Center for Performance Sciences, 2001...Vagin al H y sterectomy So urce: IQIP W e i gh t e d M ea n...

Center for Performance Sciences, 2001

International Quality Indicator Project®

Acute Care Indicator Set

Implementation Manual

Implementation Manualν Each indicator chapter contains…

θ Table of Performance Measuresθ Overviewθ Glossary of Termsθ Implementation Rulesθ Formulasθ Displaying Your Dataθ Optional Patient-Level Variablesθ Data Collection Tools

Some Key Concepts

Acute care inpatients

ν Unless otherwise specified, indicators do only apply to acute care inpatients

ν Excluded areθ Patients on psychiatric units/wardsθ Outpatientsθ Emergency room patientsθ Observation status patientsθ Patients in long-term care beds

Indicator and measures

ν Indicators can comprise multiple measuresν A measure is either a rate or a ratioν Submeasures are percentage breakdown of

“parent” measures and one therefore has to participate in all submeasures belonging to a parent measure

Acute Care Indicators

1a. Device-Associated Infections in the ICU

1a. Device-Associated Infections in the ICUν Measures explore

θ Central-line associated bloodstream infectionsθ Ventilator-associated pneumoniasθ Indwelling urinary catheter-associated UTIs

ν May report forθ APICU (all purpose ICU)θ Or

ν CCU (coronary care unit)ν MICU (medical ICU)ν M/S ICU (medical/surgical ICU)ν SICU (surgical ICU)


1a. Device-Associated Infections in the ICUν Device-associated infection

θ An infection in an ICU patient who has had the device in use within 48 hours of onset of the infectionν Must be compelling evidence of association if > 48 hours

θ Infection not present or incubating at time of admission to the ICU

1a. Device-Associated Infections in the ICUν Infection is counted in the month in which it

occursν Measures exclude post-discharge infectionsν Use Centers for Disease Control (CDC)

criteria for infectionsν Facility determines time of count each day

1a. Device-Associated Infections in the ICUν Patient populations not exclusive

θ APICU-mixed population of critically illθ CCU-primarily cardiac, non-surgicalθ MICU-primarily medical, non-cardiacθ M/S ICU-mixed population with medical and/or

surgical conditionsθ SICU-primarily surgical

ν PCUs (progressive care units) are not ICUs

1a. Device-Associated Infections in the ICUν Measures are reported by unit

θ Numerator—number of device-associated infections

θ Denominator—number of device days for that specific device


D ev ice-A s s o ciat ed In fect io n s in t h e A P IC U

2 .0

2 .5

3 .0

3 .5

4 .0

4 .5

5 .0

5 .5

6 .0

6 .5

O c t 0 3 D e c 0 3 F e b 0 4 A p r 0 4 Jun 0 4 A ug 0 4

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evic

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C en t ral L in e-A s s o ciat ed

V en t ilat o r-A s s o ciat ed

C at h et er-A s s o ciat ed


APICU CCU MICU MSICU SICUSource: IQIP, 3Q 2004

0

5

10

15

20R

ate

per 1

000

Indw

elli

ng U

rina

ry C

athe

ter D

ays

Symptomatic Indwelling Urinary Catheter-Associated UTIs



0

50

100

150

200R

ate

per 1

000

Ven

tilat

or D

ays

Ventilator-Associated Pneumonia

1b. Device Use in Intensive Care Units

ν Measures exploreθ Central line useθ Ventilator useθ Indwelling urinary catheter use

ν May report forθ APICU orθ CCU, MICU, M/S ICU, and/or SICU


ν Central line day, ventilator day, or indwelling urinary catheter dayθ Counted if the device is in use at the time of the

count


ν Patient daysθ The sum of the number of days all patient stayed

in an individual ICU during the month ~ same as census days


ν Device “X” use in the “Y”θ Numerator— number of device days for that

specific deviceθ Denominator— number of patient days for that

specific ICU


D e v ic e U se in t h e A P I C U

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0


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C e n t r a l L in e

Ve n t ila t o r

I n dwe llin g U r in a r y C a t h e t e r



0

20

40

60

80

100R

ate

per 1

00 In

patie

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ays

Indwelling Urinary Catheter Use



0

20

40

60

80

100R

ate

per 1

00 In

patie

nt D

ays

Ventilator Use

2a. Surgical Site Infections

ν Measures explore site infections forθ CABG ~ chest incision onlyθ CABG ~ chest and donor siteθ Hip arthroplastyθ Knee arthroplastyθ Abdominal hysterectomy


ν Risk-stratified using NNISθ Score of 0 to 3 based on

ν ASA class assignment > P3?ν Wound dirty or contaminated?ν Operation lasting more the “T” hours?

ν Measures reported by procedure and NNIS score


Elements Patient X Patient Y

ASA Class III (1 point) IV (1 point)

Operation > “T” hours

No (0 point) Yes (1 point)

Wound Class Clean (0 point) ______________

Dirty (1 point) ______________

Risk Index Category

1

3


ν Surgical site infections for procedure “X” with NNIS Risk Index score “Y”θ Numerator— number of surgical site infections for

“X” procedures with NNIS Risk Index “Y”θ Denominator— number of “X” procedures with

NNIS Risk Index “Y”


0 20 40 60 80 100Source: IQIP, 3Q 2004

0

50

100

150

200

250

Num

ber

of R

epor

ting

Hos

pita

ls

Infection Rates per 100 Inpatients w/NNIS Risk Index 1, Hip Arthroplasty

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Measures explore prophylaxis for

θ CABG ~ chest incision onlyθ CABG ~ chest and donor siteθ Hip arthroplastyθ Knee arthroplastyθ Appendectomyθ Abdominal hysterectomyθ Vaginal hysterectomy

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Antiobiotic prophylaxis

θ Prophylaxis within 30 minutes prior to incisionθ Prophylaxis within 1 hour prior to incisionθ Prophylaxis within 2 hours prior to incisionθ Prophylaxis for 24 hours or less

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Prophylactic antibiotic

θ Administered as a preventative with no prior knowledge or suspicion of infection

