Jci International Library Of Measures 3d1m30

t Commission International’s

International Library of Measures

Pre-Publication Copy

t Commission International A division of t Commission Resources, Inc. The mission of t 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. t Commission Resources educational programs and publications , but are separate from, the accreditation activities of t Commission International. Attendees at t Commission Resources educational programs and purchasers of t Commission Resources publications receive no special consideration or treatment in, or confidential information about, the accreditation process.

© 2011 t 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 t Commission Resources One Renaissance Boulevard Oakbrook Terrace, Illinois 60181 U.S.A. [email protected] For more information about t Commission Resources, please visit http://www.jcrinc.com. For more information about t Commission International, please visit http://www.tcommissioninternational.org.

Last Updated: Version 1.2 January 2011

© 2011 t Commission International 1

Foreword t Commission International (JCI) is very pleased to present this first edition of the t 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 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. This first edition of the Library reaffirms JCI’s mission to improve the quality and safety of patient care around the world.

© 2011 t Commission International 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 Code

Measure Description

Acute Myocardial Infarction (AMI) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-AMI-1

Aspirin received within 24 hours of arrival to the hospital for patients having an acute myocardial infarction (AMI).

I-AMI-2

Aspirin prescribed at discharge for patients who had an acute myocardial infarction.

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.

I-AMI-4

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

I-AMI-5

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

I-AMI-9

Acute myocardial infarction (AMI) patients who expire during the hospital stay

Heart Failure (HF) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

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

© 2011 t Commission International 3

Measure Code

Measure Description

I-HF-3

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) 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) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

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

Children’s Asthma Care (CAC) 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) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-HBIPS-2

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 itted to a hospital-based inpatient psychiatric setting

I-HBIPS-3

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 itted to a hospital-based inpatient psychiatric setting.

© 2011 t Commission International 4

Measure Code

Measure Description

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

I-NSC-2

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 how to collect this measure.

I-NSC-4

All documented falls with or without injury, experienced by patients in a calendar month.

I-NSC-5

All documented falls by a patient with an injury level of minor (2) or greater.

Perinatal Care (PC) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-PC-01

Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed

I-PC-02

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

I-PC-05

Exclusive breast milk feeding during the newborn's entire hospitalization

Pneumonia (PN) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-PN-2

Pneumonia patients, aged 65 and older, who were screened for pneumococcal vaccine status and were istered the vaccine prior to discharge, if indicated

I-PN-4

Adult smoking cessation advice/counseling given to patients who smoke cigarettes and who are hospitalized for pneumonia

© 2011 t Commission International 5

Measure Code I-PN-7

Measure Description 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

Surgical Care Improvement Project (SCIP) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-SCIP-Inf-1d

Prophylactic antibiotics received one hour prior to surgical incision for hip arthroplasty patients

I-SCIP-Inf-1e

Prophylactic antibiotics received one hour prior to surgical incision for knee arthroplasty patients

I-SCIP-Inf-2d

Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent with current guidelines

I-SCIP-Inf-2e

Surgical patients (knee arthoplasty) who received prophylactic antibiotics consistent with current guidelines

I-SCIP-Inf-3d

Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued within 24 hours after anesthesia end time

I-SCIP-Inf-3e

Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued within 24 hours after anesthesia end time

I-SCIP-VTE-1

Surgical patients (hip/knee arthroplasty) with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time

I-SCIP-VTE-2

Surgical patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia end time

© 2011 t Commission International 6

Measure Code

Measure Description

Venous Thromboembolism (VTE) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-VTE-1

Patients who received VTE prophylaxis (or reasons of why this was not done) on the day of or day after hospital ission or surgery.
Note: This measure applies to medical and surgical cases that are not included in the SCIP measure population

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 ission 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 ission or transfer

© 2011 t Commission International 7

Acute Myocardial Infarction (AMI) Measure Set

© 2011 t Commission International 8

Measure Code

Measure Description

Acute Myocardial Infarction (AMI) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-AMI-1

Aspirin received within 24 hours of arrival to the hospital for patients having an acute myocardial infarction (AMI).

I-AMI-2

Aspirin prescribed at discharge for patients who had an acute myocardial infarction.

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.

I-AMI-4

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

I-AMI-5

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

I-AMI-9

Acute myocardial infarction (AMI) patients who expire during the hospital stay

© 2011 t Commission International 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: Aspirin received within 24 hours of arrival to the hospital for patients having an acute 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 Reissions 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 ■ Appropriateness

QPS Standards QPS.3 – patient assessments

CC ■ AMI

IPSG ■ Goal 1

■ Availability ■ Continuity ■ Effectiveness

QPS.3 – antibiotic and other medication use

■ Timeliness © 2011 t Commission International 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 istrative 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:  Aspirin received within 24 hours before or after hospital arrival Denominator: AMI patients who are >= 18 years Data elements:  ission Date  Birthdate  ICD Principal Diagnosis Code  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:  Patients less than 18 years of age  Patients who left against medical advice or discontinued care on day of or day after arrival  Patients who expired on day of or day after arrival  Patients with a documented Reason for No Aspirin on Arrival

© 2011 t Commission International 11

I-AMI-1 References 

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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/non–ST-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/Non–ST-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:e1–157. 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. 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 non–ST-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 Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99. 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. 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. 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.

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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: Mortality: Decreased mortality Reissions within 30 days : Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Medical/Surgical units 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 ■ Appropriateness ■ Continuity

QPS Standards QPS.3 – patient assessments

CC ■ AMI

IPSG ■ Goal 1

■ Effectiveness ■ Prevention/Early

QPS.3 – antibiotic and other medication use

Detection

© 2011 t Commission International 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 longterm aspirin for the secondary prevention of subsequent cardiovascular events in eligible patients discharged after AMI. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: AMI patients who are prescribed aspirin at hospital discharge Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Aspirin Prescribed at Discharge Denominator: AMI patients who are >= 18 years Data elements:  Birthdate  ICD Principal Diagnosis Code  Reason for no aspirin at discharge 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:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients with a documented Reason for No Aspirin at Discharge

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I-AMI – 2 References 

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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/non–ST-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/Non–ST-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:e1–157. 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. 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. 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 non– ST-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 Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99. 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.

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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: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate 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 Domains of Performance

QPS Standards

■ Appropriateness

QPS.3 – patient assessments

■ Continuity

QPS.3 – radiology and diagnostic imaging services

■ Effectiveness

CC ■ AMI

IPSG ■ Goal 1

QPS.3 – antibiotic and other medication use © 2011 t Commission International 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 committees have also ed the inclusion of ARB’s in performance measures for AMI. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  ACEI Prescribed at Discharge  ARB Prescribed at Discharge Denominator: AMI patients with LVSD and who are >= 18 years Data elements:  Birthdate  ICD Principal Diagnosis Code  LVSD  Reason for No ACEI and No ARB at Discharge Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for 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 Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients with a documented Reason for No ACEI or ARB at Discharge

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I-AMI – 3 References 

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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/non–ST-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/Non–ST-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:e1–157. 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. 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. 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. 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 non– ST-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 Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99. 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. 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.

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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.

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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. 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.

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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: Mortality: Decreased mortality Reissions within 30 days : Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Medical/Surgical units 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

Domains of Performance ■ Appropriateness ■ Continuity

QPS Standards QPS.3 – patient assessments

CC

IPSG

■ AMI

■ Effectiveness ■ Prevention/Early Detection © 2011 t Commission International 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: AMI patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  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:  Adult Smoking History  Birthdate  ICD Principal Diagnosis Code Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for AMI as defined in Appendix A, Table 1.1 and a history of smoking cigarettes anytime during the year prior to hospital arrival Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired

© 2011 t Commission International 21

I-AMI – 4 References 

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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/non–ST-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/Non–ST-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:e1–157. 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. Fiore MC, Jaén 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. 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 non– ST-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 Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99. 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.

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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: Mortality: Decreased mortality Reissions within 30 days : Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Medical/Surgical units Indicator Name: Beta-blocker prescribed at discharge Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge Denominator: AMI patients who are >= 18 years Domains of Performance ■ Appropriateness ■ Continuity

QPS Standards QPS.3 – patient assessments

CC ■ AMI

IPSG ■ Goal 1

■ Effectiveness ■ Prevention/Early

QPS.3 – antibiotic and other medication use

Detection

© 2011 t Commission International 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 betablocker therapy for the secondary prevention of subsequent cardiovascular events in patients discharged after AMI. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Beta-Blocker Prescribed at Discharge Denominator: AMI patients who are >= 18 years Data elements:  Birthdate  ICD Principal Diagnosis Code  Reason for no Beta-blocker at discharge 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:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients with a documented Reason for No Beta-Blocker at Discharge

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I-AMI – 5 References 

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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/non–ST-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/Non–ST-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:e1–157. 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. 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 non– ST-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 Non–ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99. Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use and effectiveness of -blockers for the treatment of elderly patients after acute myocardial infarction: National Cooperative Cardiovascular Project. JAMA. 1998;280:623-629. 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. 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.

© 2011 t Commission International 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 Patient Settings/Services Intensive Care Units Medical/Surgical units Indicator Name: Inpatient mortality Numerator: Inpatient mortality of AMI patients Denominator: AMI patients who are >= 18 years

Domains of Performance

QPS Standards

■ Effectiveness

CC

IPSG

■ AMI

© 2011 t Commission International 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Inpatient mortality of AMI patients Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Discharge status Denominator: AMI patients who are >= 18 years Data elements:  Birthdate  ICD Principal Diagnosis Code 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:  Patients less than 18 years of age Note: This measure population does not include deaths that occurred in the emergency department

© 2011 t Commission International 27

I-AMI – 9 References 





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. 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 non–STelevation 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 Non– ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 –99. Maggioni AP, et al: Age related increase in mortality among patients with first myocardial infarctions treated with thrombolysis: the Investigators of the Gruppo Italiano per lo Studio della Sopravvivenza nell’Infarto Miocardico (GISSI-2). N Engl J Med. 1993;329:1442-1448.

© 2011 t Commission International 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 Code Code Code Code

Shortened Description

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

© 2011 t Commission International 29

Heart Failure (HF) Measure Set

© 2011 t Commission International 30

Measure Code

Measure Description

Heart Failure (HF) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

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

I-HF-3

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker) for heart failure patients who have LVSD (Left Ventricular Systolic Dysfunction)

I-HF-4

Adult smoking cessation advice/counseling given to heart failure patients

© 2011 t Commission International 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: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Medical/Surgical units 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

© 2011 t Commission International 32

Domains of Performance ■ Appropriateness ■ Availability ■ Continuity ■ Effectiveness

QPS Standards QPS.3 – patient assessments

CC ■ HF

IPSG ■ Goal 1

QPS.3 – radiology and diagnostic imaging services

■ Timeliness

© 2011 t Commission International 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: Retrospective data sources for the required data elements include istrative data and medical records. 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 Inclusions to the population: Not Applicable Exclusions to the population: None Data elements: 

LVF Assessment

Denominator: Heart failure patients who are >= 18 years Data elements:   

Birthdate ICD Principal Diagnosis Code LVF Assessment

Inclusions to the population: Patients with ICD principal diagnosis code for heart failure as defined in Appendix A, Table 2.1 Exclusions to the population:     

Patients less than 18 years of age Patients who left against medical advice Patients who expired Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay Patients with reasons documented for no LVS function evaluation

© 2011 t Commission International 34

I-HF-2 References 

 

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;46:1144–78. Available at http://www.acc.org and http://www.americanheart.org. Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2006 Feb;12(1):e1-2. 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.

© 2011 t Commission International 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: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Medical/Surgical units 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 © 2011 t Commission International 36

Domains of Performance ■ Appropriateness ■ Continuity ■ Effectiveness

QPS Standards QPS.3 – patient assessments

CC ■ HF

IPSG ■ Goal 1

QPS,3 – radiology and diagnostic imaging services QPS.3 – antibiotic and other med use

© 2011 t Commission International 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 ed the inclusion of ARB’s in performance measures for heart failure. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital discharge Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  

ACEI Prescribed at Discharge or ARB Prescribed at Discharge

Denominator: Heart failure patients with LVSD who are >= 18 years Data elements:    

Birthdate ICD Principal Diagnosis Code LVSD 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 Exclusions to the population:   

Patients less than 18 years of age Patients who left against medical advice Patients who expired

© 2011 t Commission International 38

 

Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during the hospital stay Patients with a documented Reason for No ACEI or ARB at Discharge

© 2011 t Commission International 39

I-HF-3 References 





 



 

 

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/non–STelevation 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/Non–ST-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:e1–157. 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. 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):15751581. 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 angiotensinconverting-enzyme inhibitors: the CHARM-Alternative trial. Lancet. 2003;362:772-776. 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 non–ST-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 Non–ST-Elevation Myocardial Infarction).J Am Coll Cardiol.2008;52:2046–99. 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. 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. 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. 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. 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.

© 2011 t Commission International 40

I-HF-4 Adult Smoking Counseling 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 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: Mortality: Decreased mortality Reissions within 30 days : Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Medical/Surgical units 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.

© 2011 t Commission International 41

Domains of Performance ■ Appropriateness ■ Continuity

QPS Standards QPS.3 – patient assessments

CC

IPSG

■ HF ■ AMI

■ Effectiveness

■Asthma

■ Prevention/Early Detection

■Primary Stroke ■Cancer ■COPD ■Diabetes

© 2011 t Commission International 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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay Inclusions to the population: Not Applicable Exclusions to the population: None Data elements: 

Adult Smoking Counseling

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:   

Adult Smoking History Birthdate ICD Principal Diagnosis Code

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 Exclusions to the population:    

Patients less than 18 years of age Patients who left against medical advice Patients who expired Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay

© 2011 t Commission International 43

I- HF-4 References 

  

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;46:1144–78. Available at http://www.acc.org and http://www.americanheart.org. Fiore MC, Jaén 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. Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure Practice Guideline. J Card Fail. 2006 Feb;12(1):e1-2. 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.

