JCI International Library of Measures
JCI International Library of Measures
International Library of
Measures
Pre-Publication Copy
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1
Foreword
Joint Commission International (JCI) is very pleased to present this first edition of the Joint
Commission International Library of Measures. The Library is an organized, descriptive
catalogue of 36 selected measures designed to assist health care organizations in choosing a
specific set of measures based on the needs of their populations. The Library will begin to
standardize measurement among organizations by standardizing the measures that are
collected and the details of how they are collected.
Measures provide healthcare professionals and organizations with valuable information about
their performance. Organizations can use this information to make comparisons with other
organizations or with themselves over time. Comparison helps organizations see where they
may be falling short and when processes may be breaking down; thus helping to facilitate
improved performance.
Accreditation programs around the world are moving toward more objective measurements of
quality and patient safety. Over time, the on-site evaluation process will be adjusted to reflect
priority evaluation issues gleaned from measurement data. Accreditation becomes continuous
when a flow of objective data comes to JCI between on-site evaluations. All of this requires
reduction in the variations between organizations in terms of what they collect and how they
collect it. The JCI International Library of Measures is a first step in a multi-year effort to bring
JCI accreditation to the next level. This first edition of the Library reaffirms JCIs mission to
improve the quality and safety of patient care around the world.
2
International Library of Measures
The 4th Edition International Standards for Hospitals (Effective 1 January 2011) require organizations to
select five (5) individual clinical measures from the JCI International Library of Measures (see QPS.3.1).
In addition, the Clinical Care Program Certification requirements include the need for programs to
choose at least two (2) of their four (4) measures from the JCI International Library of Measures. There
are a total of ten (10) measures sets, each containing from two (2) to eight (8) individual measures.
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Aspirin received within 24 hours of arrival to the hospital for patients having an acute
I-AMI-1 myocardial infarction (AMI).
I-AMI-2 Aspirin prescribed at discharge for patients who had an acute myocardial infarction.
I-AMI-9 Acute myocardial infarction (AMI) patients who expire during the hospital stay
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival, during hospitalization, or is
I-HF-2 planned for after discharge
3
Measure Measure Description
Code
ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)
I-HF-3 for heart failure patients who have LVSD (Left Ventricular Systolic Dysfunction)
Stroke (STK)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
I-STK-8 Stroke patients who were given stroke education during their hospital stay
I-STK-10 Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services
I-CAC-2 Pediatric asthma patients who received systemic corticosteroids during hospitalization
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Psychiatric patients who were placed in physical restraints during their inpatient
hospitalization. This measure will determine the total number of hours that patients
were maintained in physical restraints for those admitted to a hospital-based inpatient
I-HBIPS-2 psychiatric setting
Psychiatric patients who were placed in seclusion during their inpatient hospitalization.
This measure will determine the total number of hours that all patients were
maintained in seclusion for those admitted to a hospital-based inpatient psychiatric
I-HBIPS-3 setting.
4
Measure Measure Description
Code
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39
I-PC-01 weeks of gestation completed
I-PC-05 Exclusive breast milk feeding during the newborn's entire hospitalization
Pneumonia (PN)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Pneumonia patients, aged 65 and older, who were screened for pneumococcal vaccine
I-PN-2 status and were administered the vaccine prior to discharge, if indicated
Adult smoking cessation advice/counseling given to patients who smoke cigarettes and
I-PN-4 who are hospitalized for pneumonia
5
Measure Measure Description
Code
Pneumonia patients, aged 50 and older, who during the flu season, were screened for
I-PN-7 influenza vaccine status and were vaccinated prior to discharge, if indicated
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Prophylactic antibiotics received one hour prior to surgical incision for hip arthroplasty
I-SCIP-Inf-1d patients
Prophylactic antibiotics received one hour prior to surgical incision for knee
I-SCIP-Inf-1e arthroplasty patients
6
Measure Measure Description
Code
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Patients who received VTE prophylaxis (or reasons of why this was not done) on the
day of or day after hospital admission or surgery.<BR>Note: This measure applies to
I-VTE-1 medical and surgical cases that are not included in the SCIP measure population
ICU patients who received VTE prophylaxis (or reasons of why this was not done) on
the day of or day after hospital admission or surgery.<BR>Note: This measure applies
to all ICU cases except those included in the SCIP measure population (knee/hip
I-VTE-2 arthroplasty) who had surgery on the day of or the day after ICU admission or transfer
7
Acute Myocardial
Infarction (AMI)
Measure Set
8
Measure Measure Description
Code
Acute Myocardial Infarction (AMI)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Aspirin received within 24 hours of arrival to the hospital for patients having an acute
I-AMI-1 myocardial infarction (AMI).
I-AMI-2 Aspirin prescribed at discharge for patients who had an acute myocardial infarction.
I-AMI-9 Acute myocardial infarction (AMI) patients who expire during the hospital stay
9
I-AMI 1
Aspirin on Arrival
Measure Overview
I-AMI 1 Aspirin received within 24 hours of arrival to the hospital for patients
having an acute myocardial infarction.
Overview/Details:
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
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
10
I-AMI 1
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who received aspirin within 24 hours before or after hospital
arrival
Data elements:
Aspirin received within 24 hours before or after hospital arrival
Data elements:
Admission 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
11
I-AMI-1
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/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
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
nonST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
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.
12
I-AMI 2
Aspirin Prescribed at Discharge
Measure Overview
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
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
13
I-AMI 2
Measure Details
Reasons and Implications: Studies have demonstrated that aspirin reduces the risk
of adverse events and mortality by 20%. Clinical guidelines strongly recommend long-
term aspirin for the secondary prevention of subsequent cardiovascular events in
eligible patients discharged after AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Aspirin Prescribed at Discharge
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
14
I-AMI 2
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/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
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
NonST-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.
15
I-AMI 3
ACEI or ARB for LVSD
Measure Overview
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
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
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 supported the inclusion of ARBs in performance measures for
AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge
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
17
I-AMI 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/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
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
NonST-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.
18
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.
19
I-AMI 4
Adult Smoking Counseling
Measure Overview
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
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
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
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 administrative data
and medical records.
Numerator: AMI patients (cigarette smokers) who receive smoking cessation advice or
counseling during the hospital stay
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
21
I-AMI 4
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/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
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, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. May 2008.
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
NonST-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.
22
I-AMI 5
Beta Blocker Prescribed at Discharge
Measure Overview
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
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
23
I-AMI - 5
Measure Details
Reasons and Implications: Studies have demonstrated that the use of beta-blockers
is associated with a 20% reduction in risk and there is evidence of effectiveness in
broad populations of patients. Clinical guidelines strongly recommend long-term beta-
blocker therapy for the secondary prevention of subsequent cardiovascular events in
patients discharged after AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Beta-Blocker Prescribed at Discharge
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
24
I-AMI 5
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/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
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
NonST-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.
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
26
I-AMI 9
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Discharge status
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
Note: This measure population does not include deaths that occurred in the
emergency department
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 nonST-
elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and 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 nellInfarto Miocardico (GISSI-2). N Engl J
Med. 1993;329:1442-1448.
28
Appendix A
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries, ICD-8,
ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in the specific
code utilized by your country to correspond to the ICD-9-CM code description for the
following diagnoses.
Table 1.1 AMI
Acute Myocardial Infarction Codes
ICD-8 ICD-9 ICD-10 ICD-9-CM Shortened Description
Code Code Code Code
410.00 AMI ANTEROLATERAL,UNSPEC
410.01 AMI ANTEROLATERAL, INIT
410.10 AMI ANTERIOR WALL,UNSPEC
410.11 AMI ANTERIOR WALL, INIT
410.20 AMI INFEROLATERAL,UNSPEC
410.21 AMI INFEROLATERAL, INIT
410.30 AMI INFEROPOST, UNSPEC
410.31 AMI INFEROPOST, INITIAL
410.40 AMI INFERIOR WALL,UNSPEC
410.41 AMI INFERIOR WALL, INIT
410.50 AMI LATERAL NEC, UNSPEC
410.51 AMI LATERAL NEC, INITIAL
410.60 TRUE POST INFARCT,UNSPEC
410.61 TRUE POST INFARCT, INIT
410.70 SUBENDO INFARCT, UNSPEC
410.71 SUBENDO INFARCT, INITIAL
410.80 AMI NEC, UNSPECIFIED
410.81 AMI NEC, INITIAL
410.90 AMI NOS, UNSPECIFIED
410.91 AMI NOS, INITIAL
29
Heart Failure (HF)
Measure Set
30
Measure Measure Description
Code
Heart Failure (HF)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)
Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival, during hospitalization, or is
I-HF-2 planned for after discharge
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:
Rationale:
Outcomes:
Patient Settings/Services
Medical/Surgical units
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
32
Domains of Performance QPS Standards CCPC IPSG
Timeliness
33
I-HF-2
Measure Details
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 administrative 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
Data elements:
LVF Assessment
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
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;46:114478. 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.
35
I-HF-3
ACEI or ARB for LVSD
Measure Overview
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:
Medical/Surgical units
Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital
discharge
Denominator: Heart failure patients with LVSD who are >= 18 years
36
Domains of Performance QPS Standards CCPC IPSG
37
I-HF-3
Measure Details
Reasons and Implications: Clinical guidelines strongly recommend ACEI for patients
hospitalized with heart failure and left ventricular systolic dysfunction. Guideline
committees have also supported the inclusion of ARBs in performance measures for
heart failure.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital
discharge
Data elements:
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
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
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/nonST-
elevation myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation
Myocardial Infarction): developed in collaboration with the American College of Emergency
Physicians, American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of Thoracic
Surgeons. J Am Coll Cardiol. 2007;50:e1157.
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 nonST-elevation
myocardial infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Performance Measures (Writing Committee to Develop
Performance Measures for ST-Elevation and NonST-Elevation Myocardial Infarction).J
Am Coll Cardiol.2008;52:204699.
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.
40
I-HF-4
Adult Smoking Counseling
Measure Overview
Overview/Details:
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:
Patient Settings/Services
Medical/Surgical units
Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Denominator: Heart failure patients with a history of smoking cigarettes anytime during
the year prior to hospital arrival and who are >= 18 years.
41
Domains of Performance QPS Standards CCPC IPSG
Effectiveness Asthma
Cancer
COPD
Diabetes
42
I-HF-4
Measure Details
Reasons and Implications: Smoking cessation reduces mortality and morbidity in all
populations. Patients who receive even brief smoking-cessation advice from their health
care providers are more likely to quit. Clinical guidelines strongly recommend smoking
cessation counseling for cigarette smokers with cardiovascular disease, including heart
failure.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Data elements:
Denominator: Heart failure patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival and who are >= 18 years
Data elements:
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
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;46:114478. Available
at http://www.acc.org and http://www.americanheart.org.
Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. May 2008.
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.
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
45
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
Table 2.2
Left Ventricular Assistive Device (LVAD) and Heart Transplant
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
33.6 COMB HEART/LUNG TRANSPLA
46
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
37.66 IMPLANTABLE HRT ASSIST
47
Stroke (STK)
Measure Set
48
Measure
Code Measure Description
Stroke (STK)
Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)
Patients with ischemic stroke prescribed antithrombotic therapy at
I-STK-2 discharge
Patients with atrial fibrillation/flutter receiving anticoagulation
I-STK-3 therapy
Stroke patients who were given stroke education during their
I-STK-8 hospital stay
Ischemic or hemorrhagic stroke patients who were assessed for
I-STK-10 rehabilitation services
49
I-STK-2
Discharged on Antithrombotic Therapy
Measure Overview
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.
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
50
I-STK-2
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative
data and medical records.
Data elements:
Antithrombotic therapy prescribed at discharge
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
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 Joint Stroke Guideline Development Committee of
the American Academy of Neurology and the American Stroke Association (a Division
of the American Heart Association) Stroke. 2002;33:1934 -1942.
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.
52
I-STK-3
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Measure Overview
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.
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
53
I-STK-3
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Anticoagulation therapy prescribed at discharge
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.
