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Partnership for Patients (PfP)
Hospital Engagement Network 2.0 (HEN)
Iowa Healthcare Collaborative (IHC)
Metric and Measurement Toolkit
Version 2.4 Updated July 11, 2016
http://www.ihconline.org
515.283.9330
This collaborative project was developed by: Iowa Healthcare Collaborative and the Partnership for
Patients (PfP) Hospital Engagement Network (HEN) 2.0
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TABLE OF CONTENTS
To jump to a specific page or definition, click on the titles below:
Introduction
PfP/HEN Reporting Database Reporting Deadlines
Accessing the Database
Open Month Management
Metric Selection Screen
Data Entry Screen
Running Reports
Focus Areas
MEASUREMENT: Patient and Family Engagement (PFE) MEASUREMENT: Readmissions and Care Coordination
MEASUREMENT: Catheter-associated Urinary Tract Infections (CAUTI)
MEASUREMENT: Central Line-associated Bloodstream Infections (CLABSI)
MEASUREMENT: Surgical Site Infections (SSI)
MEASUREMENT: Ventilator-associated Events (VAE)
MEASUREMENT: Adverse Drug Events (ADE)
MEASUREMENT: Falls and Immobility
MEASUREMENT: Obstetrical Adverse Events
MEASUREMENT: Pressure Ulcers
MEASUREMENT: Venous Thromboembolism (VTE)
MEASUREMENT: Clostridium difficile (C. diff)
MEASUREMENT: Sepsis
Additional Focus Areas MEASUREMENT: Worker Safety
MEASUREMENT: Undue Exposure to Radiation
MEASUREMENT: Safety Across the Board
Appendices Appendix I
Appendix II
Appendix III
Appendix IV
Appendix V
Appendix VI
Appendix VII
Appendix VIII
Appendix IX
Appendix X
Appendix XI
Appendix XII
Appendix XIII
Appendix XIV
Appendix XV
Introduction During Hospital Engagement Network (HEN) 1.0, the Iowa Healthcare Collaborative (IHC) HEN built
a web-based Partnership for Patients (PfP) HEN Reporting Database (the Database) to track and
monitor progress toward the campaign PfP Aims, 40% reduction in Hospital-acquired Conditions and
20% reduction in Readmissions (40/20/14). This PfP Reporting Database design supported the
improvement work of the network hospitals and allowed hospitals to monitor trends in Process and
Outcomes measures.
Now in HEN 2.0, the Database continues to allow identified hospital leadership (e.g. – Quality Director,
Infection Preventionist, etc.) to securely and privately enter hospital performance metric data and
quality improvement (QI) project data. Importantly, the Database serves as a Quality Measurement and
Reporting System (QMRS) for the HEN program. The Database requires hospital staff to login and
complete and update work plans for all PfP focus areas. Also within the Database, hospitals select
process and outcome measures that are reported for the PfP focus areas. Hospitals, along with support
from their HEN Improvement Advisor (IA), will continuously update the work plan throughout HEN
2.0 as interventions are implemented, goals are attained, and improvements are made to focus area
work. The Database continuously captures the submission of monthly process and outcome measures
for the focus areas. To see the complete HEN measures, see APPENDIX XIII.
The Database is populated with monthly hospital-specific numerator/denominator information. During
HEN 2.0, the IHC HEN will continue to use a three-pronged approach to support reporting
methodologies to include manual data entry, uploaded results of grouping methodologies applied to
statewide database, and data obtained from CDC NHSN (hospitals must confer rights). See APPENDIX
VIII for instructions on how-to confer rights.
The Database allows IAs and hospital HEN staff to accomplish a variety of project management
functions. The Database allows IHC to assist hospital project management designees in monitoring,
tracking data management, and improvement activities. IHC staff utilizes the Database reporting
functions to communicate program performance to hospital leadership and to support IHC HEN
contract program management and reporting functions.
Hospital staff can access on-demand run charts after completing monthly data entry requirements.
Results for each of the process and outcome metrics allow visual display that includes denominator
results, hospital median, and statewide average. These run charts are a vital tool that can be shared
during hospital team meetings to track and to drive clinical improvement efforts (see screenshot on page
4).
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Based on lessons learned over the past three years, CMS has fostered convergence on a set of
commonly reported, nationally-standardized measures. In HEN 2.0, the IHC HEN has updated the IHC
HEN measures to ensure that there is alignment with the national 40/20/14 goals and measurement
methodology. Historically, the IHC HEN encouraged the use of broad measures to generate the 40/20
reduction across the network.