ν Therapeutic antibioticθ Administered to treat an infection

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Measures apply to both inpatients and

outpatients who undergo any of the specified procedures

ν Patients who die perioperatively and who received prophylaxis should be counted in numerator and denominator for the specified procedure

ν Measures reported by procedure

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Prophylaxis for procedure “X”

θ Numerator— number of “X” procedure patients receiving prophylaxis

θ Denominator— number of patients undergoing “X” procedure

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Prophylaxis within 30 minutes, 1 hour, or 2

hours prior to incisionθ Numerator— number of “X” procedure patients

who received prophylaxis within 30 minutes or 2 hours prior to incision

θ Denominator— number of “X” procedure patients receiving prophylaxis

2b. Antiobiotic Prophylaxis for Surgical Proceduresν Prophylaxis for 24-hours or less

θ Numerator— number of “X” procedure patients who received prophylaxis for 24 hours or less perioperatively

θ Denominator— number of “X” procedure patients receiving prophylaxis

2b. Antiobiotic Prophylaxis for Surgical Procedures

A n t ibio t ic P r o p h y la x is f o r Sur gic a l P r o c e dur e s

8 0

8 5

9 0

9 5

1 0 0


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C A B G H ip A r t h ro p las t yK n ee A rt h ro p las t y A p p en d ect o m yA b d o m in al H y s t erect o m y V agin al H y s t erect o m y


A n t ib io t ic P ro p h y laxis fo r Su rgical P ro ced u res fo r a D u rat io n < = 2 4 H o u rs , 3 Q 2 0 0 4

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

C A B G H ip A r t h r o p la st y K n e eA r t h r o p la st y

A p p e n de c t o m y A bdo m in a lH y st e r e c t o m y

Va gin a lH y st e r e c t o m y

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A n t ib io t ic P ro p h y laxis fo r Su rgical P ro ced u res 3 0 M in u t es P rio r t o In cis io n , 3 Q 2 0 0 4

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

C A B G H ip A r t h r o p la st y K n e eA r t h r o p la st y

A p p e n de c t o m y A bdo m in a lH y st e r e c t o m y

Va gin a lH y st e r e c t o m y

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3. Inpatient Mortality

ν Measures exploreθ Total inpatient mortalityθ Inpatient mortality by specific DRG category

ν Encouraged but not required to report inpatient deaths in all eleven DRG categories


ν DRG 014 CVAν DRG 079 Respiratory infectionsν DRG 088 COPDν DRG 089 Pneumoniaν DRG 127 Heart failure/shockν DRG 174 GI hemorrhage


ν DRG 316 - Renal failureν DRG 416 – Septicemiaν DRG 475 – Respiratory diagnosis/ ventilatory

supportν DRG 489 - HIV/major related conditionν XXX - All other DRGs


ν Availability of crosswalk for DRGs toθ ICD-9 codesθ ICD-10 codes

ν Should be address in manual and software translations


ν Total inpatient mortalityθ Numerator— number of inpatient deathsθ Denominator— number of inpatient discharges


ν Total inpatient mortality by DRGθ Numerator— number of inpatient deaths for the

specified DRGθ Denominator— number of inpatient discharges for

the specified DRG


T o t al A cu t e C are In p at ien t M o rt alit y

0 .0

0 .5

1 .0

1 .5

2 .0

2 .5

3 .0

3 .5

4 .0

A p r 0 3 Jun 0 3 A ug 0 3 O c t 0 3 D e c 0 3 F e b 0 4 A p r 0 4 Jun 0 4 A ug 0 4

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U SA E u ro p e A s ia


DRG 14 79 88 89 127 174 316 416 475 489Source: IQIP, 3Q 2004

0

20

40

60

80

100R

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per 1

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arge

sInpatient Mortality by DRG

4. Neonatal Mortality

ν Measures exploreθ Neonatal mortality of direct admissionsθ Neonatal mortality of transfers-in (your facility

provides a higher level of care)


ν Risk-stratified by birth weight categoriesν Neonate— live birth through day 28


ν Birth weight categoriesθ < 750 gramsθ 751 to 1,000 gramsθ 1,001 to 1,800 gramsθ > 1,801 grams


ν Direct admissions includeθ Live birthsθ Inpatient neonatal admissionsθ Neonatal admissions of births out of asepsis

(BOA)


ν Direct admissions includeθ Neonatal readmissionsθ Neonates transferred from a facility with a higher

level of care to your facility


ν Death is counted in the month in which it occurs

ν Measures are reported by birth weight category


ν Neonatal mortality for direct admissionsθ Numerator— number of neonatal deaths of direct

admissions by birth weight “X”θ Denominator— number of neonatal direct

admissions with birth weight “X”


ν Neonatal mortality for transfers-inθ Numerator— number of neonatal transfers-in

deaths with birth weight “X”θ Denominator— number of transfers-in with birth

weight “X”

4. Neonatal MortalityNeonatal Mortality by Admission Status and Birth Weight, 3Q 2004

0

5

10

15

20

25

30

35

40

45

50

4.1 4.2 4.3 4.4 4.5 4.6 4.7 4.8

Source: IQIP

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In

Measure ID

5. Perioperative Mortality

ν Measures exploreθ Total perioperative mortality for all ASA classesθ Perioperative mortality for a specific ASA class—

P1 through P5


ν Perioperative mortalityθ Death of any patient who has had an inpatient

anesthesia episode and dies at the same hospital within 48 hours of time noted in medical record for induction of anesthesia


ν Inpatient anesthesia episode is an occasion when an inpatientθ is assigned an ASA classθ receives anesthesia from Anesthesia staffθ undergoes one or more inpatient operative

procedures within the ICD-9-CM ranges of 01.0 to 86.99


ν At the time of death, individuals having undergone an inpatient anesthesia episode may beθ Inpatientsθ Outpatientsθ ED patients

ν Individuals receiving sedation and analgesia are excluded


ν Individuals who die during the inpatient anesthesia episode should be included if they satisfy definitions and rules

ν Neonates and obstetrical inpatients should be included if they satisfy definitions and rules


ν Total perioperative mortality for all ASA classesθ Numerator— number of perioperative deaths for all