54
I- STK-3
References
55
I-STK-8 Stroke Education
Measure Overview
I-STK 8 Stroke patients who were given stroke education during their hospital
stay
Overview/Details:
Patients with ischemic stroke or hemorrhagic stroke who are given educational
materials on all of the following; activation of emergency medical system, need for
follow-up after discharge, medications prescribed at discharge, risk factors for stroke,
and warning signs and symptoms of stroke.
Rationale:
Clinical practice guidelines include recommendations for patient and family education
during hospitalization as well as information about resources for social support services.
Some clinical trials have shown measurable benefits in patient and caregiver outcomes
with the application of education and support strategies. The type of stroke experienced
and the resulting outcomes will play a large role in determining not only the course of
treatment but also what education will be required.
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
56
Domains of Performance QPS Standards CCPC IPSG
Appropriateness QPS.3 clinical assessments Stroke
Continuity
Effectiveness
Prevention/Early
Detection
57
I-STK-8
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
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
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.
59
I-STK-8
References
60
I-STK-10 Assessed for Rehabilitation
Measure Overview
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
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Denominator: Ischemic stroke or hemorrhagic stroke patients who are >= 18 years.
61
Domains of Performance QPS Standards CCPC IPSG
Appropriateness QPS.3 patient assessments Stroke Goal 1
Availability
Continuity
Effectiveness
Prevention/Early Detection
Timeliness
62
I-STK-10
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
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.
63
STK-10
References
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 ICD-9- Shortened Description
CM
Code Code Code
Code
65
Table 8.2
Hemorrhagic Stroke (STK)
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CM
Code
430 SUBARACHNOID HEMORRHAGE
431 INTRACEREBRAL HEMORRHAGE
66
Childrens Asthma
Care (CAC)
Measure Set
67
Measure
Code Measure Description
68
I-CAC-1
Relievers for Childrens Inpatient Asthma
Measure Overview
Overview/Details:
Rationale:
Asthma is the most common chronic disease in children and a major cause of morbidity
and increased health care expenditures. For children, asthma is one of the most
frequent reasons for admission to hospitals. Under-treatment and/or inappropriate
treatment of asthma are recognized as major contributors to asthma morbidity and
mortality. Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of relievers to gain control of acute asthma exacerbation and
reduce severity as quickly as possible, with step down medication to the least
medication necessary to maintain control.
Pediatric units
Medical/Surgical units (serving pediatric patients)
Free-standing Pediatric hospitals
Measure Name: Relievers for Childrens 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
69
Domains of Performance QPS Standards CCPC IPSG
Continuity
QPS.3 antibiotic and other
Effectiveness medication use
Prevention/Early Detection
Timeliness
70
I-CAC-1
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Relievers Administered
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 Administering Relievers
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, Elixhauser A, Thompson J and Simpson L (2000). Annual
Report on Access to and Utilization of Health Care for Children and Youth in the
United States 1999. Pediatrics, 105:1, 219-230.
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
72
I-CAC-2
Systemic Corticosteroids for Children Inpatient Asthma
Measure Overview
Rationale:
Asthma is the most common chronic disease in children and a major cause of morbidity
and increased health care expenditures nationally. For children, asthma is one of the
most frequent reasons for admission to hospitals. Under-treatment and/or inappropriate
treatment of asthma are recognized as major contributors to asthma morbidity and
mortality. Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of systemic corticosteroids to gain control of acute asthma
exacerbation and reduce severity as quickly as possible, with step down medication to
the least medication necessary to maintain control.
Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were
discharged with a principal diagnosis of asthma
73
Domains of Performance QPS Standards CCPC IPSG
Continuity
QPS.3 antibiotic and
Effectiveness other medication use
Prevention/Early Detection
Timeliness
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 administrative data
and medical records.
Numerator: Pediatric asthma inpatients who received systemic corticosteroids during
hospitalization.
Inclusions to the population: Patients who were administered systemic corticosteroids
during this hospitalization.
Exclusions to the population: None
Data elements:
Systemic Corticosteroids Administered
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 Administering Systemic Corticosteroids
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, Elixhauser A, Thompson J and Simpson L (2000). Annual
Report on Access to and Utilization of Health Care for Children and Youth in the
United States 1999. Pediatrics, 105:1, 219-230.
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
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
77
Hospital Based
Inpatient Psychiatric
Services (HBIPS)
Measure Sets
78
Measure
Code Measure Description
79
I-HBIPS-2
Hours of physical restraint use
Measure Overview
Overview/Details:
Patients who are placed in physical restraint while admitted to a hospital-based inpatient
psychiatric setting.
Rationale:
The use of seclusion and restraint is limited to situations that may present imminent
danger to either the patient and/or staff. The use of restraint is rigorously monitored and
analyzed to prevent future restraint use and to prevent harm.
Patient Settings/Services
Psychiatric units
Numerator: The total number of hours that all psychiatric inpatients were maintained in
physical restraints.
80
Domains of Performance QPS Standards CCPC IPSG
Appropriateness Goal 2
Prevention/Early Detection
Safety
81
I-HBIPS-2
Measure Details
Reasons and Implications: The use of restraint is limited to situations that may present
imminent danger to either the patient and/or staff. The use of restraint is rigorously
monitored and analyzed to prevent future restraint use and to prevent harm. Providers also
seek to prevent violence or aggression from occurring in their treatment environments by
focusing their attention on prevention activities that have a growing evidence base.
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Numerator: The total number of hours that all psychiatric inpatients were maintained in
physical restraints.
Inclusions to the population: Patients for whom at least one physical restraint event is
reported during the month.
Data elements:
Event Date
Event Type
Minutes of Physical Restraint
Data elements:
Admission Date
Birthdate
Psychiatric Care Setting
Psychiatric Inpatient days
82
I-HBIPS-2
References
83
I-HBIPS-3
Hours of seclusion use
Measure Overview
NOTE: This measure will determine the total number of hours that all patients were
maintained in seclusion for those admitted to a hospital-based inpatient psychiatric
setting.
Overview/Details:
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.
Patient Settings/Services
Psychiatric units
Numerator: The total number of hours that all psychiatric inpatients were held in
seclusion.
84
Domains of Performance QPS Standards CCPC IPSG
Prevention/Early Detection
Safety
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
administrative 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.
Data elements:
Event Date
Event Type
Minutes of Seclusion
Data elements:
Admission Date
Birthdate
Psychiatric Care Setting
Psychiatric Inpatient days
86
I-HBIPS-3
References
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 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
88
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
89
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
295.10 HEBEPHRENIA-UNSPEC
295.11 HEBEPHRENIA-SUBCHRONIC
295.12 HEBEPHRENIA-CHRONIC
295.13 HEBEPHREN-SUBCHR/EXACERB
295.14 HEBEPHRENIA-CHR/EXACERB
90
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
295.15 HEBEPHRENIA-REMISSION
295.20 CATATONIA-UNSPEC
295.21 CATATONIA-SUBCHRONIC
295.22 CATATONIA-CHRONIC
295.23 CATATONIA-SUBCHR/EXACERB
295.24 CATATONIA-CHR/EXACERB
295.25 CATATONIA-REMISSION
91
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
92
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
93
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
94
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
297.2 PARAPHRENIA
95
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
96
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
300.5 NEURASTHENIA
300.7 HYPOCHONDRIASIS
97
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
302.1 ZOOPHILIA
302.2 PEDOPHILIA
98
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
302.4 EXHIBITIONISM
302.81 FETISHISM
302.82 VOYEURISM
99
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
307.0 STUTTERING
100
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
307.52 PICA
307.6 ENURESIS
307.7 ENCOPRESIS
101
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
102
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
312.32 KLEPTOMANIA
312.33 PYROMANIA
103
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
104
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CMCode
Code Code Code
315.01 ALEXIA
105
Nursing Sensitive
Care (NSC)
Measure Set
106
Measure
Code Measure Description
107
I-NSC-2
Pressure Ulcer Prevalence (Hospital-Acquired)
Measure Overview
Overview/Details:
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.
108
Patient Settings/Services:
Medical/surgical units
Intensive Care units/Critical care units
Measure Name: Pressure Ulcer Prevalence (Hospital-Acquired)
Denominator: All patients surveyed for the study who are > = 18 years.
Effectiveness CKD
QPS.3 infection,
Prevention/Early Detection prevention and Diabetes (Type I/II)
HIV/AIDS
Cancer
COPD
109
I-NSC-2
Measure Details
Data Collection:
Data elements:
110
Denominator: All patients surveyed for the study who are > = 18 years.
Data elements:
Admission Date
Birthdate
Sex
Type of unit
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
Panel.National Pressure Ulcer Advisory Panel'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 patients 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, 70-
76.
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel. Prevention and treatment of pressure ulcers: quick reference guide.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.
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), 345-
353.
112
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 (AHCPR, 1992). URL:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409
Adults: Prediction and Prevention. Clinical Practice
Guideline Number 3. AHCPR 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):151-
68.
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 Panel. (2005). Coming to consensus on deep tissue injury. Advances in
Skin & Wound Care, 18(1), 28-29.
113
I-NSC-4
Patient Falls
Measure Overview
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.
Medical/surgical units
Intensive Care units/Critical care units
Measure Name: Patient Falls
114
Domains of QPS CCPC IPSG
Performance
Standards
Effectiveness CKD
HIV/AIDS
Cancer
COPD
115
I-NSC-4
Measure Details
Reasons and Implications: Patient falls occurring during hospitalization can result in
serious and even potentially life threatening consequences for many patients. Efforts to
reduce this adverse event have included the development of tools to assess and identify
patients at risk of falling and the implementation of fall prevention protocols. More
recently, research has suggested that staffing on patient care units, specifically the
number of professional nurses, may impact the incidence of this patient outcome.
Nurses are responsible for identifying patients who are at risk for falls and for developing
a plan of care to minimize that risk. High performance measure rates may suggest the
need to examine clinical and organizational processes related to the identification of, and
care for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Total number of patient falls (with or without injury to the (patient) during the
calendar month.
Data elements:
Month
Number of Injury Falls
Type of Unit
Year
116
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
117
I-NSC-4
References
118
I-NSC-5
Patient Falls with Injury
Measure Overview
I-NSC 5 All documented falls by a patient with an injury level of minor (2) or
greater.
Overview/Details:
119
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.
Effectiveness CKD
HIV/AIDS
Cancer
COPD
120
I-NSC-5
Measure Details
Reasons and Implications: Patient falls occurring during hospitalization can result in
serious and even potentially life threatening consequences for many patients. Nurses are
responsible for identifying patients who are at risk for falls and for developing a plan of care
to minimize that risk. Short staffing, nurse inexperience and inadequate nurse knowledge
could place patients at risk for injury. High performance measure rates may suggest the
need to examine clinical and organizational processes related to the identification of, and
care for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Number of patient falls with an injury level of minor or greater during the
calendar month
Visitors
Students
Staff members
121
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:
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 patients 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.
122
I-NSC-5
References
123
Appendix E
Nursing Sensitive Care
Prevalence Study Methodology
General Information
The time and staff required to do a prevalence study depends on the size of the hospital
and the units as well as the study teams 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.
1) Assign a coordinator
124
2) Determine Who Will Conduct the Study
4) Observation
b. Restraint Use Prevalence: Each patient on the assigned unit is observed (i.e.,
observations are not to be referred by staff for those patients thought to be
restrained).
125
5) Chart Review
7) Data Submission
a. Pressure Ulcer Prevalence: After the chart review and patient observation
have been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure for internal analysis or following procedures as defined for external
data submission.
126
b. Restraint Use Prevalence: After the chart review and patient observation have
been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure developed for internal analysis or following procedures as defined for
external data submission.
8) Important Notes
f. Actively dying and medically unstable patients: The terms actively dying
and medically unstable are terms 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
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.
128
Perinatal Care (PC)
Measure Set
129
Measure
Code Measure Description
130
I-PC-01
Elective Delivery
Measure Overview
Overview/Details:
Patients who had an elective vaginal delivery or elective cesarean section performed
at greater than or equal to 37 weeks and less than 39 weeks gestation completed.