Monthly data are due 45 days after the end of a month (click this link to view deadlines):
Self-reported measures must be entered into the data collection database explained in this
document
The statewide database (SID – statewide inpatient database, SOD – statewide outpatient
database) will be utilized for populating select measures
Monthly run charts will be refreshed during an open quarter until verified quarterly data are
ready
Hospital contacts are encouraged to work with inpatient/outpatient data submission personnel in
their facilities to make results available in a timely manner
NHSN metrics that are conferred to IHC and entered within 45 days after the end of a month will be
downloaded for inclusion into run charts. Monthly run charts will be refreshed during any subsequent
month.
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Reporting Deadlines 2015 - 2016
*Note: For more information on the MBQIP Phase 3 measure (ER Transfer Communication),
follow this link.
September 2015 - March 2016 -
MBQIP Phase 3 measure due October 23, 2015 MBQIP Phase 3 measure due April 15, 2016
All reporting due November 15, 2015 All reporting due May 15, 2016
60 day CEO Reminder sent out on December 1, 2015 60 day CEO Reminder sent out on June 1, 2016
October 2015 - April 2016 -
MBQIP Phase 3 measure due November 20, 2015 MBQIP Phase 3 measure due May 20, 2016
All reporting due December 15, 2015 All reporting due June 15, 2016
60 day CEO Reminder sent out on January 1, 2016 60 day CEO Reminder sent out on July 1, 2016
November 2015 - May 2016 -
MBQIP Phase 3 measure due December 18, 2015 MBQIP Phase 3 measure due June 17, 2016
All reporting due January 15, 2016 All reporting due July 15, 2016
60 day CEO Reminder sent out on February 1, 2016 60 day CEO Reminder sent out on August 1, 2016
December 2015 - June 2016 -
MBQIP Phase 3 measure due January 15, 2016 MBQIP Phase 3 measure due July 15, 2016
All reporting due February 15, 2016 All reporting due August 15, 2016
60 day CEO Reminder sent out on March 1, 2016 60 day CEO Reminder sent out on September 1, 2016
January 2016 - July 2016 -
MBQIP Phase 3 measure due February 19, 2016 MBQIP Phase 3 measure due August 19, 2016
All reporting due March 15, 2016 All reporting due September 15, 2016
60 day CEO Reminder sent out on April 1, 2016 60 day CEO Reminder sent out on October 1, 2016
February 2016 - August 2016 -
MBQIP Phase 3 measure due March 18, 2016 MBQIP Phase 3 measure due September 16, 2016
All reporting due April 15, 2016 All reporting due October 15, 2016
60 day CEO Reminder sent out on May 1, 2016 60 day CEO Reminder sent out on November 1, 2016
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Access the PfP/HEN Database Follow the narrative below for login and database navigation instructions.
First, click the following link to access the PfP HEN Reporting Database:
http://pfp.ihconline.org/
PfP/HEN Reporting Database – Login and Registration Screen
Login using full email address as username and the secure password set up on registration.
Password is cap sensitive.
A forgot password feature is available if necessary. Enter email address into the field designated,
click on “Send Password” and current password will be automatically emailed to that address.
New users may register by following the New User Registration prompts. A confirmation email
will alert user when access is confirmed.
See the screenshot below to view the login screen:
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PfP/HEN Reporting Database – Open Month Management The Open Month Management screen allows the user:
Access to select metrics for open months
Access for entry of data in open months
Informational messaging on monthly data entry status
Access to run charts
Access to the PfP Reporting Toolkit
Ability to open an Outlook episode for help on the program
See screenshot below:
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PfP/HEN Reporting Database - Metric Selection Screen Hospitals are required to report on at least one process and at least one outcome measure for each of
the focus areas (*expect ADE) that match their service delivery (e.g. – hospitals that do not deliver
babies are excluded from the requirement to submit on OB Adverse Events). To select the metrics,
each hospital will determine their options. Mark the checkbox to the left of the desired metrics.
Choices will be continued in any subsequent month but changes to reporting options are available at
any time.
*Hospitals must report on all ADE measures. Click this link to view the ADE measure information.
Metric Selection - Navigation buttons at the top and bottom of the page include:
Save and Home – saves any changes and takes user back to the Welcome page
Save and Enter Data – saves any changes and takes user to the data entry page
Home – does not save changes and takes user to the Welcome page
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PfP/HEN Reporting Database - Data Entry Screen
General rules applying to all metrics:
All facilities must select at least one process and at least one outcome measure per focus
area except for ADE, hospitals must report on all ADE measures
Interventions may be entered for each month in which they occur (NOTE: this information
will appear on reports)
Fields are numeric only. Do not use decimals or characters
Please note that on PFE you have a Yes/No choice
Edits will apply only upon selection of Complete Month
Discharges are reported in the month of the discharge date
Data Entry - Navigation buttons at the top and bottom of the page include:
Save Data – saves any changes and user remains on data entry page
Save Data/Return Home – saves any changes and takes user to the Welcome page
Run Edits – applies system edits against all fields and returns data entry problems
Complete Month – saves all changes, communicates that data entry is done for the month,
runs edits and takes user to the Welcome page if no data issues are found. If edits are
highlighted, they must be corrected in order to save data entered
Closing a month for data inclusion on monthly run charts:
All data are due 45 days after the end of a month to be included in that month’s run charts
“Complete Month” must be selected and all edits corrected in order to be included in
monthly run charts
**Remember to save after each update. If the information is not saved, the user
will be prompted to save before leaving the page through a popup alert.
