prior to arrival.

173

I-SCIP-Inf-1e
References
1715.
x Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in
selected inpatient surgical procedures. Am J Surg. 1996;171:548-552.
x Larsen RA, Evans RS, Burke JP, et al. Improved perioperative antibiotic use and
reduced surgical wound infections through use of computer decision analysis.
Infect Control Hosp Epidemiol. 1989;10:316-320.
x Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic
prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097.
x Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care:
administration of preoperative antibiotics in the operating room. Am Surg.
1997;63:500-503.
x Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients
undergoing common surgical procedures in a community teaching hospital: the
chaos continues. World J Surg. 1999;23:429-432.
x Bernard HR, Cole WR. The prophylaxis of surgical infections: the effect of
prophylactic antimicrobial drugs on the incidence of infection following potentially
contaminated operations. Surgery. 1964;56:151-157.
x Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of
determinant factors and prevention. Surgery. 1969;66:97-103.
x Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary,
and colonic surgery. Ann Surg. 1976;184:443-452.

174

I-SCIP-Inf-2d
Prophylactic Antibiotic Selection
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 2d Prophylactic antibiotic selection for surgical patients (hip

arthroplasty).
Overview/Details:
Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent with
current guidelines.
Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-
effective, and has a spectrum of action that covers most of the probable intraoperative
contaminants for the operation. First or second-generation cephalosporins satisfy these
criteria for most operations, although anaerobic coverage is needed for colon surgery.

Patient Settings/Services: Medical/surgical units
Measure Name: Prophylactic antibiotic selection for surgical patients (hip arthroplasty)
Numerator: Number of surgical patients (hip arthroscopy) who received prophylactic

antibiotics recommended for their specific surgical procedure.
infection who are >= 18 years.

175


Replacement
Availability Goal 4
mediation use
Effectiveness
Prevention/Early
Detection
reporting

176

I-SCIP-Inf-2d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to use an agent

that is safe, cost-effective, and has a spectrum of action that covers most of the
probable intraoperative contaminants for the operation. First or second-generation
cephalosporins satisfy these criteria for most operations, although anaerobic coverage
is needed for colon surgery. Vancomycin is not recommended for routine use because
of the potential for development of antibiotic resistance, but is acceptable if a patient is
allergic to beta-lactams, as are fluoroquinolones and clindamycin in selected situations.
Data Collection:
Numerator: Number of surgical patients (hip arthroplasty) who received prophylactic

Data elements:
x Antibiotic Administration Route
x Antibiotic Allergy
x Antibiotic Name
x Vancomycin
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of

prior infection and are >= 18 years.
Data elements:
x Admission date
x Antibiotic admission route
x Birthdate
x Surgical Incision time

177

defined in Appendix A, Table 5.04.)

x Patients who had a previous diagnosis suggestive of preoperative infectious
disease (as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest (hip
arthroplasty)
x Patients who did not receive any antibiotics before or during surgery, or within
24 hours after Anesthesia End time (i.e., patient did not receive prophylactic
antibiotics)
x Patients who did not receive any antibiotics during this hospitalization

178

I-SCIP-Inf-2d
References
1715.
x American Society of Health-System Pharmacists. ASHP therapeutic guidelines
on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:1839-
1888.
x No author listed. The Medical letter. Antimicrobial prophylaxis for Surgery. Med
Lett Drugs Ther. 2009; 82: 47-52.
x Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial
prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427.
x Gilbert DN, Moellering RC Jr., Elipoulos GM, Chamber HF, Saag MS, eds. The
Sanford Guide to Antimicrobial Therapy 2009. 39st ed. Sperryville, VA:
Antimicrobial Therapy, Inc; 2009.
x Itani KMF, Wilson SE, Awad SS, Jensen EH, Finn TS, Abramson MA. Ertapenem
versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 2006
Dec 21; 355 (25): 2640-2651.
Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical
wounds. Arch Surg. 1993;128:79-88.

179

I-SCIP-Inf-2e
Prophylactic Antibiotic Selection
(Knee arthroplasty)
Measure Overview
I-SCIP-Inf 2e Prophylactic antibiotic selection for surgical patients (knee

arthoplasty).
Overview/Details:
Surgical patients (knee arthroplasty) who received prophylactic antibiotics consistent
with current guidelines.
Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-
effective, and has a spectrum of action that covers most of the probable intraoperative
contaminants for the operation. First or second-generation cephalosporins satisfy these
criteria for most operations, although anaerobic coverage is needed for colon surgery.

Measure Name: Prophylactic antibiotic selection for surgical patients (knee

arthroplasty).
Numerator: Number of surgical patients (knee arthroplasty) who received prophylactic


prior infection who are >= 18 years.

Availability QPS.3 antibiotics and other Replacement Goal 4
mediation use
Continuity Goal 5
Effectiveness
Prevention/Early Detection reporting

180

I-SCIP-Inf-2e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to use an agent

that is safe, cost-effective, and has a spectrum of action that covers most of the
probable intraoperative contaminants for the operation. First or second-generation
cephalosporins satisfy these criteria for most operations, although anaerobic
coverage is needed for colon surgery. Vancomycin is not recommended for routine
use because of the potential for development of antibiotic resistance, but is
acceptable if a patient is allergic to beta-lactams, as are fluoroquinolones and
clindamycin in selected situations.
Data Collection:
Numerator: Number of surgical patients (knee arthroplasty) who received

prophylactic antibiotics recommended for their specific surgical procedure.
Data elements:
x Antibiotic allergy
x Antibiotic name
x Vancomycin

prior infection and are >= 18 years.
Data elements:
x Admission date
x Antibiotic Received
x Birthdate
x Surgical Incision time

181

Inclusions to the population: ICD Principal Procedure Code of selected surgeries

(as defined in Appendix A, Table 5.05).

x Patients who had a previous diagnosis suggestive of preoperative infectious
disease (as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest
(knee arthroplasty)
x Patients who did not receive any antibiotics before or during surgery, or within
24 hours after Anesthesia End time (i.e., patient did not receive prophylactic
antibiotics)

182

I-SCIP-Inf-2e
References
1715.
x American Society of Health-System Pharmacists. ASHP therapeutic guidelines
on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:1839-
1888.
x No author listed. The Medical letter. Antimicrobial prophylaxis for Surgery. Med
Lett Drugs Ther. 2009; 82: 47-52.
x Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial
prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427.
x Gilbert DN, Moellering RC Jr., Elipoulos GM, Chamber HF, Saag MS, eds. The
Sanford Guide to Antimicrobial Therapy 2009. 39st ed. Sperryville, VA:
Antimicrobial Therapy, Inc; 2009.
x Itani KMF, Wilson SE, Awad SS, Jensen EH, Finn TS, Abramson MA. Ertapenem
versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 2006
Dec 21; 355 (25): 2640-2651.
Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical
wounds. Arch Surg. 1993;128:79-88.

183

I-SCIP-Inf-3d
Prophylactic Antibiotics Discontinued within
24 Hours After Surgery End Time
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 3d Prophylactic antibiotics discontinued within 24 Hours after surgery

end time (Hip arthroplasty)
Overview/Details:
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued
within 24 hours after anesthesia end time.
Rationale: It is important to maintain therapeutic serum and tissue levels throughout

the operation. Intraoperative re-dosing may be needed for long operations.

Measure Name: Prophylactic antibiotic discontinued within 24 hours after surgery end
time (hip arthroplasty).
Numerator: Number of surgical patients (hip arthroplasty) whose prophylactic

antibiotics were discontinued within 24 hours after Anesthesia End Time
infection who are >= 18 years

184


Replacement
Availability Goal 4
mediation use
Effectiveness
Prevention/Early
Detection
Timeliness reporting

185

I-SCIP-Inf-3d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to provide benefit to the
patient with as little risk as possible. It is important to maintain therapeutic serum and tissue
levels throughout the operation. Intraoperative re-dosing may be needed for long
operations. However, administration of antibiotics for more than a few hours after the
incision is closed offers no additional benefit to the surgical patient. Prolonged
administration does increase the risk of Clostridium difficile infection and the development of
antimicrobial resistant pathogens.
Numerator: Number of surgical patients (hip arthroplasty) whose prophylactic antibiotics

were discontinued within 24 hours after Anesthesia End Time
Data elements:
x Anesthesia end date
x Anesthesia end time
Denominator: All selected surgical patients (hip arthroscopy) with no evidence of prior
Data elements:
x Admission date
x Antibiotic name
x Birthdate
x Other surgeries
x Reason to extend antibiotics

186

defined in Appendix A, Table 5.04.)

x Patients with a documented infection prior to surgical procedure of interest (hip
arthroplasty)
x Patients who were receiving antibiotics more than 24 hours prior to arrival
x Patients with reasons to extend antibiotics

187

I-SCIP-Inf-3d
References
1715.
x Crabtree TD, Pelletier SJ, Gleason TG, et al. Clinical characteristics and
antibiotic utilization in surgical patients with Clostridium difficile-associated
diarrhea. Am Surg. 1999;65:507-511.
x Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of
Thoracic Surgeons Practice Guideline Series: Antibiotic prophylaxis in cardiac
surgery, Part I: Duration, 2006. Ann Thoracic Surg 2006; 81: 397-404.
x McDonald M, Grabsch E, Marshall C, et al. Single- versus multiple-dose
antimicrobial prophylaxis for major surgery: a systemic review. Aust N Z J Surg.
1988;68:388-396.
x Scher KS. Studies on the duration of antibiotic administration for surgical
prophylaxis. Am Surg. 1997;63:59-62.

188

I-SCIP-Inf-3e
Prophylactic Antibiotics Discontinued within
24 Hours After Surgery End Time
(Knee Arthroplasty)
Measure Overview
I-SCIP-Inf 3e Prophylactic antibiotics discontinued within 24 hours after

surgery end time (knee arthroplasty).
Overview/Details:
Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued
within 24 hours after anesthesia end time.
Rationale: It is important to maintain therapeutic serum and tissue levels throughout

the operation. Intraoperative re-dosing may be needed for long operations.

Measure Name: Prophylactic antibiotic discontinued within 24 hours after surgery end
time (knee arthroplasty)
Numerator: Number of surgical patients (knee arthroplasty) whose prophylactic

antibiotics were discontinued within 24 hours after Anesthesia End Time

prior infection who are >= 18 years.

189


Appropriateness QPS.3 surgical Joint *RDO
procedures Replacement
Availability Goal 4
Continuity Goal 5
Effectiveness
other mediation use
Prevention/Early
Detection
QPS.3 infection,
Timeliness prevention and control,
surveillance and reporting

190

I-SCIP-Inf-3e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to provide benefit to the
patient with as little risk as possible. It is important to maintain therapeutic serum and tissue
levels throughout the operation. Intraoperative re-dosing may be needed for long operations.
However, administration of antibiotics for more than a few hours after the incision is closed
offers no additional benefit to the surgical patient. Prolonged administration does increase the
risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens.
Numerator: Number of surgical patients (knee arthroplasty) whose prophylactic antibiotics

were discontinued within 24 hours after Anesthesia End Time
Data elements:
x Anesthesia End Date
x Anesthesia End Time
x Antibiotic Administration Date
x Antibiotic Administration Time
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior
Data elements:
x Admission date
x Antibiotic name
x Birthdate
x Other surgeries
x Reason to extend antibiotics

191

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined
in Appendix A, Table 5.05)

x Patients who had other procedures requiring general or spinal anesthesia that occurred
within 3 days prior to or after the procedure of interest (during separate surgical
episodes) during this hospital stay
x Patients who had a previous diagnosis suggestive of preoperative infectious disease (as
defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest (knee
arthroplasty)
x Patients who were receiving antibiotics more than 24 hours prior to arrival
x Patients with reasons to extend antibiotics

192

I-SCIP- Inf-3e
References
1715.
x Crabtree TD, Pelletier SJ, Gleason TG, et al. Clinical characteristics and
antibiotic utilization in surgical patients with Clostridium difficile-associated
diarrhea. Am Surg. 1999;65:507-511.
x Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of
Thoracic Surgeons Practice Guideline Series: Antibiotic prophylaxis in cardiac
surgery, Part I: Duration, 2006. Ann Thoracic Surg 2006; 81: 397-404.
x McDonald M, Grabsch E, Marshall C, et al. Single- versus multiple-dose
antimicrobial prophylaxis for major surgery: a systemic review. Aust N Z J Surg.
1988;68:388-396.
x Scher KS. Studies on the duration of antibiotic administration for surgical
prophylaxis. Am Surg. 1997;63:59-62.

193

I-SCIP-VTE-1
Surgical Patients (hip/knee arthroplasty) with Recommended
Venous Thromboembolism (VTE) Prophylaxis Ordered
Measure Overview
I=SCIP-VTE 1 Surgical patients (hip/knee arthroplasty) with recommended

venous thromboembolism (VTE) prophylaxis ordered
Overview/Details:
Surgical patients (hip/knee arthroplasty who received venous thromboembolism (VTE)
prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End
Time.
Rationale: Despite the evidence that VTE is one of the most common postoperative
complications and prophylaxis is the most effective strategy to reduce morbidity and
mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and
duration of surgery, patient risk factors, duration and extent of postoperative
immobilization, and use or nonuse of prophylaxis.

Measure Name: Surgery patients (hip/knee arthroplasty) with recommended venous

thromboembolism (VTE) prophylaxis ordered
Numerator: Surgery patients (hip/knee arthroplasty) with recommended venous

thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours
after Anesthesia End Time
Denominator: All selected (hip/knee arthoroplasty) patients who are >= 18 years.