Rationale:
Clinical guidelines have had in place a standard requiring 39 completed weeks
gestation prior to ELECTIVE delivery, either vaginal or operative. Studies have
determined that elective delivery or elective cesarean section prior to the gestational
age of 39 weeks may result in significant short term neonatal morbidity (neonatal
intensive care unit admission rates of 13-21%).
Patient Settings/Services
Obstetric/Maternal units
Medical/Surgical units
Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation
completed
131
I-PC-01
Measure Details
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
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
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:
Admission Date
Birthdate
Gestational age
ICD principal/other diagnosis code
132
I-PC-01
References
133
I-PC-02
Cesarean Section
Measure Overview
Overview/Details:
Patients, during their first pregnancy who presented with a single fetus in a normal
(vertex position) who were delivered by cesarean section at 37 or more weeks of
gestation completed.
Rationale:
Studies have demonstrated that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor admission rates.
Clinical studies have shown if labor was forced when the cervix was not ready, the
outcomes were poorer. Studies have also shown the use of that labor and delivery
guidelines can make a difference in labor outcomes.
Patient Settings/Services
Labor and Delivery units
Medical/Surgical units
134
I-PC-02
Measure Details
Clinical studies found that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor admission
rates. The results have shown if labor was forced when the cervix was not ready,
the outcomes were poorer. Many authors have shown that physician factors,
rather than patient characteristics or obstetric diagnoses are the major driver for
the difference in rates within a hospital.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Inclusions to the population: ICD Principal Procedure Code or ICD Other Procedure
Codes for cesarean section as defined in Appendix A, Table 11.06
Data elements:
ICD principal/other procedure Code
Data elements:
Admission Date
Birthdate
Gestational age
ICD other diagnosis code
ICD other procedure code
ICD principal diagnosis code
ICD procedure code
Parity
135
Inclusions to the population: Nulliparous patients with ICD Principal Diagnosis Code
or ICD Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table
11.08 and with a delivery of a newborn with 37 weeks or more of gestation completed
136
I-PC-02
References
Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators
Guide to Inpatient Quality Indicators: Quality of Care in HospitalsVolume,
Mortality, and Utilization. Revision 4 (December 22, 2004). AHRQ Pub. No. 02-
RO204.
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.
137
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.188:1579-
85.
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): 1-
5.
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.
138
I-PC-05
Exclusive Breast Milk Feeding
Measure Overview
Overview/Details:
Exclusive breast milk feeding during the newborns 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.
Patient Settings/Services
Numerator: Newborns that were fed breast milk only since birth
139
I-PC-05
Measure Details
Exclusive breast milk feeding for the first 6 months of neonatal life has long been the
expressed goal of World Health Organization (WHO) and other authorities of women and
child health care. A recent study substantiates the benefits of exclusively feeding
newborn infants breast milk.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Newborns that were fed breast milk only since birth
Data elements:
Exclusive Breast Milk Feeding
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/downloads/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 one-
month 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):e283-
90.
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.
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-9- Shortened Description
Code Code Code CMCode
73.01 INDUCT LABOR-RUPT MEMB
73.1 SURG INDUCT LABOR NEC
73.4 MEDICAL INDUCTION LABOR
Table 11.06
Cesarean Section
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code 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-9- Shortened 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
142
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code 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
143
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code 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
144
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code 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
145
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
651.13 TRIPLET PREG-ANTEPARTUM
651.20 QUADRUPLET PREG-UNSPEC
651.21 QUADRUPLET PREG-DELIVER
651.23 QUADRUPLET PREG-ANTEPART
651.30 TWINS W FETAL LOSS-UNSP
651.31 TWINS W FETAL LOSS-DEL
651.33 TWINS W FETAL LOSS-ANTE
651.40 TRIPLETS W FET LOSS-UNSP
651.41 TRIPLETS W FET LOSS-DEL
651.43 TRIPLETS W FET LOSS-ANTE
651.50 QUADS W FETAL LOSS-UNSP
651.51 QUADS W FETAL LOSS-DEL
651.53 QUADS W FETAL LOSS-ANTE
651.60 MULT GES W FET LOSS-UNSP
651.61 MULT GES W FET LOSS-DEL
651.63 MULT GES W FET LOSS-ANTE
651.80 MULTI GESTAT NEC-UNSPEC
651.81 MULTI GESTAT NEC-DELIVER
651.83 MULTI GEST NEC-ANTEPART
651.90 MULTI GESTAT NOS-UNSPEC
651.91 MULT GESTATION NOS-DELIV
651.93 MULTI GEST NOS-ANTEPART
652.20 BREECH PRESENTAT-UNSPEC
652.21 BREECH PRESENTAT-DELIVER
652.23 BREECH PRESENT-ANTEPART
652.30 TRANSV/OBLIQ LIE-UNSPEC
652.31 TRANSVER/OBLIQ LIE-DELIV
146
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
652.33 TRANSV/OBLIQ LIE-ANTEPAR
652.40 FACE/BROW PRESENT-UNSPEC
652.41 FACE/BROW PRESENT-DELIV
652.43 FACE/BROW PRES-ANTEPART
652.60 MULT GEST MALPRESEN-UNSP
652.61 MULT GEST MALPRES-DELIV
652.63 MULT GES MALPRES-ANTEPAR
654.20 PREV C-DELIVERY UNSPEC
654.21 PREV C-DELIVERY-DELIVRD
654.23 PREV C-DELIVERY-ANTEPART
656.40 INTRAUTERINE DEATH-UNSPEC
656.41 INTRAUTER DEATH-DELIV
656.43 INTRAUTER DEATH-ANTEPART
660.50 LOCKED TWINS-UNSPECIFIED
660.51 LOCKED TWINS-DELIVERED
660.53 LOCKED TWINS-ANTEPARTUM
662.30 DELAY DEL 2ND TWIN-UNSP
662.31 DELAY DEL 2ND TWIN-DELIV
662.33 DELAY DEL 2 TWIN-ANTEPAR
669.60 BREECH EXTR NOS-UNSPEC
669.61 BREECH EXTR NOS-DELIVER
761.5 MULT PREGNANCY AFF NB
V27.1 DELIVER SINGLE-STILLBORN
V27.2 DELIVER-TWINS, BOTH LIVE
V27.3 DEL-TWINS, 1 NB, 1 SB
V27.4 DELIVER-TWINS, BOTH SB
V27.5 DEL-MULT BIRTH, ALL LIVE
147
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
V27.6 DEL-MULT BIRTH, SOME LIVE
V27.7 DEL-MULT BIRTH, ALL SB
148
Pneumonia (PN)
Measure Set
149
Measure
Code Measure Description
Pneumonia (PN)
Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)
Pneumonia patients, aged 65 and older, who were screened for
pneumococcal vaccine status and were administered the vaccine prior
I-PN-2 to discharge, if indicated
Pneumonia patients, aged 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to
I-PN-7 discharge, if indicated
150
I-PN-2
Pneumococcal Vaccination
Measure Overview
I-PN 2 Pneumonia patients, aged 65 and older, who were screened for
pneumococcal vaccine status and were administered the vaccine prior to
discharge, if indicated
Overview/Details:
Patients (aged 65 and older) who were diagnosed with pneumonia, and who received
pneumococcal vaccine prior to discharge from the hospital.
Rationale:
Pneumococcal vaccination is indicated for persons 65 years of age and older because it
is up to 75% effective in preventing pneumococcal bacteremia and meningitis. It is also
an important vaccine due to increasing antibiotic resistance among pneumocci.
Patient Settings/Services
Intensive Care Units
Medical/Surgical units
Numerator: Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if indicated.
151
Domains of QPS CCPC IPSG
Performance Standards
Appropriateness QPS.3 patient AMI Goal 1
assessments
Availability HF
Continuity Stroke
QPS.3 infection
Effectiveness Diabetes (Type I/II)
prevention and control,
Prevention/Early surveillance and ESRD
Detection reporting Traumatic
Timeliness Brain Injury
HIV/AIDS
Asthma
COPD
152
I-PN-2
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative
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.
Data elements:
Pneumococcal Vaccination Status
Data elements:
Admission Date
Birthdate
Chest X-ray
ICD principal or other diagnosis code
153
I-PN-2
References
154
I-PN 4
Adult Smoking Counseling
Measure Overview
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.
Denominator: Pneumonia patients 18 years of age and older with a history of smoking
cigarettes anytime during the year prior to hospital arrival
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 patients
medical recovery.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Adult Smoking Counseling
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
156
I-PN-4
References
Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and
Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD:
U.S. Department of Health and Human Services. Public Health
Service. May 2008.
Hudmon KS, Hemberger KK, Corelli RL, et al. The pharmacists role in
smoking cessation counseling: perceptions of users of nonprescription
nicotine replacement therapy. J Am Pharm Assoc 2003; 43(5):573-
582.
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 Panel and Staff:
The Agency for Health Care Policy and Research. Smoking Cessation
Clinical Practice Guideline. JAMA, 275:1270-1280, 1996.
157
I-PN 7
Influenza Vaccination
Measure Overview
I-PN 07 Pneumonia patients, aged 50 and older, who during the flu season, were
screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated
Overview/Details:
Patients (aged 50 and older) who were diagnosed with pneumonia (during the flu
season), and who received influenza vaccine prior to discharge from the hospital.
Rationale:
Pneumococcal vaccination is indicated for persons 50 years of age and older because it
is highly effective in preventing influenza-related pneumonia.
Patient Settings/Services
Intensive Care Units
Medical/Surgical units
Numerator: Patients with pneumonia, age 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated.
Denominator: Pneumonia patients 50 years and older (during the flu season)
158
Domains of Performance QPS Standards CCPC IPSG
Appropriateness QPS.3 patient AMI Goal 1
assessments
Availability HF
Continuity Stroke
QPS.3 infection
Effectiveness Diabetes (Type I/II)
prevention and
Prevention/Early Detection control, surveillance, Traumatic Brain Injury
Timeliness and reporting Asthma
COPD
159
I-PN 7
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative 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.
Data elements:
Influenza Vaccination Status
Denominator: Pneumonia patients 50 years of age and older (during the flu season)
Data elements:
Admission 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)
160
I-PN - 7
References
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 ICD-10 ICD-9- Shortened Description
Code Code Code 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 MYCPLSM PNEUMONIAE
483.1 PNEUMONIA D/T CHLAMYDIA
483.8 PNEUMON OTH SPEC ORGNSM
485 BRONCHOPNEUMONIA ORG NOS
486 PNEUMONIA, ORGANISM NOS
162
Surgical Care
Improvement Project
(SCIP)
Measure Set
163
Measure
Code Measure Description
Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)
164
I-SCIP-Inf-1d
Prophylactic Antibiotic Received
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 1d Prophylactic antibiotics received within one hour prior to surgical
incision for hip arthroplasty patients.
Overview/Details:
Surgical patients (hip arthroplasty) with prophylactic antibiotics initiated within one hour
prior to surgical incision.
Note: Patients who received vancomycin or a fluroquinolone for prophylactic antibiotics should
have the antibiotics initiated within two hours prior to a surgical incision. Due to the longer
infusion time required for vancomycin or a fluroquinolone, it is acceptable to start these
antibiotics within two hours prior to incision time.
Rationale:
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels
at the time of skin incision. Clinical studies have demonstrated that a common reason
for failure of prophylaxis was delay of antibiotic administration until after the operation.
In a comprehensive study, it was found that the lowest incidence of post-operative
infection was associated with antibiotic administration during the one hour prior to
surgery. The risk of infection increased progressively with greater time intervals
between administration and skin incision. Therefore, opportunities to improve care have
been demonstrated and timely administration has been recommended.
Patient Settings/Services:
Medical/surgical units
Measure Name: Prophylactic antibiotic received within one hour prior to surgical
incision for hip arthroplasty.
165
Domains of Performance QPS CCPC IPSG
Standards
Appropriateness QPS.3 surgical Joint Goal 1
procedures Replacement
Availability Goal 4
Continuity Goal 5
QPS.3 antibiotics and
Effectiveness
other mediation use
Prevention/Early
Detection
QPS.3 infection,
Timeliness prevention and control,
surveillance and reporting
166
I-SCIP-Inf-1d
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Data elements:
Anesthesia start date
Antibiotic administration date
Antibiotic administration time
Surgical incision time
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection and who are >= 18 years.