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PfP/HEN Reporting Database – Running Reports
Select “View Run Charts” on the Welcome page to generate hospital-specific report.
On-demand reports display monthly data points for completed months
Statewide comparative results are shown for data verified quarterly
Report questions or concerns to your Improvement Advisor if you have issues
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Focus Areas
1. PFE (Patient and Family Engagement)
2. Readmissions and Care Coordination
3. CAUTI (Catheter-associated Urinary Tract Infections)
4. CLABSI (Central Line-associated Bloodstream Infections)
5. SSI (Surgical Site Infections)
6. VAE (Ventilator-associated Events)
7. ADE (Adverse Drug Events)
8. Falls & Immobility
9. Obstetrical Adverse Events
10. Pressure Ulcers
11. VTE (Venous Thromboembolism)
12. Sepsis
13. Clostridium difficile
Additional Focus Areas
1. Worker Safety
2. Undue Exposure to Radiation
3. Safety Across the Board
In an effort to minimize the reporting burden, the following data resources will be employed:
Self-reported (monthly numerator and denominator entered into PfP HEN reporting database),
Statewide databases (SID/SOD – inpatient and outpatient)
National Healthcare Safety Network (NHSN)
For metrics using the statewide databases, hospitals are encouraged to submit monthly data by 45
days after the end of each month. Point-in-time data results will be populated to each applicable
area and data points will be displayed, if available, on the monthly run charts. During an open
quarter, provisional results will be refreshed each month. Finalized, validated data points will
provide comparative results for all participating HEN hospitals.
NHSN metrics must have hospital approval for use in HEN reporting by conferring rights at
the measure level to IHC HEN to be included in run charts. See APPENDIX VIII.
SAMPLING
Measurement should speed improvement, not slow it down. Often, organizations get bogged down
in measurement and delay making changes until they have collected all of the data they believe they
require. Remember, measurement is not the goal; improvement is the goal. In order to move
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forward to the next step, a team needs just enough data to make a sensible judgment as to next
steps. Instead of measuring the entire process (e.g., all patients waiting in the clinic during a month;
all transfers from the ICU to the floor), measuring a sample (e.g., every sixth patient for one week;
the next eight patients) is a simple, efficient way to help a team understand how a system is
performing. Sampling saves time and resources while accurately tracking performance. The
recommended sample size is 15-20% of the population you are sampling.
Sampling Resource:
IHI Sampling
Directions for Systematic and Block Sampling
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Focus Area Measurement
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MEASUREMENT: Patient and Family Engagement (PFE)
Description and Rationale
The three-year HEN 1.0 campaign built a solid foundation for Patient and Family
Engagement (PFE), recognizing that partnering with patients and families is a critical factor
in achieving improvements in the quality and safety of care.
In HEN 2.0, CMS continues to focus on PFE as a necessary component of improved quality
and safety. In previous years IHC sent out periodic surveys to hospitals regarding 5 specific
PFE metrics. We tracked progress in relation to each one of those 5 metrics within your
organization based on your responses to those surveys. These PFE metrics were included in
the HEN 2.0 work plan that each hospital completed. In the HEN 2.0 database, those 5 PFE
metrics have been added to monthly data collection. Hospitals will re-evaluate their PFE
status and make changes as necessary on a monthly basis.
Measures
1. Prior to scheduled admission, hospital staff provides and discusses a planning checklist that
is similar to CMS’ Discharge Planning Checklist with every patient, allowing time for
questions and comments from patient and family.
2. Hospital conducts shift change huddles and does bedside reporting with patients and family
members in all feasible cases.
3. Hospital has a dedicated person or functional area that is proactively responsible for patient
and family engagement and systematically evaluates patient and family engagement
activities.
4. Hospital has an active Patient and Family Engagement Committee or at least one former
patient that serves on a patient safety or quality improvement committee or team.
5. Hospital has at least one or more patient(s) who serve on a governing or leadership board
and serves as a patient representative.
IHC HEN Suggested Resources:
Measure 1 Resources
AHRQ Strategy 4: Care Transitions from Hospital to Home - IDEAL Discharge Planning
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Patient and Family as full partners in the discharge planning process. 5 key areas to prevent
problems at home. Documents on Discharge Planning.
CMS Discharge Planning Checklist
Sample of discharge planning with resources to consider.
AHRQ Communicating to Improve Quality
Documents to encourage patient participation in care.