ASA classesθ Denominator— number of inpatient anesthesia

episodes for all ASA classes


ν Perioperative mortality by ASA classθ Numerator— number of perioperative deaths for

ASA class “X”θ Denominator— number of inpatient anesthesia

episodes for ASA class “X”


P erio p erat iv e M o rt alit y , A SA 3 an d A SA 4

0 .0

0 .2

0 .4

0 .6

0 .8

1 .0

1 .2

1 .4

1 .6

1 .8

2 .0


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A SA 3

A SA 4


ASA 1 ASA 2 ASA 3 ASA 4 ASA 5Source: IQIP, 3Q 2004

0

20

40

60

80

100R

ate

per 1

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nesth

esia

Epi

sode

s

Perioperative Mortality by ASA Class

6. C-Sections and Management of Labor

ν C-sectionθ The removal of a fetus by means of an incision

into the uterus

ν VBACθ A vaginal birth after previous C-section


ν Trial of laborθ An instance when a purposeful attempt is made to

allow active labor to develop and proceed so that a vaginal delivery can take placeν Drugs may or may not be usedν Active labor does not have to be established


ν Multiple deliveries count as a single birthν Multiple deliveries involving both vaginal and

C-section are counted as C-sectionsν Stillborns are excluded— whether delivered

vaginally or by C-section


ν Primary C-sectionθ Numerator— number of primary C-sectionsθ Denominator— number of deliveries minus

(number of repeat C-sections + number of VBACs)


ν Repeat C-sectionθ Numerator— number of repeat C-sectionsθ Denominator— (number of repeat C-sections +

number of VBACs)


ν Total C-section frequencyθ Numerator— number of C-sectionsθ Denominator— number of deliveries


ν VBACsθ Numerator— number of VBACsθ Denominator— (number of VBACs + number of

repeat C-sections)


ν Trial of labor successθ Numerator— number of VBACs resulting from a

successful trial of laborθ Denominator— number of previously C-sectioned

women who underwent a trial of labor


Repeat C-Section

60

65

70

75

80

85

90

95

100

Apr 03 Jun 03 Aug 03 Oct 03 Dec 03 Feb 04 Apr 04 Jun 04 Aug 04

Source: IQIP

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the

Den

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USA Project-Wide

Europe Asia


Asia Europe USASource: IQIP, 3Q 2004

30

40

50

60

70

80

90

100R

ate

per 1

00 o

f the

Den

omin

ator

Repeat Cesarean Section



0

10

20

30

40

50

60

70R

ate

per 1

00 o

f the

Den

omin

ator

Vaginal Birth After Cesarean Section (VBAC)



0

20

40

60

80

100R

ate

per 1

00 o

f the

Den

omin

ator

Trial of Labor Success

7. Unscheduled Readmissions

ν Unscheduled readmissionsθ An inpatient readmission to the same facility for

the same or a related condition that was not scheduled at the time of the previous discharge


ν DRG 079-Respiratory infections & inflammations

ν DRG 088-COPDν DRG 089-Simple pneumoniaν DRG 127-Heart failure & shockν DRG 140 to143-Angina, chest pain


ν Readmission intervalsθ 0 to 15 daysθ 0 to 31 days

ν HCFA DRGs are usedν DRGs represent five of the most frequent

reasons for unscheduled readmission


ν Availability for crosswalks from DRGs toθ ICD-9θ ICD-10

ν Translations should be addressed in manual and software translation


ν Time frames are not mutually exclusiveν Chronic conditions are included within the

scope of these measuresν Neonates discharged as a normal newborn

should be included in the denominatorν Day count begins with the day of discharge


ν Unscheduled readmissions within 15 and/or 31 daysθ Numerator— number of unscheduled

readmissions within “X” daysθ Denominator— number of inpatient discharges


ν Unscheduled readmissions within “X” days for DRG “Y”θ Numerator— number of unscheduled

readmissions within “X” days for DRG “Y” or a related condition

θ Denominator— number of discharges for DRG “Y”


Oct 03 Dec 03 Feb 04 Apr 04 Jun 04 Aug 04

Source: IQIP

0

5

10

15

20

25R

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per 1

00 In

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sUnscheduled Acute Care Readmissions within 31 Days


DRG 79 88 89 127 140/143Source: IQIP, 3Q 2004

0

20

40

60

80

100

Rat

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Inpa

tient

Day

sUnscheduled Readmissions Within 31 Days by DRG

8. Unscheduled Admissions Following Ambulatory Proceduresν Unscheduled admission

θ An admission to the same facility either as an inpatient or for observation that was not scheduled at the time of the procedureν Must occur within 48 hours of the elective procedure

performed at facility or freestanding surgical center that is facility-owned or operated

8. Unscheduled Admissions Following Ambulatory Proceduresν Ambulatory procedure patient

θ An outpatient undergoing an elective operative procedure within the ICD-9-CM code range of 01.0 to 86.99 in . . .ν An ambulatory surgery suiteν Another designated area of a facilityν A freestanding surgical center that is hospital-owned or

operated

8. Unscheduled Admissions Following Ambulatory Proceduresν Admission following an ambulatory procedure

may result from procedure findingsθ Considered unscheduled unless it is documented

prior to the procedure that an admission might occur

ν Individuals undergoing multiple procedures are counted only once

8. Unscheduled Admissions Following Ambulatory Proceduresν Ambulatory procedure categories

θ Cardiac catheterization proceduresθ Digestive, respiratory, and urinary system

diagnostic endoscopic proceduresθ All other general operative procedures 01.0

through 86.99 except those above

8. Unscheduled Admissions Following Ambulatory Proceduresν Unscheduled admissions following procedure

“X”θ Numerator— number of unscheduled admissions

(inpatient and observation) following procedure “X”

θ Denominator— number of ambulatory procedure patients undergoing procedure “X”

8. Unscheduled Admissions Following Ambulatory Proceduresν Unscheduled inpatient admissions following

procedure “X”θ Numerator— number of unscheduled inpatient

admissions following procedure “X”θ Denominator— number of unscheduled

admissions (inpatient and observation) following procedure “X”

8. Unscheduled Admissions Following Ambulatory Proceduresν Unscheduled observation admissions

following procedure “X”θ Numerator— number of unscheduled observation

admissions following procedure “X”θ Denominator— number of unscheduled

admissions (inpatient and observation) following procedure “X”