Data elements:
Admission date
Anesthesia start date
Antibiotic name
Antibiotic received
Antibiotic administration route
Birthdate
ICD principal diagnosis code
ICD principal procedure Code
Infection prior to anesthesia
Other surgeries
167
Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04).
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):1706-
1715.
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:
administration of preoperative antibiotics in the operating room. Am Surg.
1997;63:500-503.
Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients
undergoing common surgical procedures in a community teaching hospital: the
chaos continues. World J Surg. 1999;23:429-432.
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.
169
I-SCIP-Inf-1e
Prophylactic Antibiotics Received
(Knee arthroplasty)
Measure Overview
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.
Patient Settings/Services:
Medical/surgical units
Measure Name: Prophylactic antibiotic received within one hour prior to surgical
incision.
170
Domains of QPS CCPC IPSG
Performance Standards
Appropriateness QPS.3 surgical procedures Joint Goal 1
Replacement
Availability Goal 4
Continuity QPS.3 antibiotics and other Goal 5
mediation use
Effectiveness
Prevention/Early
QPS.3 infection, prevention
Detection
and control, surveillance and
Timeliness reporting
171
I-SCIP-Inf-1e
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Data elements:
Anesthesia start date
Antibiotic administration date
Antibiotic administration time
Surgical incision time
Denominator: All selected surgical patients (knee arthoplasty) with no evidence of prior
infection and who are >= 18 years.
Data elements:
Admission date
Anesthesia start date
Antibiotic name
Antibiotic received
Antibiotic administration route
Birthdate
ICD principal diagnosis code
ICD principal procedure code
Infection prior to anesthesia
Other surgeries
172
Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.05).
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):1706-
1715.
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:
administration of preoperative antibiotics in the operating room. Am Surg.
1997;63:500-503.
Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients
undergoing common surgical procedures in a community teaching hospital: the
chaos continues. World J Surg. 1999;23:429-432.
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.
174
I-SCIP-Inf-2d
Prophylactic Antibiotic Selection
(Hip arthroplasty)
Measure Overview
Overview/Details:
Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent with
current guidelines.
Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-
effective, and has a spectrum of action that covers most of the probable intraoperative
contaminants for the operation. First or second-generation cephalosporins satisfy these
criteria for most operations, although anaerobic coverage is needed for colon surgery.
Measure Name: Prophylactic antibiotic selection for surgical patients (hip arthroplasty)
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection who are >= 18 years.
175
Domains of QPS CCPC IPSG
Performance Standards
Appropriateness QPS.3 surgical procedures Joint Goal 1
Replacement
Availability Goal 4
Continuity QPS.3 antibiotics and other Goal 5
mediation use
Effectiveness
Prevention/Early
QPS.3 infection, prevention
Detection
and control, surveillance and
reporting
176
I-SCIP-Inf-2d
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Data elements:
Antibiotic Administration Route
Antibiotic Allergy
Antibiotic Name
Vancomycin
Data elements:
Admission date
Antibiotic administration date
Antibiotic administration time
Antibiotic received
Antibiotic admission route
Birthdate
ICD principal diagnosis code
ICD principal procedure code
Infection prior to anesthesia
Surgical Incision time
177
Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04.)
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):1706-
1715.
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;56:1839-
1888.
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 CP, 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.
179
I-SCIP-Inf-2e
Prophylactic Antibiotic Selection
(Knee arthroplasty)
Measure Overview
Overview/Details:
Surgical patients (knee arthroplasty) who received prophylactic antibiotics consistent
with current guidelines.
Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, cost-
effective, and has a spectrum of action that covers most of the probable intraoperative
contaminants for the operation. First or second-generation cephalosporins satisfy these
criteria for most operations, although anaerobic coverage is needed for colon surgery.
180
I-SCIP-Inf-2e
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative
data and medical records.
Data elements:
Antibiotic administration route
Antibiotic allergy
Antibiotic name
Vancomycin
Data elements:
Admission date
Antibiotic administration date
Antibiotic administration time
Antibiotic Received
Birthdate
ICD principal diagnosis code
ICD principal procedure code
Infection prior to anesthesia
Surgical Incision time
181
Inclusions to the population: ICD Principal Procedure Code of selected surgeries
(as defined in Appendix A, Table 5.05).
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):1706-
1715.
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;56:1839-
1888.
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 CP, 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.
183
I-SCIP-Inf-3d
Prophylactic Antibiotics Discontinued within
24 Hours After Surgery End Time
(Hip arthroplasty)
Measure Overview
Overview/Details:
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued
within 24 hours after anesthesia end time.
Measure Name: Prophylactic antibiotic discontinued within 24 hours after surgery end
time (hip arthroplasty).
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection who are >= 18 years
184
Domains of QPS CCPC IPSG
Performance Standards
Appropriateness QPS.3 surgical procedures Joint Goal 1
Replacement
Availability Goal 4
Continuity QPS.3 antibiotics and other Goal 5
mediation use
Effectiveness
Prevention/Early
QPS.3 infection, prevention
Detection
and control, surveillance and
Timeliness reporting
185
I-SCIP-Inf-3d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to provide benefit to the
patient with as little risk as possible. It is important to maintain therapeutic serum and tissue
levels throughout the operation. Intraoperative re-dosing may be needed for long
operations. However, administration of antibiotics for more than a few hours after the
incision is closed offers no additional benefit to the surgical patient. Prolonged
administration does increase the risk of Clostridium difficile infection and the development of
antimicrobial resistant pathogens.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Data elements:
Anesthesia end date
Anesthesia end time
Antibiotic administration date
Antibiotic administration time
Denominator: All selected surgical patients (hip arthroscopy) with no evidence of prior
infection and who are >= 18 years.
Data elements:
Admission date
Anesthesia start date
Antibiotic administration 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
186
Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04.)
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):1706-
1715.
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 administration for surgical
prophylaxis. Am Surg. 1997;63:59-62.
188
I-SCIP-Inf-3e
Prophylactic Antibiotics Discontinued within
24 Hours After Surgery End Time
(Knee Arthroplasty)
Measure Overview
Overview/Details:
Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued
within 24 hours after anesthesia end time.
Patient Settings/Services:
Medical/surgical units
Measure Name: Prophylactic antibiotic discontinued within 24 hours after surgery end
time (knee arthroplasty)
189
Domains of QPS CCPC IPSG
Performance Standards
Appropriateness QPS.3 surgical Joint Goal 1
procedures Replacement
Availability Goal 4
Continuity Goal 5
QPS.3 antibiotics and
Effectiveness
other mediation use
Prevention/Early
Detection
QPS.3 infection,
Timeliness prevention and control,
surveillance and reporting
190
I-SCIP-Inf-3e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to provide benefit to the
patient with as little risk as possible. It is important to maintain therapeutic serum and tissue
levels throughout the operation. Intraoperative re-dosing may be needed for long operations.
However, administration of antibiotics for more than a few hours after the incision is closed
offers no additional benefit to the surgical patient. Prolonged administration does increase the
risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Data elements:
Anesthesia End Date
Anesthesia End Time
Antibiotic Administration Date
Antibiotic Administration Time
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior
infection and who are >= 18 years.
Data elements:
Admission date
Anesthesia start date
Antibiotic administration 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
191
Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined
in Appendix A, Table 5.05)
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):1706-
1715.
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 administration for surgical
prophylaxis. Am Surg. 1997;63:59-62.
193
I-SCIP-VTE-1
Surgical Patients (hip/knee arthroplasty) with Recommended
Venous Thromboembolism (VTE) Prophylaxis Ordered
Measure Overview
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.
Patient Settings/Services:
Medical/surgical units
Denominator: All selected (hip/knee arthoroplasty) patients who are >= 18 years.
194
Domains of Performance QPS CCPC IPSG
Standards
Appropriateness QPS.3 patient Joint Goal 1
assessments Replacement
Availability
Continuity
QPS.3 surgical
Effectiveness
procedures
Prevention/Early
Detection
QPS.3 antibiotics and
Timeliness other mediation use
195
I-SCIP-VTE-1
Measure Details
Reasons and Implications: Despite the evidence that VTE is one of the most common
postoperative complications and prophylaxis is the most effective strategy to reduce morbidity
and mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and duration of
surgery, patient risk factors, duration and extent of postoperative immobilization, and use or
nonuse of prophylaxis. According to clinical trials, surgery was associated with over a twenty-
fold increase in the odds of being diagnosed with VTE. Studies have shown that appropriately
used thromboprophylaxis has a positive risk/benefit ratio and is cost effective. Prophylaxis
recommendations for this measure are based on clinical practice guidelines.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Denominator: All selected (hip/knee arthoroplasty) patients who are >= 18 years.
Data elements:
Anesthesia type
VTE Prophylaxis
Data elements:
Admission date
Anesthesia end date
Anesthesia end time
Anesthesia start date
Anesthesia start time
Birthdate
ICD principal diagnosis code
ICD principal procedure code
Preadmission Warfarin
Reason for Not Administering VTE Prophylaxis
196
Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04, 5.05.)
197
I-SCIP-VTE-1
References
198
Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of low-
molecular-weight heparin prophylaxis against venous thromboembolism in patients
undergoing elective hip replacement. Arch Intern Med. 1999;159:137-141. PMID:
9927095.
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 joint 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.
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
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.
Patient Settings/Services:
Medical/surgical units
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.
201
I-SCIP-VTE-2
Measure Details
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Denominator: All selected (hip/knee arthroplasty) patients who are >= 18 years.
Data elements:
Anesthesia type
VTE Prophylaxis
VTE Timely
Data elements:
Admission date
Anesthesia start date
Anesthesia start time
Anesthesia end date
Anesthesia end time
Birthdate
ICD principal diagnosis code
ICD principal procedure code
Preadmission warfarin
Reason for not administering VTE prophylaxis
202
Inclusions to the population: ICD Principal Procedure Code of selected surgeries
(as defined in Appendix A, Table 5.04, 5.05).
Su
VTE Prophylaxis Options for Surgery
Surgery Type Recommended Prophylaxis Options
Elective Total Hip
5B Any of the following started within 24 hours of surgery:
Replacement Low molecular weight heparin (LMWH)
Factor Xa Inhibitor (Fondaparinux)
Warfarin
Oral Factor Xa Inhibitor (Rivaroxaban)
Elective Total Knee
6B Any of the following:
Replacement Low molecular weight heparin (LMWH)
Factor Xa Inhibitor (Fondaparinux)
Warfarin
Intermittent pneumatic compression devices (IPC)
Venous foot pump (VFP)
Oral Factor Xa Inhibitor (Rivaroxaban)
Elective Total Hip Any of the following:
Replacement with a Intermittent pneumatic compression devices (IPC)
reason for not Venous foot pump (VFP)
administering
pharmacological
prophylaxis
203
I-SCIP-VTE-2
References
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;159:137-
141. 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 joint 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.