© 2011 t Commission International 44

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 2.1 Heart Failure Codes ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 45

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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 ICD-8 ICD-9 ICD-10 ICD-9Shortened Description 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

© 2011 t Commission International 46

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

37.66

IMPLANTABLE HRT ASSIST

37.68

PERCUTAN HRT ASSIST SYST

© 2011 t Commission International 47

Stroke (STK) Measure Set

© 2011 t Commission International 48

Measure Code

Measure Description

Stroke (STK) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-STK-2 I-STK-3 I-STK-8 I-STK-10

Patients with ischemic stroke prescribed antithrombotic therapy at discharge Patients with atrial fibrillation/flutter receiving anticoagulation therapy Stroke patients who were given stroke education during their hospital stay Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services

© 2011 t Commission International 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: Mortality: Decreased mortality Reissions 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 Measure Name: Discharged on Antithrombotic Therapy Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Denominator: Ischemic stroke patients who are >= 18 years. Domains of Performance ■ Appropriateness ■ Continuity ■ Effectiveness ■ Prevention/Early Detection

QPS Standards QPS.3 – patient assessments

CC ■ Stroke

IPSG ■ Goal 1

QPS.3 – antibiotic and other medication use

■ Timeliness © 2011 t Commission International 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 istrative data and medical records. Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital discharge Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Antithrombotic therapy prescribed at discharge Denominator: Ischemic stroke patients who are > = 18 years. Data elements:  Birthdate  Elective Carotid Intervention  ICD principal diagnosis code  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 Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients itted for the performance of elective carotid intervention

© 2011 t Commission International 51

I-STK-2 References 



  



 

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. 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. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and Thrombolytic Therapy for Ischemic Stroke. Chest Vol. 119, 2001: 300-320. Brott TG, Clark WM, Grotta JC, et al. Stroke the first hours. Guidelines for acute treatment. Consensus Statement. National Stroke Association. 2000. 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. Coull BM, Williams LS, Goldstein LB, et al. Anticoagulants and Antiplatelet Agents in Acute Ischemic Stroke. Report of the t 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. 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. 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.

© 2011 t Commission International 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 Related Outcomes: Mortality: Decreased mortality Reissions 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 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

CC

IPSG

■ Stroke

■ Goal 1

Standards ■ Appropriateness ■ Continuity ■ Effectiveness ■ Prevention/Early Detection © 2011 t Commission International 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 istration 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Ischemic stroke patients prescribed anticoagulation therapy at discharge Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Anticoagulation therapy prescribed at discharge Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter who are >= 18 years Data elements:  Atrial Fibrillation/Flutter  Birthdate  Elective Carotid Intervention  ICD principal diagnosis code  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. Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients itted for the performance of elective carotid intervention

© 2011 t Commission International 54

I- STK-3 References 

     

Kearon C, Kahn, SR, Agnelli G, Goldhaber S, Raskob, GE, Comerota AJ. Antithrombotic therapy for venous thromboembolic disease. The Eighth AC Conference on antithrombotic and thrombolytic therapy. Chest. 2008;133: 454S545S. 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. 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. 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. 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. Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology and management of the vitamin K antagonists: The Eighth AC Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2008 133:160S-198S. 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.

© 2011 t Commission International 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 services. Some clinical trials have shown measurable benefits in patient and caregiver outcomes with the application of education and 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 Related Outcomes: Mortality: Decreased mortality Reissions 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 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 © 2011 t Commission International 56

Domains of Performance QPS Standards

CC

■ Appropriateness

■ Stroke

QPS.3 – clinical assessments

IPSG

■ Continuity ■ Effectiveness ■ Prevention/Early Detection

© 2011 t Commission International 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 services. Some clinical trials have shown measurable benefits in patient and caregiver outcomes with the application of education and 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: Retrospective data sources for the required data elements include istrative data and medical records. 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 Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Education Addresses Activation of Emergency Medical System  Education Addresses Follow-up after Discharge  Education Addresses Medications Prescribed at Discharge  Education Addresses Risk Factors for Stroke  Education Addresses Warning Signs and Symptoms of Stroke Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home who are >= 18 years.

© 2011 t Commission International 58

Data elements:  Elective Carotid Intervention  Birthdate  ICD principal diagnosis code

Inclusions to the population: Patients with ICD principal diagnosis code for ischemic stroke as defined in Appendix A, Table 8.1, or Table 8.2 and who are discharged to home or home care. Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients itted for elective carotid intervention

© 2011 t Commission International 59

I-STK-8 References     

Duncan et al, Stroke Rehabilitation Clinical Practice Guidelines Stroke. 2005;36:e100-e143. Evans RL, Matlock AL, Bishop DS, Stranahan S, Pederson C. Family intervention after stroke: Does counseling or education help?, Stroke 1988;19:1243-1249. Kaiser Permanente Clinical Practice Guidelines for Acute Stroke, Kaiser Permanente Medical Group, 1998. 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. 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.

© 2011 t Commission International 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: Mortality: Decreased mortality Reissions 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 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.

© 2011 t Commission International 61

Domains of Performance

QPS Standards

CC

■ Appropriateness

QPS.3 – patient assessments ■ Stroke

IPSG ■ Goal 1

■ Availability ■ Continuity ■ Effectiveness ■ Prevention/Early Detection ■ Timeliness

© 2011 t Commission International 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received rehabilitation services. Inclusions to the population: Not Applicable Exclusions to the population: None Data elements: Assessed for Rehabilitation Services Denominator: Ischemic stroke or hemorrhagic stroke patients who are > = 18 years Data elements:  Birthdate  Elective Carotid Intervention  ICD principal diagnosis code Inclusions to the population: Patients with ICD principal diagnosis code for ischemic stroke or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2. Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients itted for elective carotid intervention

© 2011 t Commission International 63

STK-10 References   

    

American Academy of Physical Medicine and Rehabilitation. Rehabilitation Helps Stroke Patients Recover Skills. AAPM&R Chicago, IL Office: Author. American Academy of Physical Medicine and Rehabilitation. Urgency Key But Perseverance Pays Off. AAPM&R Chicago, IL Office: Author. Bates B, Choi JY, Duncan PW, Glasberg JJ, Graham GD, Katz RC, Lamberty K, Recker D, Zorowitz R. American Heart Association/American Stroke Associationendorsed 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. Management of patients with stroke. Rehabilitation, prevention and management of complications, and discharge planning, Scottish Intercollegiate network Guidelines Network (SIGN), 2002. National Institute of Neurological Disorders. Post-Stroke Rehabilitation Fact Sheet. National Institute of Neurological Disorders Bethesda, MD Office: Author. 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. VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation in the Primary Care Setting, 2003. Zorowitz RD, et al, the Post-Stroke Rehabilitation Outcomes Project (PSROP), Top Stroke Rehabil. 2005 Fall;12(4).

© 2011 t Commission International 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) ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM Code

Shortened Description

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

© 2011 t Commission International 65

Table 8.2 Hemorrhagic Stroke (STK) ICD-8 ICD-9 ICD-10 Code Code Code

ICD-9CM Code

Shortened Description

430

SUBARACHNOID HEMORRHAGE

431

INTRACEREBRAL HEMORRHAGE

© 2011 t Commission International 66

Children’s Asthma Care (CAC) Measure Set

© 2011 t Commission International 67

Measure Code

Measure Description

Children’s Asthma Care (CAC) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-CAC-1

Pediatric asthma patients who received relievers during this hospitalization

I-CAC-2

Pediatric asthma patients who received systemic corticosteroids during hospitalization

© 2011 t Commission International 68

I-CAC-1 Relievers for Children’s Inpatient Asthma Measure Overview I-CAC-1 Relievers for Children’s Inpatient Asthma Overview/Details: Use of relievers in pediatric patients itted 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 ission 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Pediatric units Medical/Surgical units (serving pediatric patients) Free-standing Pediatric hospitals Measure Name: Relievers for Children’s Inpatient 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 © 2011 t Commission International 69

Domains of Performance ■ Appropriateness ■ Availability

QPS Standards QPS.3 – patient assessments

CC ■ Asthma

IPSG ■ Goal 1

■ Continuity ■ Effectiveness

QPS.3 – antibiotic and other medication use

■ Prevention/Early Detection ■ Timeliness

© 2011 t Commission International 70

I-CAC-1 Measure Details Reasons and Implications: 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Pediatric asthma inpatients who received relievers during this hospitalization. Inclusions to the population: Patients who were istered relievers during this hospitalization. Exclusions to the population: None Data elements: 

Relievers istered

Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were discharged with a principal diagnosis of asthma Data elements:   

Birthdate ICD Principal Diagnosis code Reason for Not istering Relievers

Inclusions to the population: Discharges with:  

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

Exclusions to the population:  

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

© 2011 t Commission International 71

I-CAC-1 References 

       

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. Clinical Practice Guidelines of the American Academy of Pediatrics: A Compendium of Evidence-Based Research for Pediatric Practice. American Academy of Pediatrics, 1999. 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. Gross KM, Ponte CD (1998). New Strategies in the Medical Management of Asthma. American Family Physician. 58:1 McCormick MC, Kass B, Elixha 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. 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. Guidelines for the Diagnosis and Management of Asthma (EPR-3) (2007). http://www.nhlbi.nih.gov Asthma Management Model System, http://www.nhlbi.nih.gov National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov

© 2011 t Commission International 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 itted 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 ission 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Pediatric units Medical/Surgical units (serving pediatric patients) Free standing Pediatric hospitals Measure Name: Systemic corticosteroids for Children’s Inpatient Asthma Numerator: Pediatric asthma inpatients who received systemic corticosteroids during hospitalization. Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were discharged with a principal diagnosis of asthma © 2011 t Commission International 73

Domains of Performance ■ Appropriateness ■ Availability

QPS Standards QPS.3 – patient assessments

CC ■ Asthma

IPSG ■ Goal 1

■ Continuity ■ Effectiveness

QPS.3 – antibiotic and other medication use

■ Prevention/Early Detection ■ Timeliness

© 2011 t Commission International 74

I-CAC-2 Measure Details Reasons and Implications: 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Pediatric asthma inpatients who received systemic corticosteroids during hospitalization. Inclusions to the population: Patients who were istered systemic corticosteroids during this hospitalization. Exclusions to the population: None Data elements: 

Systemic Corticosteroids istered

Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were discharged with a principal diagnosis of asthma Data elements:   

Birthdate ICD Principal Diagnosis code Reason for Not istering Systemic Corticosteroids

Inclusions to the population: Discharges with:  

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

Exclusions to the population:  

Patients less than 2 years of age or greater than 18 years of age Patients with a documented ―Reason for Not istering‖ systemic corticosteroids

© 2011 t Commission International 75

I-CAC-2 References 

       

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. Clinical Practice Guidelines of the American Academy of Pediatrics: A Compendium of Evidence-Based Research for Pediatric Practice. American Academy of Pediatrics, 1999. 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. Gross KM, Ponte CD (1998). New Strategies in the Medical Management of Asthma. American Family Physician. 58:1 McCormick MC, Kass B, Elixha 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. 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. Guidelines for the Diagnosis and Management of Asthma (EPR-3) (2007). http://www.nhlbi.nih.gov Asthma Management Model System, http://www.nhlbi.nih.gov National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov

© 2011 t Commission International 76

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 6.1 Asthma Codes ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM Code

Shortened Description

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

© 2011 t Commission International 77

Hospital Based Inpatient Psychiatric Services (HBIPS) Measure Sets

© 2011 t Commission International 78

Measure Code

Measure Description

Hospital-Based Inpatient Psychiatric Service (HBIPS) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-HBIPS-2

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 itted to a hospital-based inpatient psychiatric setting

I-HBIPS-3

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 itted to a hospital-based inpatient psychiatric setting.

© 2011 t Commission International 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 itted to a hospital-based inpatient psychiatric setting. Overview/Details: Patients who are placed in physical restraint while itted 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. Measure Related Outcomes: Reliability: Increased delivery of evidence based care Improvement noted as: Decrease in rate Patient Settings/Services 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

© 2011 t Commission International 80

Domains of Performance

QPS Standards

■ Appropriateness ■ Effectiveness

CC

IPSG ■ Goal 2

QPS.3 – patient assessments

■ Prevention/Early Detection ■ Safety

© 2011 t Commission International 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 istrative 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. Exclusions to the population: None Data elements:   

Event Date Event Type Minutes of Physical Restraint

Denominator: Number of psychiatric inpatient days Denominator Basis: Per 1,000 hours (psychiatric inpatient) Data elements:    

ission Date Birthdate Psychiatric Care Setting Psychiatric Inpatient days

Inclusions to the population: All psychiatric inpatient days Exclusions to the population: 

None

© 2011 t Commission International 82

I-HBIPS-2 References      

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. 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. 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. 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. Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services, 56 (9), 1104-1142. 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

© 2011 t Commission International 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 itted to a hospital-based inpatient psychiatric setting. Overview/Details: Patients who are placed in seclusion while itted 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. Measure Related Outcomes: Reliability: Increased delivery of evidence based care Improvement noted as: Decrease in rate Patient Settings/Services Psychiatric units Measure Name: Hours of seclusion Numerator: The total number of hours that all psychiatric inpatients were held in seclusion. Denominator: Number of psychiatric inpatient days

© 2011 t Commission International 84

Domains of Performance ■ Appropriateness ■ Effectiveness

QPS Standards QPS.3 – patient assessments

CC

IPSG ■ Goal 2

■ Prevention/Early Detection ■ Safety

© 2011 t Commission International 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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. 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. Exclusions to the population: None Data elements:   

Event Date Event Type Minutes of Seclusion

Denominator: Number of psychiatric inpatient days Denominator Basis: Per 1,000 hours (psychiatric inpatient) Data elements:    

ission Date Birthdate Psychiatric Care Setting Psychiatric Inpatient days

Inclusions to the population: All psychiatric inpatient days Exclusions to the population: None

© 2011 t Commission International 86

I-HBIPS-3 References     

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. 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. 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. Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services, 56 (9), 1104-1142. 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

© 2011 t Commission International 87

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 10.01 Mental Disorders ICD-8 ICD-9 Code

Code

ICD-10 Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 88

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 89

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 90

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 91

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 92

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 93

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 94

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 95

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 96

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 97

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

IVE-AGGRESSIV PERSON

301.89

PERSONALITY DISORDER NEC

301.9

PERSONALITY DISORDER NOS

302.0

EGO-DYSTONIC SEX ORIENT

302.1

ZOOPHILIA

302.2

PEDOPHILIA

© 2011 t Commission International 98

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 99

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 100

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 101

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 102

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 103

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

© 2011 t Commission International 104

ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

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

RE-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

© 2011 t Commission International 105

Nursing Sensitive Care (NSC) Measure Set

© 2011 t Commission International 106

Measure Code

Measure Description

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

I-NSC-2

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 how to collect this measure.

I-NSC-4

All documented falls with or without injury, experienced by patients in a calendar month.

I-NSC-5

All documented falls by a patient with an injury level of minor (2) or greater.

© 2011 t Commission International 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: A decrease in rate © 2011 t Commission International 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.