NAQC Fostering Successful Patient and Family Engagement: Nursing’s Critical Role
What is patient engagement, why is patient engagement a nursing priority? Model and
roadmap for nurse contribution to patient engagement.
Measure 2 Resources
AHRQ Strategy 3: Nurse Bedside Shift Report
Bedside checklist, training and education.
Bedside Shift Report Tools & Resources from Vanderbilt Medical Center Nursing
Department
Resources for bedside shift report and hourly rounding.
AHRQ Nurse Bedside Shift Report Implementation Handbook
Rationale, implantation and case studies for bedside shift report.
AHRQ Nurse Bedside Shift Report Brochure
Brochure for patient and family education.
AHRQ Bedside Shift Report Checklist
Checklist including SBAR.
AHRQ Training PowerPoint
Nurse bedside shift report training. Education on patient and family engagement,
components of bedside shift report, HIPAA information and practice exercises.
AHRQ Training PowerPoint - PDF Format
Measure 3 Resources
AHRQ Working with Patient and Families as Advisors - Implementation Handbook
Resources include identifying a staff liaison, opportunities for PFAC, recruiting, selecting
and training.
Patient and Family Advisor - Orientation Manual
Responsibilities, expectations, tips for being an engaged advisor.
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AHRQ Guide to Patient and Family Engagement in Hospital Quality and Safety
4 primary strategies for promoting patient/family engagement in hospital safety and quality
of care.
Patient Engagement Who, What, Why
Measure 4 Resources
Pt and Family Advisor Tools
AHRQ Patient and Family Advisor Application Form
Become a Patient and Family Advisor - Brochure
Am I Ready to Become an Advisor - Checklist
Confidentiality Statement for Advisors
Patient and Family Participation Interests
Do You Have Ideas to Help Improve our Hospital? - Postcard
Readiness to Partner with Patient and Family Advisors
Sample Letter of Invitation for Advisory Council Applicants
Sharing My Story: A Planning Worksheet
Working with Patient and Family Advisors
Working with Patient and Family Advisors on Short-Term Projects
Become a Patient and Family Advisor: Information Session
Working with Patient and Family Advisors: Introduction and Overview
Policy and Protocol Tools
PFCC Go Shadow
Patient and Family Centered Care Methodology and Practice. Build care teams, develop
high-performance care teams, drive change and innovation.
AHA Strategies for Leadership: Patient and Family Centered Care
Videos, resource guide and hospital self-assessment tool for Patient and family centered
care.
Institute for Patient and Family Centered Care - Free resources
Strategies for Leadership, tools to foster the collaboration with patient and family advisors
and tools to assist in designing supportive health care environments.
Advancing the Practice of Patient- and Family-Centered Care in Hospitals
Education on patient and family centered care, rationale, role of the leaders, selecting
preparing and supporting patient and family advisors and checklist for attitudes about
partnering with patients and families.
Partnering with Patients and Families to Enhance Safety and Quality: A Mini Toolkit
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Patient and family advisors vision, application, champions, rapid response team, patient
safety.
Measure 5 Resources
The Power of Having the Board on Board
6 crucial activities for boards.
H2Pi Effecting Safety Across the Board Through Patient and Family Partnership Councils
for Quality and Safety (PEPCQS)
Tools, assessment of your organization, roadmap to success, strategic planning.
Engaging Health Care Users: A Framework for Health Individuals and Communities Guide
Strategies at the community, organization, health care team and individual levels.
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MEASUREMENT: Readmissions and Care Coordination
Description and Rationale Readmissions are defined as several admissions, inpatient stays, to a hospital or multiple
hospitals by one patient within 30 days.
These measures look at the internal processes (e.g. patient teach-back and communications)
used to reduce hospital readmissions, as well as an outcome measure, looking at the number
of acute care inpatient discharges meeting the all-cause 30-day readmission criteria.
These measures help to determine how many and how often patients are readmitted.
Measures
Outcome Measure: Unplanned All-Cause, 30-Day Readmissions
Numerator: Number of Acute Care inpatient discharges that meet criteria for all-cause, 30-
day, all-payer readmission (includes admits to other facilities)
Denominator: Number of Acute Care Inpatient discharges meeting eligibility for inclusion
as an index admission
Data Source: SID
Baseline: July 2012 to June 2013
Process Measures: Patient Teach-Back
Numerator: Number of observations of nurses where teach-back is used to assess
understanding
Denominator: Number of observations of nurse teaching
“0” denominator not allowed.
Data Source: Self-Reported
Baseline: January 2012 to December 2012
Community Involvement in Identifying Post-Discharge Needs
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient
discharges where community providers (e.g. home care, primary care, nurses, skilled
nursing) were included in assessing post discharge needs
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Denominator: Number of discharges for Acute Care, Skilled Nursing Care and Swing Bed
inpatient discharges
“0” denominator not allowed.