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 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
81.51 TOTAL HIP REPLACEMENT
81.52 PARTIAL HIP REPLACEMENT
Table 5.05
Knee Arthroplasty
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
81.54 TOTAL KNEE REPLACEMENT
Table 5.09
Infection Codes
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
Code Shortened Description
001.0 CHOLERA D/T VIB CHOLERAE
001.1 CHOLERA D/T VIB EL TOR
001.9 CHOLERA NOS
002.0 TYPHOID FEVER
002.1 PARATYPHOID FEVER A
002.2 PARATYPHOID FEVER B
002.3 PARATYPHOID FEVER C
002.9 PARATYPHOID FEVER NOS
003.0 SALMONELLA ENTERITIS
003.1 SALMONELLA SEPTICEMIA
003.20 LOCAL SALMONELLA INF NOS
003.21 SALMONELLA MENINGITIS
003.22 SALMONELLA PNEUMONIA
2011 Joint Commission International
206
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
003.23 SALMONELLA ARTHRITIS
003.24 SALMONELLA OSTEOMYELITIS
003.29 LOCAL SALMONELLA INF NEC
003.8 SALMONELLA INFECTION NEC
003.9 SALMONELLA INFECTION NOS
004.0 SHIGELLA DYSENTERIAE
004.1 SHIGELLA FLEXNERI
004.2 SHIGELLA BOYDII
004.3 SHIGELLA SONNEI
004.8 SHIGELLA INFECTION NEC
004.9 SHIGELLOSIS NOS
006.0 AC AMEBIASIS W/O ABSCESS
006.1 CHR AMEBIASIS W/O ABSCES
006.2 AMEBIC NONDYSENT COLITIS
006.3 AMEBIC LIVER ABSCESS
006.4 AMEBIC LUNG ABSCESS
006.5 AMEBIC BRAIN ABSCESS
006.6 AMEBIC SKIN ULCERATION
006.8 AMEBIC INFECTION NEC
006.9 AMEBIASIS NOS
007.1 GIARDIASIS
008.00 INTEST INFEC E COLI NOS
008.01 INT INF E COLI ENTRPATH
008.02 INT INF E COLI ENTRTOXGN
008.03 INT INF E COLI ENTRNVSV
008.04 INT INF E COLI ENTRHMRG
008.09 INT INF E COLI SPCF NEC
008.1 ARIZONA ENTERITIS
008.2 AEROBACTER ENTERITIS
008.3 PROTEUS ENTERITIS
008.41 STAPHYLOCOCC ENTERITIS
008.42 PSEUDOMONAS ENTERITIS
008.43 INT INFEC CAMPYLOBACTER
008.44 INT INF YRSNIA ENTRCLTCA
008.45 INT INF CLSTRDIUM DFCILE
008.46 INTES INFEC OTH ANEROBES
008.47 INT INF OTH GRM NEG BCTR
008.49 BACTERIAL ENTERITIS NEC
008.5 BACTERIAL ENTERITIS NOS
207
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
008.8 VIRAL ENTERITIS NOS
009.0 INFECTIOUS ENTERITIS NOS
009.1 ENTERITIS OF INFECT ORIG
009.2 INFECTIOUS DIARRHEA NOS
009.3 DIARRHEA OF INFECT ORIG
020.0 BUBONIC PLAGUE
020.1 CELLULOCUTANEOUS PLAGUE
020.2 SEPTICEMIC PLAGUE
020.3 PRIMARY PNEUMONIC PLAGUE
020.4 SECONDARY PNEUMON PLAGUE
020.5 PNEUMONIC PLAGUE NOS
020.8 OTHER TYPES OF PLAGUE
020.9 PLAGUE NOS
021.0 ULCEROGLANDUL TULAREMIA
021.1 ENTERIC TULAREMIA
021.2 PULMONARY TULAREMIA
021.3 OCULOGLANDULAR TULAREMIA
021.8 TULAREMIA NEC
021.9 TULAREMIA NOS
022.0 CUTANEOUS ANTHRAX
022.1 PULMONARY ANTHRAX
022.2 GASTROINTESTINAL ANTHRAX
022.3 ANTHRAX SEPTICEMIA
022.8 OTHER ANTHRAX MANIFEST
022.9 ANTHRAX NOS
023.0 BRUCELLA MELITENSIS
023.1 BRUCELLA ABORTUS
023.2 BRUCELLA SUIS
023.3 BRUCELLA CANIS
023.8 BRUCELLOSIS NEC
023.9 BRUCELLOSIS NOS
024 GLANDERS
025 MELIOIDOSIS
026.0 SPIRILLARY FEVER
026.1 STREPTOBACILLARY FEVER
026.9 RAT-BITE FEVER NOS
027.0 LISTERIOSIS
027.1 ERYSIPELOTHRIX INFECTION
027.2 PASTEURELLOSIS
208
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
027.8 ZOONOTIC BACT DIS NEC
027.9 ZOONOTIC BACT DIS NOS
030.0 LEPROMATOUS LEPROSY
030.1 TUBERCULOID LEPROSY
030.2 INDETERMINATE LEPROSY
030.3 BORDERLINE LEPROSY
030.8 LEPROSY NEC
030.9 LEPROSY NOS
031.0 PULMONARY MYCOBACTERIA
031.1 CUTANEOUS MYCOBACTERIA
031.2 DMAC BACTEREMIA
031.8 MYCOBACTERIAL DIS NEC
031.9 MYCOBACTERIAL DIS NOS
032.0 FAUCIAL DIPHTHERIA
032.1 NASOPHARYNX DIPHTHERIA
032.2 ANT NASAL DIPHTHERIA
032.3 LARYNGEAL DIPHTHERIA
032.81 CONJUNCTIVAL DIPHTHERIA
032.82 DIPHTHERITIC MYOCARDITIS
032.83 DIPHTHERITIC PERITONITIS
032.84 DIPHTHERITIC CYSTITIS
032.85 CUTANEOUS DIPHTHERIA
032.89 DIPHTHERIA NEC
032.9 DIPHTHERIA NOS
033.0 BORDETELLA PERTUSSIS
033.1 BORDETELLA PARAPERTUSSIS
033.8 WHOOPING COUGH NEC
033.9 WHOOPING COUGH NOS
034.0 STREP SORE THROAT
034.1 SCARLET FEVER
035 ERYSIPELAS
036.0 MENINGOCOCCAL MENINGITIS
036.1 MENINGOCOCC ENCEPHALITIS
036.2 MENINGOCOCCEMIA
036.3 MENINGOCOCC ADRENAL SYND
036.40 MENINGOCOCC CARDITIS NOS
036.41 MENINGOCOCC PERICARDITIS
036.42 MENINGOCOCC ENDOCARDITIS
036.43 MENINGOCOCC MYOCARDITIS
209
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
036.81 MENINGOCOCC OPTIC NEURIT
036.82 MENINGOCOCC ARTHROPATHY
036.89 MENINGOCOCCAL INFECT NEC
036.9 MENINGOCOCCAL INFECT NOS
037 TETANUS
038.0 STREPTOCOCCAL SEPTICEMIA
038.10 STAPHYLCOCC SEPTICEM NOS
038.11 METH SUSC STAPH AUR SEPT
038.12 MRSA SEPTICEMIA
038.19 STAPHYLCOCC SEPTICEM NEC
038.2 PNEUMOCOCCAL SEPTICEMIA
038.3 ANAEROBIC SEPTICEMIA
038.40 GRAM-NEG SEPTICEMIA NOS
038.41 H. INFLUENAE SEPTICEMIA
038.42 E COLI SEPTICEMIA
038.43 PSEUDOMONAS SEPTICEMIA
038.44 SERRATIA SEPTICEMIA
038.49 GRAM-NEG SEPTICEMIA NEC
038.8 SEPTICEMIA NEC
038.9 SEPTICEMIA NOS
039.0 CUTANEOUS ACTINOMYCOSIS
039.1 PULMONARY ACTINOMYCOSIS
039.2 ABDOMINAL ACTINOMYCOSIS
039.3 CERVICOFAC ACTINOMYCOSIS
039.4 MADURA FOOT
039.8 ACTINOMYCOSIS NEC
039.9 ACTINOMYCOSIS NOS
040.0 GAS GANGRENE
040.1 RHINOSCLEROMA
040.2 WHIPPLE'S DISEASE
040.3 NECROBACILLOSIS
040.81 TROPICAL PYOMYOSITIS
040.82 TOXIC SHOCK SYNDROME
040.89 BACTERIAL DISEASES NEC
041.00 STREPTOCOCCUS UNSPECF
041.01 STREPTOCOCCUS GROUP A
041.02 STREPTOCOCCUS GROUP B
041.03 STREPTOCOCCUS GROUP C
041.04 ENTEROCOCCUS GROUP D
210
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
041.05 STREPTOCOCCUS GROUP G
041.09 OTHER STREPTOCOCCUS
041.10 STAPHYLOCOCCUS UNSPCFIED
041.11 MTH SUS STPH AUR ELS/NOS
041.12 MRSA ELSEWHERE/NOS
041.19 OTHER STAPHYLOCOCCUS
041.2 PNEUMOCOCCUS INFECT NOS
041.3 KLEBSIELLA PNEUMONIAE
041.4 E. COLI INFECT NOS
041.5 H. INFLUENZAE INFECT NOS
041.6 PROTEUS INFECTION NOS
041.7 PSEUDOMONAS INFECT NOS
041.81 MYCOPLASMA
041.82 BACTEROIDES FRAGILIS
041.83 CLOSTRIDIUM PERFRINGENS
041.84 OTHER ANAEROBES
041.85 OTH GRAM NEGATV BACTERIA
041.86 HELICOBACTER PYLORI
041.89 OTH SPECF BACTERIA
041.9 BACTERIAL INFECTION NOS
051.2 CONTAGIOUS PUSTULAR DERM
073.0 ORNITHOSIS PNEUMONIA
073.7 ORNITHOSIS COMPLICAT NEC
073.8 ORNITHOSIS COMPLICAT NOS
073.9 ORNITHOSIS NOS
076.0 TRACHOMA, INITIAL STAGE
076.1 TRACHOMA, ACTIVE STAGE
076.9 TRACHOMA NOS
078.2 SWEATING FEVER
078.3 CAT-SCRATCH DISEASE
078.4 FOOT & MOUTH DISEASE
078.6 HEM NEPHROSONEPHRITIS
078.88 OTH SPEC DIS CHLAMYDIAE
079.88 OTH SPCF CHLAMYDIAL INFC
079.98 CHLAMYDIAL INFECTION NOS
082.40 EHRLICHIOSIS NOS
082.41 EHRLICHIOSIS CHAFEENSIS
082.49 EHRLICHIOSIS NEC
082.8 TICK-BORNE RICKETTS NEC
211
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
082.9 TICK-BORNE RICKETTS NOS
083.2 RICKETTSIALPOX
083.8 RICKETTSIOSES NEC
083.9 RICKETTSIOSIS NOS
088.0 BARTONELLOSIS
088.81 LYME DISEASE
090.0 EARLY CONG SYPH SYMPTOM
090.1 EARLY CONGEN SYPH LATENT
090.2 EARLY CONGEN SYPH NOS
090.3 SYPHILITIC KERATITIS
090.40 JUVENILE NEUROSYPH NOS
090.41 CONGEN SYPH ENCEPHALITIS
090.42 CONGEN SYPH MENINGITIS
090.49 JUVENILE NEUROSYPH NEC
090.5 LATE CONGEN SYPH SYMPTOM
090.6 LATE CONGEN SYPH LATENT
090.7 LATE CONGEN SYPH NOS
090.9 CONGENITAL SYPHILIS NOS
091.0 PRIMARY GENITAL SYPHILIS
091.1 PRIMARY ANAL SYPHILIS
091.2 PRIMARY SYPHILIS NEC
091.3 SECONDARY SYPH SKIN
091.4 SYPHILITIC ADENOPATHY
091.50 SYPHILITIC UVEITIS NOS
091.51 SYPHILIT CHORIORETINITIS
091.52 SYPHILITIC IRIDOCYCLITIS
091.61 SYPHILITIC PERIOSTITIS
091.62 SYPHILITIC HEPATITIS
091.69 SECOND SYPH VISCERA NEC
091.7 SECOND SYPHILIS RELAPSE
091.81 ACUTE SYPHIL MENINGITIS
091.82 SYPHILITIC ALOPECIA
091.89 SECONDARY SYPHILIS NEC
091.9 SECONDARY SYPHILIS NOS
092.0 EARLY SYPH LATENT RELAPS
092.9 EARLY SYPHIL LATENT NOS
093.0 AORTIC ANEURYSM, SYPHIL
093.1 SYPHILITIC AORTITIS
093.20 SYPHIL ENDOCARDITIS NOS
212
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
093.21 SYPHILITIC MITRAL VALVE
093.22 SYPHILITIC AORTIC VALVE
093.23 SYPHIL TRICUSPID VALVE
093.24 SYPHIL PULMONARY VALVE
093.81 SYPHILITIC PERICARDITIS
093.82 SYPHILITIC MYOCARDITIS
093.89 CARDIOVASCULAR SYPH NEC
093.9 CARDIOVASCULAR SYPH NOS
094.0 TABES DORSALIS
094.1 GENERAL PARESIS