Domains of Performance ■ Appropriateness ■ Continuity

QPS Standards QPS.3 – patient assessments

CC ■ HF

■ Goal 5

■ Stroke

■ Effectiveness

■ CKD

QPS.3 – infection, ■ Prevention/Early Detection prevention and

■ Diabetes (Type I/II)

■ Timeliness

IPSG

control, surveillance ■ ESRD and reporting ■ Traumatic Brain Injury ■ HIV/AIDS ■ Cancer ■ COPD

© 2011 t Commission International 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 ission)   

Category/stage II or greater pressure ulcers Unstageable/unclassified pressure ulcers Suspected deep tissue injury

Exclusions to the population: None Data elements:   

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

© 2011 t Commission International 110

Denominator: All patients surveyed for the study who are > = 18 years. Data elements:    

ission Date Birthdate Sex Type of unit

Exclusions to the population:     

Patients less than 18 years of age Patients who refuse to be assessed Patients who are off the unit at the time of the prevalence study, i.e. surgery, x-ray, physical therapy, etc. 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. Patients who are actively dying and pressure ulcer prevention is no longer a treatment goal.

© 2011 t Commission International 111

I-NSC-2 References      



     

AHRQ, Agency for Healthcare Quality and Research (2006). Numbers of patients with pressure sores increasing. ttp://hcup.ahrq.gov/HCUPnet.asp Allman, R. (1997). Pressure ulcer prelavence, incidence and risk factors and impact. Clinics in Geriatric Medicine, 13(3), 421-436. Allman, R. (2001). Pressure ulcers: Using what we know to improve quality of care. Journal of the American Geriatric Society, 49, 996-997. 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. Anderson, C. & Rappl, L. (2004). Lateral rotation mattresses for wound healing. Ostomy/Wound Management, 50(4), 50-62. 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. Black J, Baharestani M, Cuddigan J, Dorner B, Edsberg L, Langemo D, Posthauer ME, Ratliff C, Taler G; National Pressure Ulcer Advisory .National Pressure Ulcer Advisory 's updated pressure ulcer staging/categorizing system. Dermatol Nurs. 2007 Aug;19(4):343-9; quiz 350. Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: An update on this easy-to-use tool that assesses a patient’s risk. Am J Nurs. 2005;105:70-72. Dale, M.C., Burns, A., Panter, L., & Morris, J. (2001). Factors affecting survival of elderly nursing home residents. Internal Journal of Geriatric Psychiatry. 16, 7076. European Pressure Ulcer Advisory and National Pressure Ulcer Advisory . Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory ; 2009. 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. 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. 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), 345353.

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          

    

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. IOM (Institute of Medicine) (1999). To error is human: Building a safer health system. Washington D.C: National Academy of Sciences. 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. 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. Maklebust, J. (2005). Pressure ulcers: The great insult. Nursing Clinics of North America, 40, 365-389. 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. Pressure Ulcers in Adults: Prediction and Prevention (AHR, 1992). URL: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409 Adults: Prediction and Prevention. Clinical Practice Guideline Number 3. AHR Pub. No. 92-0047:May 1992 Rastinehad, D. (2006). Pressure ulcer pain. Journal of Wound, Ostomy & Continence Nursing, 33, 252-257. 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. 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. 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):15168. Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, Robson MC,Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pressure ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):663-79. 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 Wound, Ostomy and Continence Nurses Society. (2003) Guideline for Prevention and Management of Pressure Ulcers. WOCN: Glenview, IL Zulkowski, K., Langemo, D., Posthauer, M.E., & the National Pressure Ulcer Advisory . (2005). Coming to consensus on deep tissue injury. Advances in Skin & Wound Care, 18(1), 28-29.

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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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: A decrease in rate Patient Settings/Services: Medical/surgical units Intensive Care units/Critical care units 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. © 2011 t Commission International 114

Domains of Performance ■ Appropriateness ■ Continuity

QPS

CC

IPSG

Standards QPS.3 – patient assessments

■ HF ■ Stroke

■ Effectiveness

■ CKD

■ Prevention/Early Detection

■ Diabetes (Type I/II)

■ Safety

■ Goal 6

■ ESRD ■ Traumatic Brain Injury ■ HIV/AIDS ■ Cancer ■ COPD

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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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Total number of patient falls (with or without injury to the (patient) during the calendar month. Inclusions to the population:   

Patient falls occurring while on an eligible reporting unit Assisted falls Repeat falls

Exclusions to the population: Falls by:     

Visitors Students Staff Patients from eligible reporting units, however patient was not on unit at time of fall (e.g., patients falls in radiology department) Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)

Data elements:    

Month Number of Injury Falls Type of Unit Year

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Denominator Statement: Patient days by Type of Unit during the calendar month. Included Populations:   

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. Adult critical care, step-down, medical, surgical, medical-surgical combined, and mixed acuity units. 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:    

Month Patient Days Type of Unit Year

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I-NSC-4 References         

  

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. Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic Value of Professional Nursing. Medical Care 47(1): 97-104. Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on acute care hospital units. Nursing Outlook. 2004; 53:53-59. Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality of care on nursing units. Nursing Management. 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. 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. McCollam, M.E. Evaluation and Implementation of a research-based falls assessment innovation. Nursing Clinics of North America. 1995;30(3):507-514. Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone patient. Canadian Journal of Aging. 1989; (8):366-377. 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. 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. Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care. 2003; 41(1):142-152. Yang KP. Relationships between nurse staffing and patient outcomes. Journal of Nursing Research. 2003; 11(3):149-158.

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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 t 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: A decrease in rate

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Patient Settings/Services: Medical/surgical units Intensive Care units/Critical care units 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 Performance ■ Appropriateness ■ Continuity

QPS Standards QPS.3 – patient assessments

CC ■ HF

■ Goal 6

■ Stroke

■ Effectiveness

■ CKD

■ Prevention/Early Detection

■ Diabetes (Type I/II)

■ Safety

IPSG

■ ESRD ■ Traumatic Brain Injury ■ HIV/AIDS ■ Cancer ■ COPD

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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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of patient falls with an injury level of minor or greater during the calendar month Inclusions to the population:  

Patient falls occurring while on an eligible reporting unit Falls with Fall Injury Level of 2 ―minor‖ 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 t 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:   

Visitors Students Staff

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  

Patients from eligible reporting units, however patient was not on unit at time of fall (e.g., patients falls in radiology department) Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc) Falls with Fall Injury Level of 1 ―none‖

Data elements:  

Number of Injury Falls Type of Unit

Denominator Statement: Patient days by Type of Unit during the calendar month. Included Populations:  

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. 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:    

Month Patient Days Type of Unit Year

Data Accuracy:    

―Injury level‖-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-up on the patient’s condition at least 24 hours later should be established. 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. 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. Fall rate is calculated by multiplying the numerator by 1,000 and then dividing by the denominator.

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I-NSC-5 References         

  

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. Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic Value of Professional Nursing. Medical Care 47(1): 97-104. Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on acute care hospital units. Nursing Outlook. 2004; 53:53-59. Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality of care on nursing units. Nursing Management. 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. 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. McCollam, M.E. Evaluation and Implementation of a research-based falls assessment innovation. Nursing Clinics of North America. 1995;30(3):507-514. Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone patient. Canadian Journal of Aging. 1989; (8):366-377. 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. 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. Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care. 2003; 41(1):142-152. Yang KP. Relationships between nurse staffing and patient outcomes. Journal of Nursing Research. 2003; 11(3):149-158.

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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 and the units as well as the study team’s experience in 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 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 organization’s first 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.

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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 documentation. Using a ―team‖ for the observation portion of the study may be helpful for conducting skin inspection (e.g., to help turn immobile patients for inspection). To help decrease the likelihood of bias in observation, consider asg observation team 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 asg observation team 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).

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5) Chart Review a. Pressure Ulcer Prevalence: Each patient’s chart is also reviewed for demographic data, documentation relative to risk assessment and, if the Braden Scale is used, Total and Subscale Scores on ission 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: Each patient’s chart is also reviewed for documentation relative to the clinical justification for use of a restraint or sitter. Additional information such as other interventions, patient’s condition and length 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 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 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.

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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 , NPUAP, 2009) b. Hospital-acquired pressure ulcers are ulcers discovered or documented after the first 24 hours from the time of inpatient ission. 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 in the patient’s 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: The ―actively dying‖ and ―medically unstable‖ are used to characterize patients who 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 turning unrealistic. ―Medically unstable‖ people may have poor hemodynamic 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 © 2011 t Commission International 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)

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Perinatal Care (PC) Measure Set

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Measure Code

Measure Description

Perinatal Care (PC) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-PC-01

Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39 weeks of gestation completed

I-PC-02

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

I-PC-05

Exclusive breast milk feeding during the newborn's entire hospitalization

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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 ission rates of 13-21%). Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement Noted: Decrease in rate Patient Settings/Services Obstetric/Maternal units Medical/Surgical units Measure Name: Elective Delivery Numerator: Patients with elective deliveries Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation completed Domains of Performance ■ Appropriateness ■ Effectiveness ■ Prevention/Early Detection ■ Timeliness

QPS Standards QPS.3 – patient assessments

CC

IPSG ■ Goal 1 ■ Goal 4

QPS.3 – surgical procedure

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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 ission rates of 13-21%). Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Patients with elective deliveries Inclusions to the population: ICD principal code for one or more of the following:  Medical induction of labor (Appendix A Table 11.05)  Cesarean section as defined in Appendix A, Table 11.06 while not in active labor, or experiencing spontaneous rupture of membranes Exclusions to the population: None Data elements:  Active Labor  ICD Principal/Other Procedure code  Spontaneous Rupture of Membranes Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation completed Data elements:  ission Date  Birthdate  Gestational age  ICD principal/other diagnosis code Inclusions to the population: Not applicable Exclusions to the population:  ICD Principal Diagnosis code for conditions possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table 11.07  Patients less than 8 years of age  Patients greater than or equal to 65 years of age © 2011 t Commission International 132

I-PC-01 References     

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. American College of Obstetricians and Gynecologists. (November 1996). ACOG Educational Bulletin. 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. Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and outcomes. [Electronic Version]. J Reprod Med. 50(4):235-40. 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.

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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 ission 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted: Decrease in rate Patient Settings/Services Labor and Delivery units Medical/Surgical units Measure Name: Cesarean Section Numerator: Patients with cesarean sections Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex presentation Domains of Performance ■ Appropriateness ■ Effectiveness ■ Prevention/Early Detection ■ Timeliness

QPS Standards QPS.3 – patient assessments

CC

IPSG ■ Goal 1 ■ Goal 4

QPS.3 – surgical procedures

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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 ission 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: Retrospective data sources for the required data elements include istrative data and medical records. 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 Exclusions to the population: None Data elements:  ICD principal/other procedure Code Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex presentation. Data elements:  ission Date  Birthdate  Gestational age  ICD other diagnosis code  ICD other procedure code  ICD principal diagnosis code  ICD procedure code  Parity

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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 Exclusions to the population:  ICD Principal Diagnosis Code or ICD Other Diagnosis Codes, for contraindications to vaginal delivery as defined in Appendix A, Table 11.09  Patients less than 8 years of age  Patients greater than or equal to 65 years of age

© 2011 t Commission International 136

I-PC-02 References 

 

 

  

 

Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators— Guide to Inpatient Quality Indicators: Quality of Care in Hospitals—Volume, Mortality, and Utilization. Revision 4 (December 22, 2004). AHRQ Pub. No. 02RO204. Alfirevic, Z., Edwards, G., & Platt, M.J. (2004). The impact of delivery suite guidelines on intrapartum care in ―standard primigravida.‖ Eur J Obstet Gynecol Reprod Biol.115:28-31. 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). 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. 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. Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob Gyn Sur. 62:207-213. 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. 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 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. 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.

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      

   

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. 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. 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. 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. 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.188:157985. Main, E.K. (1999). Reducing cesarean birth rates with data-driven quality improvement activities. Peds. 103: 374-383. 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. 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. 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): 15. 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. 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. 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.

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I-PC-05 Exclusive Breast Milk Feeding Measure Overview I-PC – 05 Exclusive breast milk feeding during the newborn's entire hospitalization Overview/Details: Exclusive breast milk feeding during the newborn’s entire hospitalization. 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services 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 Domains of Performance

QPS Standards

CC

IPSG

■ Appropriateness ■ Prevention/Early Detection ■ Timeliness

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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 newborn infant’s breast milk. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Newborns that were fed breast milk only since birth Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Exclusive Breast Milk Feeding Denominator: Term newborns discharged from the hospital . Data elements:  ission Date  Birthdate  ICD other diagnosis code  ICD other procedure code  ICD principal diagnosis code  ICD procedure code  Reason for Not Exclusively Feeding Breast Milk Inclusions to the population: Live-born newborns Exclusions to the population:  Infants itted to the Neonatal Intensive Care Unit (NICU) during this hospitalization  ICD Principal Diagnosis Code or ICD Other Diagnosis Codes, for galactosemia Table Appendix A, Table 11.21  ICD Principal Procedure Code or ICD Other Procedure Codes for parenteral infusion as defined in Appendix A, Table 11.22  Newborns who die at birth  Documented reason for Not Exclusively Feeding Breast Milk © 2011 t Commission International 140

I-PC-05 References  American Academy of Pediatrics. (2005). Section on Breastfeeding. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics.115:496– 506.  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.  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.  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.  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.  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/s/pub/evidence/pdf/brfout/brfout.pdf  Kramer, M.S. & Kakuma, R. (2002).Optimal duration of exclusive breastfeeding. [107 refs] Cochrane Database of Systematic Reviews. (1):CD003517.  Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and onemonth exclusive breastfeeding in association with the in-hospital feeding modality. Breastfeeding Medicine. 2(2):92-8.  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.  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):e28390.  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.  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. © 2011 t Commission International 141

Appendix A Perinatal Care ICD Code Tables 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 11.05 Medical Induction of Labor Codes ICD-8 ICD-9 ICD-10 ICD-9Shortened Description Code Code Code CMCode 73.01 INDUCT LABOR-RUPT MEMB

Table 11.06 Cesarean Section ICD-8 ICD-9 Code Code

ICD-10 Code

73.1

SURG INDUCT LABOR NEC

73.4

MEDICAL INDUCTION LABOR

ICD-9Shortened Description CMCode 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 ICD-8 ICD-9 ICD-10 ICD-9Shortened Description Code Code Code CMCode 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

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9Shortened Description CMCode 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

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9Shortened Description CMCode 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

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9Shortened Description CMCode 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 ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode V27.0

Shortened Description DELIVER-SINGLE LIVEBORN

Table 11.09 Contraindications to Vaginal Delivery ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode

Shortened Description

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

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode

Shortened Description

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

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode

Shortened Description

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

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode

Shortened Description

V27.6

DEL-MULT BIRTH, SOME LIVE

V27.7

DEL-MULT BIRTH, ALL SB

Table 11.20.1 Term Gestation ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode 765.29

Shortened Description 37+ Comp WKS GESTATION

Table 11.21 Galactosemia ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode 271.1

Shortened Description GALACTOSEMIA

Table 11.22 Parenteral Infusion ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode 99.15

Shortened Description PARENT INFUS NUTRIT SUB

© 2011 t Commission International 148

Pneumonia (PN) Measure Set

© 2011 t Commission International 149

Measure Code

Measure Description

Pneumonia (PN) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-PN-2

Pneumonia patients, aged 65 and older, who were screened for pneumococcal vaccine status and were istered the vaccine prior to discharge, if indicated

I-PN-4

Adult smoking cessation advice/counseling given to patients who smoke cigarettes and who are hospitalized for pneumonia

I-PN-7

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

© 2011 t Commission International 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 istered 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: Increase in rate Patient Settings/Services Intensive Care Units Medical/Surgical units 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.