Data Source: Self-Reported
Baseline: January 2012 to December 2012
Post-Hospital Follow-Up Appointment
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed
inpatient discharges with follow-up appointment scheduled before discharge in
accordance with risk assessment
Denominator: Number of discharges for Acute Care, Skilled Nursing Care and
Swing Bed inpatient discharges
“0” denominator not allowed.
Data Source: Self-Reported
Baseline: January 2012 to December 2012
Timely Handover Communication
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed
inpatient discharges where critical information is transmitted to the next site of care
(e.g. office, LTC, HH) or person continuing care
Denominator: Number of discharges for Acute Care, Skilled Nursing Care and
Swing Bed inpatient discharges
“0” denominator not allowed.
Data Source: Self-Reported
Baseline: January 2012 to December 2012
ED Transfer Communication (MBQIP Phase 3)
Compliance for each category means all components have documentation in the ED record. Report
up to 45 or less (no more) per quarter to meet Rural Emergency Department Transfer
Communication measure. To meet HRSA/Flex requirements for MBQIP Phase 3, report
monthly data by expected timelines as follows:
April 2016 – due May 20, 2016
May 2016 – due June 17, 2016
June 2016 – due July 15, 2016
July 2016 – due August 19, 2016
August 2016 – due September 16, 2016
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ED Transfer Communication
Numerator: Number of ED patients transferred to another healthcare facility where all
elements were communicated to the receiving facility
Denominator: Number of ED patients transferred to another healthcare facility (Hospice-
Healthcare Facility, Acute Care Facility (CAH/General Inpatient
Care/Cancer/Children's/VA)
Data Source: Self-Reported
Baseline: October 2015 to December 2015
For the following breakouts, report numerator information matching each area for same
denominator as defined above.
I. Administrative Communication
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Administrative Communication (nurse-to-nurse
communication and physician-to-physician communication) was communicated
Data Source: Self-Reported
II. Patient Information
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Patient Information (name, address, age, gender,
significant other contact info and insurance information) was communicated
Data Source: Self-Reported
III. Vital Signs
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Vital Signs (pulse, respiratory rate, blood pressure,
oxygen saturation, temperature and Glasgow Coma Scale/neuro assessment) were
communicated
Data Source: Self-Reported
IV. Medication Information
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Medication Information (medications administered in ED,
allergies and home medications) was communicated
Data Source: Self-Reported
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V. Physician- or Practitioner-Generated Information
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Practitioner-Generated Information (history and physical,
reason for transfer and plan of care) was communicated
Data Source: Self-Reported
VI. Nurse-Generated Information
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Nurse-Generated Information (nursing
assessments/interventions/response, sensory status, catheters, immobilizations, respiratory
support and oral limitations) was communicated
Data Source: Self-Reported
VII. Procedures and Tests
Numerator: Number of ED patients transferred to another healthcare facility whose medical
record documents indicate that all Tests and Procedures done and Tests and Procedure
Results Sent were communicated
Data Source: Self-Reported
IHC HEN Suggested Resources:
HRET Top Ten Checklist for Readmissions
A checklist to review current, or initiate new interventions to prevent avoidable
readmissions in your facility.
AHA HRET Hospital Engagement Network – Resources
Resources to drive improvement in Preventable Readmissions – Suggested resources:
Hospital Guide to Reducing Medicaid Readmissions AHRQ; Risk Assessment tools,
Preventable Readmission. Change Package 2014; Preventable Readmission Checklist 2014
Click on topics and choose readmissions.
Institute for Healthcare Improvement Overview
State Action on Avoidable Re-hospitalizations – STAAR Model, also see APPENDIX I.
Lace Tool
Hospital-wide (All-Condition) 30-Day Readmission Measure
Yale New Haven Health Services Corporation/Center for Outcomes Research & Evaluation.
Measure developed in cooperation with the Wisconsin Hospital Association and adapted to
display observed readmission rates. Details explained in APPENDIX II.
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Can Teach-back Reduce Hospital Readmissions
Teach back essentials
IHI Process and Outcome Measures
All measures are included here, how and what to measure.
AHRQ National Quality Measures Clearinghouse
ED Transfer Communication Resources for all measures
QIO Stratis Health Rural EC Transfer Communication Resources
Data specifications manual, action plan, checklists and data collection tool
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MEASUREMENT: Catheter-Associated Urinary Tract Infections (CAUTI)
Description and Rationale A Catheter-associated Urinary Tract Infection (CAUTI) is a serious infection that occurs
when bacteria enters the body through a urinary catheter.
These measures look at catheter utilization in inpatient settings and within the emergency
department. The Outcome measure focuses on the number of hospital-acquired urinary tract
infections that occur. See below for more detailed information about each measure.
The current NHSN Manual – Patient Safety Component is utilized for defining and
reporting on these measures. To access the manual, follow this link:
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
These measures help to determine how many patients are harmed by CAUTIs.