094.2 SYPHILITIC MENINGITIS
094.3 ASYMPTOMAT NEUROSYPHILIS
094.81 SYPHILITIC ENCEPHALITIS
094.82 SYPHILITIC PARKINSONISM
094.83 SYPH DISSEM RETINITIS
094.84 SYPHILITIC OPTIC ATROPHY
094.85 SYPH RETROBULB NEURITIS
094.86 SYPHIL ACOUSTIC NEURITIS
094.87 SYPH RUPT CEREB ANEURYSM
094.89 NEUROSYPHILIS NEC
094.9 NEUROSYPHILIS NOS
095.0 SYPHILITIC EPISCLERITIS
095.1 SYPHILIS OF LUNG
095.2 SYPHILITIC PERITONITIS
095.3 SYPHILIS OF LIVER
095.4 SYPHILIS OF KIDNEY
095.5 SYPHILIS OF BONE
095.6 SYPHILIS OF MUSCLE
095.7 SYPHILIS OF TENDON/BURSA
095.8 LATE SYMPT SYPHILIS NEC
095.9 LATE SYMPT SYPHILIS NOS
096 LATE SYPHILIS LATENT
097.0 LATE SYPHILIS NOS
097.1 LATENT SYPHILIS NOS
097.9 SYPHILIS NOS
098.0 ACUTE GC INFECT LOWER GU
098.10 GC (ACUTE) UPPER GU NOS
098.11 GC CYSTITIS (ACUTE)
098.12 GC PROSTATITIS (ACUTE)
213
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
098.13 GC ORCHITIS (ACUTE)
098.14 GC SEM VESICULIT (ACUTE)
098.15 GC CERVICITIS (ACUTE)
098.16 GC ENDOMETRITIS (ACUTE)
098.17 ACUTE GC SALPINGITIS
098.19 GC (ACUTE) UPPER GU NEC
098.2 CHR GC INFECT LOWER GU
098.30 CHR GC UPPER GU NOS
098.31 GC CYSTITIS, CHRONIC
098.32 GC PROSTATITIS, CHRONIC
098.33 GC ORCHITIS, CHRONIC
098.34 GC SEM VESICULITIS, CHR
098.35 GC CERVICITIS, CHRONIC
098.36 GC ENDOMETRITIS, CHRONIC
098.37 GC SALPINGITIS (CHRONIC)
098.39 CHR GC UPPER GU NEC
098.40 GONOCOCCAL CONJUNCTIVIT
098.41 GONOCOCCAL IRIDOCYCLITIS
098.42 GONOCOCCAL ENDOPHTHALMIA
098.43 GONOCOCCAL KERATITIS
098.49 GONOCOCCAL EYE NEC
098.50 GONOCOCCAL ARTHRITIS
098.51 GONOCOCCAL SYNOVITIS
098.52 GONOCOCCAL BURSITIS
098.53 GONOCOCCAL SPONDYLITIS
098.59 GC INFECT JOINT NEC
098.6 GONOCOCCAL INFEC PHARYNX
098.7 GC INFECT ANUS & RECTUM
098.81 GONOCOCCAL KERATOSIS
098.82 GONOCOCCAL MENINGITIS
098.83 GONOCOCCAL PERICARDITIS
098.84 GONOCOCCAL ENDOCARDITIS
098.85 GONOCOCCAL HEART DIS NEC
098.86 GONOCOCCAL PERITONITIS
098.89 GONOCOCCAL INF SITE NEC
099.0 CHANCROID
099.1 LYMPHOGRANULOMA VENEREUM
099.2 GRANULOMA INGUINALE
099.3 REITER'S DISEASE
214
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
099.40 UNSPCF NONGNCCL URETHRTS
099.41 CHLMYD TRACHOMATIS URETH
099.49 NONGC URTH OTH SPF ORGSM
099.50 OTH VD CHLM TRCH UNSP ST
099.51 OTH VD CHLM TRCH PHARYNX
099.52 OTH VD CHLM TRCH ANS RCT
099.53 OTH VD CHLM TRCH LOWR GU
099.54 OTH VD CHLM TRCH OTH GU
099.55 OT VD CHLM TRCH UNSPF GU
099.56 OT VD CHLM TRCH PRTONEUM
099.59 OTH VD CHLM TRCH SPCF ST
099.8 VENEREAL DISEASE NEC
099.9 VENEREAL DISEASE NOS
100.0 LEPTOSPIROS ICTEROHEM
100.81 LEPTOSPIRAL MENINGITIS
100.89 LEPTOSPIRAL INFECT NEC
100.9 LEPTOSPIROSIS NOS
101 VINCENT'S ANGINA
102.0 INITIAL LESIONS YAWS
102.1 MULTIPLE PAPILLOMATA
102.2 EARLY SKIN YAWS NEC
102.3 HYPERKERATOSIS OF YAWS
102.4 GUMMATA AND ULCERS, YAWS
102.5 GANGOSA
102.6 YAWS OF BONE & JOINT
102.7 YAWS MANIFESTATIONS NEC
102.8 LATENT YAWS
102.9 YAWS NOS
103.0 PINTA PRIMARY LESIONS
103.1 PINTA INTERMED LESIONS
103.2 PINTA LATE LESIONS
103.3 PINTA MIXED LESIONS
103.9 PINTA NOS
104.0 NONVENEREAL ENDEMIC SYPH
104.8 SPIROCHETAL INFECT NEC
104.9 SPIROCHETAL INFECT NOS
130.0 TOXOPLASM MENINGOENCEPH
130.1 TOXOPLASM CONJUNCTIVITIS
130.2 TOXOPLASM CHORIORETINIT
215
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
130.3 TOXOPLASMA MYOCARDITIS
130.4 TOXOPLASMA PNEUMONITIS
130.5 TOXOPLASMA HEPATITIS
130.7 TOXOPLASMOSIS SITE NEC
130.8 MULTISYSTEM TOXOPLASMOS
131.00 UROGENITAL TRICHOMON NOS
131.01 TRICHOMONAL VAGINITIS
131.02 TRICHOMONAL URETHRITIS
131.03 TRICHOMONAL PROSTATITIS
131.09 UROGENITAL TRICHOMON NEC
131.8 TRICHOMONIASIS NEC
131.9 TRICHOMONIASIS NOS
320.0 HEMOPHILUS MENINGITIS
320.1 PNEUMOCOCCAL MENINGITIS
320.2 STREPTOCOCCAL MENINGITIS
320.3 STAPHYLOCOCC MENINGITIS
320.7 MENING IN OTH BACT DIS
320.81 ANAEROBIC MENINGITIS
320.82 MNINGTS GRAM-NEG BCT NEC
320.89 MENINGITIS OTH SPCF BACT
320.9 BACTERIAL MENINGITIS NOS
322.9 MENINGITIS NOS
323.1 RICKETTSIAL ENCEPHALITIS
324.0 INTRACRANIAL ABSCESS
324.1 INTRASPINAL ABSCESS
324.9 CNS ABSCESS NOS
380.10 INFEC OTITIS EXTERNA NOS
380.11 ACUTE INFECTION OF PINNA
380.12 ACUTE SWIMMERS' EAR
380.13 AC INFECT EXTERN EAR NEC
380.14 MALIGNANT OTITIS EXTERNA
380.15 CHR MYCOT OTITIS EXTERNA
380.16 CHR INF OTIT EXTERNA NEC
380.21 CHOLESTEATOMA EXTERN EAR
380.22 ACUTE OTITIS EXTERNA NEC
380.23 CHR OTITIS EXTERNA NEC
382.00 AC SUPP OTITIS MEDIA NOS
382.01 AC SUPP OM W DRUM RUPT
382.02 AC SUPP OM IN OTH DIS
216
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
382.1 CHR TUBOTYMPAN SUPPUR OM
382.2 CHR ATTICOANTRAL SUP OM
421.0 AC/SUBAC BACT ENDOCARD
421.1 AC ENDOCARDIT IN OTH DIS
421.9 AC/SUBAC ENDOCARDIT NOS
422.0 AC MYOCARDIT IN OTH DIS
422.90 ACUTE MYOCARDITIS NOS
422.91 IDIOPATHIC MYOCARDITIS
422.92 SEPTIC MYOCARDITIS
422.93 TOXIC MYOCARDITIS
422.99 ACUTE MYOCARDITIS NEC
462 ACUTE PHARYNGITIS
463 ACUTE TONSILLITIS
464.00 AC LARYNGITIS W/O OBST
464.01 AC LARYNGITIS W OBSTRUCT
464.10 AC TRACHEITIS NO OBSTRUC
464.11 AC TRACHEITIS W OBSTRUCT
464.20 AC LARYNGOTRACH NO OBSTR
464.21 AC LARYNGOTRACH W OBSTR
464.30 AC EPIGLOTTITIS NO OBSTR
464.31 AC EPIGLOTTITIS W OBSTR
464.50 SUPRAGLOTTIS W/O OBS NOS
464.51 SUPRAGLOTTIS W OBSTR NOS
475 PERITONSILLAR ABSCESS
476.0 CHRONIC LARYNGITIS
476.1 CHR LARYNGOTRACHEITIS
481 PNEUMOCOCCAL PNEUMONIA
482.0 K. PNEUMONIAE PNEUMONIA
482.1 PSEUDOMONAL PNEUMONIA
482.2 H.INFLUENZAE PNEUMONIA
482.30 STREPTOCOCCAL PNEUMN NOS
482.31 PNEUMONIA STRPTOCOCCUS A
482.32 PNEUMONIA STRPTOCOCCUS B
482.39 PNEUMONIA OTH STREP
482.40 STAPHYLOCOCCAL PNEU NOS
482.41 METH SUS PNEUM D/T STAPH
482.42 METH RES PNEU D/T STAPH
482.49 STAPH PNEUMONIA NEC
482.81 PNEUMONIA ANAEROBES
217
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
482.82 PNEUMONIA E COLI
482.83 PNEUMO OTH GRM-NEG BACT
482.84 LEGIONNAIRES' DISEASE
482.89 PNEUMONIA OTH SPCF BACT
482.9 BACTERIAL PNEUMONIA NOS
483.0 PNEU MYCPLSM PNEUMONIAE
483.1 PNEUMONIA D/T CHLAMYDIA
483.8 PNEUMON OTH SPEC ORGNSM
484.1 PNEUM W CYTOMEG INCL DIS
484.3 PNEUMONIA IN WHOOP COUGH
484.5 PNEUMONIA IN ANTHRAX
484.6 PNEUM IN ASPERGILLOSIS
484.7 PNEUM IN OTH SYS MYCOSES
484.8 PNEUM IN INFECT DIS NEC
485 BRONCHOPNEUMONIA ORG NOS
486 PNEUMONIA, ORGANISM NOS
487.0 INFLUENZA WITH PNEUMONIA
487.1 FLU W RESP MANIFEST NEC
487.8 FLU W MANIFESTATION NEC
490 BRONCHITIS NOS
491.0 SIMPLE CHR BRONCHITIS
491.1 MUCOPURUL CHR BRONCHITIS
491.20 OBST CHR BRONC W/O EXAC
491.21 OBS CHR BRONC W(AC) EXAC
491.22 OBS CHR BRONC W AC BRONC
491.8 CHRONIC BRONCHITIS NEC
491.9 CHRONIC BRONCHITIS NOS
510.0 EMPYEMA WITH FISTULA
510.9 EMPYEMA W/O FISTULA
513.0 ABSCESS OF LUNG
513.1 ABSCESS OF MEDIASTINUM
540.0 AC APPEND W PERITONITIS
540.1 ABSCESS OF APPENDIX
540.9 ACUTE APPENDICITIS NOS
541 APPENDICITIS NOS
542 OTHER APPENDICITIS
562.01 DVRTCLI SML INT W/O HMRG
562.11 DVRTCLI COLON W/O HMRHG
562.13 DVRTCLI COLON W HMRHG
218
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
566 ANAL & RECTAL ABSCESS
567.21 PERITONITIS (ACUTE) GEN
567.22 PERITONEAL ABSCESS
567.23 SPONTAN BACT PERITONITIS
567.29 SUPPURAT PERITONITIS NEC
567.31 PSOAS MUSCLE ABSCESS
567.38 RETROPERITON ABSCESS NEC
567.39 RETROPERITON INFECT NEC
567.81 CHOLEPERITONITIS
567.82 SCLEROSING MESENTERITIS
567.89 PERITONITIS NEC
567.9 PERITONITIS NOS
569.5 INTESTINAL ABSCESS
569.61 COLOSTY/ENTEROST INFECTN
575.0 ACUTE CHOLECYSTITIS
590.00 CHR PYELONEPHRITIS NOS
590.01 CHR PYELONEPH W MED NECR
590.10 AC PYELONEPHRITIS NOS
590.11 AC PYELONEPHR W MED NECR
590.2 RENAL/PERIRENAL ABSCESS
590.3 PYELOURETERITIS CYSTICA
590.80 PYELONEPHRITIS NOS
590.81 PYELONEPHRIT IN OTH DIS
590.9 INFECTION OF KIDNEY NOS
595.0 ACUTE CYSTITIS
599.0 URIN TRACT INFECTION NOS
601.0 ACUTE PROSTATITIS
601.1 CHRONIC PROSTATITIS
601.2 ABSCESS OF PROSTATE
601.3 PROSTATOCYSTITIS
601.4 PROSTATITIS IN OTH DIS
601.8 PROSTATIC INFLAM DIS NEC
601.9 PROSTATITIS NOS
614.0 AC SALPINGO-OOPHORITIS
614.1 CHR SALPINGO-OOPHORITIS
614.2 SALPINGO-OOPHORITIS NOS
614.3 ACUTE PARAMETRITIS
614.4 CHRONIC PARAMETRITIS
614.5 AC PELV PERITONITIS-FEM