194


Standards
Appropriateness QPS.3 patient Joint *RDO
assessments Replacement
Availability
Continuity
QPS.3 surgical
Effectiveness
procedures
Prevention/Early
Detection
Timeliness other mediation use

195

I-SCIP-VTE-1
Measure Details
Reasons and Implications: Despite the evidence that VTE is one of the most common
postoperative complications and prophylaxis is the most effective strategy to reduce morbidity
and mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and duration of
surgery, patient risk factors, duration and extent of postoperative immobilization, and use or
nonuse of prophylaxis. According to clinical trials, surgery was associated with over a twenty-
fold increase in the odds of being diagnosed with VTE. Studies have shown that appropriately
used thromboprophylaxis has a positive risk/benefit ratio and is cost effective. Prophylaxis
recommendations for this measure are based on clinical practice guidelines.
Numerator: Surgery patients (hip/knee arthroplasty) with recommended venous

thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after
Anesthesia End Time
Denominator: All selected (hip/knee arthoroplasty) patients who are >= 18 years.
Data elements:
x Anesthesia type
x VTE Prophylaxis
Denominator: All selected surgical patients (hip/knee arthroplasty).
Data elements:
x Admission date
x Anesthesia start time
x Birthdate
x Preadmission Warfarin
x Reason for Not Administering VTE Prophylaxis

196

defined in Appendix A, Table 5.04, 5.05.)

x Patients with hospital stay of less than or equal to 3 calendar days
x Patients who are on warfarin prior to admission
x Patients whose total surgery time is less than or equal to 60 minutes
x Patients with reasons for not administering both mechanical and pharmocolgical
prophylaxis
Elective Total Hip

5B Any of the following started within 24 hours of surgery:
Replacement x Low molecular weight heparin (LMWH)
x Factor Xa Inhibitor (Fondaparinux)
x Warfarin
x Oral Factor Xa Inhibitor (Rivaroxaban)
Elective Total Knee
6B Any of the following:
x Warfarin
x Intermittent pneumatic compression devices (IPC)
x Venous foot pump (VFP)
Elective Total Hip Any of the following:
Replacement with a x Intermittent pneumatic compression devices (IPC)
reason for not x Venous foot pump (VFP)
administering
pharmacological
prophylaxis

197

I-SCIP-VTE-1
References
x Chapter 31 of Making Healthcare Safer: A Critical Analysis of Patient Safety

Practices. Prepared for Agency for Healthcare Research and Quality, Contract No.
290-97-0013. Prevention of Venous Thromboembolism. PMID: 00000.
x Stratton MA, Anderson FA, Bussey HI, Caprini J. Prevention of venous
thromboembolism: adherence to the 1995 American College of Chest Physicians
Consensus Guidelines for Surgical Patients. Arch Intern Med. 2000;160:334-3.
PMID: 10668835.
x Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein
thrombosis. The Cochrane Library. Issue1, 2001. PMID: 10908501.
x Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention
of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med.
2000;160:2327-2332. PMID: 10927730.
x Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism
among hospitalized patients at Brigham and Women's Hospital is caused more
often by prophylaxis failure than by withholding treatment. Chest. 2000;118:1680-
1684. PMID: 11115458.
x 2'RQQHOO0:HLW]-,7KURPERSURSK\OD[LVLQVXUJLFDOSDWLHQWVCan J Surg. 2003;
46(2): 129-135. PMID: 12691354.
x Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest 2008; 133:381S-453S. PMID:
18574271.
x Janku GV, Paiement GD, Green HD. Prevention of venous thromboembolism in
orthopaedics in the United States. Clin Ortho & Related Research. 1996:313-321.
PMID: 8998892.
x Koch A, Bouges S, Ziegler S, et al. Low molecular weight heparin and
infractionated heparin in thrombosis prophylaxis after major surgical intervention:
update of previous meta-analyses. Br J Surg. 1997;84:750-759. PMID: 9189079.
x Palmer AJ, Schramm W, Kirchhof B, et al. Low molecular weight heparin and
unfractionated heparin for prevention of thrombo-embolism in general surgery: a
meta-analysis of randomised clinical trials. Haemostasis. 1997;27:65-74. PMID:
9212354.
x Bratzler DW, Raskob GE, Murray CK, et al. Underuse of venous thromboembolism
prophylaxis for general surgery patients: physician practices in the community
hospital setting. Arch Intern Med. 1998;158:1909-1912. PMID: 9759687.
x Vanek VW. Meta-analysis of effectiveness of intermittent pneumatic compression
devices with a comparison of thigh-high to knee-high sleeves. American Surgeon.
1998;64:1050-1058. PMID: 9798767.

198

x Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of low-
molecular-weight heparin prophylaxis against venous thromboembolism in patients
undergoing elective hip replacement. Arch Intern Med. 1999;159:137-141. PMID:
9927095.
x Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ, III. Risk
factors for deep vein thrombosis and pulmonary embolism: a population-based
case-control study. Arch Intern Med 2000;160:809-815.
x Abrams PJ, Emerson CR. Rivaroxaban: a novel, oral, direct factor Xa Inhibitor. Pub
Med. Feb.2009; 167-81
x Borris LC, Rivaroxaban, a new, oral direct factor Xa inhibitor for
thromboprophylaxis after major joint arthroplasty. Pub Med. April 2009; 10 6):1083-
8.
x Eriksson BI, Kakkar AK, Turpie AG, Gent M, Bandel TJ, Homering M, Misselwitz F,
Lassen MR. Oral rivaroxaban for the prevention of symptomatic venous
thromboembolism after elective hip and knee replacement. Pub Med. May
2009;91(5):636-44.
x Turpie AG, Lassen MR, Davidson BL, et. Al. Rivaroxaban versus Enoxaparin for
thromboprophylaxis after total knee arthroplasty (RECORD4): a randomized trial.
Pub Med. May 16;373(9676):1673-80. Equb 2009 Mat 4.

199

I-SCIP-VTE-2
Surgical Patients (hip/knee arthorplasty) who Received
appropriate Venous Thromboembolism (VTE) Prophylaxis
within 24 hours prior to Anesthesia Start Time to 24 hours
after Anesthesia End Time.
Measure Overview
I=SCIP_VTE 2 Surgical patients (hip/knee arthroplasty) who received

appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to
anesthesia start time to 24 hours after anesthesia end time.
Overview/Details:
Surgical patients (hip/knee arthroplasty) who received appropriate venous
thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start time to 24
hours after anesthesia end time.
Rationale: Despite the evidence that VTE is one of the most common postoperative
complications and prophylaxis is the most effective strategy to reduce morbidity and
mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and
duration of surgery, patient risk factors, duration and extent of postoperative
immobilization, and use or nonuse of prophylaxis. According to a clinical study, surgery
was associated with over a twenty-fold increase in the odds of being diagnosed with
VTE. Studies have shown that appropriately used thromboprophylaxis has a positive
risk/benefit ratio and is cost effective.

Measure Name: Surgery Patients (hip/knee arthroplasty) Who Received Appropriate

Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Anesthesia Start Time
to 24 Hours After Anesthesia Start Time

200

Numerator: Surgery patients (hip/knee arthroplasty) who received appropriate Venous
Thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to
24 hours after Anesthesia End Time.
Denominator: All selected (hip/knee arthroplasty) patients who are > = 18 years.

Standards
Appropriateness QPS.3 patient Joint *RDO
assessments Replacement
Availability
Continuity
QPS.3 surgical
Effectiveness
procedures
Prevention/Early
Detection
Timeliness other mediation use

201

I-SCIP-VTE-2
Measure Details
Reasons and Implications: Timing of prophylaxis is based on the type of procedure,

prophylaxis selection, and clinical judgment regarding the impact of patient risk
factors. The optimal start of pharmacologic prophylaxis in surgical patients varies and
must be balanced with the efficacy-versus-bleeding potential. Due to the inherent
variability related to the initiation of prophylaxis for surgical procedures, 24 hours prior
to surgery to 24 hours post surgery was recommended for use in this measure set in
order to establish a timeframe that would encompass most procedures.
Data Collection:
Numerator: Surgery patients (hip/knee arthroplasty) who received appropriate

venous thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start
time to 24 hours after anesthesia end time
Denominator: All selected (hip/knee arthroplasty) patients who are >= 18 years.
Data elements:
x Anesthesia type
x VTE Prophylaxis
x VTE Timely
Denominator: All selected surgical patients (hip/knee arthroplasty).
Data elements:
x Admission date
x Anesthesia start time
x Birthdate
x Preadmission warfarin
x Reason for not administering VTE prophylaxis

202

Inclusions to the population: ICD Principal Procedure Code of selected surgeries

(as defined in Appendix A, Table 5.04, 5.05).

x Patients with length of stay less than or equal to 3 calendar days
x Patients who are on warfarin prior to admission
x Patients whose total surgery time is less than or equal to 60 minutes
x Patients with reasons for not administering both mechanical and
pharmocolgical prophylaxis
x Patients who did not receive VTE Prophylaxis
Su
VTE Prophylaxis Options for Surgery
Surgery Type Recommended Prophylaxis Options
Elective Total Hip
5B Any of the following started within 24 hours of surgery:
x Warfarin
Elective Total Knee
6B Any of the following:
x Warfarin
x Intermittent pneumatic compression devices (IPC)
x Venous foot pump (VFP)
Elective Total Hip Any of the following:
Replacement with a x Intermittent pneumatic compression devices (IPC)
reason for not x Venous foot pump (VFP)
administering
pharmacological
prophylaxis

203

I-SCIP-VTE-2
References
x Chapter 31 of Making Healthcare Safer: A Critical Analysis of Patient Safety

Practices. Prepared for Agency for Healthcare Research and Quality, Contract
No. 290-97-0013. Prevention of Venous Thromboembolism. PMID: 00000.
x Anderson FA, Wheeler HB, Goldberg RJ, et al. Physician practices in the
prevention of VTE. Ann Intern Med. 1991;115-591-595. PMID: 1892330.
antithrombotic and thrombolytic therapy. Chest 2008; 133:381S-453S. PMID:
18574271.
x Stratton MA, Anderson FA, Bussey HI, Caprini J. Prevention of venous
thromboembolism: adherence to the 1995 American College of Chest Physicians
Consensus Guidelines for Surgical Patients. Arch Intern Med. 2000;160:334-3.
PMID: 10668835.
x Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein
thrombosis. The Cochrane Library, Issue1, 2001. PMID: 10908501.
x Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for
prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch
Intern Med. 2000;160:2327-2332. PMID: 10927730.
x Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism
among hospitalized patients at Brigham and Women's Hospital is caused more
often by prophylaxis failure than by withholding treatment. Chest. 000;118:1680-
1684. PMID: 11115458.
x 2'RQQHOO0:HLW]-,7KURPERSURSK\OD[LVLQVXUJLFDOSDWLHQWVCan J Surg.
2003; 46(2): 129-135. PMID: 12691354.
x Janku GV, Paiement GD, Green HD. Prevention of venous thromboembolism in
orthopaedics in the United States. Clin Ortho & Related Research. 1996:313-
321. PMID: 8998892.
x Koch A, Bouges S, Ziegler S, et al. Low molecular weight heparin and
infractionated heparin in thrombosis prophylaxis after major surgical intervention:
update of previous meta-analyses. Br J Surg. 1997;84:750-759. PMID: 9189079.
x Palmer AJ, Schramm W, Kirchhof B, et al. Low molecular weight heparin and
unfractionated heparin for prevention of thrombo-embolism in general surgery: a
meta-analysis of randomised clinical trials. Haemostasis. 1997;27:65-74. PMID:
9212354.
x Bratzler DW, Raskob GE, Murray CK, et al. Underuse of venous
thromboembolism prophylaxis for general surgery patients: physician practices in
the community hospital setting. Arch Intern Med. 1998;158:1909-1912. PMID:
9759687.

204

x Vanek VW. Meta-analysis of effectiveness of intermittent pneumatic compression
devices with a comparison of thigh-high to knee-high sleeves. American
Surgeon. 1998;64:1050-1058. PMID: 9798767.
x Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of
low-molecular-weight heparin prophylaxis against venous thromboembolism in
patients undergoing elective hip replacement. Arch Intern Med. 1999;159:137-
141. PMID: 9927095.
x Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant
prophylaxis against venous thromboembolism after major orthopedic surgery.
Chest. 2003 Dec;124(6 Suppl):379S-385S.
x Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ, III.
Risk factors for deep vein thrombosis and pulmonary embolism: a
population-based case-control study. Arch Intern Med 2000;160:809-815.
x Abrams PJ, Emerson CR. Rivaroxaban: a novel, oral, direct factor Xa Inhibitor.
Pub Med. Feb.2009; 167-81
x Borris LC, Rivaroxaban, a new, oral direct factor Xa inhibitor for
thromboprophylaxis after major joint arthroplasty. Pub Med. April 2009; 10
6):1083-8.
x Eriksson BI, Kakkar AK, Turpie AG, Gent M, Bandel TJ, Homering M, Misselwitz
F, Lassen MR. Oral rivaroxaban for the prevention of symptomatic venous
thromboembolism after elective hip and knee replacement. Pub Med. May
2009;91(5):636-44.
x Turpie AG, Lassen MR, Davidson BL, et. Al. Rivaroxaban versus Enoxaparin for
thromboprophylaxis after total knee arthroplasty (RECORD4): a randomized trial.
Pub Med. May 16;373(9676):1673-80. Equb 2009 Mat 4.