8. Unscheduled Admissions Following Ambulatory Procedures

U n s ch ed u led A d m is s io n s F o llo w in g D iagn o s t ic E n d o s co p y b y R egio n

0 .0

0 .2

0 .4

0 .6

0 .8

1 .0

1 .2

1 .4

1 .6

1 .8

2 .0


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U SA P ro ject -W id e

E u ro p e A s ia

8. Unscheduled Admissions Following Ambulatory Procedures


Source: IQIP

0

20

40

60

80

100R

ate

per 1

00 D

iagn

ostic

End

osco

py P

roce

dure

sUnscheduled Admissions Following Ambulatory Diagnostic Endoscopy

9. Unscheduled Returns to an Intensive Care Unitν Unscheduled return to an ICU

θ An unexpected return to an Intensive Care Unit during the same inpatient admissionν Unscheduled return may be to the same or to another

ICU

9. Unscheduled Returns to an Intensive Care Unitν Transfers-out

θ The movement from an ICU to a lower level of careν PCUν General med/surg, OB, or pediatric bedν PACUs (post anesthesia care unit)

9. Unscheduled Returns to an Intensive Care Unitν Excluded are

θ NICUs (neonatal ICU)θ Burn ICUsθ Neurotrauma ICUsθ PICUs (pediatric ICU)

ν Units serve a specialized subpopulation— not typical of the general critically ill population

9. Unscheduled Returns to an Intensive Care Unitν Exclude patients who die in an ICU from the

denominatorν Exclude returns from non-acute care beds

from the numerator

9. Unscheduled Returns to an Intensive Care Unitν Unscheduled returns to ICUs

θ Numerator— number of unscheduled returns to ICUs

θ Denominator— number of transfers-out from ICUs

9. Unscheduled Returns to an Intensive Care Unit


Source: IQIP

0

20

40

60

80

100R

ate

per 1

00 T

rans

fers

-Out

from

ICU

sProject-Wide - Unscheduled Returns to Intensive Care Units

9. Unscheduled Returns to an Intensive Care Unit


Source: IQIP

0

5

10

15

20R

ate

per 1

00 T

rans

fers

-Out

from

ICU

sEurope- Unscheduled Returns to Intensive Care Units

10. Unscheduled Returns to the Operating Roomν Unscheduled return

θ A return to the OR during the same inpatient admission for complications or untoward outcomes related to a prior inpatient operative procedure performed in the OR

θ Return not scheduled at the time of the prior operative procedure

10. Unscheduled Returns to the Operating Roomν Inpatient trip to the OR

θ Any trip to the OR where one or more procedures within ICD-9-CM code range of 01.0 through 86.99 are performed on an inpatient

10. Unscheduled Returns to the Operating Roomν It is assumed operative procedures are not

undertaken without some expectation of success and that additional or staged surgical procedures would be identified at the time of the prior procedureθ This measure doesn’t address likelihood for

complications or possibility of failure

10. Unscheduled Returns to the Operating Roomν Count the number of inpatient returns rather

than the number of inpatientsν Returns for organ procurement are not

included

10. Unscheduled Returns to the Operating Roomν Unscheduled returns during which the patient

dies are only counted in the numeratorν One trip to the OR may include multiple

procedures done at the same time

10. Unscheduled Returns to the Operating Roomν Unscheduled returns to the OR

θ Numerator— number of unscheduled inpatient returns to the OR

θ Denominator— number of inpatient trips to the OR

10. Unscheduled Returns to the Operating Roomν Unscheduled returns to the operating room with prior peripheral

vascular proceduresθ 38.12 Endarterectomy – head or neckθ 38.44 Resection of vessel with replacement – aorta abdominalθ 38.7 Interruption of vena cavaθ 39.29 Other (peripheral bypass)θ 39.49 Other revision of vascular procedureθ 39.50 Angioplasty or artherectomy of non-coronary vesselθ 39.71 Endovascular implantation of graft in abdominal aorta

10. Unscheduled Returns to the Operating Roomν Unscheduled returns to the operating room with prior cardio-thoracic procedures

θ 35.22 Other replacement of aortic valveθ 36.01 Single vessel percutaneous transluminal coronary angioplasty or coronary

atherectomy without mention of thrombolytic agentθ 36.05 Multiple vessel percutaneous transluminal coronary angioplasty or coronary

atherectomy performed during the same operation, with or without mention ofthrombolytic agent

θ 36.11 Aortocoronary bypass of one coronary arteryθ 36.12 Aortocoronary bypass of two coronary arteriesθ 36.13 Aortocoronary bypass of three coronary arteriesθ 36.14 Aortocoronary bypass of four or more coronary arteriesθ 36.15 Single internal mammary-coronary artery bypassθ 37.94 Implantation or replacement of automatic cardioconverter/defibrillator, total

system [AICD]

10. Unscheduled Returns to the Operating Room


Source: IQIP

0

10

20

30

40R

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per 1

00 In

patie

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rips

to th

e O

pera

ting

Roo

mProject-Wide - Unscheduled Returns to the Operating Room

10. Unscheduled Returns to the Operating Room


Source: IQIP

0

2

4

6

8

10R

ate

per 1

00 In

patie

nt T

rips

to th

e O

pera

ting

Roo

mEurope- Unscheduled Returns to the Operating Room

11. Isolated CABG PerioperativeMortalityν Isolated CABG perioperative death

θ The death of any patient who has undergone an isolated CABG procedure and who dies within 48 hours of induction of anesthesia during the same inpatient admission

11. Isolated CABG PerioperativeMortalityν Isolated CABG procedure

θ A CABG procedure during which no other cardiac-associated procedure is performed

11. Isolated CABG PerioperativeMortalityν Facilities must report on all ASA classes to

participate in this measureν Heart-port access CABG surgery is included

even though there is, at present, no associated ICD-9-CM code

11. Isolated CABG PerioperativeMortalityν Facilities report observed perioperative

mortality for each ASA classθ QI Project® calculates the expected perioperative

mortality for each ASA class

11. Isolated CABG PerioperativeMortalityν Observed isolated CABG perioperative

mortality for ASA class “X”θ Numerator— number of ASA class “X”

perioperative deathsθ Denominator— number of ASA class “X” isolated

CABG surgeries

12. Physical Restraint Use

ν Restraintθ A process that restricts an individual from having

free, unimpeded access to their body or which prevents them from moving freely at will within their environment