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Domains of Performance

QPS

■ Appropriateness

QPS.3 – patient assessments

■ Availability ■ Continuity ■ Effectiveness ■ Prevention/Early Detection

CC

IPSG

■ AMI

■ Goal 1

Standards ■ HF

■ Stroke QPS.3 – infection ■ Diabetes (Type I/II) prevention and control, ■ ESRD surveillance and reporting ■ Traumatic

■ Timeliness

Brain Injury ■ HIV/AIDS ■ Asthma ■ COPD

© 2011 t Commission International 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 istration are recommended, and hospitalization is an underutilized opportunity for adult vaccination. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Patients with pneumonia, age 65 and older, who were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated. Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Pneumococcal Vaccination Status Denominator: Pneumonia patients 65 years of age and older. Data elements:  ission Date  Birthdate  Chest X-ray  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) Exclusions to the population:  Patients less than 65 years of age  Patients who left against medical advice  Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to or during this hospital stay  Patients who expired © 2011 t Commission International 153

I-PN-2 References  

 

 



Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare inpatients: a missed opportunity. Arch Intern Med 2002;162:23492356. 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. Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton’s Law applied to prevention. Infect Control Hosp Epi. 2000;21:692-699. 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. 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. 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. Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of vaccination against pneumococcal bacteremia among elderly people. JAMA, 1997; 278:1333-1339.

© 2011 t Commission International 154

I-PN – 4 Adult Smoking Counseling 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 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 than those who receive no counseling whatsoever. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care 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 advice or counseling during the hospital stay Denominator: Pneumonia patients 18 years of age and older with a history of smoking cigarettes anytime during the year prior to hospital arrival Domains of Performance

QPS Standards

CC

■ Appropriateness

QPS.3 – patient assessments

■ HF

■ Continuity

IPSG

■ Stroke

■ Effectiveness

■ Diabetes

■ Prevention/Early Detection

■ Traumatic Brain Injury ■ Asthma ■ COPD

© 2011 t Commission International 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 for a patient to stop smoking, and smoking cessation may promote the patient’s medical recovery. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Pneumonia patients (cigarette smokers) who receive smoking cessation advice or counseling during the hospital stay Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Adult Smoking Counseling 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:  Adult Smoking History  Birthdate  ICD Principal Diagnosis Code or Other  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 Exclusions to the population:  Patients less than 18 years of age  Patients who left against medical advice  Patients who expired  Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to or during this hospital stay © 2011 t Commission International 156

I-PN-4 References 



 

 

Fiore MC, Jaèn 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. Hudmon KS, Hemberger KK, Corelli RL, et al. The pharmacist’s role in smoking cessation counseling: perceptions of s of nonprescription nicotine replacement therapy. J Am Pharm Assoc 2003; 43(5):573582. Kikano GE, et al: The value of brief, targeted smoking-cessation advice. Family Practice Management. pp. 50-2000. 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. Sheahan SL. How to help older adults quit smoking. Nurse Pract 2002; 27:27-33. The Smoking Cessation Clinical Practice Guideline and Staff: The Agency for Health Care Policy and Research. Smoking Cessation Clinical Practice Guideline. JAMA, 275:1270-1280, 1996.

© 2011 t Commission International 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement Noted as: An increase in rate/score/number of occurrences Patient Settings/Services Intensive Care Units Medical/Surgical units 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)

© 2011 t Commission International 158

Domains of Performance

QPS Standards

CC

IPSG

■ Appropriateness

QPS.3 – patient assessments

■ AMI

■ Goal 1

■ Availability

■ HF

■ Continuity

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

© 2011 t Commission International 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 istration are recommended especially during the flu season, and hospitalization is an underutilized opportunity to provide vaccination to adults. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. 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. Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:  Influenza Vaccination Status Denominator: Pneumonia patients 50 years of age and older (during the flu season) Data elements:  ission Date  Birthdate  Chest X-ray  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) Exclusions to the population:  Patients less than 50 years of age  Patients who left against medical advice  Patients who had no chest x-ray or CT scan that indicated abnormal findings within 24 hours prior to or during this hospital stay  Patients who expired  Patients with a secondary diagnosis of influenza pneumonia © 2011 t Commission International 160

I-PN - 7 References    

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. Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and pneumococcal vaccination: Sutton’s Law applied to prevention. Infect Control Hosp Epi. 2000;21:692-699. Kissam S, Gifford DR, Patry G, et al. Is signed consent for influenza or pneumococcal polysaccharide vaccination required? Arch Intern Med 2004; 164:1316. 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.

© 2011 t Commission International 161

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 3.1 Pneumonia (PN) ICD-8 ICD-9 Code Code

ICD-10 Code

ICD-9Shortened Description CMCode 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 MYLSM PNEUMONIAE

483.1

PNEUMONIA D/T CHLAMYDIA

483.8

PNEUMON OTH SPEC ORGNSM

485

BRONCHOPNEUMONIA ORG NOS

486

PNEUMONIA, ORGANISM NOS

© 2011 t Commission International 162

Surgical Care Improvement Project (SCIP) Measure Set

© 2011 t Commission International 163

Measure Code

Measure Description

Surgical Care Improvement Project (SCIP) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-SCIP-Inf-1d

Prophylactic antibiotics received one hour prior to surgical incision for hip arthroplasty patients

I-SCIP-Inf-1e

Prophylactic antibiotics received one hour prior to surgical incision for knee arthroplasty patients

I-SCIP-Inf-2d

Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent with current guidelines

I-SCIP-Inf-2e

Surgical patients (knee arthoplasty) who received prophylactic antibiotics consistent with current guidelines

I-SCIP-Inf-3d

Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued within 24 hours after anesthesia end time

I-SCIP-Inf-3e

Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued within 24 hours after anesthesia end time

I-SCIP-VTE-1

Surgical patients (hip/knee arthroplasty) with recommended venous thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End Time

I-SCIP-VTE-2

Surgical patients who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia end time

© 2011 t Commission International 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 istration until after the operation. In a comprehensive study, it was found that the lowest incidence of post-operative infection was associated with antibiotic istration during the one hour prior to surgery. The risk of infection increased progressively with greater time intervals between istration and skin incision. Therefore, opportunities to improve care have been demonstrated and timely istration has been recommended. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units 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. © 2011 t Commission International 165

Domains of Performance QPS

CC

IPSG

■ t Replacement

■ Goal 1

Standards ■ Appropriateness ■ Availability

QPS.3 – surgical procedures

■ Continuity ■ Effectiveness ■ Prevention/Early Detection ■ Timeliness

■ Goal 4 ■ Goal 5

QPS.3 – antibiotics and other mediation use QPS.3 – infection, prevention and control, surveillance and reporting

© 2011 t Commission International 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 istration until after the operation. In a comprehensive study, it was found that the lowest incidence of postoperative infection was associated with antibiotic istration during the one hour prior to surgery. The risk of infection increased progressively with greater time intervals between istration and skin incision. Therefore, opportunities to improve care have been demonstrated and timely istration has been recommended. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of surgical patients (hip arthroplasty) with prophylactic antibiotics initiated within one hour prior to surgical incision Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Anesthesia start date  Antibiotic istration date  Antibiotic istration time  Surgical incision time Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior infection and who are >= 18 years. Data elements:  ission date  Anesthesia start date  Antibiotic name  Antibiotic received  Antibiotic istration route  Birthdate  ICD principal diagnosis code  ICD principal procedure Code  Infection prior to anesthesia  Other surgeries © 2011 t Commission International 167

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.04). Exclusions to the population:  Patients less than 18 years of age  Patients who had a previous diagnosis suggestive of preoperative infectious disease (as defined in Appendix A, Table 5.09)  Patients with a documented infection prior to the surgical procedure of interest (hip arthroplasty)  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  Patients who were receiving antibiotics within 24 hours prior to arrival  Patients who were receiving antibiotics more than 24 hours prior to surgery

© 2011 t Commission International 168

I-SCIP-Inf-1d References 

         

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):17061715. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280. 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. 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. Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097. Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care: istration of preoperative antibiotics in the operating room. Am Surg. 1997;63:500-503. Gorecki P, Schein M, Rucinski JC, et al. Antibiotic istration in patients undergoing common surgical procedures in a community teaching hospital: the chaos continues. World J Surg. 1999;23:429-432. 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. Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969;66:97-103. Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary, and colonic surgery. Ann Surg. 1976;184:443-452. 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.

© 2011 t Commission International 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units Measure Name: Prophylactic antibiotic received within one hour prior to surgical incision. Numerator: Number of surgical patients (knee arthroplasty) with prophylactic antibiotics initiated within one hour prior to surgical incision Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior infection and > = 18 years.

© 2011 t Commission International 170

Domains of Performance

QPS

■ Availability ■ Effectiveness

IPSG

■ t Replacement

■ Goal 1

Standards

■ Appropriateness QPS.3 – surgical procedures ■ Continuity

CC

QPS.3 – antibiotics and other mediation use

■ Goal 4 ■ Goal 5

■ Prevention/Early Detection ■ Timeliness

QPS.3 – infection, prevention and control, surveillance and reporting

© 2011 t Commission International 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 istration until after the operation. In a comprehensive study, it was found that the lowest incidence of post-operative infection was associated with antibiotic istration during the one hour prior to surgery. The risk of infection increased progressively with greater time intervals between istration and skin incision. Therefore, opportunities to improve care have been demonstrated and timely istration has been recommended. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of surgical patients (knee arthroplasty) with prophylactic antibiotics initiated within one hour prior to surgical incision Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Anesthesia start date  Antibiotic istration date  Antibiotic istration time  Surgical incision time Denominator: All selected surgical patients (knee arthoplasty) with no evidence of prior infection and who are >= 18 years. Data elements:  ission date  Anesthesia start date  Antibiotic name  Antibiotic received  Antibiotic istration route  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Infection prior to anesthesia  Other surgeries © 2011 t Commission International 172

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.05). Exclusions to the population:  Patients less than 18 years of age  Patients who had a previous diagnosis suggestive of preoperative infectious disease (as defined in Appendix A, Table 5.09)  Patients with a documented infection prior to surgical procedure of interest (knee arthroplasty)  Patients who were receiving antibiotics within 24 hours prior to arrival  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  Patients who were receiving antibiotics more than 24 hours prior to surgery  Patients who were receiving antibiotics within 24 hours prior to arrival.

© 2011 t Commission International 173

I-SCIP-Inf-1e References 

         

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):17061715. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280. 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. 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. Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097. Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care: istration of preoperative antibiotics in the operating room. Am Surg. 1997;63:500-503. Gorecki P, Schein M, Rucinski JC, et al. Antibiotic istration in patients undergoing common surgical procedures in a community teaching hospital: the chaos continues. World J Surg. 1999;23:429-432. 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. Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of determinant factors and prevention. Surgery. 1969;66:97-103. Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary, and colonic surgery. Ann Surg. 1976;184:443-452. 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.

© 2011 t Commission International 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, costeffective, 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate 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. Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior infection who are >= 18 years.

© 2011 t Commission International 175

Domains of Performance

QPS

■ Appropriateness

QPS.3 – surgical procedures

■ Effectiveness

IPSG

■ t Replacement

■ Goal 1

Standards

■ Availability ■ Continuity

CC

QPS.3 – antibiotics and other mediation use

■ Goal 4 ■ Goal 5

■ Prevention/Early Detection

QPS.3 – infection, prevention and control, surveillance and reporting

© 2011 t Commission International 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of surgical patients (hip arthroplasty) who received prophylactic antibiotics recommended for their specific surgical procedure. Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Antibiotic istration Route  Antibiotic Allergy  Antibiotic Name  Vancomycin Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior infection and are >= 18 years. Data elements:  ission date  Antibiotic istration date  Antibiotic istration time  Antibiotic received  Antibiotic ission route  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Infection prior to anesthesia  Surgical Incision time © 2011 t Commission International 177

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.04.) Exclusions to the population:  Patients less than 18 years of age  Patients who had a previous diagnosis suggestive of preoperative infectious disease (as defined in Appendix A, Table 5.09)  Patients with a documented infection prior to surgical procedure of interest (hip arthroplasty)  Patients who were receiving antibiotics within 24 hours prior to arrival  Patients who were receiving antibiotics more than 24 hours prior to surgery  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)  Patients who did not receive any antibiotics during this hospitalization

© 2011 t Commission International 178

I-SCIP-Inf-2d References 

     



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):17061715. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:18391888. No author listed. The Medical letter. Antimicrobial prophylaxis for Surgery. Med Lett Drugs Ther. 2009; 82: 47-52. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427. 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. 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 , Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds. Arch Surg. 1993;128:79-88. 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.

© 2011 t Commission International 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, costeffective, 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units Measure Name: Prophylactic antibiotic selection for surgical patients (knee arthroplasty). Numerator: Number of surgical patients (knee arthroplasty) who received prophylactic antibiotics recommended for their specific surgical procedure. Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior infection who are >= 18 years. Domains of Performance

QPS Standards

■ Appropriateness

QPS.3 – surgical procedures

■ Availability ■ Continuity

CC

■ t QPS.3 – antibiotics and other Replacement mediation use

IPSG ■ Goal 1 ■ Goal 4 ■ Goal 5

QPS.3 – infection, prevention and control, surveillance and ■ Prevention/Early Detection reporting ■ Effectiveness

© 2011 t Commission International 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: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of surgical patients (knee arthroplasty) who received prophylactic antibiotics recommended for their specific surgical procedure. Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Antibiotic istration route  Antibiotic allergy  Antibiotic name  Vancomycin Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior infection and are >= 18 years. Data elements:  ission date  Antibiotic istration date  Antibiotic istration time  Antibiotic Received  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Infection prior to anesthesia  Surgical Incision time © 2011 t Commission International 181

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.05). Exclusions to the population:  Patients less than 18 years of age  Patients who had a previous diagnosis suggestive of preoperative infectious disease (as defined in Appendix A, Table 5.09)  Patients with a documented infection prior to surgical procedure of interest (knee arthroplasty)  Patients who were receiving antibiotics within 24 hours prior to arrival  Patients who were receiving antibiotics more than 24 hours prior to surgery  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)  Patients who did not receive any antibiotics during this hospitalization

© 2011 t Commission International 182

I-SCIP-Inf-2e References 

     



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):17061715. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280. American Society of Health-System Pharmacists. ASHP therapeutic guidelines on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:18391888. No author listed. The Medical letter. Antimicrobial prophylaxis for Surgery. Med Lett Drugs Ther. 2009; 82: 47-52. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427. 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. 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 , Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical wounds. Arch Surg. 1993;128:79-88. 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.