205

Appendix A
ICD Codes
Table 5.04
Hip Arthroplasty
81.51 TOTAL HIP REPLACEMENT
81.52 PARTIAL HIP REPLACEMENT
Table 5.05
Knee Arthroplasty
81.54 TOTAL KNEE REPLACEMENT
Table 5.09
Infection Codes
Code Shortened Description
001.0 CHOLERA D/T VIB CHOLERAE
001.1 CHOLERA D/T VIB EL TOR
001.9 CHOLERA NOS
002.0 TYPHOID FEVER
002.1 PARATYPHOID FEVER A
002.2 PARATYPHOID FEVER B
002.3 PARATYPHOID FEVER C
002.9 PARATYPHOID FEVER NOS
003.0 SALMONELLA ENTERITIS
003.1 SALMONELLA SEPTICEMIA
003.20 LOCAL SALMONELLA INF NOS
003.21 SALMONELLA MENINGITIS
003.22 SALMONELLA PNEUMONIA

206

003.23 SALMONELLA ARTHRITIS
003.24 SALMONELLA OSTEOMYELITIS
003.29 LOCAL SALMONELLA INF NEC
003.8 SALMONELLA INFECTION NEC
003.9 SALMONELLA INFECTION NOS
004.0 SHIGELLA DYSENTERIAE
004.1 SHIGELLA FLEXNERI
004.2 SHIGELLA BOYDII
004.3 SHIGELLA SONNEI
004.8 SHIGELLA INFECTION NEC
004.9 SHIGELLOSIS NOS
006.0 AC AMEBIASIS W/O ABSCESS
006.1 CHR AMEBIASIS W/O ABSCES
006.2 AMEBIC NONDYSENT COLITIS
006.3 AMEBIC LIVER ABSCESS
006.4 AMEBIC LUNG ABSCESS
006.5 AMEBIC BRAIN ABSCESS
006.6 AMEBIC SKIN ULCERATION
006.8 AMEBIC INFECTION NEC
006.9 AMEBIASIS NOS
007.1 GIARDIASIS
008.00 INTEST INFEC E COLI NOS
008.01 INT INF E COLI ENTRPATH
008.02 INT INF E COLI ENTRTOXGN
008.03 INT INF E COLI ENTRNVSV
008.04 INT INF E COLI ENTRHMRG
008.09 INT INF E COLI SPCF NEC
008.1 ARIZONA ENTERITIS
008.2 AEROBACTER ENTERITIS
008.3 PROTEUS ENTERITIS
008.41 STAPHYLOCOCC ENTERITIS
008.42 PSEUDOMONAS ENTERITIS
008.43 INT INFEC CAMPYLOBACTER
008.44 INT INF YRSNIA ENTRCLTCA
008.45 INT INF CLSTRDIUM DFCILE
008.46 INTES INFEC OTH ANEROBES
008.47 INT INF OTH GRM NEG BCTR
008.49 BACTERIAL ENTERITIS NEC
008.5 BACTERIAL ENTERITIS NOS

207

008.8 VIRAL ENTERITIS NOS
009.0 INFECTIOUS ENTERITIS NOS
009.1 ENTERITIS OF INFECT ORIG
009.2 INFECTIOUS DIARRHEA NOS
009.3 DIARRHEA OF INFECT ORIG
020.0 BUBONIC PLAGUE
020.1 CELLULOCUTANEOUS PLAGUE
020.2 SEPTICEMIC PLAGUE
020.3 PRIMARY PNEUMONIC PLAGUE
020.4 SECONDARY PNEUMON PLAGUE
020.5 PNEUMONIC PLAGUE NOS
020.8 OTHER TYPES OF PLAGUE
020.9 PLAGUE NOS
021.0 ULCEROGLANDUL TULAREMIA
021.1 ENTERIC TULAREMIA
021.2 PULMONARY TULAREMIA
021.3 OCULOGLANDULAR TULAREMIA
021.8 TULAREMIA NEC
021.9 TULAREMIA NOS
022.0 CUTANEOUS ANTHRAX
022.1 PULMONARY ANTHRAX
022.2 GASTROINTESTINAL ANTHRAX
022.3 ANTHRAX SEPTICEMIA
022.8 OTHER ANTHRAX MANIFEST
022.9 ANTHRAX NOS
023.0 BRUCELLA MELITENSIS
023.1 BRUCELLA ABORTUS
023.2 BRUCELLA SUIS
023.3 BRUCELLA CANIS
023.8 BRUCELLOSIS NEC
023.9 BRUCELLOSIS NOS
024 GLANDERS
025 MELIOIDOSIS
026.0 SPIRILLARY FEVER
026.1 STREPTOBACILLARY FEVER
026.9 RAT-BITE FEVER NOS
027.0 LISTERIOSIS
027.1 ERYSIPELOTHRIX INFECTION
027.2 PASTEURELLOSIS

208

027.8 ZOONOTIC BACT DIS NEC
027.9 ZOONOTIC BACT DIS NOS
030.0 LEPROMATOUS LEPROSY
030.1 TUBERCULOID LEPROSY
030.2 INDETERMINATE LEPROSY
030.3 BORDERLINE LEPROSY
030.8 LEPROSY NEC
030.9 LEPROSY NOS
031.0 PULMONARY MYCOBACTERIA
031.1 CUTANEOUS MYCOBACTERIA
031.2 DMAC BACTEREMIA
031.8 MYCOBACTERIAL DIS NEC
031.9 MYCOBACTERIAL DIS NOS
032.0 FAUCIAL DIPHTHERIA
032.1 NASOPHARYNX DIPHTHERIA
032.2 ANT NASAL DIPHTHERIA
032.3 LARYNGEAL DIPHTHERIA
032.81 CONJUNCTIVAL DIPHTHERIA
032.82 DIPHTHERITIC MYOCARDITIS
032.83 DIPHTHERITIC PERITONITIS
032.84 DIPHTHERITIC CYSTITIS
032.85 CUTANEOUS DIPHTHERIA
032.89 DIPHTHERIA NEC
032.9 DIPHTHERIA NOS
033.0 BORDETELLA PERTUSSIS
033.1 BORDETELLA PARAPERTUSSIS
033.8 WHOOPING COUGH NEC
033.9 WHOOPING COUGH NOS
034.0 STREP SORE THROAT
034.1 SCARLET FEVER
035 ERYSIPELAS
036.0 MENINGOCOCCAL MENINGITIS
036.1 MENINGOCOCC ENCEPHALITIS
036.2 MENINGOCOCCEMIA
036.3 MENINGOCOCC ADRENAL SYND
036.40 MENINGOCOCC CARDITIS NOS
036.41 MENINGOCOCC PERICARDITIS
036.42 MENINGOCOCC ENDOCARDITIS
036.43 MENINGOCOCC MYOCARDITIS

209

036.81 MENINGOCOCC OPTIC NEURIT
036.82 MENINGOCOCC ARTHROPATHY
036.89 MENINGOCOCCAL INFECT NEC
036.9 MENINGOCOCCAL INFECT NOS
037 TETANUS
038.0 STREPTOCOCCAL SEPTICEMIA
038.10 STAPHYLCOCC SEPTICEM NOS
038.11 METH SUSC STAPH AUR SEPT
038.12 MRSA SEPTICEMIA
038.19 STAPHYLCOCC SEPTICEM NEC
038.2 PNEUMOCOCCAL SEPTICEMIA
038.3 ANAEROBIC SEPTICEMIA
038.40 GRAM-NEG SEPTICEMIA NOS
038.41 H. INFLUENAE SEPTICEMIA
038.42 E COLI SEPTICEMIA
038.43 PSEUDOMONAS SEPTICEMIA
038.44 SERRATIA SEPTICEMIA
038.49 GRAM-NEG SEPTICEMIA NEC
038.8 SEPTICEMIA NEC
038.9 SEPTICEMIA NOS
039.0 CUTANEOUS ACTINOMYCOSIS
039.1 PULMONARY ACTINOMYCOSIS
039.2 ABDOMINAL ACTINOMYCOSIS
039.3 CERVICOFAC ACTINOMYCOSIS
039.4 MADURA FOOT
039.8 ACTINOMYCOSIS NEC
039.9 ACTINOMYCOSIS NOS
040.0 GAS GANGRENE
040.1 RHINOSCLEROMA
040.2 WHIPPLE'S DISEASE
040.3 NECROBACILLOSIS
040.81 TROPICAL PYOMYOSITIS
040.82 TOXIC SHOCK SYNDROME
040.89 BACTERIAL DISEASES NEC
041.00 STREPTOCOCCUS UNSPECF
041.01 STREPTOCOCCUS GROUP A
041.02 STREPTOCOCCUS GROUP B
041.03 STREPTOCOCCUS GROUP C
041.04 ENTEROCOCCUS GROUP D

210

041.05 STREPTOCOCCUS GROUP G
041.09 OTHER STREPTOCOCCUS
041.10 STAPHYLOCOCCUS UNSPCFIED
041.11 MTH SUS STPH AUR ELS/NOS
041.12 MRSA ELSEWHERE/NOS
041.19 OTHER STAPHYLOCOCCUS
041.2 PNEUMOCOCCUS INFECT NOS
041.3 KLEBSIELLA PNEUMONIAE
041.4 E. COLI INFECT NOS
041.5 H. INFLUENZAE INFECT NOS
041.6 PROTEUS INFECTION NOS
041.7 PSEUDOMONAS INFECT NOS
041.81 MYCOPLASMA
041.82 BACTEROIDES FRAGILIS
041.83 CLOSTRIDIUM PERFRINGENS
041.84 OTHER ANAEROBES
041.85 OTH GRAM NEGATV BACTERIA
041.86 HELICOBACTER PYLORI
041.89 OTH SPECF BACTERIA
041.9 BACTERIAL INFECTION NOS
051.2 CONTAGIOUS PUSTULAR DERM
073.0 ORNITHOSIS PNEUMONIA
073.7 ORNITHOSIS COMPLICAT NEC
073.8 ORNITHOSIS COMPLICAT NOS
073.9 ORNITHOSIS NOS
076.0 TRACHOMA, INITIAL STAGE
076.1 TRACHOMA, ACTIVE STAGE
076.9 TRACHOMA NOS
078.2 SWEATING FEVER
078.3 CAT-SCRATCH DISEASE
078.4 FOOT & MOUTH DISEASE
078.6 HEM NEPHROSONEPHRITIS
078.88 OTH SPEC DIS CHLAMYDIAE
079.88 OTH SPCF CHLAMYDIAL INFC
079.98 CHLAMYDIAL INFECTION NOS
082.40 EHRLICHIOSIS NOS
082.41 EHRLICHIOSIS CHAFEENSIS
082.49 EHRLICHIOSIS NEC
082.8 TICK-BORNE RICKETTS NEC

211

082.9 TICK-BORNE RICKETTS NOS
083.2 RICKETTSIALPOX
083.8 RICKETTSIOSES NEC
083.9 RICKETTSIOSIS NOS
088.0 BARTONELLOSIS
088.81 LYME DISEASE
090.0 EARLY CONG SYPH SYMPTOM
090.1 EARLY CONGEN SYPH LATENT
090.2 EARLY CONGEN SYPH NOS
090.3 SYPHILITIC KERATITIS
090.40 JUVENILE NEUROSYPH NOS
090.41 CONGEN SYPH ENCEPHALITIS
090.42 CONGEN SYPH MENINGITIS
090.49 JUVENILE NEUROSYPH NEC
090.5 LATE CONGEN SYPH SYMPTOM
090.6 LATE CONGEN SYPH LATENT
090.7 LATE CONGEN SYPH NOS
090.9 CONGENITAL SYPHILIS NOS
091.0 PRIMARY GENITAL SYPHILIS
091.1 PRIMARY ANAL SYPHILIS
091.2 PRIMARY SYPHILIS NEC
091.3 SECONDARY SYPH SKIN
091.4 SYPHILITIC ADENOPATHY
091.50 SYPHILITIC UVEITIS NOS
091.51 SYPHILIT CHORIORETINITIS
091.52 SYPHILITIC IRIDOCYCLITIS
091.61 SYPHILITIC PERIOSTITIS
091.62 SYPHILITIC HEPATITIS
091.69 SECOND SYPH VISCERA NEC
091.7 SECOND SYPHILIS RELAPSE
091.81 ACUTE SYPHIL MENINGITIS
091.82 SYPHILITIC ALOPECIA
091.89 SECONDARY SYPHILIS NEC
091.9 SECONDARY SYPHILIS NOS
092.0 EARLY SYPH LATENT RELAPS
092.9 EARLY SYPHIL LATENT NOS
093.0 AORTIC ANEURYSM, SYPHIL
093.1 SYPHILITIC AORTITIS
093.20 SYPHIL ENDOCARDITIS NOS