ν Physical restraint eventθ A discrete instance in which physical restraint is

used


ν Restraint event begins when an individual is first restrained and ends when the use of restraint ceases— regardless of the number of orders or renewalsθ Individuals may experience multiple events in a

24-hour periodθ Individuals may experience a single restraint

event that lasts 24-hours or more


ν Trial release of restraint may not exceed 60 minutes

ν Releases for circulation checks, toileting, or range of motion don’t constitute new events

ν Bed rails not considered restraintν Chemical restraint not recognizedν Neonates are excluded


ν Physical restraint eventsθ Numerator— number of physical restraint eventsθ Denominator— number of patient days


ν Physical restraint events by durationθ Lasting 1 hour or lessθ Lasting > 1 hour but < 4 hoursθ Lasting > 4 hours but < 8 hoursθ Lasting > 8 hours but < 16 hoursθ Lasting > 16 hours but < 24 hoursθ Lasting > 24 hours


ν Physical restraint events by durationθ Numerator— number of physical restraint events

for a specified interval of timeθ Denominator— number of physical restraint events


ν Physical restraint events by reasonθ Cognitive disorderθ Risk of fallingθ Disruptive behaviorθ Facilitate treatmentθ All other reasons


ν Physical restraint events by reasonθ Numerator— number of physical restraint events

by reasonθ Denominator— number of physical restraint events


ν Physical restraint events by time restraint initiatedθ Day (7 a.m. – 2:59 p.m.)θ Evening (3:00 p.m. – 10:59 p.m.)θ Night (11:00 p.m. – 6:59 a.m.)


ν Physical restraint events by time restraint initiatedθ Numerator— number of physical restraint events

initiated between the times of day specifiedθ Denominator— number of physical restraint events


ν Inpatients with one or more physical restraint eventsθ Numerator— number of inpatients experiencing

one or more physical restraint eventsθ Denominator— number of inpatients


ν Patients with two or more physical restraint eventsθ Numerator— number of inpatients experiencing

two or more physical restraint eventsθ Denominator— number of inpatients experiencing

one or more physical restraint events


ν Physical restraint hoursθ Numerator-Number of acute care physical hoursθ Denominator-Number of acute inpatient care days

(converted into hours by the software)


U s e o f P h y s ical R es t ra in t b y D u rat io nP ro ject -W id e W eigh t ed M ean R at es (So u rce: IQ IP , 3 Q 2 0 0 4 )

> 8 an d < = 1 6 H o u rs> 2 4 H o u rs

> 1 6 an d < = 2 4 H o u rs

> 4 an d < = 8 H o u rs

> 1 an d < = 4 H o u rs

< = 1 H o u r


U s e o f P h y s ical R es t ra in t b y R eas o nP ro ject -W id e W eigh t ed M ean R at es (So u rce: IQ IP , 3 Q 2 0 0 4 )

t o facilit a t e t reat m en t

co gn it iv e d is o rd er

r is k o f fa llin g

d is ru p t iv e b eh av io r

all o t h er reas o n s


U s e o f P h y s ical R es t ra in t b y T im e o f In it ia t io nP ro ject -W id e W eigh t ed M ean R at es (So u rce: IQ IP , 3 Q 2 0 0 4 )

7 :0 0 A M t o 2 :5 9 P M

3 :0 0 P M t o 1 0 :5 9 P M

1 1 :0 0 P M t o 6 :5 9 A M

13. Documented Falls

ν Fallsθ An unplanned movement of a patient to the

ground or from one plane to another

ν Documented fallsθ A fall that is recorded in the patient’s medical

record, in an incident report, a risk management report, or in some other official organizational record


ν Documented fallsθ Numerator— number of documented fallsθ Denominator— number of patient days


ν Documented falls by reasonθ Patient’s health statusθ Response to treatment, medication, or anesthesiaθ Environmental hazardθ Other causes


ν Documented falls by reasonθ Numerator— number of documented falls by

specific reasonθ Denominator— number of documented falls


ν Injuryθ A disruption of structure or function of some part

of the body that is the result of a fall


ν Falls resulting in injuryθ Numerator— number of documented falls that

resulted in injuryθ Denominator— number of documented falls


ν Documented falls resulting in injury by severity scoreθ Severity Score 1 (little or no care)θ Severity Score 2 (some med or nursing

intervention)θ Severity Score 3 (clearly require medical

intervention or consultation)


ν Falls resulting in injury by severity scoreθ Numerator— number of documented falls by

specific Severity Scoreθ Denominator— number of documented falls that

resulted in injury


ν Repeat fallsθ Numerator— number of patients with two or more

documented fallsθ Denominator— number of patients with one or

more documented falls


D o cu m en t ed F alls R es u lt in g in In ju ry

0 .0

5 .0

1 0 .0

1 5 .0

2 0 .0

2 5 .0

3 0 .0

3 5 .0

4 0 .0

4 5 .0

5 0 .0


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Source: IQIP

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1.0

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Europe- Documented Falls



Source: IQIP

0

20

40

60

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llsEurope- Inpatients with Two or More Documented Falls

14a-14e. Sedation and Analgesia in the “X”ν Sedation and analgesia monitored by

location— not procedureν Locations

θ 14a— Intensive Care Unitsθ 14b— Cardiac Cath Labsθ 14c— Endoscopy Suitesθ 14d— Emergency Departmentθ 14e— Radiology Suite

14a-14e. Sedation and Analgesia in the “X”ν Sedation and analgesia

θ A state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation

14a-14e. Sedation and Analgesia in the “X”ν Sedation and analgesia episode

θ An occasion during which a patient undergoes one or more procedures while receiving medications administered by non-anesthesia staff that result in sedation and analgesia