© 2011 t Commission International 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units 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 Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior infection who are >= 18 years

© 2011 t Commission International 184

Domains of Performance

QPS

■ Appropriateness

QPS.3 – surgical procedures

■ Effectiveness

IPSG

■ t Replacement

■ Goal 1

Standards

■ Availability ■ Continuity

CC

QPS.3 – antibiotics and other mediation use

■ Goal 4 ■ Goal 5

■ Prevention/Early Detection ■ Timeliness

QPS.3 – infection, prevention and control, surveillance and reporting

© 2011 t Commission International 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, istration of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient. Prolonged istration does increase the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Anesthesia end date  Anesthesia end time  Antibiotic istration date  Antibiotic istration time Denominator: All selected surgical patients (hip arthroscopy) with no evidence of prior infection and who are >= 18 years. Data elements:  ission date  Anesthesia start date  Antibiotic istration route  Antibiotic name  Antibiotic received  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Infection prior to anesthesia  Other surgeries  Reason to extend antibiotics  Surgical incision time © 2011 t Commission International 186

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.04.) Exclusions to the population:  Patients less than 18 years of age  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  Patients who had a previous diagnosis suggestive of preoperative infectious disease (as defined in Appendix A, Table 5.09)  Patients with a documented infection prior to surgical procedure of interest (hip arthroplasty)  Patients who were receiving antibiotics more than 24 hours prior to arrival  Patients who were receiving antibiotics more than 24 hours prior to surgery  Patients who did not receive any antibiotics during this hospitalization  Patients with reasons to extend antibiotics

© 2011 t Commission International 187

I-SCIP-Inf-3d References 

    

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):17061715. 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. 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. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280. 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. Scher KS. Studies on the duration of antibiotic istration for surgical prophylaxis. Am Surg. 1997;63:59-62.

© 2011 t Commission International 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units 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 Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior infection who are >= 18 years.

© 2011 t Commission International 189

Domains of Performance

QPS

■ Appropriateness

QPS.3 – surgical procedures

■ Availability

■ Prevention/Early Detection ■ Timeliness

IPSG

■ t Replacement

■ Goal 1

Standards

■ Continuity ■ Effectiveness

CC

■ Goal 4 ■ Goal 5

QPS.3 – antibiotics and other mediation use QPS.3 – infection, prevention and control, surveillance and reporting

© 2011 t Commission International 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, istration of antibiotics for more than a few hours after the incision is closed offers no additional benefit to the surgical patient. Prolonged istration does increase the risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Number of surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued within 24 hours after Anesthesia End Time Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Anesthesia End Date  Anesthesia End Time  Antibiotic istration Date  Antibiotic istration Time Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior infection and who are >= 18 years. Data elements:  ission date  Anesthesia start date  Antibiotic istration route  Antibiotic name  Antibiotic received  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Infection prior to anesthesia  Other surgeries  Reason to extend antibiotics  Surgical incision time © 2011 t Commission International 191

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.05) Exclusions to the population:  Patients less than 18 years of age  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  Patients who had a previous diagnosis suggestive of preoperative infectious disease (as defined in Appendix A, Table 5.09)  Patients with a documented infection prior to surgical procedure of interest (knee arthroplasty)  Patients who were receiving antibiotics more than 24 hours prior to arrival  Patients who were receiving antibiotics more than 24 hours prior to surgery  Patients who did not receive any antibiotics during this hospitalization  Patients with reasons to extend antibiotics

© 2011 t Commission International 192

I-SCIP- Inf-3e References 

    

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):17061715. 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. 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. Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280. 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. Scher KS. Studies on the duration of antibiotic istration for surgical prophylaxis. Am Surg. 1997;63:59-62.

© 2011 t Commission International 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units 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.

© 2011 t Commission International 194

Domains of Performance

QPS

CC

IPSG

■ t Replacement

■ Goal 1

Standards ■ Appropriateness ■ Availability

QPS.3 – patient assessments

■ Continuity ■ Effectiveness ■ Prevention/Early Detection ■ Timeliness

QPS.3 – surgical procedures QPS.3 – antibiotics and other mediation use

© 2011 t Commission International 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 twentyfold 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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. 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. Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Anesthesia type  VTE Prophylaxis Denominator: All selected surgical patients (hip/knee arthroplasty). Data elements:  ission date  Anesthesia end date  Anesthesia end time  Anesthesia start date  Anesthesia start time  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Preission Warfarin  Reason for Not istering VTE Prophylaxis © 2011 t Commission International 196

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.04, 5.05.) Exclusions to the population:  Patients less than 18 years of age  Patients with hospital stay of less than or equal to 3 calendar days  Patients who are on warfarin prior to ission  Patients whose total surgery time is less than or equal to 60 minutes  Patients with reasons for not istering both mechanical and pharmocolgical prophylaxis

Elective Total Hip Replacement 5B

Elective Total Knee Replacement 6B

Elective Total Hip Replacement with a reason for not istering pharmacological prophylaxis

Any of the following started within 24 hours of surgery:  Low molecular weight heparin (LMWH)  Factor Xa Inhibitor (Fondaparinux)  Warfarin  Oral Factor Xa Inhibitor (Rivaroxaban) Any of the following:  Low molecular weight heparin (LMWH)  Factor Xa Inhibitor (Fondaparinux)  Warfarin  Intermittent pneumatic compression devices (IPC)  Venous foot pump (VFP)  Oral Factor Xa Inhibitor (Rivaroxaban) Any of the following:  Intermittent pneumatic compression devices (IPC)  Venous foot pump (VFP)

© 2011 t Commission International 197

I-SCIP-VTE-1 References  

  

 

  

 

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. 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. Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. The Cochrane Library. Issue1, 2001. PMID: 10908501. 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. 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;118:16801684. PMID: 11115458. O’Donnell M, Weitz JI. Thromboprophylaxis in surgical patients. Can J Surg. 2003; 46(2): 129-135. PMID: 12691354. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth AC Conference on antithrombotic and thrombolytic therapy. Chest 2008; 133:381S-453S. PMID: 18574271. 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. 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. 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. 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. 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. © 2011 t Commission International 198



   



Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of lowmolecular-weight heparin prophylaxis against venous thromboembolism in patients undergoing elective hip replacement. Arch Intern Med. 1999;159:137-141. PMID: 9927095. 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. Abrams PJ, Emerson CR. Rivaroxaban: a novel, oral, direct factor Xa Inhibitor. Pub Med. Feb.2009; 167-81 Borris LC, Rivaroxaban, a new, oral direct factor Xa inhibitor for thromboprophylaxis after major t arthroplasty. Pub Med. April 2009; 10 6):10838. 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. 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.

© 2011 t Commission International 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units 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

© 2011 t Commission International 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.

Domains of Performance QPS

CC

IPSG

■ t Replacement

■ Goal 1

Standards ■ Appropriateness ■ Availability

QPS.3 – patient assessments

■ Continuity ■ Effectiveness ■ Prevention/Early Detection ■ Timeliness

QPS.3 – surgical procedures QPS.3 – antibiotics and other mediation use

© 2011 t Commission International 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 encom most procedures. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. 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. Inclusions to the population: Not applicable Exclusions to the population: None Data elements:  Anesthesia type  VTE Prophylaxis  VTE Timely Denominator: All selected surgical patients (hip/knee arthroplasty). Data elements:  ission date  Anesthesia start date  Anesthesia start time  Anesthesia end date  Anesthesia end time  Birthdate  ICD principal diagnosis code  ICD principal procedure code  Preission warfarin  Reason for not istering VTE prophylaxis © 2011 t Commission International 202

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined in Appendix A, Table 5.04, 5.05). Exclusions to the population:  Patients less than 18 years of age  Patients with length of stay less than or equal to 3 calendar days  Patients who are on warfarin prior to ission  Patients whose total surgery time is less than or equal to 60 minutes  Patients with reasons for not istering both mechanical and pharmocolgical prophylaxis  Patients who did not receive VTE Prophylaxis

Su

Surgery Type Elective Total Hip Replacement 5B

Elective Total Knee Replacement 6B

Elective Total Hip Replacement with a reason for not istering pharmacological prophylaxis

VTE Prophylaxis Options for Surgery Recommended Prophylaxis Options Any of the following started within 24 hours of surgery:  Low molecular weight heparin (LMWH)  Factor Xa Inhibitor (Fondaparinux)  Warfarin  Oral Factor Xa Inhibitor (Rivaroxaban) Any of the following:  Low molecular weight heparin (LMWH)  Factor Xa Inhibitor (Fondaparinux)  Warfarin  Intermittent pneumatic compression devices (IPC)  Venous foot pump (VFP)  Oral Factor Xa Inhibitor (Rivaroxaban) Any of the following:  Intermittent pneumatic compression devices (IPC)  Venous foot pump (VFP)

© 2011 t Commission International 203

I-SCIP-VTE-2 References   



  

   



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. Anderson FA, Wheeler HB, Goldberg RJ, et al. Physician practices in the prevention of VTE. Ann Intern Med. 1991;115-591-595. PMID: 1892330. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth AC Conference on antithrombotic and thrombolytic therapy. Chest 2008; 133:381S-453S. PMID: 18574271. 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. Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein thrombosis. The Cochrane Library, Issue1, 2001. PMID: 10908501. 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. 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;118:16801684. PMID: 11115458. O’Donnell M, Weitz JI. Thromboprophylaxis in surgical patients. Can J Surg. 2003; 46(2): 129-135. PMID: 12691354. Janku GV, Paiement GD, Green HD. Prevention of venous thromboembolism in orthopaedics in the United States. Clin Ortho & Related Research. 1996:313321. PMID: 8998892. 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. 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. 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.

© 2011 t Commission International 204

 

    



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. 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;159:137141. PMID: 9927095. 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. 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. Abrams PJ, Emerson CR. Rivaroxaban: a novel, oral, direct factor Xa Inhibitor. Pub Med. Feb.2009; 167-81 Borris LC, Rivaroxaban, a new, oral direct factor Xa inhibitor for thromboprophylaxis after major t arthroplasty. Pub Med. April 2009; 10 6):1083-8. 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. 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.

© 2011 t Commission International 205

Appendix A ICD Codes Surgical Care Improvement Project (SCIP) 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 5.04 Hip Arthroplasty ICD-8 ICD-9 Code Code

ICD-10 Code

ICD-9Shortened Description CMCode 81.51 TOTAL HIP REPLACEMENT 81.52 PARTIAL HIP REPLACEMENT

Table 5.05 Knee Arthroplasty ICD-8 ICD-9 Code Code

ICD-10 Code

ICD-9Shortened Description CMCode 81.54 TOTAL KNEE REPLACEMENT

Table 5.09 Infection Codes ICD-8 ICD-9 Code Code

ICD-10 Code

ICD-9CMCode Code 001.0 001.1 001.9 002.0 002.1 002.2 002.3 002.9 003.0 003.1 003.20 003.21 003.22

Shortened Description Shortened Description CHOLERA D/T VIB CHOLERAE CHOLERA D/T VIB EL TOR CHOLERA NOS TYPHOID FEVER PARATYPHOID FEVER A PARATYPHOID FEVER B PARATYPHOID FEVER C PARATYPHOID FEVER NOS SALMONELLA ENTERITIS SALMONELLA SEPTICEMIA LOCAL SALMONELLA INF NOS SALMONELLA MENINGITIS SALMONELLA PNEUMONIA

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode 003.23 003.24 003.29 003.8 003.9 004.0 004.1 004.2 004.3 004.8 004.9 006.0 006.1 006.2 006.3 006.4 006.5 006.6 006.8 006.9 007.1 008.00 008.01 008.02 008.03 008.04 008.09 008.1 008.2 008.3 008.41 008.42 008.43 008.44 008.45 008.46 008.47 008.49 008.5

Shortened Description SALMONELLA ARTHRITIS SALMONELLA OSTEOMYELITIS LOCAL SALMONELLA INF NEC SALMONELLA INFECTION NEC SALMONELLA INFECTION NOS SHIGELLA DYSENTERIAE SHIGELLA FLEXNERI SHIGELLA BOYDII SHIGELLA SONNEI SHIGELLA INFECTION NEC SHIGELLOSIS NOS AC AMEBIASIS W/O ABSCESS CHR AMEBIASIS W/O ABSCES AMEBIC NONDYSENT COLITIS AMEBIC LIVER ABSCESS AMEBIC LUNG ABSCESS AMEBIC BRAIN ABSCESS AMEBIC SKIN ULCERATION AMEBIC INFECTION NEC AMEBIASIS NOS GIARDIASIS INTEST INFEC E COLI NOS INT INF E COLI ENTRPATH INT INF E COLI ENTRTOXGN INT INF E COLI ENTRNVSV INT INF E COLI ENTRHMRG INT INF E COLI SPCF NEC ARIZONA ENTERITIS AEROBACTER ENTERITIS PROTEUS ENTERITIS STAPHYLOCOCC ENTERITIS PSEUDOMONAS ENTERITIS INT INFEC CAMPYLOBACTER INT INF YRSNIA ENTRCLTCA INT INF CLSTRDIUM DFCILE INTES INFEC OTH ANEROBES INT INF OTH GRM NEG BCTR BACTERIAL ENTERITIS NEC BACTERIAL ENTERITIS NOS

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ICD-9CMCode 008.8 009.0 009.1 009.2 009.3 020.0 020.1 020.2 020.3 020.4 020.5 020.8 020.9 021.0 021.1 021.2 021.3 021.8 021.9 022.0 022.1 022.2 022.3 022.8 022.9 023.0 023.1 023.2 023.3 023.8 023.9 024 025 026.0 026.1 026.9 027.0 027.1 027.2