212

093.21 SYPHILITIC MITRAL VALVE
093.22 SYPHILITIC AORTIC VALVE
093.23 SYPHIL TRICUSPID VALVE
093.24 SYPHIL PULMONARY VALVE
093.81 SYPHILITIC PERICARDITIS
093.82 SYPHILITIC MYOCARDITIS
093.89 CARDIOVASCULAR SYPH NEC
093.9 CARDIOVASCULAR SYPH NOS
094.0 TABES DORSALIS
094.1 GENERAL PARESIS
094.2 SYPHILITIC MENINGITIS
094.3 ASYMPTOMAT NEUROSYPHILIS
094.81 SYPHILITIC ENCEPHALITIS
094.82 SYPHILITIC PARKINSONISM
094.83 SYPH DISSEM RETINITIS
094.84 SYPHILITIC OPTIC ATROPHY
094.85 SYPH RETROBULB NEURITIS
094.86 SYPHIL ACOUSTIC NEURITIS
094.87 SYPH RUPT CEREB ANEURYSM
094.89 NEUROSYPHILIS NEC
094.9 NEUROSYPHILIS NOS
095.0 SYPHILITIC EPISCLERITIS
095.1 SYPHILIS OF LUNG
095.2 SYPHILITIC PERITONITIS
095.3 SYPHILIS OF LIVER
095.4 SYPHILIS OF KIDNEY
095.5 SYPHILIS OF BONE
095.6 SYPHILIS OF MUSCLE
095.7 SYPHILIS OF TENDON/BURSA
095.8 LATE SYMPT SYPHILIS NEC
095.9 LATE SYMPT SYPHILIS NOS
096 LATE SYPHILIS LATENT
097.0 LATE SYPHILIS NOS
097.1 LATENT SYPHILIS NOS
097.9 SYPHILIS NOS
098.0 ACUTE GC INFECT LOWER GU
098.10 GC (ACUTE) UPPER GU NOS
098.11 GC CYSTITIS (ACUTE)
098.12 GC PROSTATITIS (ACUTE)

213

098.13 GC ORCHITIS (ACUTE)
098.14 GC SEM VESICULIT (ACUTE)
098.15 GC CERVICITIS (ACUTE)
098.16 GC ENDOMETRITIS (ACUTE)
098.17 ACUTE GC SALPINGITIS
098.19 GC (ACUTE) UPPER GU NEC
098.2 CHR GC INFECT LOWER GU
098.30 CHR GC UPPER GU NOS
098.31 GC CYSTITIS, CHRONIC
098.32 GC PROSTATITIS, CHRONIC
098.33 GC ORCHITIS, CHRONIC
098.34 GC SEM VESICULITIS, CHR
098.35 GC CERVICITIS, CHRONIC
098.36 GC ENDOMETRITIS, CHRONIC
098.37 GC SALPINGITIS (CHRONIC)
098.39 CHR GC UPPER GU NEC
098.40 GONOCOCCAL CONJUNCTIVIT
098.41 GONOCOCCAL IRIDOCYCLITIS
098.42 GONOCOCCAL ENDOPHTHALMIA
098.43 GONOCOCCAL KERATITIS
098.49 GONOCOCCAL EYE NEC
098.50 GONOCOCCAL ARTHRITIS
098.51 GONOCOCCAL SYNOVITIS
098.52 GONOCOCCAL BURSITIS
098.53 GONOCOCCAL SPONDYLITIS
098.59 GC INFECT JOINT NEC
098.6 GONOCOCCAL INFEC PHARYNX
098.7 GC INFECT ANUS & RECTUM
098.81 GONOCOCCAL KERATOSIS
098.82 GONOCOCCAL MENINGITIS
098.83 GONOCOCCAL PERICARDITIS
098.84 GONOCOCCAL ENDOCARDITIS
098.85 GONOCOCCAL HEART DIS NEC
098.86 GONOCOCCAL PERITONITIS
098.89 GONOCOCCAL INF SITE NEC
099.0 CHANCROID
099.1 LYMPHOGRANULOMA VENEREUM
099.2 GRANULOMA INGUINALE
099.3 REITER'S DISEASE

214

099.40 UNSPCF NONGNCCL URETHRTS
099.41 CHLMYD TRACHOMATIS URETH
099.49 NONGC URTH OTH SPF ORGSM
099.50 OTH VD CHLM TRCH UNSP ST
099.51 OTH VD CHLM TRCH PHARYNX
099.52 OTH VD CHLM TRCH ANS RCT
099.53 OTH VD CHLM TRCH LOWR GU
099.54 OTH VD CHLM TRCH OTH GU
099.55 OT VD CHLM TRCH UNSPF GU
099.56 OT VD CHLM TRCH PRTONEUM
099.59 OTH VD CHLM TRCH SPCF ST
099.8 VENEREAL DISEASE NEC
099.9 VENEREAL DISEASE NOS
100.0 LEPTOSPIROS ICTEROHEM
100.81 LEPTOSPIRAL MENINGITIS
100.89 LEPTOSPIRAL INFECT NEC
100.9 LEPTOSPIROSIS NOS
101 VINCENT'S ANGINA
102.0 INITIAL LESIONS YAWS
102.1 MULTIPLE PAPILLOMATA
102.2 EARLY SKIN YAWS NEC
102.3 HYPERKERATOSIS OF YAWS
102.4 GUMMATA AND ULCERS, YAWS
102.5 GANGOSA
102.6 YAWS OF BONE & JOINT
102.7 YAWS MANIFESTATIONS NEC
102.8 LATENT YAWS
102.9 YAWS NOS
103.0 PINTA PRIMARY LESIONS
103.1 PINTA INTERMED LESIONS
103.2 PINTA LATE LESIONS
103.3 PINTA MIXED LESIONS
103.9 PINTA NOS
104.0 NONVENEREAL ENDEMIC SYPH
104.8 SPIROCHETAL INFECT NEC
104.9 SPIROCHETAL INFECT NOS
130.0 TOXOPLASM MENINGOENCEPH
130.1 TOXOPLASM CONJUNCTIVITIS
130.2 TOXOPLASM CHORIORETINIT

215

130.3 TOXOPLASMA MYOCARDITIS
130.4 TOXOPLASMA PNEUMONITIS
130.5 TOXOPLASMA HEPATITIS
130.7 TOXOPLASMOSIS SITE NEC
130.8 MULTISYSTEM TOXOPLASMOS
131.00 UROGENITAL TRICHOMON NOS
131.01 TRICHOMONAL VAGINITIS
131.02 TRICHOMONAL URETHRITIS
131.03 TRICHOMONAL PROSTATITIS
131.09 UROGENITAL TRICHOMON NEC
131.8 TRICHOMONIASIS NEC
131.9 TRICHOMONIASIS NOS
320.0 HEMOPHILUS MENINGITIS
320.1 PNEUMOCOCCAL MENINGITIS
320.2 STREPTOCOCCAL MENINGITIS
320.3 STAPHYLOCOCC MENINGITIS
320.7 MENING IN OTH BACT DIS
320.81 ANAEROBIC MENINGITIS
320.82 MNINGTS GRAM-NEG BCT NEC
320.89 MENINGITIS OTH SPCF BACT
320.9 BACTERIAL MENINGITIS NOS
322.9 MENINGITIS NOS
323.1 RICKETTSIAL ENCEPHALITIS
324.0 INTRACRANIAL ABSCESS
324.1 INTRASPINAL ABSCESS
324.9 CNS ABSCESS NOS
380.10 INFEC OTITIS EXTERNA NOS
380.11 ACUTE INFECTION OF PINNA
380.12 ACUTE SWIMMERS' EAR
380.13 AC INFECT EXTERN EAR NEC
380.14 MALIGNANT OTITIS EXTERNA
380.15 CHR MYCOT OTITIS EXTERNA
380.16 CHR INF OTIT EXTERNA NEC
380.21 CHOLESTEATOMA EXTERN EAR
380.22 ACUTE OTITIS EXTERNA NEC
380.23 CHR OTITIS EXTERNA NEC
382.00 AC SUPP OTITIS MEDIA NOS
382.01 AC SUPP OM W DRUM RUPT
382.02 AC SUPP OM IN OTH DIS

216

382.1 CHR TUBOTYMPAN SUPPUR OM
382.2 CHR ATTICOANTRAL SUP OM
421.0 AC/SUBAC BACT ENDOCARD
421.1 AC ENDOCARDIT IN OTH DIS
421.9 AC/SUBAC ENDOCARDIT NOS
422.0 AC MYOCARDIT IN OTH DIS
422.90 ACUTE MYOCARDITIS NOS
422.91 IDIOPATHIC MYOCARDITIS
422.92 SEPTIC MYOCARDITIS
422.93 TOXIC MYOCARDITIS
422.99 ACUTE MYOCARDITIS NEC
462 ACUTE PHARYNGITIS
463 ACUTE TONSILLITIS
464.00 AC LARYNGITIS W/O OBST
464.01 AC LARYNGITIS W OBSTRUCT
464.10 AC TRACHEITIS NO OBSTRUC
464.11 AC TRACHEITIS W OBSTRUCT
464.20 AC LARYNGOTRACH NO OBSTR
464.21 AC LARYNGOTRACH W OBSTR
464.30 AC EPIGLOTTITIS NO OBSTR
464.31 AC EPIGLOTTITIS W OBSTR
464.50 SUPRAGLOTTIS W/O OBS NOS
464.51 SUPRAGLOTTIS W OBSTR NOS
475 PERITONSILLAR ABSCESS
476.0 CHRONIC LARYNGITIS
476.1 CHR LARYNGOTRACHEITIS
481 PNEUMOCOCCAL PNEUMONIA
482.0 K. PNEUMONIAE PNEUMONIA
482.1 PSEUDOMONAL PNEUMONIA
482.2 H.INFLUENZAE PNEUMONIA
482.30 STREPTOCOCCAL PNEUMN NOS
482.31 PNEUMONIA STRPTOCOCCUS A
482.32 PNEUMONIA STRPTOCOCCUS B
482.39 PNEUMONIA OTH STREP
482.40 STAPHYLOCOCCAL PNEU NOS
482.41 METH SUS PNEUM D/T STAPH
482.42 METH RES PNEU D/T STAPH
482.49 STAPH PNEUMONIA NEC
482.81 PNEUMONIA ANAEROBES

217

482.82 PNEUMONIA E COLI
482.83 PNEUMO OTH GRM-NEG BACT
482.84 LEGIONNAIRES' DISEASE
482.89 PNEUMONIA OTH SPCF BACT
482.9 BACTERIAL PNEUMONIA NOS
483.0 PNEU MYCPLSM PNEUMONIAE
483.1 PNEUMONIA D/T CHLAMYDIA
483.8 PNEUMON OTH SPEC ORGNSM
484.1 PNEUM W CYTOMEG INCL DIS
484.3 PNEUMONIA IN WHOOP COUGH
484.5 PNEUMONIA IN ANTHRAX
484.6 PNEUM IN ASPERGILLOSIS
484.7 PNEUM IN OTH SYS MYCOSES
484.8 PNEUM IN INFECT DIS NEC
485 BRONCHOPNEUMONIA ORG NOS
486 PNEUMONIA, ORGANISM NOS
487.0 INFLUENZA WITH PNEUMONIA
487.1 FLU W RESP MANIFEST NEC
487.8 FLU W MANIFESTATION NEC
490 BRONCHITIS NOS
491.0 SIMPLE CHR BRONCHITIS
491.1 MUCOPURUL CHR BRONCHITIS
491.20 OBST CHR BRONC W/O EXAC
491.21 OBS CHR BRONC W(AC) EXAC
491.22 OBS CHR BRONC W AC BRONC
491.8 CHRONIC BRONCHITIS NEC
491.9 CHRONIC BRONCHITIS NOS
510.0 EMPYEMA WITH FISTULA
510.9 EMPYEMA W/O FISTULA
513.0 ABSCESS OF LUNG
513.1 ABSCESS OF MEDIASTINUM
540.0 AC APPEND W PERITONITIS
540.1 ABSCESS OF APPENDIX
540.9 ACUTE APPENDICITIS NOS
541 APPENDICITIS NOS
542 OTHER APPENDICITIS
562.01 DVRTCLI SML INT W/O HMRG
562.11 DVRTCLI COLON W/O HMRHG
562.13 DVRTCLI COLON W HMRHG

218

566 ANAL & RECTAL ABSCESS
567.21 PERITONITIS (ACUTE) GEN
567.22 PERITONEAL ABSCESS
567.23 SPONTAN BACT PERITONITIS
567.29 SUPPURAT PERITONITIS NEC
567.31 PSOAS MUSCLE ABSCESS
567.38 RETROPERITON ABSCESS NEC
567.39 RETROPERITON INFECT NEC
567.81 CHOLEPERITONITIS
567.82 SCLEROSING MESENTERITIS
567.89 PERITONITIS NEC
567.9 PERITONITIS NOS
569.5 INTESTINAL ABSCESS
569.61 COLOSTY/ENTEROST INFECTN
575.0 ACUTE CHOLECYSTITIS
590.00 CHR PYELONEPHRITIS NOS
590.01 CHR PYELONEPH W MED NECR
590.10 AC PYELONEPHRITIS NOS
590.11 AC PYELONEPHR W MED NECR
590.2 RENAL/PERIRENAL ABSCESS
590.3 PYELOURETERITIS CYSTICA
590.80 PYELONEPHRITIS NOS
590.81 PYELONEPHRIT IN OTH DIS
590.9 INFECTION OF KIDNEY NOS
595.0 ACUTE CYSTITIS
599.0 URIN TRACT INFECTION NOS
601.0 ACUTE PROSTATITIS
601.1 CHRONIC PROSTATITIS
601.2 ABSCESS OF PROSTATE
601.3 PROSTATOCYSTITIS
601.4 PROSTATITIS IN OTH DIS
601.8 PROSTATIC INFLAM DIS NEC
601.9 PROSTATITIS NOS
614.0 AC SALPINGO-OOPHORITIS
614.1 CHR SALPINGO-OOPHORITIS
614.2 SALPINGO-OOPHORITIS NOS
614.3 ACUTE PARAMETRITIS
614.4 CHRONIC PARAMETRITIS
614.5 AC PELV PERITONITIS-FEM