14a-14e. Sedation and Analgesia in the “X”ν Not the specific meds administered but the

physiologic state produced by their administration

ν Because of the limited duration of sedation and analgesia, adverse events related to S&A must occur within 12-hours of administration of the last dose of medication

14a-14e. Sedation and Analgesia in the “X”ν Because of differences in use, administration

and other associated risk factors, patients <12 years or age are excluded

ν Measures apply equally to outpatients, observation status patients, or inpatients provided they receive S&A in the specified location

14a-14e. Sedation and Analgesia in the “X”ν Preoperative medications do not count as

sedation and analgesiaν Only adverse outcomes related to sedation

and analgesia should be included— adverse events related to the procedure itself are excluded

14a-14e. Sedation and Analgesia in the “X”ν An adverse event to sedation and analgesia

may produce a variety of responses and be counted in more than one measure

14a-14e. Sedation and Analgesia in the “X”ν Sedation and analgesia and ASA

assessmentθ Numerator— number of sedation and analgesia

episodes for each ASA class or without an ASA classification

θ Denominator— number of sedation and analgesia episodes

14a-14e. Sedation and Analgesia in the “X”ν Measurement of oxygen saturation

θ Numerator— number of sedation and analgesia episodes with documented oxygen saturation


14a-14e. Sedation and Analgesia in the “X”ν Mild oxygen desaturation

θ Numerator— number of sedation and analgesia episodes where mild oxygen desaturation occurred (90% to 94%)

θ Denominator— number of sedation and analgesia episodes with documented oxygen saturation

14a-14e. Sedation and Analgesia in the “X”ν Severe oxygen desaturation

θ Numerator— number of sedation and analgesia episodes where severe oxygen desaturation occurred (< 90%)

θ Denominator— number of sedation and analgesia episodes with documented oxygen saturation

14a-14e. Sedation and Analgesia in the “X”ν Aspiration

θ Numerator— number of sedation and analgesia episodes where aspiration occurred


14a-14e. Sedation and Analgesia in the “X”ν Airway obstruction

θ Numerator— number of sedation and analgesia episodes where airway obstruction occurred


14a-14e. Sedation and Analgesia in the “X”ν Drop in systolic blood pressure

θ Numerator— number of sedation and analgesia episodes where a drop in systolic blood pressure of > 20 percent occurred


14a-14e. Sedation and Analgesia in the “X”ν Use of reversal agents

θ Numerator— number of sedation and analgesia episodes where reversal agents were used


14a-14e. Sedation and Analgesia in the “X”ν Involvement of anesthesia staff

θ Numerator— number of sedation and analgesia episodes where involvement of anesthesia staff occurred


14a-14e. Sedation and Analgesia in the “X”ν Unintentional loss of consciousness

θ Numerator— number of sedation and analgesia episodes with an Aldrete Score of zero


14a-14e. Sedation and Analgesia in the “X”

M eas u rem en t o f O xy gen Sat u rat io n b y L o cat io n , 3 Q 2 0 0 4

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

1 0 0

I n t e n siv e C a r eU n it s

C a r dia c C a t h L a bs E n do sc o p y Suit e s E m e r ge n c yD e p a r t m e n t s

R a dio lo gy Suit e s

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15. Pressure Ulcers in Acute Inpatient Careν Total PU point prevalence

θ By stateν Patients admitted with PU

θ By stageθ By admission source

ν PU incidenceθ By PU location

ν Total muptiple PU incidence

15. Pressure Ulcers in Acute Care

ν Pressure ulcer point prevalence: number of pressure ulcers present in a specified population at a specified point in time

ν Data Collection Processθ A single day each monthθ Same consistent nursing shift


ν Pressure Ulcer Point Prevalenceθ Numerator— Number of acute care inpatients with

one or more pressure ulcers of any stage on the day of the count

θ Denominator— Number of acute care inpatients on the day of the count


ν Ulcers are staged based on degree of tissue damage θ Stage I: nonblanching erythemaθ Stage II: partial thickness skin lossθ Stage III: full thickness skin loss down to, but not

through, underlying fasciaθ Stage IV: full thickness with extensive destruction

and damage to muscle, etc.


ν Stage “X” pressure ulcer point prevalenceθ Numerator— Number of acute care inpatients with

one or more stage “x” pressure ulcers on the day of the count

θ Denominator— Number of acute care inpatients on the day of the count


ν Pressure ulcers cannot be “reverse staged” or “back staged”

ν Accurate staging of pressure ulcers is not possible when eschar is present


ν Inpatients with multiple pressure ulcers should be reported once in each of the applicable point prevalence PU measures


ν Example: A patient with one Stage II ulcer and one Stage III ulcer should be reported as followsθ Once in the total prevalence measureθ Once in the Stage II measureθ Once in the Stage III measure


ν Patients with pressure ulcers admitted to acute inpatient careθ Stage Iθ Stage IIθ Stage IIIθ Stage IV

ν Denominator: number of acute care inpatient admissions


ν A patient has two stage I and one stage III PUs

ν We count the patient once in the overall rage, once in the stage I and once in the respective stage III measures, since we are counting patients with PUs, not the number of PUs.


ν Patients with PUs admitted to acute inpatient care by admission sourceθ Homeθ Nursing facilitiesθ Another hospitalθ Other admission source

ν Denominator: acute inpatient care admissions


ν One patient can only be admitted from one admission source

ν A patient with one PU stage 2 admitted from a nursing home would be countedθ In the overall rate for patients admitted with a pressure

ulcer 15.6θ In the rate for patients admitted with one or more stage I

PUs 15.7θ In the rate for patients admitted with one or more PUs from

home 15.11


ν PU incidence in acute inpatient care θ Overall measure

ν Sacralν Ischialν Trochanterianν Calcanealν Malleolarν Scapularν Occipital ν Other

θ Denominator: Number of acute care inpatient days


ν Total multiple PU incidence in acute inpatient care (ratio)θ Numerator: inpatients developing two ore more

pressure ulcers during the same inpatient admission

θ Denominator: inpatients developing one more pressure ulcers during the same inpatient admission


ν A patient developing a sacral and and an ischial PU would be countedθ In the overall measure 15.15θ In the sacral measure 15.16θ In the ischial measure 15.17θ In the multiple pressure ulcers incidence measure