Shortened Description VIRAL ENTERITIS NOS INFECTIOUS ENTERITIS NOS ENTERITIS OF INFECT ORIG INFECTIOUS DIARRHEA NOS DIARRHEA OF INFECT ORIG BUBONIC PLAGUE CELLULOCUTANEOUS PLAGUE SEPTICEMIC PLAGUE PRIMARY PNEUMONIC PLAGUE SECONDARY PNEUMON PLAGUE PNEUMONIC PLAGUE NOS OTHER TYPES OF PLAGUE PLAGUE NOS ULCEROGLANDUL TULAREMIA ENTERIC TULAREMIA PULMONARY TULAREMIA OCULOGLANDULAR TULAREMIA TULAREMIA NEC TULAREMIA NOS CUTANEOUS ANTHRAX PULMONARY ANTHRAX GASTROINTESTINAL ANTHRAX ANTHRAX SEPTICEMIA OTHER ANTHRAX MANIFEST ANTHRAX NOS BRUCELLA MELITENSIS BRUCELLA ABORTUS BRUCELLA SUIS BRUCELLA CANIS BRUCELLOSIS NEC BRUCELLOSIS NOS GLANDERS MELIOIDOSIS SPIRILLARY FEVER STREPTOBACILLARY FEVER RAT-BITE FEVER NOS LISTERIOSIS ERYSIPELOTHRIX INFECTION PASTEURELLOSIS

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ICD-9CMCode 027.8 027.9 030.0 030.1 030.2 030.3 030.8 030.9 031.0 031.1 031.2 031.8 031.9 032.0 032.1 032.2 032.3 032.81 032.82 032.83 032.84 032.85 032.89 032.9 033.0 033.1 033.8 033.9 034.0 034.1 035 036.0 036.1 036.2 036.3 036.40 036.41 036.42 036.43

Shortened Description ZOONOTIC BACT DIS NEC ZOONOTIC BACT DIS NOS LEPROMATOUS LEPROSY TUBERCULOID LEPROSY INDETERMINATE LEPROSY BORDERLINE LEPROSY LEPROSY NEC LEPROSY NOS PULMONARY MYCOBACTERIA CUTANEOUS MYCOBACTERIA DMAC BACTEREMIA MYCOBACTERIAL DIS NEC MYCOBACTERIAL DIS NOS FAUCIAL DIPHTHERIA NASOPHARYNX DIPHTHERIA ANT NASAL DIPHTHERIA LARYNGEAL DIPHTHERIA CONJUNCTIVAL DIPHTHERIA DIPHTHERITIC MYOCARDITIS DIPHTHERITIC PERITONITIS DIPHTHERITIC CYSTITIS CUTANEOUS DIPHTHERIA DIPHTHERIA NEC DIPHTHERIA NOS BORDETELLA PERTUSSIS BORDETELLA PARAPERTUSSIS WHOOPING COUGH NEC WHOOPING COUGH NOS STREP SORE THROAT SCARLET FEVER ERYSIPELAS MENINGOCOCCAL MENINGITIS MENINGOCOCC ENCEPHALITIS MENINGOCOCCEMIA MENINGOCOCC ADRENAL SYND MENINGOCOCC CARDITIS NOS MENINGOCOCC PERICARDITIS MENINGOCOCC ENDOCARDITIS MENINGOCOCC MYOCARDITIS

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ICD-9CMCode 036.81 036.82 036.89 036.9 037 038.0 038.10 038.11 038.12 038.19 038.2 038.3 038.40 038.41 038.42 038.43 038.44 038.49 038.8 038.9 039.0 039.1 039.2 039.3 039.4 039.8 039.9 040.0 040.1 040.2 040.3 040.81 040.82 040.89 041.00 041.01 041.02 041.03 041.04

Shortened Description MENINGOCOCC OPTIC NEURIT MENINGOCOCC ARTHROPATHY MENINGOCOCCAL INFECT NEC MENINGOCOCCAL INFECT NOS TETANUS STREPTOCOCCAL SEPTICEMIA STAPHYLCOCC SEPTICEM NOS METH SUSC STAPH AUR SEPT MRSA SEPTICEMIA STAPHYLCOCC SEPTICEM NEC PNEUMOCOCCAL SEPTICEMIA ANAEROBIC SEPTICEMIA GRAM-NEG SEPTICEMIA NOS H. INFLUENAE SEPTICEMIA E COLI SEPTICEMIA PSEUDOMONAS SEPTICEMIA SERRATIA SEPTICEMIA GRAM-NEG SEPTICEMIA NEC SEPTICEMIA NEC SEPTICEMIA NOS CUTANEOUS ACTINOMYCOSIS PULMONARY ACTINOMYCOSIS ABDOMINAL ACTINOMYCOSIS CERVICOFAC ACTINOMYCOSIS MADURA FOOT ACTINOMYCOSIS NEC ACTINOMYCOSIS NOS GAS GANGRENE RHINOSCLEROMA WHIPPLE'S DISEASE NECROBACILLOSIS TROPICAL PYOMYOSITIS TOXIC SHOCK SYNDROME BACTERIAL DISEASES NEC STREPTOCOCCUS UNSPECF STREPTOCOCCUS GROUP A STREPTOCOCCUS GROUP B STREPTOCOCCUS GROUP C ENTEROCOCCUS GROUP D

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ICD-9CMCode 041.05 041.09 041.10 041.11 041.12 041.19 041.2 041.3 041.4 041.5 041.6 041.7 041.81 041.82 041.83 041.84 041.85 041.86 041.89 041.9 051.2 073.0 073.7 073.8 073.9 076.0 076.1 076.9 078.2 078.3 078.4 078.6 078.88 079.88 079.98 082.40 082.41 082.49 082.8

Shortened Description STREPTOCOCCUS GROUP G OTHER STREPTOCOCCUS STAPHYLOCOCCUS UNSPCFIED MTH SUS STPH AUR ELS/NOS MRSA ELSEWHERE/NOS OTHER STAPHYLOCOCCUS PNEUMOCOCCUS INFECT NOS KLEBSIELLA PNEUMONIAE E. COLI INFECT NOS H. INFLUENZAE INFECT NOS PROTEUS INFECTION NOS PSEUDOMONAS INFECT NOS MYCOPLASMA BACTEROIDES FRAGILIS CLOSTRIDIUM PERFRINGENS OTHER ANAEROBES OTH GRAM NEGATV BACTERIA HELICOBACTER PYLORI OTH SPECF BACTERIA BACTERIAL INFECTION NOS CONTAGIOUS PUSTULAR DERM ORNITHOSIS PNEUMONIA ORNITHOSIS COMPLICAT NEC ORNITHOSIS COMPLICAT NOS ORNITHOSIS NOS TRACHOMA, INITIAL STAGE TRACHOMA, ACTIVE STAGE TRACHOMA NOS SWEATING FEVER CAT-SCRATCH DISEASE FOOT & MOUTH DISEASE HEM NEPHROSONEPHRITIS OTH SPEC DIS CHLAMYDIAE OTH SPCF CHLAMYDIAL INFC CHLAMYDIAL INFECTION NOS EHRLICHIOSIS NOS EHRLICHIOSIS CHAFEENSIS EHRLICHIOSIS NEC TICK-BORNE RICKETTS NEC

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ICD-9CMCode 082.9 083.2 083.8 083.9 088.0 088.81 090.0 090.1 090.2 090.3 090.40 090.41 090.42 090.49 090.5 090.6 090.7 090.9 091.0 091.1 091.2 091.3 091.4 091.50 091.51 091.52 091.61 091.62 091.69 091.7 091.81 091.82 091.89 091.9 092.0 092.9 093.0 093.1 093.20

Shortened Description TICK-BORNE RICKETTS NOS RICKETTSIALPOX RICKETTSIOSES NEC RICKETTSIOSIS NOS BARTONELLOSIS LYME DISEASE EARLY CONG SYPH SYMPTOM EARLY CONGEN SYPH LATENT EARLY CONGEN SYPH NOS SYPHILITIC KERATITIS JUVENILE NEUROSYPH NOS CONGEN SYPH ENCEPHALITIS CONGEN SYPH MENINGITIS JUVENILE NEUROSYPH NEC LATE CONGEN SYPH SYMPTOM LATE CONGEN SYPH LATENT LATE CONGEN SYPH NOS CONGENITAL SYPHILIS NOS PRIMARY GENITAL SYPHILIS PRIMARY ANAL SYPHILIS PRIMARY SYPHILIS NEC SECONDARY SYPH SKIN SYPHILITIC ADENOPATHY SYPHILITIC UVEITIS NOS SYPHILIT CHORIORETINITIS SYPHILITIC IRIDOCYCLITIS SYPHILITIC PERIOSTITIS SYPHILITIC HEPATITIS SECOND SYPH VISCERA NEC SECOND SYPHILIS RELAPSE ACUTE SYPHIL MENINGITIS SYPHILITIC ALOPECIA SECONDARY SYPHILIS NEC SECONDARY SYPHILIS NOS EARLY SYPH LATENT RELAPS EARLY SYPHIL LATENT NOS AORTIC ANEURYSM, SYPHIL SYPHILITIC AORTITIS SYPHIL ENDOCARDITIS NOS

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ICD-9CMCode 093.21 093.22 093.23 093.24 093.81 093.82 093.89 093.9 094.0 094.1 094.2 094.3 094.81 094.82 094.83 094.84 094.85 094.86 094.87 094.89 094.9 095.0 095.1 095.2 095.3 095.4 095.5 095.6 095.7 095.8 095.9 096 097.0 097.1 097.9 098.0 098.10 098.11 098.12

Shortened Description SYPHILITIC MITRAL VALVE SYPHILITIC AORTIC VALVE SYPHIL TRICUSPID VALVE SYPHIL PULMONARY VALVE SYPHILITIC PERICARDITIS SYPHILITIC MYOCARDITIS CARDIOVASCULAR SYPH NEC CARDIOVASCULAR SYPH NOS TABES DORSALIS GENERAL PARESIS SYPHILITIC MENINGITIS ASYMPTOMAT NEUROSYPHILIS SYPHILITIC ENCEPHALITIS SYPHILITIC PARKINSONISM SYPH DISSEM RETINITIS SYPHILITIC OPTIC ATROPHY SYPH RETROBULB NEURITIS SYPHIL ACOUSTIC NEURITIS SYPH RUPT CEREB ANEURYSM NEUROSYPHILIS NEC NEUROSYPHILIS NOS SYPHILITIC EPISCLERITIS SYPHILIS OF LUNG SYPHILITIC PERITONITIS SYPHILIS OF LIVER SYPHILIS OF KIDNEY SYPHILIS OF BONE SYPHILIS OF MUSCLE SYPHILIS OF TENDON/BURSA LATE SYMPT SYPHILIS NEC LATE SYMPT SYPHILIS NOS LATE SYPHILIS LATENT LATE SYPHILIS NOS LATENT SYPHILIS NOS SYPHILIS NOS ACUTE GC INFECT LOWER GU GC (ACUTE) UPPER GU NOS GC CYSTITIS (ACUTE) GC PROSTATITIS (ACUTE)

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ICD-9CMCode 098.13 098.14 098.15 098.16 098.17 098.19 098.2 098.30 098.31 098.32 098.33 098.34 098.35 098.36 098.37 098.39 098.40 098.41 098.42 098.43 098.49 098.50 098.51 098.52 098.53 098.59 098.6 098.7 098.81 098.82 098.83 098.84 098.85 098.86 098.89 099.0 099.1 099.2 099.3

Shortened Description GC ORCHITIS (ACUTE) GC SEM VESICULIT (ACUTE) GC CERVICITIS (ACUTE) GC ENDOMETRITIS (ACUTE) ACUTE GC SALPINGITIS GC (ACUTE) UPPER GU NEC CHR GC INFECT LOWER GU CHR GC UPPER GU NOS GC CYSTITIS, CHRONIC GC PROSTATITIS, CHRONIC GC ORCHITIS, CHRONIC GC SEM VESICULITIS, CHR GC CERVICITIS, CHRONIC GC ENDOMETRITIS, CHRONIC GC SALPINGITIS (CHRONIC) CHR GC UPPER GU NEC GONOCOCCAL CONJUNCTIVIT GONOCOCCAL IRIDOCYCLITIS GONOCOCCAL ENDOPHTHALMIA GONOCOCCAL KERATITIS GONOCOCCAL EYE NEC GONOCOCCAL ARTHRITIS GONOCOCCAL SYNOVITIS GONOCOCCAL BURSITIS GONOCOCCAL SPONDYLITIS GC INFECT T NEC GONOCOCCAL INFEC PHARYNX GC INFECT ANUS & RECTUM GONOCOCCAL KERATOSIS GONOCOCCAL MENINGITIS GONOCOCCAL PERICARDITIS GONOCOCCAL ENDOCARDITIS GONOCOCCAL HEART DIS NEC GONOCOCCAL PERITONITIS GONOCOCCAL INF SITE NEC CHANCROID LYMPHOGRANULOMA VENEREUM GRANULOMA INGUINALE REITER'S DISEASE

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ICD-9CMCode 099.40 099.41 099.49 099.50 099.51 099.52 099.53 099.54 099.55 099.56 099.59 099.8 099.9 100.0 100.81 100.89 100.9 101 102.0 102.1 102.2 102.3 102.4 102.5 102.6 102.7 102.8 102.9 103.0 103.1 103.2 103.3 103.9 104.0 104.8 104.9 130.0 130.1 130.2

Shortened Description UNSPCF NONGNCCL URETHRTS CHLMYD TRACHOMATIS URETH NONGC URTH OTH SPF ORGSM OTH VD CHLM TRCH UNSP ST OTH VD CHLM TRCH PHARYNX OTH VD CHLM TRCH ANS RCT OTH VD CHLM TRCH LOWR GU OTH VD CHLM TRCH OTH GU OT VD CHLM TRCH UNSPF GU OT VD CHLM TRCH PRTONEUM OTH VD CHLM TRCH SPCF ST VENEREAL DISEASE NEC VENEREAL DISEASE NOS LEPTOSPIROS ICTEROHEM LEPTOSPIRAL MENINGITIS LEPTOSPIRAL INFECT NEC LEPTOSPIROSIS NOS VINCENT'S ANGINA INITIAL LESIONS YAWS MULTIPLE PAPILLOMATA EARLY SKIN YAWS NEC HYPERKERATOSIS OF YAWS GUMMATA AND ULCERS, YAWS GANGOSA YAWS OF BONE & T YAWS MANIFESTATIONS NEC LATENT YAWS YAWS NOS PINTA PRIMARY LESIONS PINTA INTERMED LESIONS PINTA LATE LESIONS PINTA MIXED LESIONS PINTA NOS NONVENEREAL ENDEMIC SYPH SPIROCHETAL INFECT NEC SPIROCHETAL INFECT NOS TOXOPLASM MENINGOENCEPH TOXOPLASM CONJUNCTIVITIS TOXOPLASM CHORIORETINIT