219

614.7 CHR PELV PERITON NEC-FEM
616.2 BARTHOLIN'S GLAND CYST
616.3 BARTHOLIN'S GLND ABSCESS
616.4 ABSCESS OF VULVA NEC
639.0 POSTABORTION GU INFECT
646.60 GU INFECT IN PREG- UNSPEC
646.61 GU INFECTION-DELIVERED
646.62 GU INFECTION-DELIV W P/P
646.63 GU INFECTION-ANTEPARTUM
646.64 GU INFECTION-POSTPARTUM
670.00 MAJ PUERP INF NOS-UNSP
670.02 MAJ PUER INF NOS-DEL P/P
670.04 MAJOR PUERP INF NOS-P/P
674.30 OB SURG COMPL NEC-UNSPEC
674.32 OB SURG COMPL-DEL W P/P
674.34 OB SURG COMP NEC- POSTPAR
680.0 CARBUNCLE OF FACE
680.1 CARBUNCLE OF NECK
680.2 CARBUNCLE OF TRUNK
680.3 CARBUNCLE OF ARM
680.4 CARBUNCLE OF HAND
680.5 CARBUNCLE OF BUTTOCK
680.6 CARBUNCLE OF LEG
680.7 CARBUNCLE OF FOOT
680.8 CARBUNCLE, SITE NEC
680.9 CARBUNCLE NOS
681.00 CELLULITIS, FINGER NOS
681.01 FELON
681.02 ONYCHIA OF FINGER
681.10 CELLULITIS, TOE NOS
681.11 ONYCHIA OF TOE
681.9 CELLULITIS OF DIGIT NOS
682.0 CELLULITIS OF FACE
682.1 CELLULITIS OF NECK
682.2 CELLULITIS OF TRUNK
682.3 CELLULITIS OF ARM
682.4 CELLULITIS OF HAND
682.5 CELLULITIS OF BUTTOCK
682.6 CELLULITIS OF LEG

220

682.7 CELLULITIS OF FOOT
682.8 CELLULITIS, SITE NEC
682.9 CELLULITIS NOS
683 ACUTE LYMPHADENITIS
684 IMPETIGO
685.0 PILONIDAL CYST W ABSCESS
685.1 PILONIDAL CYST W/O ABSC
686.00 PYODERMA NOS
686.01 PYODERMA GANGRENOSUM
686.09 PYODERMA NEC
686.1 PYOGENIC GRANULOMA
686.8 LOCAL SKIN INFECTION NEC
686.9 LOCAL SKIN INFECTION NOS
711.90 INF ARTHRITIS NOS-UNSPEC
711.91 INF ARTHRITIS NOS-SHLDER
711.92 INF ARTHRITIS NOS-UP/ARM
711.93 INF ARTHRIT NOS-FOREARM
711.94 INF ARTHRIT NOS-HAND
711.95 INF ARTHRIT NOS-PELVIS
711.96 INF ARTHRIT NOS-L/LEG
711.97 INF ARTHRIT NOS-ANKLE
711.98 INF ARTHRIT NOS-OTH SITE
711.99 INF ARTHRITIS NOS-MULT
730.00 AC OSTEOMYELITIS-UNSPEC
730.01 AC OSTEOMYELITIS-SHLDER
730.02 AC OSTEOMYELITIS-UP/ARM
730.03 AC OSTEOMYELITIS-FOREARM
730.04 AC OSTEOMYELITIS-HAND
730.05 AC OSTEOMYELITIS-PELVIS
730.06 AC OSTEOMYELITIS-L/LEG
730.07 AC OSTEOMYELITIS-ANKLE
730.08 AC OSTEOMYELITIS NEC
730.09 AC OSTEOMYELITIS-MULT
730.10 CHR OSTEOMYELITIS-UNSP
730.11 CHR OSTEOMYELIT-SHLDER
730.12 CHR OSTEOMYELIT-UP/ARM
730.13 CHR OSTEOMYELIT-FOREARM
730.14 CHR OSTEOMYELIT-HAND
730.15 CHR OSTEOMYELIT-PELVIS

221

730.16 CHR OSTEOMYELIT-L/LEG
730.17 CHR OSTEOMYELIT-ANKLE
730.18 CHR OSTEOMYELIT NEC
730.19 CHR OSTEOMYELIT-MULT
730.20 OSTEOMYELITIS NOS-UNSPEC
730.21 OSTEOMYELITIS NOS-SHLDER
730.22 OSTEOMYELITIS NOS-UP/ARM
730.23 OSTEOMYELIT NOS-FOREARM
730.24 OSTEOMYELITIS NOS-HAND
730.25 OSTEOMYELITIS NOS-PELVIS
730.26 OSTEOMYELITIS NOS-L/LEG
730.27 OSTEOMYELITIS NOS-ANKLE
730.28 OSTEOMYELIT NOS-OTH SITE
730.29 OSTEOMYELITIS NOS-MULT
730.30 PERIOSTITIS-UNSPEC
730.31 PERIOSTITIS-SHLDER
730.32 PERIOSTITIS-UP/ARM
730.33 PERIOSTITIS-FOREARM
730.34 PERIOSTITIS-HAND
730.35 PERIOSTITIS-PELVIS
730.70 POLIO OSTEOPATHY-UNSPEC
730.71 POLIO OSTEOPATHY-SHLDER
730.72 POLIO OSTEOPATHY-UP/ARM
730.73 POLIO OSTEOPATHY-FOREARM
730.74 POLIO OSTEOPATHY-HAND
730.75 POLIO OSTEOPATHY-PELVIS
730.76 POLIO OSTEOPATHY-L/LEG
730.77 POLIO OSTEOPATHY-ANKLE
730.78 POLIO OSTEOPATHY NEC
730.79 POLIO OSTEOPATHY-MULT
730.80 BONE INFECT NEC-UNSPEC
730.81 BONE INFECT NEC-SHLDER
730.82 BONE INFECT NEC-UP/ARM
730.83 BONE INFECT NEC-FOREARM
730.84 BONE INFECT NEC-HAND
730.85 BONE INFECT NEC-PELVIS
730.86 BONE INFECT NEC-L/LEG
730.87 BONE INFECT NEC-ANKLE
730.88 BONE INFECT NEC-OTH SITE

222

730.89 BONE INFECT NEC-MULT
730.90 BONE INFEC NOS-UNSP SITE
730.91 BONE INFECT NOS-SHLDER
730.92 BONE INFECT NOS-UP/ARM
730.93 BONE INFECT NOS-FOREARM
730.94 BONE INFECT NOS-HAND
730.95 BONE INFECT NOS-PELVIS
730.96 BONE INFECT NOS-L/LEG
730.97 BONE INFECT NOS-ANKLE
730.98 BONE INFECT NOS-OTH SITE
730.99 BONE INFECT NOS-MULT
785.52 SEPTIC SHOCK
790.7 BACTEREMIA
996.60 REACTION-UNSP DEVIC/GRFT
996.61 REACT-CARDIAC DEV/GRAFT
996.62 REACT-OTH VASC DEV/GRAFT
996.63 REACT-NERV SYS DEV/GRAFT
996.64 REACT-INDWELL URIN CATH
996.65 REACT-OTH GENITOURIN DEV
996.66 REACT-INTER JOINT PROST
996.67 REACT-OTH INT ORTHO DEV
996.68 REACT- PERITON DIALY CATH
996.69 REACT-INT PROS DEVIC NEC
997.31 VENTLTR ASSOC PNEUMONIA
998.51 INFECTED POSTOP SEROMA
998.59 OTHER POSTOP INFECTION

223

Venous
Thromboembolism
(VTE) Measure Set

224

Measure

Patients who received VTE prophylaxis (or reasons of why this was not
done) on the day of or day after hospital admission or
surgery. Note: This measure applies to medical and surgical cases
I-VTE-1 that are not included in the SCIP measure population
ICU patients who received VTE prophylaxis (or reasons of why this was
not done) on the day of or day after hospital admission or
surgery. Note: This measure applies to all ICU cases except those
included in the SCIP measure population (knee/hip arthroplasty) who
I-VTE-2 had surgery on the day of or the day after ICU admission or transfer

225

I-VTE-1
Venous Thromboembolism Prophylaxis
Measure Overview
I-VTE 1 Patients who received VTE prophylaxis (or reasons of why this was not
done) on the day of or day after hospital admission or surgery.
Note: This measure applies to medical and surgical cases that are not included
in the SCIP measure population.
Overview/Details:
VTE prophylaxis given on the day of or the day after hospital admission or surgery or a
reason documented of why VTE prophylaxis was not given.
See Appendix A.
Rationale:
Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein
thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is
suspected. Therefore, the best approach is for every patient to be evaluated for primary
prophylaxis since preventing DVT is essential to reducing morbidity and mortality.
There is clinical evidence that appropriately used thromboprophylaxis has a desirable
risk/benefit ratio and is cost effective. Thromboprophylaxis provides an opportunity to
improve patient outcomes and reduce hospital costs.

Measure Name: Venous Thromboembolism Prophylaxis

226

Numerator: Patients who received VTE prophylaxis or have documentation of why no

VTE prophylaxis was given:
x the day of or the day after hospital admission

x the day of or day after surgery end date for surgeries that start the day of or day
after hospital admission
Denominator: All patients who are >=18 years.
$SSURSULDWHQHVV QPS.3 patient $0, *RDO

assessments
$YDLODELOLW\ +) *RDO
&RQWLQXLW\ 6WURNH
QPS.3 surgical
(IIHFWLYHQHVV procedures &.D
3UHYHQWLRQ(DUO\ 'LDEHWHV
Detection QPS.3 antibiotic (Type I/II)
7LPHOLQHVV and other (65'

medication use
-RLQW5HSODFHPHQW
+,9$,'6
&DQFHU
7UDQVSODQWDWLRQ
&23'

227

I-VTE-1
Measure Details
Reasons and Implications: Hospitalized patients at high-risk for VTE may develop an
asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE)
even before the diagnosis is suspected. There is clinical evidence that appropriately
used thromboprophylaxis has a desirable risk/benefit ratio and is cost effective.
Thromboprophylaxis provides an opportunity to improve patient outcomes and reduce
hospital costs.

x the day of or the day after hospital admission

after hospital admission
Data elements:
x Reason for No VTE Prophylaxis Hospital admission

x Surgery end date
x Surgical procedure
x VTE Prophylaxis
x VTE Prophylaxis date
Denominator: All patients who are > = 18 years.
Data elements:
x Admission Date
x Birthdate
x ICD diagnosis code
x ICU admission date
x ICU admission/transfer

228


x Patients who are direct admits to the intensive care unit (ICU)
x Patients with an ICD Principal diagnosis code of Mental disorders
x Patients with an ICD Principal or other diagnosis code of Obstetrics or VTE

229

I-VTE-1
References
antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
x Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism:
the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
x Kucher N, Koo S, Quiroz R, Cooper JM, et al. Electronic alerts to prevent venous
thromboembolism among hospitalized patients. New England Journal of
Medicine. 2005, 352(10), 969-1036.
x Caprini JA, Arcelus JI. State of the art venous thromboembolism prophylaxis.
SCOPE on Phlebology & Lymphology 1:2005, 228-240.
x Michota FA. Venous thromboembolism prophylaxis in medical patients. Curr
Opin Cardiol. 2004 Nov;19(6):570-4.

230

I-VTE-2
ICU Venous Thromboembolism Prophylaxis
Measure Overview
I-VTE 2 ICU patients who received VTE prophylaxis (or reasons of why this was
not done) on the day of or day after hospital admission or surgery.
Note: This measure applies to all ICU cases except those included in the SCIP measure
population (knee/hip arthroplasty) who had surgery on the day of or the day after ICU admission
or transfer.
Overview/Details:
ICU VTE prophylaxis given on the day of or the day after ICU hospital admission or
surgery or a reason documented of why VTE prophylaxis was not given.
See Appendix A.
Rationale:
The vast majority of patients admitted to a critical care unit (CCU) have a major risk
factor for VTE, and many may have multiple risk factors including advanced age,
serious medical illness or recent surgical procedures or trauma. The use of
thromboprophylaxis has been clinically demonstrated to be efficacious in preventing
deep venous thrombosis in these patients.

Patient Settings/Services: Intensive Care Units
Measure Name: Intensive Care Unit Venous Thromboembolism Prophylaxis

x the day of or the day after ICU admission (or transfer)

231

after ICU admission (or transfer)
Denominator: Patients directly admitted or transferred to ICU who are >= 18 years
Domains of QPS Standards CCPC IPSG

Performance
$SSURSULDWHQHVV QPS.3 patient $0, *RDO

assessments
$YDLODELOLW\ +) *RDO
&RQWLQXLW\ 6WURNH
QPS.3 surgical
(IIHFWLYHQHVV procedures &.'
Detection QPS.3 antibiotic and (65'
7LPHOLQHVV other medication use -RLQW5HSODFHPHQW
7UDXPDWLF%DLQ,QMXU\
+,9$,'6
&DQFHU
7UDQVSODQWDWLRQ
&23'

232

I-VTE-2
Measure Details
Reasons and Implications: The vast majority of patients admitted to a critical care
unit (CCU) have a major risk factor for VTE, and many may have multiple risk factors
including advanced age, serious medical illness or recent surgical procedures or
trauma. The use of thromboprophylaxis has been clinically demonstrated to be
efficacious in preventing deep venous thrombosis in these patients.

x the day of or the day after ICU admission (or transfer)

after ICU admission (or transfer)
Data elements:

x ICU VTE Prophylaxis
x ICU VTE Prophylaxis date
x Reason for No VTE Prophylaxis ICU admission
x Surgery end date ICU admit or transfer
x Surgical procedure- ICU admit or transfer
Denominator: All patients who are > = to 18 years.
Data elements:
x Admission Date
x Birthdate
x ICD diagnosis code
x ICU discharge date
x ICU admission date
x ICU admission or Transfer

233


x Patients with an ICD Principal or other diagnosis code of Obstetrics or VTE

234

I-VTE-2
References
antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
x Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism:
the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
x Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH. Deep vein
thrombosis and its prevention in critically ill adults. Arch Intern Med. 2001 May
28;161(10):1268-79.
x Geerts WH, Selby R. Prevention of venous thromboembolism in the ICU. Chest.
2003 Dec;124(6 Suppl):357S-363S.