15.24


P at ien t s w it h O n e o r M o re P res s u re U lcers b y A d m is s io n So u rce

0 .0

0 .2

0 .4

0 .6

0 .8

1 .0

1 .2

H o m e N ur sin g F a c ilit y A n o t h e r H o sp it a l O t h e r

So ur c e : I Q I P , 3 Q 2 0 0 4

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s


P res s u re U lcer In cid en ce b y L o cat io n o f U lcer

0 .0 0

0 .0 1

0 .0 2

0 .0 3

0 .0 4

0 .0 5

0 .0 6

S acral

Is ch ia l Bon e

T roc h an

te r ian

C al can e al

Mall

eola r

S cap u l ar

O cci pita

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O th er

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Source: IQIP

0

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10

15

20R

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Total Pressure Ulcer Point Prevalence


Oct 03 Dec 03 Feb 04 Apr 04 Jun 04 Aug 04Source: IQIP

0

2

4

6

8R

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per 1

00 In

patie

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dmis

sion

sPatients with Pressure Ulcers Admitted to Acute Care



Source: IQIP

0.0

0.2

0.5

0.8

1.0

1.2

1.5R

ate

per 1

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Total Pressure Ulcer Incidence in Acute Care

16a Deep Vein Thrombosis and Pulmonary Thromboembolism Following Surgery

ν DVT and PE following surgeryθ Overall measureθ CABGθ Hip arthroplastyθ Knee arthroplastyθ Abdominal hysterectomyθ Colon surgery

16a Deep Vein Thrombosis and Pulmonary Thromboembolism Following Surgery

ν Numerator: Number of inpatient operative cases developing DVT/PE following “type” surgery

ν Denominator: Number of inpatient operative cases undergoing “type” surgery

16b Thromboprophylaxis for Surgery

ν CABGν Hip arthroplastyν Knee arthroplastyν Abdominal hysterectomyν Colon surgery


ν Numerator: Number of inpatient operative cases receiving thromboprophylaxis for “type” surgery

ν Denominator: Number of inpatient operative cases undergoing a “type” surgery


ν Thromboprophylaxisθ Warfarinθ Factor Xa inhibitors such as Fondaparinuxθ Low dose unfractionated Heparin (LDUH)θ Low molecular weight Heparin (LMWH) such as bemiparin,

certoparin, dalteparin, enoxaparin, reviparin, or tinzaparinθ Elastic stockingsθ Inferior vena cava (IVC) filter

ν Aspirin alone does not qualify as thromboprophylaxis.

A1. Unscheduled Returns to the Emergency Department

A1. Unscheduled Returns to the Emergency Departmentν Unscheduled return

θ An unexpected return to the same ED, within the specified time frame, for the same or a related problem that was treated in a prior ED visit or a return to the ED, arranged after the patient was discharged from the ED

A1. Unscheduled Returns to the Emergency Departmentν Registered patient

θ An individual who presents for ED services and who has completed the process that establishes an official record as an ED patient

θ Process may be manual or electronic

A1. Unscheduled Returns to the Emergency Departmentν Six time frames

θ Unscheduled returns within 0 to 24 hoursθ Unscheduled returns within 0 to 48 hoursθ Unscheduled returns within 0 to 72 hoursθ Unscheduled returns within 7 daysθ Unscheduled returns within 14 daysθ Unscheduled returns within 30 days

A1. Unscheduled Returns to the Emergency Departmentν Submeasures for those six timeframes: ν Dispositions following an unscheduled return

θ a. resulting in inpatient admissionθ b. resulting in observation admission


ν A1.7 Patients with two or more unscheduled returns to the ED within 30 days (ratio)

ν Numerator: Number of patients with two or more unscheduled returns to the ED within 30 days

ν Denominator: Number of patients with one or more unscheduled returns to the ED within 30 days

A1. Unscheduled Returns to the Emergency Departmentν Apply only to registered ED patientsν Applies to all ED licensed beds

θ Fast Trackθ Express Care

ν Time frames aren’t mutually exclusive

A1. Unscheduled Returns to the Emergency Departmentν Standard injunction to ‘return if you are not

better’ is not a scheduled return

A1. Unscheduled Returns to the Emergency Departmentν Special considerations

θ Psychiatric or substance abuse patients registered in the ED

θ Patients having had an ED visit who return DOA or who die in the ED

θ Elopements or AMA

A1. Unscheduled Returns to the Emergency Departmentν Unscheduled returns within “X”

θ Numerator— number of unscheduled returns to the ED within “X”

θ Denominator— number of ED visits

A1. Unscheduled Returns to the Emergency Departmentν Unscheduled returns within “X” resulting in an

inpatient admissionθ Numerator— number of inpatient admissions

following an unscheduled return to the ED within “X”

θ Denominator— number of unscheduled returns to the ED within “X”

A1. Unscheduled Returns to the Emergency Departmentν Unscheduled returns within “X” resulting in an

observation admissionθ Numerator— number of observation admissions

following an unscheduled return to the ED within “X”

θ Denominator— number of unscheduled returns to the ED within “X”


U n s ch ed u led R et u rn s t o t h e E D w it h in 7 2 H o u rs

0

1

2

3

4

5

6

7

8


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E u ro p e A s ia


Asia USASource: IQIP, 3Q 2004

0

2

4

6

8R

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Unscheduled Returns to the ED within 72 Hours

A2. Length of Stay in the Emergency Department

A2. Length of Stay in the Emergency Departmentν Length of stay (LOS)

θ The total time that a registered patient spends in the ED, measured from the time the patient is registered until the time the patient physically leaves the ED— regardless of disposition

A2. Length of Stay in the Emergency Departmentν Registered patient



A2. Length of Stay in the Emergency Departmentν Length of stay intervals

θ Length of stay < 2 hoursθ Length of stay > 2 hours but < 4 hoursθ Length of stay > 4 hours but < 6 hoursθ Length of stay > 6 hours

A2. Length of Stay in the Emergency Departmentν Disposition options within each interval

θ Discharged homeθ Admitted as an inpatientθ Transferred to observation statusθ Transferred to another acute care facility