219
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
614.7 CHR PELV PERITON NEC-FEM
616.2 BARTHOLIN'S GLAND CYST
616.3 BARTHOLIN'S GLND ABSCESS
616.4 ABSCESS OF VULVA NEC
639.0 POSTABORTION GU INFECT
646.60 GU INFECT IN PREG- UNSPEC
646.61 GU INFECTION-DELIVERED
646.62 GU INFECTION-DELIV W P/P
646.63 GU INFECTION-ANTEPARTUM
646.64 GU INFECTION-POSTPARTUM
670.00 MAJ PUERP INF NOS-UNSP
670.02 MAJ PUER INF NOS-DEL P/P
670.04 MAJOR PUERP INF NOS-P/P
674.30 OB SURG COMPL NEC-UNSPEC
674.32 OB SURG COMPL-DEL W P/P
674.34 OB SURG COMP NEC- POSTPAR
680.0 CARBUNCLE OF FACE
680.1 CARBUNCLE OF NECK
680.2 CARBUNCLE OF TRUNK
680.3 CARBUNCLE OF ARM
680.4 CARBUNCLE OF HAND
680.5 CARBUNCLE OF BUTTOCK
680.6 CARBUNCLE OF LEG
680.7 CARBUNCLE OF FOOT
680.8 CARBUNCLE, SITE NEC
680.9 CARBUNCLE NOS
681.00 CELLULITIS, FINGER NOS
681.01 FELON
681.02 ONYCHIA OF FINGER
681.10 CELLULITIS, TOE NOS
681.11 ONYCHIA OF TOE
681.9 CELLULITIS OF DIGIT NOS
682.0 CELLULITIS OF FACE
682.1 CELLULITIS OF NECK
682.2 CELLULITIS OF TRUNK
682.3 CELLULITIS OF ARM
682.4 CELLULITIS OF HAND
682.5 CELLULITIS OF BUTTOCK
682.6 CELLULITIS OF LEG
220
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
682.7 CELLULITIS OF FOOT
682.8 CELLULITIS, SITE NEC
682.9 CELLULITIS NOS
683 ACUTE LYMPHADENITIS
684 IMPETIGO
685.0 PILONIDAL CYST W ABSCESS
685.1 PILONIDAL CYST W/O ABSC
686.00 PYODERMA NOS
686.01 PYODERMA GANGRENOSUM
686.09 PYODERMA NEC
686.1 PYOGENIC GRANULOMA
686.8 LOCAL SKIN INFECTION NEC
686.9 LOCAL SKIN INFECTION NOS
711.90 INF ARTHRITIS NOS-UNSPEC
711.91 INF ARTHRITIS NOS-SHLDER
711.92 INF ARTHRITIS NOS-UP/ARM
711.93 INF ARTHRIT NOS-FOREARM
711.94 INF ARTHRIT NOS-HAND
711.95 INF ARTHRIT NOS-PELVIS
711.96 INF ARTHRIT NOS-L/LEG
711.97 INF ARTHRIT NOS-ANKLE
711.98 INF ARTHRIT NOS-OTH SITE
711.99 INF ARTHRITIS NOS-MULT
730.00 AC OSTEOMYELITIS-UNSPEC
730.01 AC OSTEOMYELITIS-SHLDER
730.02 AC OSTEOMYELITIS-UP/ARM
730.03 AC OSTEOMYELITIS-FOREARM
730.04 AC OSTEOMYELITIS-HAND
730.05 AC OSTEOMYELITIS-PELVIS
730.06 AC OSTEOMYELITIS-L/LEG
730.07 AC OSTEOMYELITIS-ANKLE
730.08 AC OSTEOMYELITIS NEC
730.09 AC OSTEOMYELITIS-MULT
730.10 CHR OSTEOMYELITIS-UNSP
730.11 CHR OSTEOMYELIT-SHLDER
730.12 CHR OSTEOMYELIT-UP/ARM
730.13 CHR OSTEOMYELIT-FOREARM
730.14 CHR OSTEOMYELIT-HAND
730.15 CHR OSTEOMYELIT-PELVIS
221
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
730.16 CHR OSTEOMYELIT-L/LEG
730.17 CHR OSTEOMYELIT-ANKLE
730.18 CHR OSTEOMYELIT NEC
730.19 CHR OSTEOMYELIT-MULT
730.20 OSTEOMYELITIS NOS-UNSPEC
730.21 OSTEOMYELITIS NOS-SHLDER
730.22 OSTEOMYELITIS NOS-UP/ARM
730.23 OSTEOMYELIT NOS-FOREARM
730.24 OSTEOMYELITIS NOS-HAND
730.25 OSTEOMYELITIS NOS-PELVIS
730.26 OSTEOMYELITIS NOS-L/LEG
730.27 OSTEOMYELITIS NOS-ANKLE
730.28 OSTEOMYELIT NOS-OTH SITE
730.29 OSTEOMYELITIS NOS-MULT
730.30 PERIOSTITIS-UNSPEC
730.31 PERIOSTITIS-SHLDER
730.32 PERIOSTITIS-UP/ARM
730.33 PERIOSTITIS-FOREARM
730.34 PERIOSTITIS-HAND
730.35 PERIOSTITIS-PELVIS
730.70 POLIO OSTEOPATHY-UNSPEC
730.71 POLIO OSTEOPATHY-SHLDER
730.72 POLIO OSTEOPATHY-UP/ARM
730.73 POLIO OSTEOPATHY-FOREARM
730.74 POLIO OSTEOPATHY-HAND
730.75 POLIO OSTEOPATHY-PELVIS
730.76 POLIO OSTEOPATHY-L/LEG
730.77 POLIO OSTEOPATHY-ANKLE
730.78 POLIO OSTEOPATHY NEC
730.79 POLIO OSTEOPATHY-MULT
730.80 BONE INFECT NEC-UNSPEC
730.81 BONE INFECT NEC-SHLDER
730.82 BONE INFECT NEC-UP/ARM
730.83 BONE INFECT NEC-FOREARM
730.84 BONE INFECT NEC-HAND
730.85 BONE INFECT NEC-PELVIS
730.86 BONE INFECT NEC-L/LEG
730.87 BONE INFECT NEC-ANKLE
730.88 BONE INFECT NEC-OTH SITE
222
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
Code Code Code CMCode
730.89 BONE INFECT NEC-MULT
730.90 BONE INFEC NOS-UNSP SITE
730.91 BONE INFECT NOS-SHLDER
730.92 BONE INFECT NOS-UP/ARM
730.93 BONE INFECT NOS-FOREARM
730.94 BONE INFECT NOS-HAND
730.95 BONE INFECT NOS-PELVIS
730.96 BONE INFECT NOS-L/LEG
730.97 BONE INFECT NOS-ANKLE
730.98 BONE INFECT NOS-OTH SITE
730.99 BONE INFECT NOS-MULT
785.52 SEPTIC SHOCK
790.7 BACTEREMIA
996.60 REACTION-UNSP DEVIC/GRFT
996.61 REACT-CARDIAC DEV/GRAFT
996.62 REACT-OTH VASC DEV/GRAFT
996.63 REACT-NERV SYS DEV/GRAFT
996.64 REACT-INDWELL URIN CATH
996.65 REACT-OTH GENITOURIN DEV
996.66 REACT-INTER JOINT PROST
996.67 REACT-OTH INT ORTHO DEV
996.68 REACT- PERITON DIALY CATH
996.69 REACT-INT PROS DEVIC NEC
997.31 VENTLTR ASSOC PNEUMONIA
998.51 INFECTED POSTOP SEROMA
998.59 OTHER POSTOP INFECTION
223
Venous
Thromboembolism
(VTE) Measure Set
224
Measure
Code Measure Description
ICU patients who received VTE prophylaxis (or reasons of why this was
not done) on the day of or day after hospital admission or
surgery.<BR>Note: This measure applies to all ICU cases except those
included in the SCIP measure population (knee/hip arthroplasty) who
I-VTE-2 had surgery on the day of or the day after ICU admission or transfer
225
I-VTE-1
Venous Thromboembolism Prophylaxis
Measure Overview
I-VTE 1 Patients who received VTE prophylaxis (or reasons of why this was not
done) on the day of or day after hospital admission or surgery.
Note: This measure applies to medical and surgical cases that are not included
in the SCIP measure population.
Overview/Details:
VTE prophylaxis given on the day of or the day after hospital admission or surgery or a
reason documented of why VTE prophylaxis was not given.
See Appendix A.
Rationale:
Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein
thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is
suspected. Therefore, the best approach is for every patient to be evaluated for primary
prophylaxis since preventing DVT is essential to reducing morbidity and mortality.
There is clinical evidence that appropriately used thromboprophylaxis has a desirable
risk/benefit ratio and is cost effective. Thromboprophylaxis provides an opportunity to
improve patient outcomes and reduce hospital costs.
226
Numerator: Patients who received VTE prophylaxis or have documentation of why no
VTE prophylaxis was given:
Continuity Stroke
QPS.3 surgical
Effectiveness procedures CKD
Prevention/Early Diabetes
HIV/AIDS
Cancer
Transplantation
COPD
227
I-VTE-1
Measure Details
Reasons and Implications: Hospitalized patients at high-risk for VTE may develop an
asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE)
even before the diagnosis is suspected. There is clinical evidence that appropriately
used thromboprophylaxis has a desirable risk/benefit ratio and is cost effective.
Thromboprophylaxis provides an opportunity to improve patient outcomes and reduce
hospital costs.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Data elements:
Data elements:
Admission Date
Birthdate
ICD diagnosis code
ICU admission date
ICU admission/transfer
228
Inclusions to the population: Not applicable
229
I-VTE-1
References
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism:
the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
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.
230
I-VTE-2
ICU Venous Thromboembolism Prophylaxis
Measure Overview
I-VTE 2 ICU patients who received VTE prophylaxis (or reasons of why this was
not done) on the day of or day after hospital admission or surgery.
Note: This measure applies to all ICU cases except those included in the SCIP measure
population (knee/hip arthroplasty) who had surgery on the day of or the day after ICU admission
or transfer.
Overview/Details:
ICU VTE prophylaxis given on the day of or the day after ICU hospital admission or
surgery or a reason documented of why VTE prophylaxis was not given.
See Appendix A.
Rationale:
The vast majority of patients admitted to a critical care unit (CCU) have a major risk
factor for VTE, and many may have multiple risk factors including advanced age,
serious medical illness or recent surgical procedures or trauma. The use of
thromboprophylaxis has been clinically demonstrated to be efficacious in preventing
deep venous thrombosis in these patients.