235

Appendix A
VTE Prophylaxis Inclusion Table
Table 2.1 VTE Prophylaxis Inclusion Table
VTE Prophylaxis Inclusion/Synonyms

Coumadin/ Warfarin Coumadin
Jantoven
Warfarin
Warfarin Sodium
Graduated Compression Anti-Embolism stockings
Stockings (GCS) Anti-thrombosis stockings
Elastic support hose
- Knee or thigh high
Graduated compression elastic stockings
Jobst stockings
Surgical hose
TED hose (TEDs)
White hose
Thrombosis stockings
Factor Xa Inhibitor Arixtra
Fonda-parinux sodium
Oral Factor Xa Inhibitor Rivaroxaban (Oral)
Low Dose Unfractionated Calciparine
Heparin (LDUH) Calcilean
HEP
- Include only Heparin given
by the subcutaneous (SQ, Hepalean
Subcu, SC, SubQ) route Heparin
Heparin Calcium
Heparin Leo
Heparin Na
Heparin Sod
Heparin Sodium
Heparin Sodium Inj.
Heparin Sodium Inj. Pork
Heparin Subcu/SQ/SC/SubQ
Liquaemin

236


Low Molecular Weight Ardeparin
Heparin (LMWH) Dalteparin
Danaparoid
Enoxaparin
Fragmin
Innohep
Lovenox
Normiflo
Orgaran
Tinzaparin
Intermittent Pneumatic AE pumps (anti-embolic pumps)-calf/thigh
Compression Device (IPC) Alternating Leg Pressure (ALP)
Athrombic pumps-calf/thigh
Continuous Enhanced Circulation Therapy (CECT)
DVT boots-calf/thigh
EPC cuffs/ stockings-External pneumatic compression-
calf/thigh
Flotron/Flotron DVT system-thigh
Impulse pump-thigh
Intermittent pneumatic compression stockings
Intermittent compression device (ICD)
KCI stockings
Leg pumpers
PAS (Pulsatile anti-embolic stockings)
Plexipulse-calf/thigh
Pneumatic intermittent impulse compression device
Rapid inflation asymmetrical compression (RIAC) devices
Sequential compression device
Sequential pneumatic hose
Thromboguard
Thrombus pumps-calf/thigh
Vascutherm
VasoPress DVT System

237


Venodyne boots-calf/thigh
Venous Foot Pump (VFP) AE pumps-foot only

A-V impulse system
Foot pump
Kendall AV impulse (foot)
Kendall boots
Plantar venous plexus pump-foot only
Plexiboots-foot only
Pneumoboots-foot only
SC boots-foot only
SCD boots-foot only
Venous foot pump
Note: This table is not meant to be an inclusive list of all available mechanical
prophylaxis; rather it represents current information available at the time of
publication.
Table 2.3 VTE Parenteral Therapy Table
Direct Thrombin Inhibitors Argatroban (Acova)

- argatroban Bivalirudin (Angiomax)
- bivalirudin
- lepirudin Lepirudin (recombinant hirudin)(Refludan)
Factor Xa Inhibitor Arixtra

Fondaparinux sodium
Unfractionated Heparin Calciparine
(UFH) Calcilean
- intravenous (IV)
- subcutaneous (fixed dose HEP
or monitored) Hepalean

238

Heparin
Heparin Calcium
Heparin Leo
Heparin Na
Heparin Sod
Heparin Sodium
Heparin Sodium Inj.
Heparin Sodium Inj. Pork
Heparin Subcu/SQ/SC
Liquaemin
Low Molecular Weight Ardeparin
Heparin (LMWH) Dalteparin
Danaparoid
Enoxaparin
Fragmin
Innohep
Lovenox
Normiflo
Orgaran
Tinzaparin

239

Appendix B
ICD Codes
VTE
Table 7.03 VTE

CM
Code Code Code Code
415.11 IATROGEN PULM EMB/INFARC
415.19 PULM EMBOL/INFARCT NEC
451.11 FEMORAL VEIN PHLEBITIS
451.19 DEEP PHLEBITIS-LEG NEC
451.2 THROMBOPHLEBITIS LEG NOS
451.81 ILIAC THROMBOPHLEBITIS
451.9 THROMBOPHLEBITIS NOS
453.40 DVT/EMBLSM LOWER EXT NOS
453.41 DVT/EMB PROX LOWER EXT
453.87 AC EMBL THORAC VEIN NEC
453.89 AC EMBOLISM VEINS NEC
453.9 VENOUS THROMBOSIS NOS

240

Table 7.04 VTE Obstetrics

CM
Code Code Code Code
634.60 SPON ABORT W EMBOL-UNSPEC
634.61 SPON ABORT W EMBOL-INC
634.62 SPON ABORT W EMBOL-COMP
635.60 LEGAL ABORT W EMBOL-UNSPEC
635.61 LEGAL ABORT W EMBOL-INC
635.62 LEGAL ABORT W EMBOL-COMP
636.60 ILLEG AB W EMBOLISM-UNSPEC
636.61 ILLEG AB W EMBOLISM-INC
636.62 ILLEG AB W EMBOLISM-COMP
637.60 AB NOS W EMBOLISM-UNSP
637.61 AB NOS W EMBOLISM-INC
637.62 AB NOS W EMBOLISM-COMP
638.6 ATTEMP ABORT W EMBOLISM
639.6 POSTABORTION EMBOLISM
671.30 DEEP THROMB ANTEPAR-UNSPEC
671.31 DEEP THROM ANTEPAR-DELIV
671.33 DEEP VEIN THROMB-ANTEPAR
671.40 DEEP THROMB POSTPAR-UNSPEC
671.42 THROMB POSTPAR-DEL W P/P

241

CM
Code Code Code Code
671.44 DEEP VEIN THROMB-POSTPAR
671.50 THROMBOSIS NEC PREG-UNSPEC
671.51 THROMBOSIS NEC-DELIV
671.52 THROMB NEC-DELIV W P/P
671.53 THROMBOSIS NEC-ANTEPART
671.54 THROMBOSIS NEC-POSTPART
671.90 VEN COMPL PREG NOS-UNSPEC
671.91 VENOUS COMPL NOS-DELIVER
671.92 VEN COMP NOS-DELIV W P/P
671.93 VENOUS COMPL NOS-ANTEPAR
671.94 VENOUS COMPL NOS-POSTPAR
673.20 OB PULM EMBOL NOS-UNSPEC
673.21 PULM EMBOL NOS-DELIV

673.22 PULM EMBOL NOS-DELIV W P/P
673.23 PULM EMBOL NOS-ANTEPART
673.24 PULM EMBOL NOS-POSTPART

242

Glossary

243

Glossary
A
Accreditation
Determination by Joint Commission International (JCI) accrediting body that an eligible
health care organization complies with applicable JCI standards (JCI)
Accreditation process
A continuous process whereby health care organizations are required to demonstrate to
JCI that they are providing safe, high-quality care, as determined by compliance with
JCI standards and International Patient Safety Goals recommendations. The key
component of this process is an on-site evaluation of an organization by JCI surveyors.
(JCI)
Accuracy of data
The extent to which data are free of identifiable errors.
Acute Hemorrhagic Stroke

A non-traumatic intracerebral hemorrhage, subarachnoid hemorrhage or hemorrhagic
infarction
Acute Ischemic Stroke

A measurable neurological deficit of sudden onset, presumed secondary to focal
cerebral ischemia, and not otherwise attributable to intracerebral hemorrhage (ICH) or
another disease process. Cerebrovascular disorder caused by deprivation of blood flow
to an area of the brain, generally as a result of thrombosis, embolism, or reduced blood
pressure

Death of heart muscle resulting from insufficient blood supply to the heart. For
purposes of this measure set, acute myocardial infarction is identified by the ICD codes
in Appendix A, Table 1.1.
Allowable value
A list of acceptable responses for a data element.
Administrative/financial performance measures

Measures that address the organizational structure for coordinating and integrating
services, functions, or activities across operational components, including financial
management (for example, financial stability, utilization, credentialing.) (CCPC)
Ambulatory care

244

Types of health care services provided to individuals on an outpatient basis.
Ambulatory care services are provided in many settings ranging from freestanding
surgical facilities to cardiac catheterization centers. (JCI)
Antithrombotic Therapy
Pharmacologic agents (oral or parenteral) preventing or interfering with the formation of
a thrombus or blood coagulation.
Appropriateness
7KHGHJUHHWRZKLFKWKHFDUHSURYLGHGLVUHOHYDQWWRWKHSDWLHQWVFOLQLFDOQHHGVJLYHQ
the current state of knowledge
Assisted Fall
A fall in which any staff member (whether nursing service employee or not) was with the
patient and DWWHPSWHGWRPLQLPL]HWKHLPSDFWRIWKHIDOOE\HDVLQJWKHSDWLHQWVGHVFHQW
WRWKHIORRURULQVRPHPDQQHUDWWHPSWLQJWREUHDNWKHSDWLHQWVIDOO$VVLVWLQJWKH
patient back into bed or chair after a fall is not an assisted fall. A fall that is reported to
have been assisted by a family member or visitor also does not count as an assisted
fall.
Atrial Fibrillation
Cardiac arrhythmia characterized by disorganized electrical activity in the atria
accompanied by an irregular ventricular response that is usually rapid. The atria quiver
instead of pumping in an organized fashion, resulting in compromised ventricular filling
and reduced stroke volume. Stasis of left atrial flow increases the risk of stroke.
Atrial Flutter
Type of atrial tachycardia characterized by contraction rates between 230/min and
380/min.
Availability
The degree to which the appropriate care is available to meet the patientVQHHGV
Best practice
Clinical, scientific, or professional technique, method, or process that is recognized by a
majority of professionals in a particular field as more effective at delivering a particular
outcome than any other practice. These practicHVDOVRVRPHWLPHVUHIHUUHGWRDVJRRG
SUDFWLFHRUEHWWHUSUDFWLFHDUHW\SLFDOO\HYLGHQFHEDVHGDQGFRQVHQVXVGULYHQ-&,
Cardiac Module
A set of evidence-based process measures designed to prevent cardiac complications
in surgical patients.

245

Certification
1. The procedure and action by which an organization evaluates and
certifies that an individual, institution, or program meets requirements
such as standards. Certification differs from accreditation in that
certification can also be applied to individuals (for example, a medical
specialist). (CCPC)
2. The process by which a nongovernment agency or association certifies
that an individual has met predetermined qualifications specified by
that agency or association.
Certification review
An evaluation of a clinical care program to assess its level of compliance with
applicable Joint Commission International standards and to make determination about
its certification status. The evaluation includes assessing documentation, reviewing
performance measurement reports, gathering verbal information, making on-site
observations, and educating and consulting with the program about standards
compliance and performance improvement. (CCPC)
Cesarean Section
Surgical delivery of a fetus through incision in the abdominal wall and the uterine wall,
Does not include removal of the fetus from the abdominal cavity in case of rupture of the
uterus or abdominal pregnancy.
&KLOGUHQV$VWKPD&DUH&$&
Asthma is defined as a lung disorder marked by breathing difficulty, wheezing, or
coughing. For purposes of this measure set, the population is defined as children equal
or greater than 2 through 17 years of age.
Clinical Care of Patients

The clinical care of patients includes medications, laboratory and diagnostic imaging
services, surgery, anesthesia, and many types of treatments that place patients at risk.
These risks may results in the mix-up of test results between patients, delays in
diagnosis and treatment, wrong side or wrong patient surgical procedures, incorrect
medications or doses, and many other harmful outcomes which for the most part are
preventable.
Clinical Care Program Certification (CCPC)

An interdisciplinary, continuum-based approach to health care delivery that prevents,
minimizes, or delays exacerbations or complications of an illness or condition by
6XSSRUWLQJWKHSDUWLFLSDQWVVHOI-management activities
Supporting the ongoing patient/practitioner relationship
Using a standardized method or process for delivering or facilitating the delivery
of clinical care based on clinical practice guidelines or evidence-based practice
7DLORULQJWUHDWPHQWVDQGLQWHUYHQWLRQVWRWKHSDUWLFLSDQWVQHHG

246

Promoting the flow of patient information across settings and providers while
protecting patient rights, security and privacy
Analyzing and using data to continually revise treatment plans
Continuously evaluating ways to improve performance and clinical practice,
thereby improving participant care.
Clinical Measures
Measures designed to evaluate the processes or outcomes of care associated with the
delivery of clinical services; may focus on the appropriateness of clinical decision
making and implementation of these decisions; must be condition specific, procedure
specific, or address function of patient care (e.g., medication use, infection control,
patient assessment, etc.)
Clinical practice guidelines