A2. Length of Stay in the Emergency Departmentν Disposition options within each interval

θ All other dispositionsν Includes deaths, elopements, AMA and transfers to non-

acute care facilities

A2. Length of Stay in the Emergency Departmentν Applies to all registered ED patients

θ Psychiatric patientsθ Alcohol/substance abuse patientsθ Fast track or express care patientsθ Patients who die in the ED

A2. Length of Stay in the Emergency Departmentν Length of stay

θ Numerator— number of registered ED patients with a LOS of “X”


A2. Length of Stay in the Emergency Departmentν Length of stay (by disposition)

θ Numerator— number of registered ED patients with a LOS of “X” with disposition “Y”

θ Denominator— number of ED visits with a LOS of “X”


L O S > 2 but < = 4 H o ur sL O S <= 2 H o ur s

L O S > 4 but <= 6 H o ur s L O S > 6 H o ur s

D ischa rged ho me A d mitted a s inp atient

A d mitted to o b se rva tio n s ta tus Transfe rred to ano ther ho sp ita l

A ll o the r


<=2 Hours >2 but <=4 >4 but <=6 >6 HoursSource: IQIP, 3Q 2004

0

20

40

60

80

100R

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Length of Stay in the Emergency Department by Duration

A3. ED X-Ray Discrepancies and Patient Managementν Discrepancy

θ A difference in medical judgment or opinion regarding the interpretation of an x-ray study

ν X-ray studyθ The sum of all films or views obtained at the same

time that relate to the study of one anatomical site

A3. ED X-Ray Discrepancies and Patient Managementν Change in patient management

θ Any adjustment in the treatment plan based on an x-ray study discrepancy

ν Emergency Department physicianθ A Member of the emergency department medical

staffν Does not include NPs, PAs, or consultants

A3. ED X-Ray Discrepancies and Patient Managementν Intended for facilities that don’t have 24-hours

in-house radiology coverageν Does not focus on the discrepancy— but on

managementν Only counts x-ray studies read by the

emergency department physician— not all x-ray studies done on ED patients

A3. ED X-Ray Discrepancies and Patient Managementν X-ray discrepancies and patient management

θ Numerator— number of ED x-ray studies in which a discrepancy required a change in the original treatment plan

θ Denominator— number of ED x-ray studies read by an ED physician

A3. ED X-Ray Discrepancies and Patient Management

Oct 03 Dec 03 Feb 04 Apr 04 Jun 04 Aug 04Source: IQIP

0

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8

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Emergency Department X-ray Discrepancies Requiring Change in Patient Management

A4. Patients Leaving the ED Before Treatment is Completeν Registered patient



A4. Leaving the ED Before Treatment is Completeν Posits a course of treatment in the ED that

begins with registration of the patient in the ED and continues until discharge instructions are given and the patient is released from the ED

A4. Patients Leaving the ED Before Treatment is Completeν Leaving the ED before treatment is complete

θ Numerator— number of registered patients who leave the ED before treatment is complete


A4. Patients Leaving the ED Before Treatment is Complete

P at ien t s L eav in g t h e E D P rio r t o C o m p let io n o f T reat m en t

0 .0

0 .5

1 .0

1 .5

2 .0

2 .5

3 .0

3 .5

A p r 0 3 J u n 0 3 A u g 0 3 O ct 0 3 D ec 0 3 F eb 0 4 A p r 0 4 J u n 0 4 A u g 0 4

So u rce: IQ IP

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W eigh t ed M ean

U n w eigh t ed M ean

A4. Patients Leaving the ED Before Treatment is Complete


Source: IQIP

0

5

10

15

20

25R

ate

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D V

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Patients Leaving the Emergency Department Prior to Completion of Treatment

A5. Cancellation of Ambulatory Proceduresν Ambulatory procedure

θ An elective ambulatory procedure that is performed on a patient who is expected to be discharged on the same day the procedure is performed

A5. Cancellation of Ambulatory Proceduresν Scheduled ambulatory procedure

θ Any procedure for which time has been reserved anywhere in the facility or any facility-owned or operated freestanding surgical center, cardiac catheterization lab, or endoscopy suite

A5. Cancellation of Ambulatory Proceduresν Ambulatory procedure categories ICD-9-CM

code specificθ Cardiac catheterization proceduresθ Digestive system endoscopic procedures

ν Differs from Indicator 8 grouping

θ Other ambulatory procedures

A5. Cancellation of Ambulatory Proceduresν Entity responsible for cancellation

θ Cancellation by the facility or physicianθ Cancellation by the patient

ν Not intended to establish blame

A5. Cancellation of Ambulatory Proceduresν Only count cancellations that occur on the

day of the procedureν Inpatients at your facility are excluded from

measures even though performed in your ambulatory service area

A5. Cancellation of Ambulatory Proceduresν Cancellation of scheduled ambulatory

proceduresθ Numerator— number of scheduled ambulatory

procedures in category “X” cancelled on the day of the procedure

θ Denominator— number of scheduled ambulatory procedures in category “X”

A5. Cancellation of Ambulatory Proceduresν Scheduled ambulatory procedures in

category “X” cancelled by the facilityθ Numerator— number of scheduled ambulatory

procedures in category “X” cancelled by the facility on the day of the procedure

θ Denominator— number of scheduled ambulatory procedures in category “X” cancelled on the day of the procedure

A5. Cancellation of Ambulatory Proceduresν Scheduled ambulatory procedures in

category “X” cancelled by the patientθ Numerator— number of scheduled ambulatory

procedures in category “X” cancelled by the patient on the day of the procedure

A5. Cancellation of Ambulatory Proceduresν Denominator— number of scheduled

ambulatory procedures in category “X” cancelled on the day of the procedure

A5. Cancellation of Ambulatory Procedures

C a n c e lla t io n o f A m bula t o r y P r o c e dur e s by So ur c e o f C a n c e lla t io n

0

1 0

2 0

3 0

4 0

5 0

6 0

7 0

8 0

9 0

C a r dia c C a t h E n do sc o p y O t h e r

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Center for Performance Sciences, 2001...Vagin al H y sterectomy So urce: IQIP W e i gh t e d M ea n...

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