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ICD-9CMCode 130.3 130.4 130.5 130.7 130.8 131.00 131.01 131.02 131.03 131.09 131.8 131.9 320.0 320.1 320.2 320.3 320.7 320.81 320.82 320.89 320.9 322.9 323.1 324.0 324.1 324.9 380.10 380.11 380.12 380.13 380.14 380.15 380.16 380.21 380.22 380.23 382.00 382.01 382.02

Shortened Description TOXOPLASMA MYOCARDITIS TOXOPLASMA PNEUMONITIS TOXOPLASMA HEPATITIS TOXOPLASMOSIS SITE NEC MULTISYSTEM TOXOPLASMOS UROGENITAL TRICHOMON NOS TRICHOMONAL VAGINITIS TRICHOMONAL URETHRITIS TRICHOMONAL PROSTATITIS UROGENITAL TRICHOMON NEC TRICHOMONIASIS NEC TRICHOMONIASIS NOS HEMOPHILUS MENINGITIS PNEUMOCOCCAL MENINGITIS STREPTOCOCCAL MENINGITIS STAPHYLOCOCC MENINGITIS MENING IN OTH BACT DIS ANAEROBIC MENINGITIS MNINGTS GRAM-NEG BCT NEC MENINGITIS OTH SPCF BACT BACTERIAL MENINGITIS NOS MENINGITIS NOS RICKETTSIAL ENCEPHALITIS INTRACRANIAL ABSCESS INTRASPINAL ABSCESS CNS ABSCESS NOS INFEC OTITIS EXTERNA NOS ACUTE INFECTION OF PINNA ACUTE SWIMMERS' EAR AC INFECT EXTERN EAR NEC MALIGNANT OTITIS EXTERNA CHR MYCOT OTITIS EXTERNA CHR INF OTIT EXTERNA NEC CHOLESTEATOMA EXTERN EAR ACUTE OTITIS EXTERNA NEC CHR OTITIS EXTERNA NEC AC SUPP OTITIS MEDIA NOS AC SUPP OM W DRUM RUPT AC SUPP OM IN OTH DIS

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ICD-9CMCode 382.1 382.2 421.0 421.1 421.9 422.0 422.90 422.91 422.92 422.93 422.99 462 463 464.00 464.01 464.10 464.11 464.20 464.21 464.30 464.31 464.50 464.51 475 476.0 476.1 481 482.0 482.1 482.2 482.30 482.31 482.32 482.39 482.40 482.41 482.42 482.49 482.81

Shortened Description CHR TUBOTYMPAN SUPPUR OM CHR ATTICOANTRAL SUP OM AC/SUBAC BACT ENDOCARD AC ENDOCARDIT IN OTH DIS AC/SUBAC ENDOCARDIT NOS AC MYOCARDIT IN OTH DIS ACUTE MYOCARDITIS NOS IDIOPATHIC MYOCARDITIS SEPTIC MYOCARDITIS TOXIC MYOCARDITIS ACUTE MYOCARDITIS NEC ACUTE PHARYNGITIS ACUTE TONSILLITIS AC LARYNGITIS W/O OBST AC LARYNGITIS W OBSTRUCT AC TRACHEITIS NO OBSTRUC AC TRACHEITIS W OBSTRUCT AC LARYNGOTRACH NO OBSTR AC LARYNGOTRACH W OBSTR AC EPIGLOTTITIS NO OBSTR AC EPIGLOTTITIS W OBSTR SUPRAGLOTTIS W/O OBS NOS SUPRAGLOTTIS W OBSTR NOS PERITONSILLAR ABSCESS CHRONIC LARYNGITIS CHR LARYNGOTRACHEITIS PNEUMOCOCCAL PNEUMONIA K. PNEUMONIAE PNEUMONIA PSEUDOMONAL PNEUMONIA H.INFLUENZAE PNEUMONIA STREPTOCOCCAL PNEUMN NOS PNEUMONIA STRPTOCOCCUS A PNEUMONIA STRPTOCOCCUS B PNEUMONIA OTH STREP STAPHYLOCOCCAL PNEU NOS METH SUS PNEUM D/T STAPH METH RES PNEU D/T STAPH STAPH PNEUMONIA NEC PNEUMONIA ANAEROBES

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ICD-9CMCode 482.82 482.83 482.84 482.89 482.9 483.0 483.1 483.8 484.1 484.3 484.5 484.6 484.7 484.8 485 486 487.0 487.1 487.8 490 491.0 491.1 491.20 491.21 491.22 491.8 491.9 510.0 510.9 513.0 513.1 540.0 540.1 540.9 541 542 562.01 562.11 562.13

Shortened Description PNEUMONIA E COLI PNEUMO OTH GRM-NEG BACT LEGIONNAIRES' DISEASE PNEUMONIA OTH SPCF BACT BACTERIAL PNEUMONIA NOS PNEU MYLSM PNEUMONIAE PNEUMONIA D/T CHLAMYDIA PNEUMON OTH SPEC ORGNSM PNEUM W CYTOMEG INCL DIS PNEUMONIA IN WHOOP COUGH PNEUMONIA IN ANTHRAX PNEUM IN ASPERGILLOSIS PNEUM IN OTH SYS MYCOSES PNEUM IN INFECT DIS NEC BRONCHOPNEUMONIA ORG NOS PNEUMONIA, ORGANISM NOS INFLUENZA WITH PNEUMONIA FLU W RESP MANIFEST NEC FLU W MANIFESTATION NEC BRONCHITIS NOS SIMPLE CHR BRONCHITIS MUCOPURUL CHR BRONCHITIS OBST CHR BRONC W/O EXAC OBS CHR BRONC W(AC) EXAC OBS CHR BRONC W AC BRONC CHRONIC BRONCHITIS NEC CHRONIC BRONCHITIS NOS EMPYEMA WITH FISTULA EMPYEMA W/O FISTULA ABSCESS OF LUNG ABSCESS OF MEDIASTINUM AC APPEND W PERITONITIS ABSCESS OF APPENDIX ACUTE APPENDICITIS NOS APPENDICITIS NOS OTHER APPENDICITIS DVRTCLI SML INT W/O HMRG DVRTCLI COLON W/O HMRHG DVRTCLI COLON W HMRHG

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ICD-9CMCode 566 567.21 567.22 567.23 567.29 567.31 567.38 567.39 567.81 567.82 567.89 567.9 569.5 569.61 575.0 590.00 590.01 590.10 590.11 590.2 590.3 590.80 590.81 590.9 595.0 599.0 601.0 601.1 601.2 601.3 601.4 601.8 601.9 614.0 614.1 614.2 614.3 614.4 614.5

Shortened Description ANAL & RECTAL ABSCESS PERITONITIS (ACUTE) GEN PERITONEAL ABSCESS SPONTAN BACT PERITONITIS SUPPURAT PERITONITIS NEC PSOAS MUSCLE ABSCESS RETROPERITON ABSCESS NEC RETROPERITON INFECT NEC CHOLEPERITONITIS SCLEROSING MESENTERITIS PERITONITIS NEC PERITONITIS NOS INTESTINAL ABSCESS COLOSTY/ENTEROST INFECTN ACUTE CHOLECYSTITIS CHR PYELONEPHRITIS NOS CHR PYELONEPH W MED NECR AC PYELONEPHRITIS NOS AC PYELONEPHR W MED NECR RENAL/PERIRENAL ABSCESS PYELOURETERITIS CYSTICA PYELONEPHRITIS NOS PYELONEPHRIT IN OTH DIS INFECTION OF KIDNEY NOS ACUTE CYSTITIS URIN TRACT INFECTION NOS ACUTE PROSTATITIS CHRONIC PROSTATITIS ABSCESS OF PROSTATE PROSTATOCYSTITIS PROSTATITIS IN OTH DIS PROSTATIC INFLAM DIS NEC PROSTATITIS NOS AC SALPINGO-OOPHORITIS CHR SALPINGO-OOPHORITIS SALPINGO-OOPHORITIS NOS ACUTE PARAMETRITIS CHRONIC PARAMETRITIS AC PELV PERITONITIS-FEM

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ICD-9CMCode 614.7 616.2 616.3 616.4 639.0 646.60 646.61 646.62 646.63 646.64 670.00 670.02 670.04 674.30 674.32 674.34 680.0 680.1 680.2 680.3 680.4 680.5 680.6 680.7 680.8 680.9 681.00 681.01 681.02 681.10 681.11 681.9 682.0 682.1 682.2 682.3 682.4 682.5 682.6

Shortened Description CHR PELV PERITON NEC-FEM BARTHOLIN'S GLAND CYST BARTHOLIN'S GLND ABSCESS ABSCESS OF VULVA NEC POSTABORTION GU INFECT GU INFECT IN PREG- UNSPEC GU INFECTION-DELIVERED GU INFECTION-DELIV W P/P GU INFECTION-ANTEPARTUM GU INFECTION-POSTPARTUM MAJ PUERP INF NOS-UNSP MAJ PUER INF NOS-DEL P/P MAJOR PUERP INF NOS-P/P OB SURG COMPL NEC-UNSPEC OB SURG COMPL-DEL W P/P OB SURG COMP NEC- POSTPAR CARBUNCLE OF FACE CARBUNCLE OF NECK CARBUNCLE OF TRUNK CARBUNCLE OF ARM CARBUNCLE OF HAND CARBUNCLE OF BUTTOCK CARBUNCLE OF LEG CARBUNCLE OF FOOT CARBUNCLE, SITE NEC CARBUNCLE NOS CELLULITIS, FINGER NOS FELON ONYCHIA OF FINGER CELLULITIS, TOE NOS ONYCHIA OF TOE CELLULITIS OF DIGIT NOS CELLULITIS OF FACE CELLULITIS OF NECK CELLULITIS OF TRUNK CELLULITIS OF ARM CELLULITIS OF HAND CELLULITIS OF BUTTOCK CELLULITIS OF LEG

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ICD-10 Code

ICD-9CMCode 682.7 682.8 682.9 683 684 685.0 685.1 686.00 686.01 686.09 686.1 686.8 686.9 711.90 711.91 711.92 711.93 711.94 711.95 711.96 711.97 711.98 711.99 730.00 730.01 730.02 730.03 730.04 730.05 730.06 730.07 730.08 730.09 730.10 730.11 730.12 730.13 730.14 730.15

Shortened Description CELLULITIS OF FOOT CELLULITIS, SITE NEC CELLULITIS NOS ACUTE LYMPHADENITIS IMPETIGO PILONIDAL CYST W ABSCESS PILONIDAL CYST W/O ABSC PYODERMA NOS PYODERMA GANGRENOSUM PYODERMA NEC PYOGENIC GRANULOMA LOCAL SKIN INFECTION NEC LOCAL SKIN INFECTION NOS INF ARTHRITIS NOS-UNSPEC INF ARTHRITIS NOS-SHLDER INF ARTHRITIS NOS-UP/ARM INF ARTHRIT NOS-FOREARM INF ARTHRIT NOS-HAND INF ARTHRIT NOS-PELVIS INF ARTHRIT NOS-L/LEG INF ARTHRIT NOS-ANKLE INF ARTHRIT NOS-OTH SITE INF ARTHRITIS NOS-MULT AC OSTEOMYELITIS-UNSPEC AC OSTEOMYELITIS-SHLDER AC OSTEOMYELITIS-UP/ARM AC OSTEOMYELITIS-FOREARM AC OSTEOMYELITIS-HAND AC OSTEOMYELITIS-PELVIS AC OSTEOMYELITIS-L/LEG AC OSTEOMYELITIS-ANKLE AC OSTEOMYELITIS NEC AC OSTEOMYELITIS-MULT CHR OSTEOMYELITIS-UNSP CHR OSTEOMYELIT-SHLDER CHR OSTEOMYELIT-UP/ARM CHR OSTEOMYELIT-FOREARM CHR OSTEOMYELIT-HAND CHR OSTEOMYELIT-PELVIS

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode 730.16 730.17 730.18 730.19 730.20 730.21 730.22 730.23 730.24 730.25 730.26 730.27 730.28 730.29 730.30 730.31 730.32 730.33 730.34 730.35 730.70 730.71 730.72 730.73 730.74 730.75 730.76 730.77 730.78 730.79 730.80 730.81 730.82 730.83 730.84 730.85 730.86 730.87 730.88

Shortened Description CHR OSTEOMYELIT-L/LEG CHR OSTEOMYELIT-ANKLE CHR OSTEOMYELIT NEC CHR OSTEOMYELIT-MULT OSTEOMYELITIS NOS-UNSPEC OSTEOMYELITIS NOS-SHLDER OSTEOMYELITIS NOS-UP/ARM OSTEOMYELIT NOS-FOREARM OSTEOMYELITIS NOS-HAND OSTEOMYELITIS NOS-PELVIS OSTEOMYELITIS NOS-L/LEG OSTEOMYELITIS NOS-ANKLE OSTEOMYELIT NOS-OTH SITE OSTEOMYELITIS NOS-MULT PERIOSTITIS-UNSPEC PERIOSTITIS-SHLDER PERIOSTITIS-UP/ARM PERIOSTITIS-FOREARM PERIOSTITIS-HAND PERIOSTITIS-PELVIS POLIO OSTEOPATHY-UNSPEC POLIO OSTEOPATHY-SHLDER POLIO OSTEOPATHY-UP/ARM POLIO OSTEOPATHY-FOREARM POLIO OSTEOPATHY-HAND POLIO OSTEOPATHY-PELVIS POLIO OSTEOPATHY-L/LEG POLIO OSTEOPATHY-ANKLE POLIO OSTEOPATHY NEC POLIO OSTEOPATHY-MULT BONE INFECT NEC-UNSPEC BONE INFECT NEC-SHLDER BONE INFECT NEC-UP/ARM BONE INFECT NEC-FOREARM BONE INFECT NEC-HAND BONE INFECT NEC-PELVIS BONE INFECT NEC-L/LEG BONE INFECT NEC-ANKLE BONE INFECT NEC-OTH SITE

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ICD-8 Code

ICD-9 Code

ICD-10 Code

ICD-9CMCode 730.89 730.90 730.91 730.92 730.93 730.94 730.95 730.96 730.97 730.98 730.99 785.52 790.7 996.60 996.61 996.62 996.63 996.64 996.65 996.66 996.67 996.68 996.69 997.31 998.51 998.59