Measures
Outcome Measure:
Catheter-Associated Urinary Tract Infection Rate
Numerator: Number of hospital-acquired urinary tract infections
Denominator: Number of Acute Care urinary catheter days
Data Source: NHSN
Baseline: January 2011 to December 2011, or next oldest calendar year
CAUTI SIR (Standardized Infection Ratios) will be obtained from NHSN information conferred to
IHC and included in the analysis of statewide and national results for each eligible facility and
reported for two cohorts – one for ICUs and another for ICUs with Other Reporting Units.
Process Measure:
Unnecessary Urinary Catheters
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with
new indwelling urinary catheters inserted without appropriate indication documented
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients
with new indwelling urinary catheter insertion
"0" denominator allowed
Data Source: Self-Reported
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Baseline: January 2014 to December 2014, or January 2015 to April 2015
Urinary Catheter Utilization Ratio
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient days
with urinary catheter in place
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatient
days
Data Source: NHSN
Baseline: January 2011 to December 2011, or next oldest calendar year
Emergency Department Catheter Utilization
Numerator: Number of Emergency Department urinary catheter insertions
Denominator: Number of Emergency Department visits
Data Source: SOD
Baseline: January 2010 to December 2010
IHC HEN Suggested Resources: AMA CPT codes that will be utilized to identify catheters inserted in the Emergency
Department:
51702
51703
HRET Top Ten Checklist for CAUTI
Top 10 evidence based interventions
CDC Device-associated Module – CAUTI
Urinary Tract Infection (Catheter-Associated Urinary Tract Infection [CAUTI] and Non-
Catheter-Associated Urinary Tract Infection [UTI]) and Other Urinary System Infection
[USI] Events, Criteria and SIRs
NHSN Urinary Tract Infection Form
This form expires 12/31/2017
Institute for Healthcare Improvement
IHI How-to Guide: Prevent Catheter-Associated Urinary Tract Infections, page 24 (Login
required with free access to information). See APPENDIX III.
MEASUREMENT: Central Line-Associated Bloodstream Infection (CLABSI)
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Description and Rationale A central line associated bloodstream infection (CLABSI) is a serious infection that occurs
when bacteria enters the bloodstream through a central line.
These measures look at central line compliance and utilization. See below for more detailed
information about each measure.
The current NHSN Manual – Patient Safety Component is utilized for defining and
reporting on these measures. To access the manual, follow this link:
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
These measures help to determine how many patients are harmed by CLABSIs.
Measures
Outcome Measure:
Central Line-Associated Bloodstream Infection Rate
Numerator: Number of hospital-acquired, central line-associated bloodstream infections
Denominator: Number of Acute Care central line catheter days
Data Source: NHSN
Baseline: January 2011 to December 2011, or next oldest calendar year, or January 2015 to
April 2015
CLABSI SIR (Standardized Infection Ratios) will be obtained from NHSN information conferred to
IHC and included in the analysis of statewide and national results for each eligible facility and
reported for two cohorts – one for ICUs and another for ICUs with Other Reporting Units.
Process Measures:
Central Line Utilization Ratio
Numerator: Number of central line days
Denominator: Total number of patient days
Data Source: NHSN
Baseline: January 2011 to December 2011, or next oldest calendar year, or January 2015 to
April 2015
Central Line Insertion Compliance
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Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with
full PICC line and/or central line catheter insertion bundle compliance
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients
with PICC line and/or central line insertions
"0" denominator allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year
IHC HEN Suggested Resources:
HRET Top Ten Checklist for CLABSI
Checklist to review current interventions or initiate new interventions
Checklist for Prevention of Central Line Associated Blood Stream Infections
Checklist for providers and facilities. See APPENDIX IV.
Institute for Healthcare Improvement
How-to Guide: Prevent Central Line-Associated Bloodstream Infections, page 22. (Login
required with free access to information)
CDC Device-associated Module - BSI
Bloodstream Infection Event (Central Line-Associated Bloodstream Infection and NON-
central line-associated Bloodstream Infection).
Joint Commission CVC Maintenance Bundles
Maintenance Bundles to reduce CLABSI Rates
Joint Commission CVC Insertion Bundles
Insertion bundle components
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MEASUREMENT: Surgical Site Infections (SSI)
Description and Rationale A surgical site infection (SSI) occurs after a surgery, in the part of the body where the
surgery took place. Surgical site infections can sometimes be superficial infections only
involving the skin. Other SSIs are more serious and can involve tissues under the skin,
organs, or implanted material.
The new Process measure looks at surgical safety checklist compliance and temperature
management. The Outcome measures focus on infection rates per number of surgical
episodes. See below for more detailed information about each measure.
The current NHSN Manual – Patient Safety Component is utilized for defining and
reporting on these measures. To access the manual, follow this link:
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
These measures help to determine how many patients are harmed by SSIs.