Statements that help practitioners and patients choose appropriate health care for
specific clinical conditions (for example, recommendations on the case management of
diarrhea in children under the age of 5). The practitioner is guided through all steps of
consultation (questions to ask, physical signs to look for, tests to perform, assessment
of the situation and treatment to prescribe). JCI
Community Acquired Pressure Ulcer

Any pressure ulcer discovered/documented at the time of hospitalization. An ulcer
observed within the first 24 hours from the time of inpatient admission should be
considered community acquired for this measure set.
Competent and Capable Workforce

Patients assume that the health care professionals providing their care and treatment
are competent and capable. Furthermore, even though health care professionals may
intend to provide quality and safe patient care every day, they are frequently not
supported by consistent and low-risk processes and systems, thus placing patients at
risk.
Contraindication
A factor or condition that may render the administration of a drug or agent or the
performance of a procedure or other practice inadvisable, improper, and/or undesirable.
Continuity
The degree to which the care for the patient is coordinated among practitioners, among
organizations and over time.
Controllers
Controllers are long term control medication for asthma. Controllers reduce airway
inflammation and prevent asthma exacerbations. Inhaled corticosteroids are the

247

preferred medications for controlling mild, moderate, and severe persistent asthma.
Refer to Appendix C, Table 6.1 for a listing of controller medications.
Corticosteroids Any of the hormones produced by the adrenal cortex or their synthetic
equivalents, used to achieve quick relief of asthma exacerbations or long term control of
the swelling, inflammation and mucus production that occurs when the airway are
irritated. Corticosteroids are available in inhaled, topical, oral, and intravenous forms.
Data Collection
The act or process of capturing raw or primary data from a single or number of sources.
$OVRFDOOHGGDWDJDWKHULQJ
Data Collection Effort

The availability and accessibility of the required data elements, the effort required to
abstract or collect data.
Data Element
$GLVFUHWHSLHFHRIGDWDVXFKDVSDWLHQWVGDWHRIELUWKRUSULQFLSDOGLDJQRVLV
Data Quality
The accuracy and completeness of measure data on performance in the context of the
analytical purposes for which they will be used.
Data Source
The data source for specific data elements refers to the primary source document(s)
used for data collection (for example, billing or administrative data, encounter form,
medical records).
Defined measure
A structured measure with defined populations that measures specific events or values;
such as may have numerators and denominators, take the form of a continuous
variable, or result from review questions. (CCPC)
Denominator
The lower portion of a fraction used to calculate a rate, proportion, or ratio. Also the
population for a rate-based measure.
Denominator Specifications
An explanation of the denominator description that consists of included population,
excluded populations, data elements, and corresponding data sources.
Denominator Statement
A statement that depicts the population evaluated by the performance measure.

248

Denominator Verification
The extent to which the population of interest is identified through data collection.
Discriminatory Capability
The extent to which an indicator demonstrates variation in performance across health
care organizations.
Domains of Performance
$WWULEXWHVRIRUJDQL]DWLRQSHUIRUPDQFHWKDWDUHUHODWHGWRRUJDQL]DWLRQVGRLQJWKHUight
WKLQJVVXFKDVDSSURSULDWHQHVVDYDLODELOLW\DQGHIILFDF\DQGGRLQJWKLQJVZHOOVXFK
as, continuity, effectiveness, efficiency, respect and caring, safety, and timeliness).
Performance domains are definable, measurable and improvable.
'RQRW XVHOLVW
A written catalog of abbreviations, acronyms, and symbols that are not to be used
throughout an organizationwhether handwritten or entered as free text into a
computerdue to their potentially confusing nature. (JCI)
Effective
Evidence-based practice that produces better outcomes than its alternative
Effectiveness
The degree to which care is provided in the correct manner, given the current state of
knowledge, to achieve the desired or projected outcome(s) for the patient.
Efficient
The appropriate use of resources at the least expense to the patient, provider, and care
setting.
Efficiency
The degree to which the care of the patient has been shown to accomplish the desired
or projected outcomes.
Elective Carotid Endarterectomy

Surgical procedure performed by choice, involving excision of atheromatous segments
of the endothelium and tunica media of the carotid artery, leaving a smooth tissue lining
and facilitating blood flow through the vessel; surgery done to prevent stroke.
Elective Carotid Intervention

Surgery (e.g., carotid endarterectomy) and othe procedures (e.g., carotid angioplasty,
VWHQWLQJLQYROYLQJWKHFDURWLGDUWHU\SHUIRUPHGGXHWRWKHSDWLHQWVFKRLFH

249

Elective Delivery
Delivery of a newborn(s) when the mother was not in active labor or presented with
spontaneous ruptured membranes prior to medical induction and/or cesarean section.
Episode of Care (EOC)

A patient or case-level record submitted to the database.
Equitable
Care delivered fairly with consideration to need and no other discriminatory factors
Evidence-based practice
Patient care and treatment grounded in science or published clinical studies over a
longitudinal and progressively rigorous empirical evidence. (CCPC)
Face validity
The preliminary expert-based judgment on the usefulness and relevance of a
performance measure for the purpose for which it is intended.
Fall
An unplanned descent to the floor (or extension of the floor, e.g., trash can or other
equipment) with or without injury to the patient.
Focus of indicator
The activity or area that the measure addresses. For example, the focus of an indicator
PLJKWEHPRQLWRULQJSDWLHQWUHVSRQVHRUXULQDU\FDWKHWHUXVDJH
General Data Elements

Data elements that must be collected by hospitals for each patient record. These data
are patient demographic data, hospital identifiers, and patient identifiers.
Health care-associated infections (HAI)

Any infection(s) acquired by an individual while receiving care or services in a health
care organization. CoPPRQ+$,VDUHXULQDU\LQIHFWLRQVVXUJLFDOZRXQGLQIHFWLRQV
pneumonia, and blood stream infections. (JCI)
Health care professional

Any person who has completed a course of study and is skilled in a field of health. This
includes a physician, dentist, nurse, or allied health professional. Health care
professionals are often licensed by a government agency or certified by a professional
organization. (JCI)

250

Health status performance measures
Measures that address the functional well-being of specific populations, both in general
and in relation to specific conditions, demonstrating change over time (for example,
physical functioning, bodily pain, social functioning, mental health.) (CCPC)
Heart Failure (HF)

A clinical syndrome characterized by signs and symptoms resulting from disturbances in
cardiac output or from increased venous pressure, including fatigue, shortness of
breath, or leg swelling. For purposes of this measure set, heart failure is identified by
the ICD codes in Appendix A, Table 2.1.
Hospital Acquired Pressure Ulcer (Nosocomial)

An ulcer observed after the first 24 hours from the time of inpatient admission AND for
which there is no documentation in the record indicating the date of first discovery;
should be considered as hospital acquired.
Hospital-Based Inpatient Psychiatric Services (HBIPS)

A measure set focused on improving quality and performance in inpatient psychiatric
settings through performance measurement.
ICD Codes
A two-part classification system in current use for coding patient medical information
used in abstracting systems and for classifying patients. The first part is a
comprehensive list of diseases with corresponding codes compatible with the World
+HDOWK2UJDQL]DWLRQVOLVWRIGLVHDVHFRGHV7KHVHFRQGSDUW contains procedure codes
independent of the disease codes.
Improvement of Quality and Safety

Health care organizations, and their patients, remain at risk from poor quality and
unsafe practices if organizations do not learn from their good and bad experiences and
take actions to continually improve. Data are at the core of this learning. Organizations
need to understand and value data collection and analysis in process improvement.
Organizations must gain experience in setting improvement priorities, collecting data,
displaying data for better analysis, and finally, planning and implementing improvement
strategies.
Infection module
A set of evidence-based process indicators designed to prevent postoperative infection
in the surgery patient.
Intensive Care Unit (ICU)

A nursing care area that provides intensive observation, diagnosis, and therapeutic
procedures for adults and/or children who are critically ill. An ICU excludes nursing

251

areas that provide step-down, intermediate care or telemetry only. Specialty care areas
are also excluded.
Intermittent Pneumatic Compression Device

Device that uses sequential and/or intermittent compression to counteract blood flow
stasis by increasing peak blood flow velocity. As a result, less blood is allowed to pool
in veins thus decreasing chances for thrombus formation.
International Essentials
7KHILYHDUHDVRIULVNRQZKLFKWRIRFXVLQLWLDOTXDOLW\DQGVDIHW\LPSURYHPHQWHIIRUWV
These five areas were developed from an extensive international literature search on
health care quality and safety. Criteria for each Risk Area provides clear and achievable
risk-reduction strategies. Levels of effort are identified for each criterion to provide a
means for evaluating progress in reducing risk and improving quality.
Intracerebral Hemorrhage (ICH)

Non-traumatic abrupt onset of headache or altered level of consciousness and/or focal
neurological deficit that is associated with a focal collection of blood within the brain
parenchyma on CT scan and is not due to trauma or hemorrhagic conversion of a
cerebral infarction.
Leadership Process and Accountability

Experience around the world has shown that in large and small health care
organizations, in general and specialty care facilities, in rural and urban settings, and in
public and private settings, the most essential factor in improving quality and patient
safety is leadership support at the highest level of the organization
Measure Information Form

Tool used to provide specific clinical and technical information on a measure. The
information contained includes: performance measure name, description, rationale,
numerator/denominator statements, included populations, excluded populations, data
elements, risk adjustment, sampling, data accuracy and selected references.
Measure set
A unique grouping of carefully selected measures, that when reviewed together, provide
DFRPSUHKHQVLYHXQGHUVWDQGLQJRUDVVHVVPHQWRIDXQLWVGHSDUWPHQWVRU
RUJDQL]DWLRQVSHUIRUPDQFH&&3&
Measure-specific data elements

Data elements used by one specific measure or several measures in one specific
measure set, such as acute myocardial infarction (AMI).

252

Medical record (data source)
Data obtained from the records or documentation maintained on a patient in any health
care setting. Includes both automated and paper medical record systems.
Nosocomial Infection
An infection acquired by a patient in a health care organization, especially a hospital.
This infection is not present or incubating before admission to a hospital.
Numerator
The upper portion of a fraction used to calculate a rate, proportion or ratio.
Numerator specifications
An explanation of the numerator description that consists of included populations,
excluded populations, data elements, and corresponding data sources.
Numerator Statement
A statement that depicts the portion of the denominator population that satisfies the
conditions of the performance measure to be an indicator event.
Nursing-Sensitive, Nursing-Sensitive Processes and Outcomes (NSC)

Processes and outcomes (and structural proxies for theses processes and outcomes,
e.g., skill mix, nurse staffing hours) are affected, provided, and/or influenced by nursing
personnel, but nursing is not exclusively responsible for them. Nursing-sensitive
measures must be quantifiably influenced by nursing personnel, but the relationship is
not necessarily causal.
Observed rate
7KHREVHUYHGUDWHLVWKHLQGLFDWRUUDWHWKDWLVEDVHGRQWKHKRVSLWDOVDJJUHJDWHGDWDIRU
a reporting period. This is calculated as the number of indicator numerator cases for
the reporting period divided by the number of denominator cases. Observed rates are
used to measure hospital performances.
Outcome
The result of the performance of a function or a process(es). The effect(s) that an
intervention has on a specific health problem. It reflects the purpose of the intervention.
For example, the outcome(s) or a rural health program on safe drinking water could be
fewer diarrhea episodes in children under five or a decreased child mortality rate by
diarrhea. (JCI)
Outpatient
Generally, persons who do not need the level of care associated with the more
structured environment of an inpatient or a residential program. In many countries,
RXWSDWLHQWFDUHLVDOVRNQRZQDVDPEXODWRU\FDUH,QVRPHFRXQWULHVRXWSDWLHQWVDUH

253

FRQVLGHUHGDGPLWWHGWRDKHDOWKFDUHRUJDQL]DWLRQLQRWKHUVRXWSDWLHQWDUHFRQVLGHUHG
UHJLVWHUHG-&,
Parenteral
Not through the alimentary canal but rather by injection through some other route, such
as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intravenous, etc.
Patient Centered
&DUHWKURXJKRXWDSDWLHQWVH[SHULHQFHVKRXOGEHFRRUGLQDWHGDQGJURXQGHGLQ
respectful interactions with care providers that is consistent ZLWKWKHSDWLHQWVYDOXHV
expectations and care decisions.
Patient Days
Conceptually, a patient day is 24 hours, beginning the hour of admission
as measured by daily or period censuses. Facilities should use all data available to
them to represent a complete count of the total number of patients per unit, including
"days" of care provided to short stay patients.
Patient Level Data

Collection of data elements that depict the health care services provided to an individual
(patient). Patient level data are aggregated to generate hospital level data and
comparison group data.
Perception of care quality performance measures

Satisfaction measures that focus on the delivery of clinical care from the
SDWLHQWVSDUWLFLSDQWVSHUVSHFWLYHLQFOXGLQJEXWQRWOLmited to, patient safety and
education, medication use, pain management, communication about plans and
outcomes of care, prevention and illness, improvement in health status, and so forth. A
measure may address one or more aspects of care. (CCPC)
Performance measure
A quantitative tool (for example, rate, ratio, index, percentage) that provides an
LQGLFDWLRQRIDQRUJDQL]DWLRQVSHUIRUPDQFHLQUHODWLRQWRDVSHFLILHGSURFHVVRU
outcome.
Performance measurement
The use of quantitative tools (for example rates, ratios, indices, percentages) to provide
DQLQGLFDWLRQRIDQRUJDQL]DWLRQVSHUIRUPDQFHLQUHODWLRQWRDVSHFLILHGSURFHVVRU
outcome. (CCPC)
Perinatal Care (PC)

The care and management of the fetus and newborn infant in the perinatal period,
before, during and after delivery.