231
the day of or day after surgery end date for surgeries that start the day of or day
after ICU admission (or transfer)
Denominator: Patients directly admitted or transferred to ICU who are >= 18 years
Continuity Stroke
QPS.3 surgical
Effectiveness procedures CKD
HIV/AIDS
Cancer
Transplantation
COPD
232
I-VTE-2
Measure Details
Reasons and Implications: The vast majority of patients admitted to a critical care
unit (CCU) have a major risk factor for VTE, and many may have multiple risk factors
including advanced age, serious medical illness or recent surgical procedures or
trauma. The use of thromboprophylaxis has been clinically demonstrated to be
efficacious in preventing deep venous thrombosis in these patients.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Data elements:
Data elements:
Admission Date
Birthdate
ICD diagnosis code
ICU discharge date
ICU admission date
ICU admission or Transfer
233
Inclusions to the population: Not applicable
234
I-VTE-2
References
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism:
the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
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.
235
Appendix A
VTE Prophylaxis Inclusion Table
Table 2.1 VTE Prophylaxis Inclusion Table
236
Table 2.1 VTE Prophylaxis Inclusion Table
237
Table 2.1 VTE Prophylaxis Inclusion Table
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
VTE Prophylaxis Inclusion/Synonyms
238
Heparin
Heparin Calcium
Heparin Leo
Heparin Na
Heparin Sod
Heparin Sodium
Heparin Sodium Inj.
Heparin Sodium Inj. Pork
Heparin Subcu/SQ/SC
Liquaemin
Low Molecular Weight Ardeparin
Heparin (LMWH) Dalteparin
Danaparoid
Enoxaparin
Fragmin
Innohep
Lovenox
Normiflo
Orgaran
Tinzaparin
239
Appendix B
ICD Codes
VTE
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.
240
Table 7.04 VTE Obstetrics
241
ICD-8 ICD-9 ICD-10 ICD-9- Shortened Description
CM
Code Code Code Code
242
Glossary
243
Glossary
A
Accreditation
Determination by Joint Commission International (JCI) accrediting body that an eligible
health care organization complies with applicable JCI standards (JCI)
Accreditation process
A continuous process whereby health care organizations are required to demonstrate to
JCI that they are providing safe, high-quality care, as determined by compliance with
JCI standards and International Patient Safety Goals recommendations. The key
component of this process is an on-site evaluation of an organization by JCI surveyors.
(JCI)
Accuracy of data
The extent to which data are free of identifiable errors.
Allowable value
A list of acceptable responses for a data element.
Ambulatory care
2011 Joint 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 patients 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 patients descent
to the floor or in some manner attempting to break the patients 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 patients 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.
245
Certification
1. The procedure and action by which an organization evaluates and
certifies that an individual, institution, or program meets requirements
such as standards. Certification differs from accreditation in that
certification can also be applied to individuals (for example, a medical
specialist). (CCPC)
2. The process by which a nongovernment agency or association certifies
that an individual has met predetermined qualifications specified by
that agency or association.
Certification review
An evaluation of a clinical care program to assess its level of compliance with
applicable Joint Commission International standards and to make determination about
its certification status. The evaluation includes assessing documentation, reviewing
performance measurement reports, gathering verbal information, making on-site
observations, and educating and consulting with the program about standards
compliance and performance improvement. (CCPC)
Cesarean Section
Surgical delivery of a fetus through incision in the abdominal wall and the uterine wall,
Does not include removal of the fetus from the abdominal cavity in case of rupture of the
uterus or abdominal pregnancy.
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.)
Contraindication
A factor or condition that may render the administration of a drug or agent or the
performance of a procedure or other practice inadvisable, improper, and/or undesirable.
Continuity
The degree to which the care for the patient is coordinated among practitioners, among
organizations and over time.
Controllers
Controllers are long term control medication for asthma. Controllers reduce airway
inflammation and prevent asthma exacerbations. Inhaled corticosteroids are the
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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 Element
A discrete piece of data, such as patients 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 administrative data, encounter form,
medical records).
Defined measure
A structured measure with defined populations that measures specific events or values;
such as may have numerators and denominators, take the form of a continuous
variable, or result from review questions. (CCPC)
Denominator
The lower portion of a fraction used to calculate a rate, proportion, or ratio. Also the
population for a rate-based measure.
Denominator Specifications
An explanation of the denominator description that consists of included population,
excluded populations, data elements, and corresponding data sources.
Denominator Statement
A statement that depicts the population evaluated by the performance measure.
248
Denominator Verification
The extent to which the population of interest is identified through data collection.
Discriminatory Capability
The extent to which an indicator demonstrates variation in performance across health
care organizations.
Domains of Performance
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.
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.
249
Elective Delivery
Delivery of a newborn(s) when the mother was not in active labor or presented with
spontaneous ruptured membranes prior to medical induction and/or cesarean section.
Equitable
Care delivered fairly with consideration to need and no other discriminatory factors
Evidence-based practice
Patient care and treatment grounded in science or published clinical studies over a
longitudinal and progressively rigorous empirical evidence. (CCPC)
Face validity
The preliminary expert-based judgment on the usefulness and relevance of a
performance measure for the purpose for which it is intended.
Fall
An unplanned descent to the floor (or extension of the floor, e.g., trash can or other
equipment) with or without injury to the patient.
Focus of indicator
The activity or area that the measure addresses. For example, the focus of an indicator
might be monitoring patient response or urinary catheter usage.
250
Health status performance measures
Measures that address the functional well-being of specific populations, both in general
and in relation to specific conditions, demonstrating change over time (for example,
physical functioning, bodily pain, social functioning, mental health.) (CCPC)
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 Organizations list of disease codes. The second part contains procedure codes
independent of the disease codes.
Infection module
A set of evidence-based process indicators designed to prevent postoperative infection
in the surgery patient.
251
areas that provide step-down, intermediate care or telemetry only. Specialty care areas
are also excluded.
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.
Measure set
A unique grouping of carefully selected measures, that when reviewed together, provide
a comprehensive understanding or assessment of a units departments, or
organizations performance. (CCPC)
252
Medical record (data source)
Data obtained from the records or documentation maintained on a patient in any health
care setting. Includes both automated and paper medical record systems.
Nosocomial Infection
An infection acquired by a patient in a health care organization, especially a hospital.
This infection is not present or incubating before admission to a hospital.
Numerator
The upper portion of a fraction used to calculate a rate, proportion or ratio.
Numerator specifications
An explanation of the numerator description that consists of included populations,
excluded populations, data elements, and corresponding data sources.
Numerator Statement
A statement that depicts the portion of the denominator population that satisfies the
conditions of the performance measure to be an indicator event.
Observed rate
The observed rate is the indicator rate that is based on the hospitals 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
253
considered admitted to a health care organization in others, outpatient are considered
registered. (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 patients experience should be coordinated, and grounded in
respectful interactions with care providers that is consistent with the patients values,
expectations and care decisions.
Patient Days
Conceptually, a patient day is 24 hours, beginning the hour of admission
as measured by daily or period censuses. Facilities should use all data available to
them to represent a complete count of the total number of patients per unit, including
"days" of care provided to short stay patients.
Performance measure
A quantitative tool (for example, rate, ratio, index, percentage) that provides an
indication of an organizations 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 organizations performance in relation to a specified process or
outcome. (CCPC)
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. (CCPC)
255
Rate-based (measure)
An aggregate data measure in which the value of each measurement is expressed as a
proportion or as a ratio. In a proportion, the numerator is expressed as a subset of the
denominator (for example, AMI patients who received aspirin within 24 hours before or
after hospital arrival over all AMI patients). In a ratio, the numerator and denominator
measure different phenomena (for example, the number of patients with central lines
who develop infections divided by the number of central line days).
Reliability
The ability of the indicator to accurately and consistently identify the events it was
designed to identify across multiple health settings.
Relevance
The applicability and/or pertinence of the indicator to its users and customers.
Repeat Fall
More than one fall by the same patient in the same month may be
classified as a repeat fall.
Safe
Delivery of care in a manner that minimizes any risk of harm to the patient.
Safety
The degree to which the risk of an intervention and the risk in the care environment are
reduced for the patient and others, including the health care provider.
Sampling Method
Describes the process used to select a sample. Sampling approaches for national
hospital inpatient quality measures are simple random sampling and systematic
256
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. (CCPC)
Stratification
A form of risk adjustment which involves classifying data into strata based on one or
more characteristics, variables, or other categories.
Stratified Measure
A performance measure that is classified into a number of strata to assist in analysis
and interpretation. The overall or un-stratified measure evaluates all of the strata
together. The stratified measure or each stratum consists of a subset of the overall
measure. For example, surgical patients who received a prophylactic antibiotic within
one hour prior to surgical incision is reported as all surgical patients with the appropriate
ICDPrincipal Procedure Code, who received the prophylactic antibiotic within one hour
prior to surgical incision; however, the stratified measure(s) for SCIP-Inf-1 is reported by
the specific ICD Principal Procedure, such as hip arthroplasty (SCIP-Inf-1d).
Stroke (STK)
See definitions for Acute Ischemic Stroke and Acute Hemorrhagic Stroke.
Structure measure
A measure of whether organizational resources and arrangements are in place to
deliver health care (for example, the number of facilities providing a service). (CCPC)
257
Subarachnoid Hemorrhage (SAH)
Non-traumatic abrupt onset of headache or altered level of consciousness that is
associated with blood in the subarachnoid space on CT or a clinical history and exam
consistent with SAH (sudden onset of severe headache or altered level of
consciousness) with xanthochromia and many red blood cells in the cerebrospinal fluid.
Structure measure
A measure of whether organizational resources and arrangements are in place to
deliver health care (for example, the number of facilities providing a service). (CCPC)
Systemic Corticosteroids
Corticosteroids are hormones produced by the adrenal cortex or their synthetic
equivalents and are administered orally or intravenous. Corticosteroids are used to
achieve quick relief of acute or moderate to severe asthma exacerbations. Oral
corticosteroids are also used for long term control of the swelling, inflammation and
mucus production in the airways. Refer to Appendix C, Table 2.15 for a listing of PN
systemic corticosteroid medications or Table 6.3 for a listing of CAC systemic
corticosteroid medications.
Timely
Care delivery that is prompt and provided without delay to mitigate the risk of harm to a
patient.
Timeliness
The degree to which the care is provided to the patient at the most beneficial or
necessary time.
Type of indicator
An explanation of the performance indicators format as to its structure, process, or
outcome.
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, administered for the prevention, amelioration, or treatment of
infectious diseases.
Validation
The process by which the integrity and correctness of data are established. Validation
process can occur immediately after a data item is collected or after a complete set of
data are collected.
Validity
Ability to identify opportunities for improvement in the quality of care; demonstration that
the indicator use results in improvements in outcomes and/or quality of care.
Variation
The differences in results obtained in measuring the same event more than once. The
sources of variations can be grouped into two major classes: common causes and
special causes. Too much variation often leads to waste and loss, such as the
occurrence of undesirable patient health outcomes and increased cost of health
services. (JCI)
259
Selected References:
Babbie, ER, The Practice of Social Research, 2nd edition, Belmont, CA:
Wadsworth Publishing Company, 1979.
Disease-Specific Care Certification Manual, 2nd Edition. Joint Commission on
Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. 2005.
Everitt, BS, The Cambridge Dictionary of Statistics, Cambridge University Press,
1998.
Joint Commission International Accreditation Standards for Hospitals, 4th Edition,
Joint 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 Administrative Data:
Preliminary Validation Results, Quality Review Bulletin, November, 1992, 361-
370.
Lexikon Second Edition, Oakbrook Terrace, IL: Joint 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.
Mosbys 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 Joint Commission, Oakbrook
Terrace, Illinois, current.
2009 Comprehensive Accreditation Manual for Hospitals; The Joint Commission,
Oakbrook Terrace, Illinois, 2008.
Tabers Cyclopedic Medical Dictionary. F.A. Davis Company, Philadelphia, PA.
1997.
260