Measures
Outcome Measures:
Colon Surgical Site Infection Rate
Numerator: Number of hospital-acquired colon surgical site infections
Denominator: Number of colon surgical episodes
Data Source: NHSN
Baseline: January 2012 to December 2012, or next oldest calendar year, or January 2015 to
April 2015
Abdominal Hysterectomy Surgical Site Infection Rate
Numerator: Number of hospital-acquired abdominal hysterectomy surgical site infections
Denominator: Number of abdominal hysterectomy surgical episodes
Data Source: NHSN
Baseline: January 2012 to December 2012, or next oldest calendar year, or January 2015 to
April 2015
Hip Replacement Surgical Site Infection Rate
Numerator: Number of hospital-acquired hip replacement surgical site infections
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Denominator: Number of hip replacement surgical episodes
Data Source: NHSN
Baseline: January 2014 to December 2014, or January 2015 to April 2015
Knee Replacement Surgical Site Infection Rate
Numerator: Number of hospital-acquired knee replacement surgical site infections
Denominator: Number of knee replacement surgical episodes
Data Source: NHSN
Baseline: January 2014 to December 2014, or January 2015 to April 2015
Colon, Abdominal Hysterectomy, Hip Replacement and Knee Replacement SIRs (Standardized
Infection Ratios) will be obtained from NHSN information conferred to IHC and included in the
analysis of statewide and national results for each eligible facility and reported for two cohorts –
one for ICUs and another for ICUs with Other Reporting Units.
Process Measures:
Surgery Patients with Perioperative Temperature Management
Numerator: Number of surgical inpatients for whom either active warming was used
intraoperatively or who had at least one body temperature equal to or greater than
96.8F/36C within 30 minutes immediately prior to or 15 minutes immediately after
anesthesia end time
Denominator: Number of surgery inpatients undergoing procedure under general or
neuraxial anesthesia of greater than or equal to 60 minutes duration
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
Surgical Safety Checklist Compliance
Numerator: Number of days in the month in which the checklist was used in all cases
Denominator: Number of operating room days in the month
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
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IHC HEN suggested resources:
HRET Top Ten Checklist for SSI
CDC Procedure-associated Module – SSI
Surgical Site Infection (SSI) Event. See APPENDIX V for SSI code list
World Health Organization Patient Safety
Surgical safety checklist and implementation manual
HOAJ Perioperative temperature measurement and management
SCIP measurement and maintenance of normothermia. Indications for intraoperative
hypothermia
CDC Surgical Site Infection Event
ICD-10 PCS and CPT Mapping, wound classes, SSI criteria and SSI event reporting
instructions
AHRQ Postoperative Sepsis Rate PSI #13
ICD-9 and ICD-10 codes and descriptions
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MEASUREMENT: Ventilator-Associated Events (VAE)
Description and Rationale Ventilator-associated events (VAEs) are events associated to the use of mechanical
ventilation in the inpatient setting.
These measures look at ventilator bundle compliance and the number of events that meet
VAC, IVAC, and possible/probable criteria. See below for more detailed information about
each measure.
The current NHSN Manual – Patient Safety Component is utilized for defining and
reporting on these measures. To access the manual, follow this link:
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
These measures help to determine how many and how often patients are harmed by VAEs.
Measures
Outcome Measures:
Ventilator-Associated Condition (VAC)
Numerator: Number of events that meet VAC criteria
Denominator: Number of ventilator days
Data Source: NHSN
Baseline: January 2013 to December 2013, or January 2014 to December 2014
Infection-Related Ventilator-Associated Complication (IVAC)
Numerator: Number of events that meet IVAC criteria
Denominator: Number of ventilator days
Data Source: NHSN
Baseline: January 2013 to December 2013, or January 2014 to December 2014
Possible/Probable Ventilator-Associated Pneumonia
Numerator: Number of events that meet possible/probable criteria
Denominator: Number of ventilator days
Data Source: NHSN
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Baseline: January 2013 to December 2013, or January 2014 to December 2014
*Ventilator Associated Event (VAE) – for use in adult locations only
Process Measure:
Ventilator Bundle Compliance
Numerator: Number of ICU patients in the denominator population on mechanical
ventilation with full ventilator-associated prevention bundle compliance
Denominator: Number of ICU patients on mechanical ventilation on day of week of sample
"0" denominator allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year
IHC HEN Suggested Resources: HRET Top Ten Checklist for VAE
Top 10 evidence based interventions
Institute for Healthcare Improvement
How-to Guide: Prevent Ventilator-Associated Pneumonia, page 27. (Login required with
free access to information), see APPENDIX VI.
Institute for Healthcare Improvement
How-to Guide: Prevent Ventilator-Associated Pneumonia, page 10-20. (Login required with
free access to information), see APPENDIX VI.