Shortened Description BONE INFECT NEC-MULT BONE INFEC NOS-UNSP SITE BONE INFECT NOS-SHLDER BONE INFECT NOS-UP/ARM BONE INFECT NOS-FOREARM BONE INFECT NOS-HAND BONE INFECT NOS-PELVIS BONE INFECT NOS-L/LEG BONE INFECT NOS-ANKLE BONE INFECT NOS-OTH SITE BONE INFECT NOS-MULT SEPTIC SHOCK BACTEREMIA REACTION-UNSP DEVIC/GRFT REACT-CARDIAC DEV/GRAFT REACT-OTH VASC DEV/GRAFT REACT-NERV SYS DEV/GRAFT REACT-INDWELL URIN CATH REACT-OTH GENITOURIN DEV REACT-INTER T PROST REACT-OTH INT ORTHO DEV REACT- PERITON DIALY CATH REACT-INT PROS DEVIC NEC VENTLTR ASSOC PNEUMONIA INFECTED POSTOP SEROMA OTHER POSTOP INFECTION

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Venous Thromboembolism (VTE) Measure Set

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Measure Code

Measure Description

Venous Thromboembolism (VTE) Originally developed through a collaborative effort between The t Commission and the Centers for Medicare and Medicaid Services (CMS)

I-VTE-1

Patients who received VTE prophylaxis (or reasons of why this was not done) on the day of or day after hospital ission or surgery.
Note: This measure applies to medical and surgical cases that are not included in the SCIP measure population

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 ission 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 ission or transfer

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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 ission 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 ission 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 Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Medical/surgical units Measure Name: Venous Thromboembolism Prophylaxis

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

the day of or the day after hospital ission the day of or day after surgery end date for surgeries that start the day of or day after hospital ission

Denominator: All patients who are >=18 years. Domains of Performance ■ Appropriateness ■ Availability

QPS Standards QPS.3 – patient assessments

■ Continuity ■ Effectiveness

■ Timeliness

IPSG

■ AMI

■ Goal 1

■ HF

■ Goal 4

■ Stroke QPS.3 – surgical procedures

■ Prevention/Early Detection

CC

■ CKD ■ Diabetes

QPS.3 – antibiotic and other medication use

(Type I/II) ■ ESRD ■ t Replacement ■ Traumatic Brain Injury ■ HIV/AIDS ■ Cancer ■ Transplantation ■ COPD

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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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given:  

the day of or the day after hospital ission the day of or day after surgery end date for surgeries that start the day of or day after hospital ission

Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:     

Reason for No VTE Prophylaxis – Hospital ission Surgery end date Surgical procedure VTE Prophylaxis VTE Prophylaxis date

Denominator: All patients who are > = 18 years. Data elements:     

ission Date Birthdate ICD diagnosis code ICU ission date ICU ission/transfer

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Inclusions to the population: Not applicable Exclusions to the population:    

Patients less than 18 years of age Patients who are direct its to the intensive care unit (ICU) Patients with an ICD Principal diagnosis code of Mental disorders Patients with an ICD Principal or other diagnosis code of Obstetrics or VTE

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I-VTE-1 References

    

Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth AC Conference on antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh AC Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. 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. Caprini JA, Arcelus JI. State of the art venous thromboembolism prophylaxis. SCOPE on Phlebology & Lymphology 1:2005, 228-240. Michota FA. Venous thromboembolism prophylaxis in medical patients. Curr Opin Cardiol. 2004 Nov;19(6):570-4.

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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 ission 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 ission or transfer.

Overview/Details: ICU VTE prophylaxis given on the day of or the day after ICU hospital ission or surgery or a reason documented of why VTE prophylaxis was not given. See Appendix A. Rationale: The vast majority of patients itted 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. Measure Related Outcomes: Mortality: Decreased mortality Reissions within 30 days: Decreased Reliability: Increased delivery of evidence based care Improvement noted as: An increase in rate Patient Settings/Services: Intensive Care Units Measure Name: Intensive Care Unit Venous Thromboembolism Prophylaxis Numerator: Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given: 

the day of or the day after ICU ission (or transfer)

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

the day of or day after surgery end date for surgeries that start the day of or day after ICU ission (or transfer)

Denominator: Patients directly itted or transferred to ICU who are >= 18 years

Domains of Performance

QPS Standards

CC

IPSG

■ Appropriateness

QPS.3 – patient assessments

■ AMI

■ Goal 1

■ HF

■ Goal 4

■ Availability ■ Continuity ■ Effectiveness

■ Stroke QPS.3 – surgical procedures

■ Prevention/Early Detection ■ Timeliness

■ CKD ■ Diabetes (Type I/II)

QPS.3 – antibiotic and other medication use

■ ESRD ■ t Replacement ■ Traumatic Bain Injury ■ HIV/AIDS ■ Cancer ■ Transplantation ■ COPD

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I-VTE-2 Measure Details Reasons and Implications: The vast majority of patients itted 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. Data Collection: Retrospective data sources for the required data elements include istrative data and medical records. Numerator: Patients who received VTE prophylaxis or have documentation of why no VTE prophylaxis was given:  

the day of or the day after ICU ission (or transfer) the day of or day after surgery end date for surgeries that start the day of or day after ICU ission (or transfer)

Inclusions to the population: Not Applicable Exclusions to the population: None Data elements:      

Anesthesia start date ICU VTE Prophylaxis ICU VTE Prophylaxis date Reason for No VTE Prophylaxis – ICU ission Surgery end date – ICU it or transfer Surgical procedure- ICU it or transfer

Denominator: All patients who are > = to 18 years. Data elements:      

ission Date Birthdate ICD diagnosis code ICU discharge date ICU ission date ICU ission or Transfer

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Inclusions to the population: Not applicable Exclusions to the population:  

Patients less than 18 years of age Patients with an ICD Principal or other diagnosis code of Obstetrics or VTE

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I-VTE-2 References    

Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of venous thromboembolism. The Eighth AC Conference on antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the Seventh AC Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004 Sep;126(3 Suppl):338S-400S. 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. Geerts WH, Selby R. Prevention of venous thromboembolism in the ICU. Chest. 2003 Dec;124(6 Suppl):357S-363S.

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Appendix A VTE Prophylaxis Inclusion Table Table 2.1 VTE Prophylaxis Inclusion Table VTE Prophylaxis

Inclusion/Synonyms

Coumadin/ Warfarin

Coumadin Jantoven Warfarin Warfarin Sodium Anti-Embolism stockings Anti-thrombosis stockings Elastic hose Graduated compression elastic stockings Jobst stockings Surgical hose TED hose (TEDs) White hose Thrombosis stockings Arixtra Fonda-parinux sodium

Graduated Compression Stockings (GCS) - Knee or thigh high

Factor Xa Inhibitor Oral Factor Xa Inhibitor Low Dose Unfractionated Heparin (LDUH) - Include only Heparin given by the subcutaneous (SQ, Subcu, SC, SubQ) route

Rivaroxaban (Oral) Calciparine Calcilean HEP Hepalean Heparin Heparin Calcium Heparin Leo Heparin Na Heparin Sod Heparin Sodium Heparin Sodium Inj. Heparin Sodium Inj. Pork Heparin Subcu/SQ/SC/SubQ Liquaemin

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Table 2.1 VTE Prophylaxis Inclusion Table VTE Prophylaxis

Inclusion/Synonyms

Low Molecular Weight Heparin (LMWH)

Ardeparin Dalteparin Danaparoid Enoxaparin Fragmin Innohep Lovenox Normiflo Orgaran Tinzaparin AE pumps (anti-embolic pumps)-calf/thigh Alternating Leg Pressure (ALP) Athrombic pumps-calf/thigh Continuous Enhanced Circulation Therapy (CECT) DVT boots-calf/thigh EPC cuffs/ stockings-External pneumatic compressioncalf/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

Intermittent Pneumatic Compression Device (IPC)

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Table 2.1 VTE Prophylaxis Inclusion Table VTE Prophylaxis

Inclusion/Synonyms 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 Inclusion/Synonyms VTE Prophylaxis Direct Thrombin Inhibitors

Argatroban (Acova)

- argatroban - bivalirudin - lepirudin

Bivalirudin (Angiomax)

Factor Xa Inhibitor

Arixtra

Lepirudin (recombinant hirudin)(Refludan)

Fondaparinux sodium Unfractionated Heparin (UFH) - intravenous (IV) - subcutaneous (fixed dose or monitored)

Calciparine Calcilean HEP Hepalean

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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 Heparin (LMWH)

Ardeparin Dalteparin Danaparoid Enoxaparin Fragmin Innohep Lovenox Normiflo Orgaran Tinzaparin

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Appendix B ICD Codes VTE 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 7.03 VTE ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM Code

Shortened Description

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

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Table 7.04 VTE Obstetrics ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM Code

Shortened Description

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

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM Code

Shortened Description

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

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Glossary

© 2011 t Commission International 243

Glossary A Accreditation Determination by t 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 Acute Myocardial Infarction (AMI) 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. istrative/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.) (CC)

Ambulatory care © 2011 t Commission International 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 The degree to which the care provided is relevant to the patient’s clinical needs, given 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 attempted to minimize the impact of the fall by easing the patient’s descent to the floor or in some manner attempting to break the patient’s fall. “Assisting” the 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 patient’s needs 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 practices, also sometimes referred to as ―good practice‖ or ―better practice,‖ are typically evidence based and consensus driven. (JCI) Cardiac Module A set of evidence-based process measures designed to prevent cardiac complications in surgical patients.

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Certification 1.

2.

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). (CC) 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 t 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. (CC) 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. Children’s Asthma Care (CAC) 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 (CC) An interdisciplinary, continuum-based approach to health care delivery that prevents, minimizes, or delays exacerbations or complications of an illness or condition by  ing the participant’s self-management activities  ing 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  Tailoring treatments and interventions to the participant’s need © 2011 t Commission International 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 ission 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 ed by consistent and low-risk processes and systems, thus placing patients at risk. Contraindication A factor or condition that may render the istration 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 © 2011 t Commission International 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. Also called ―data gathering.‖ Data Collection Effort The availability and accessibility of the required data elements, the effort required to abstract or collect data. Data Element A discrete piece of data, such as patient’s date of birth or principal diagnosis. 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 istrative 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. (CC) 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. © 2011 t Commission International 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 Attributes of organization performance that are related to organizations ―doing the right things‖ (such as appropriateness, availability, and efficacy) and ―doing things well‖ (such as, continuity, effectiveness, efficiency, respect and caring, safety, and timeliness). Performance domains are definable, measurable and improvable. “Do not use” list A written catalog of abbreviations, acronyms, and symbols that are not to be used throughout an organization—whether handwritten or entered as free text into a computer—due 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, stenting) involving the carotid artery, performed due to the patient’s choice.

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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. (CC) 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 might be ―monitoring patient response‖ or ―urinary catheter usage‖. 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. Common HAI’s are urinary infections, surgical wound infections, 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)

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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.) (CC) 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 ission 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 Health Organization’s list of disease codes. The second part 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 © 2011 t Commission International 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 The five areas of ―risk‖ on which to focus initial quality and safety improvement efforts. 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 ability 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 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 a comprehensive understanding or assessment of a unit’s department’s, or organization’s performance. (CC) 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).

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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 ission 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 The observed rate is the indicator rate that is based on the hospital’s aggregate data for 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, outpatient care is also known as ―ambulatory care.‖ In some countries, outpatients are © 2011 t Commission International 253

considered ―itted‖ to a health care organization in others, outpatient are considered ―ed.‖ (JCI) 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 Care throughout a patient’s experience should be coordinated, and grounded in respectful interactions with care providers that is consistent with the patient’s values, expectations and care decisions. Patient Days Conceptually, a patient day is 24 hours, beginning the hour of ission 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 patient’s/participant’s perspective, including, but not limited 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. (CC) Performance measure A quantitative tool (for example, rate, ratio, index, percentage) that provides an indication of an organization’s performance in relation to a specified process or outcome. Performance measurement The use of quantitative tools (for example rates, ratios, indices, percentages) to provide an indication of an organization’s performance in relation to a specified process or outcome. (CC) Perinatal Care (PC) The care and management of the fetus and newborn infant in the perinatal period, before, during and after delivery. © 2011 t Commission International 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. Prevention/Early Detection 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. (CC) © 2011 t Commission International 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 s 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 the patient’s needs, expectations, and individual differences. 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 © 2011 t Commission International 256

sampling. Refer to the ―Sampling Approaches‖ discussion in the Population and 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. (CC) 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). (CC)

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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. Surgical Care Improvement Project (SCIP) 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). (CC) Systemic Corticosteroids Corticosteroids are hormones produced by the adrenal cortex or their synthetic equivalents and are istered 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 An explanation of the performance indicator’s format as to its structure, process, or outcome. Unable to Determine (UTD) Each data element that is applicable per the algorithm for each of the measures within a measure set must be ―touched‖ by the abstractor. While there is an expectation that all 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 © 2011 t Commission International 258

determines that a value is not documented or is not able to determine the answer value, the abstractor must select ―Unable to Determine (UTD)‖ as the answer. Vaccine A vaccine is a suspension of an attenuated (weakened) or killed microorganism, such as bacteria or virus, istered 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) Venous Thromboembolism (VTE) A term that includes deep vein thrombosis and/or pulmonary embolism.

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Babbie, ER, The Practice of Social Research, 2nd edition, Belmont, CA: Wadsworth Publishing Company, 1979. Disease-Specific Care Certification Manual, 2nd Edition. t Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. 2005. Everitt, BS, The Cambridge Dictionary of Statistics, Cambridge University Press, 1998. t Commission International Accreditation Standards for Hospitals, 4th Edition, t Commission International, Aokbrook Terrace, Il 2010. Iezonni, LI, Foley, SM, Heeran, T, Daley, J, Duncan, CC, Fisher, ES, Hughes, J, ―A Method for Screening the Quality of Hospital Care Using istrative Data: Preliminary Validation Results,‖ Quality Review Bulletin, November, 1992, 361370. Lexikon Second Edition, Oakbrook Terrace, IL: t Commission on Accreditation of Healthcare Organizations, 1998. McHorney, CA, Kosinski, M, and Ware, Jr., JE, ―Comparisons of the Cost and Quality of Norms for the SF-36 Health Survey Collected by Mail Versus Telephone Interview: Results From a National Survey,‖ Medical Care, 32, (1994), 551-567. Mosby’s Dictionary of Medicine, Nursing & Health Professions, 7th Edition. Mosby Elsevier, St. Louis, MO. 2006. Nichols, T and Earl, L, Basic ICD-9-CM Coding Handbook, Chicago, IL: American Health Information Management Association, 1992. ORYX® Technical Implementation Guide, The t Commission, Oakbrook Terrace, Illinois, current. 2009 Comprehensive Accreditation Manual for Hospitals; The t Commission, Oakbrook Terrace, Illinois, 2008. Taber’s Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA. 1997.

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