254

Physical Restraint
Any manual method, physical or mechanical device, material, or equipment that
immobilizes or reduces the ability of a patient to move his or her arms, legs, body or
head freely.
Pneumonia (PN)
Pneumonia is defined as an acute infection of the pulmonary parenchyma that is
associated with at least some of the symptoms of acute infection, accompanied by
presence of acute infiltrate on chest radiograph or auscultatory findings consistent with
pneumonia (such as altered breath sounds and/or localized rales.
Pressure Ulcer
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear. A
number of contributing or confounding factors are also associated with pressure ulcers;
the significance of these factors is yet to be elucidated.
The degree to which appropriate services are provided for promotion preservation, and
restoration of health and for the early detection of disease.
Prophylactic Antibiotic
An antibiotic used to prevent, rather than treat or cure, disease. For the purposed of
SCIP-Inf-1 through 3, antibiotics given to prevent postoperative infection will be
collected. Because the overuse of antibiotics can lead to resistance, antibiotics taken to
prevent infarction should be used only for a short time.
Process measure
A measure used to assess a goal directed, interrelated series of actions, events,
mechanisms or steps. For example, a performance measure describing what is done
to, for or by patients, as in performance of a procedure.
Quality of Care
The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge. Dimensions of performance include the following: patient perspective
issues, safety of the care environment; and accessibility, appropriateness, continuity,
effectiveness, efficacy, efficiency, and timeliness of care.
Quality Improvement
An approach to the continuous study and improvement of the processes of providing
health care services to meet the needs of individuals and others. Synonyms include
continuous quality improvement, continuous improvement, organizationwide
performance improvement, and total quality management. (CCPC)

255

Rate-based (measure)
An aggregate data measure in which the value of each measurement is expressed as a
proportion or as a ratio. In a proportion, the numerator is expressed as a subset of the
denominator (for example, AMI patients who received aspirin within 24 hours before or
after hospital arrival over all AMI patients). In a ratio, the numerator and denominator
measure different phenomena (for example, the number of patients with central lines
who develop infections divided by the number of central line days).
Reliability
The ability of the indicator to accurately and consistently identify the events it was
designed to identify across multiple health settings.
Relevance
The applicability and/or pertinence of the indicator to its users and customers.
Repeat Fall
More than one fall by the same patient in the same month may be
classified as a repeat fall.
Respect and Caring

The degree to which the patient or a designee is involved in his or her own care
decisions, and to which those providing services do so with sensitivity and respect for
WKHSDWLHQWVQHHGVH[SHFWDWLRQVDQGLQGLYLGXDOGLIIHUHQFHV
Safe
Delivery of care in a manner that minimizes any risk of harm to the patient.
Safe Environment for Staff and Patients

Health care organizations are very complex places which house a significant amount of
equipment, hazardous materials, and many types of patient supplies. Health care
practitioners may be proficient in using equipment, but may often lack the expertise to
inspect and maintain equipment. Those inspecting and maintaining equipment may not
have the required skills and knowledge to ensure that equipment if functional and safe.
Safety
The degree to which the risk of an intervention and the risk in the care environment are
reduced for the patient and others, including the health care provider.
Sampling Method
Describes the process used to select a sample. Sampling approaches for national
hospital inpatient quality measures are simple random sampling and systematic

256

VDPSOLQJ5HIHUWRWKH6DPSOLQJ$SSURDFKHVGLVFXVVLRQLQWKH3RSXODWLRQDQG
Sampling Specifications section for further information.
Sample Size
The number of individuals or particular patients included in a study. Usually chosen so
that the study has a particular statistical power of detecting an effect of a particular size.
Seclusion
Seclusion is the involuntary confinement of a patient alone in a room or an area where
the patient is physically prevented from leaving.
Standard
A statement that defines the performance expectations, structures, or processes that
must be in place for an organization to provide safe and high-quality care, treatment,
and service. (JCI)
Standardized measure
A performance measure that has precisely defined specifications, standardized data
collection protocols, meets established evaluation criteria, and can be uniformly adopted
for use. (CCPC)
Stratification
A form of risk adjustment which involves classifying data into strata based on one or
more characteristics, variables, or other categories.
Stratified Measure
A performance measure that is classified into a number of strata to assist in analysis
and interpretation. The overall or un-stratified measure evaluates all of the strata
together. The stratified measure or each stratum consists of a subset of the overall
measure. For example, surgical patients who received a prophylactic antibiotic within
one hour prior to surgical incision is reported as all surgical patients with the appropriate
ICDPrincipal Procedure Code, who received the prophylactic antibiotic within one hour
prior to surgical incision; however, the stratified measure(s) for SCIP-Inf-1 is reported by
the specific ICD Principal Procedure, such as hip arthroplasty (SCIP-Inf-1d).
Stroke (STK)
See definitions for Acute Ischemic Stroke and Acute Hemorrhagic Stroke.
Structure measure
A measure of whether organizational resources and arrangements are in place to
deliver health care (for example, the number of facilities providing a service). (CCPC)

257

Subarachnoid Hemorrhage (SAH)
Non-traumatic abrupt onset of headache or altered level of consciousness that is
associated with blood in the subarachnoid space on CT or a clinical history and exam
consistent with SAH (sudden onset of severe headache or altered level of
consciousness) with xanthochromia and many red blood cells in the cerebrospinal fluid.

The Surgical Care Improvement Project (SCIP) is a national quality partnership of
organizations focused on improving surgical care by significantly reducing surgical
complications through performance measurement. Utilizing ten process measures in
three separate modules (infection, cardiac, and VTE), the goal is to reduce the
incidence of surgical complications nationally by 25 percent by the year 2010.
Structure measure
A measure of whether organizational resources and arrangements are in place to
deliver health care (for example, the number of facilities providing a service). (CCPC)
Systemic Corticosteroids
Corticosteroids are hormones produced by the adrenal cortex or their synthetic
equivalents and are administered orally or intravenous. Corticosteroids are used to
achieve quick relief of acute or moderate to severe asthma exacerbations. Oral
corticosteroids are also used for long term control of the swelling, inflammation and
mucus production in the airways. Refer to Appendix C, Table 2.15 for a listing of PN
systemic corticosteroid medications or Table 6.3 for a listing of CAC systemic
corticosteroid medications.
Timely
Care delivery that is prompt and provided without delay to mitigate the risk of harm to a
patient.
Timeliness
The degree to which the care is provided to the patient at the most beneficial or
necessary time.
Type of indicator
$QH[SODQDWLRQRIWKHSHUIRUPDQFHLQGLFDWRUVIRUPDWDVWRLWVVWUXFWXUHSURFHVVRU
outcome.
Unable to Determine (UTD)

Each data element that is applicable per the algorithm for each of the measures within a
PHDVXUHVHWPXVWEHWRXFKHGE\WKHDEVWUDFWRU:KLOHWKHUHLVDQH[SHFWDWLRQWKDWDOO
data elements are collected, it is recognized that in certain situations information may
not be available (e.g., dates, times, codes, etc.). If, after due diligence, the abstractor

258

determines that a value is not documented or is not able to determine the answer value,
WKHDEVWUDFWRUPXVWVHOHFW8QDEOHWR'HWHUPLQH87'DVWKHDQVZHU
Vaccine
A vaccine is a suspension of an attenuated (weakened) or killed microorganism, such
as bacteria or virus, administered for the prevention, amelioration, or treatment of
infectious diseases.
Validation
The process by which the integrity and correctness of data are established. Validation
process can occur immediately after a data item is collected or after a complete set of
data are collected.
Validity
Ability to identify opportunities for improvement in the quality of care; demonstration that
the indicator use results in improvements in outcomes and/or quality of care.
Variation
The differences in results obtained in measuring the same event more than once. The
sources of variations can be grouped into two major classes: common causes and
special causes. Too much variation often leads to waste and loss, such as the
occurrence of undesirable patient health outcomes and increased cost of health
services. (JCI)

A term that includes deep vein thrombosis and/or pulmonary embolism.

259

Selected References:
x Babbie, ER, The Practice of Social Research, 2nd edition, Belmont, CA:
Wadsworth Publishing Company, 1979.
x Disease-Specific Care Certification Manual, 2nd Edition. Joint Commission on
Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. 2005.
x Everitt, BS, The Cambridge Dictionary of Statistics, Cambridge University Press,
1998.
x Joint Commission International Accreditation Standards for Hospitals, 4th Edition,
Joint Commission International, Aokbrook Terrace, Il 2010.
x Iezonni, LI, Foley, SM, Heeran, T, Daley, J, Duncan, CC, Fisher, ES, Hughes, J,
$0HWKRGIRU6FUHHQLQJWKH4XDOLW\RI+RVSLWDO&DUHUsing Administrative Data:
3UHOLPLQDU\9DOLGDWLRQ5HVXOWVQuality Review Bulletin, November, 1992, 361-
370.
x Lexikon Second Edition, Oakbrook Terrace, IL: Joint Commission on
Accreditation of Healthcare Organizations, 1998.
x McHorney, CA, Kosinski, M, and :DUH-U-(&RPSDULVRQVRIWKH&RVWDQG
Quality of Norms for the SF-36 Health Survey Collected by Mail Versus
7HOHSKRQH,QWHUYLHZ5HVXOWV)URPD1DWLRQDO6XUYH\Medical Care, 32, (1994),
551-567.
x 0RVE\V'LFWLRQDU\RI0HGLFLQH1XUVLQJ +HDOWK3URfessions, 7th Edition. Mosby
Elsevier, St. Louis, MO. 2006.
x Nichols, T and Earl, L, Basic ICD-9-CM Coding Handbook, Chicago, IL:
American Health Information Management Association, 1992.
x ORYX Technical Implementation Guide, The Joint Commission, Oakbrook
Terrace, Illinois, current.
x 2009 Comprehensive Accreditation Manual for Hospitals; The Joint Commission,
Oakbrook Terrace, Illinois, 2008.
x 7DEHUV&\FORSHGLF0HGLFDO'LFWLRQDU\)$'DYLV&RPSDQ\3KLODGHOSKLD3$
1997.

260

JCI International Library of Measures

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

JCI International Library of Measures

Uploaded by

Copyright:

Available Formats

Joint Commission Internationals

Last Updated: Version 1.2 January 2011

2011 Joint Commission International

2011 Joint Commission International

Measure Measure Description

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)

Adult smoking cessation advice/counseling given to patients who had an acute

Beta-blocker prescribed at discharge for patients who had an acute myocardial

Heart Failure (HF)

2011 Joint Commission International

Measure Measure Description

I-HF-4 Adult smoking cessation advice/counseling given to heart failure patients

I-STK-2 Patients with ischemic stroke prescribed antithrombotic therapy at discharge

I-STK-3 Patients with atrial fibrillation/flutter receiving anticoagulation therapy

Hospital-Based Inpatient Psychiatric Service (HBIPS)

2011 Joint Commission International

Measure Measure Description

Nursing-Sensitive Care (NSC)

Originally developed by the National Quality Forum (NQF)

Perinatal Care (PC)

Nulliparous women with a term, singleton baby in a vertex position delivered by

2011 Joint Commission International

Measure Measure Description

Surgical Care Improvement Project (SCIP)

Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent

Surgical patients (knee arthoplasty) who received prophylactic antibiotics consistent

Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued

Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued

Surgical patients (hip/knee arthroplasty) with recommended venous

Surgical patients who received appropriate venous thromboembolism (VTE)

2011 Joint Commission International

Measure Measure Description

Venous Thromboembolism (VTE)

2011 Joint Commission International

2011 Joint Commission International

Measure Measure Description

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)

Adult smoking cessation advice/counseling given to patients who had an acute

Beta-blocker prescribed at discharge for patients who had an acute myocardial

2011 Joint Commission International

Indicator Name: Aspirin on arrival

Numerator: AMI patients who received aspirin within 24 hours before

Denominator: AMI patients who are age >= 18 years

Domains of Performance QPS Standards CCPC IPSG

Appropriateness QPS.3 patient assessments AMI *RDO

2011 Joint Commission International

Reasons and Implications: The benefits of aspirin therapy on mortality is

Inclusions to the population: Not Applicable

Exclusions to the population: None

Denominator: AMI patients who are >= 18 years

Exclusions to the population:

2011 Joint Commission International

2011 Joint Commission International

I-AMI 2 Aspirin prescribed at discharge for patients who had an

Indicator Name: Aspirin at discharge

Numerator: AMI patients who are prescribed aspirin at hospital discharge

Denominator: AMI patients who are >= 18 years

Domains of Performance QPS Standards CCPC IPSG

Appropriateness QPS.3 patient AMI *RDO

2011 Joint Commission International

Numerator: AMI patients who are prescribed aspirin at hospital discharge

Inclusions to the population: Not Applicable

Exclusions to the population: None

Denominator: AMI patients who are >= 18 years

Appropriateness QPS.3 patient assessments AMI *RDO

Appropriateness QPS.3 patient AMI *RDO

$SSURSULDWHQHVV QPS.3 patient +) *RDO