National Healthcare Safety Network
Surveillance for Ventilator-Associated Events - resources for NHSN users already enrolled.
National Rural Health Resource Center
MBQIP Inpatient resource library, contains information on pneumonia.
CDC Device-associated Module
Ventilator-Associated Event (VAE)
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MEASUREMENT: Adverse Drug Events (ADE)
Description and Rationale An adverse drug event (ADE) is an injury resulting from the use of a drug. ADEs in
hospitals can be caused by medication errors, such as accidental overdoses or providing a
drug to the wrong patient, or by adverse drug reactions, such as allergic reactions or
excessive bleeding after treatment with the intended dose of a drug that prevents dangerous
blood clots.
These measures look at the number of adverse drug events in the acute care, skilled nursing,
swing bed, and observation units. In addition, these measures look at the number of lab
measurements, blood glucose measurements, and electronically entered med orders in the
inpatient setting. New pediatric measures have been added. See below for more detailed
information about each measure.
These measures help to determine how many and how often patients are harmed by ADEs.
Measures
Outcome Measures:
Adverse Drug Event Rate per 1,000 Patient Days
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed or Observation
adverse drug events
Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patient days
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year, or January 2015 to
April 2015
Adverse Drug Events Originating During Hospital Stay (AHRQ)
Numerator: Number of Acute Care adverse drug events that cause harm
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed discharges
Data Source: SID
Baseline: January 2010 to December 2010
Process Measures:
* Blood Glucose Less Than 50
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Numerator: Number of blood glucose measurements (per lab reports, POCT, EMR, Charge
Data, etc.) for Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients
where blood glucose <50
Denominator: Number of blood glucose measurements (per lab reports/POCT, EMR,
Charge Data, etc.) for Acute Care, Skilled Nursing Care, Swing Bed and Observation
patients
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2014 to December 2014, or January 2015 to April 2015
*Documented INRs Greater Than 5
Numerator: Number of lab measurements for Acute Care, Skilled Nursing Facility, Swing
Bed and Observation patients on Warfarin where documented INR >5
Denominator: Number of INR lab measurements for Acute Care, Skilled Nursing Facility,
Swing Bed and Observation patients on Warfarin
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2014 to December 2014
*Stat Narcan Administered
Numerator: Number of episodes when a reversal agent (e.g. naloxone) is administered to
Acute Care, Skilled Nursing Facility, Swing Bed and Observation patients prescribed
opioids exclude ED patients and opioid use for nausea or pruritus
Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients prescribed opioids, exclude ED patients and opioid use for nausea or
pruritus
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2014 to December 2014, or January 2015 to April 2015
Pediatric Process Measures:
*Blood Glucose Less Than 50 for Distinct Unit Pediatrics
Numerator: Number of blood glucose measurements (per lab reports, POCT, EMR, Charge
Data, etc.) for distinct unit pediatric patients where blood glucose <50
Denominator: Number of blood glucose measurements (per lab reports/POCT, EMR,
Charge Data, etc.) for distinct unit pediatric patients
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"0" denominator not allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
*Documented INRs Greater Than 5 for Distinct Unit Pediatrics
Numerator: Number of lab measurements for distinct unit pediatric patients on Warfarin
where documented INR >5
Denominator: Number of INR lab measurements for distinct unit pediatric patients on
Warfarin
"0" denominator not allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
*Stat Narcan Administered for Distinct Unit Pediatrics
Numerator: Number of episodes when a reversal agent (e.g. naloxone) is administered to
distinct unit pediatric patients prescribed opioids exclude ED patients and opioid use for
nausea or pruritus
Denominator: Number of distinct unit pediatric patients prescribed opioids exclude ED
patients and opioid use for nausea or pruritus
"0" denominator not allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
CPOE Medication Order Pharmacist Verification
Numerator: Number of electronically entered med orders (CPOE) for Acute Care inpatients
that are verified by a pharmacist or directly entered by a pharmacist within 24 hours.
Denominator: Number of electronically entered medication orders (CPOE) for Acute Care
inpatients.
Data Source: Self-Reported
Baseline: October 2015 to December 2015
*ADE Process measures for Blood Glucose, INR and Opioids are a surrogate measure for
measuring harm. These measures may include an Adverse Drug Event (ADE) or Potential Adverse
Drug Event (pADE). It is critical that the HEN team evaluate all data and assess level of harm
according to the NCC-MERP scale.
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IHC HEN Suggested Resources: HRET Top Ten Checklist for ADE
Top ten evidence based interventions for ADE
The National Coordinating Council for Medication Error Reporting and Prevention (NCC
MERP)
Medication Errors Definition, taxonomy and index for categorizing medication errors
University of Southern California School of Pharmacy
Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0),
pages 8-9. Adverse Drug Reaction (ADR) definition, see APPENDIX VII.
Agency for Healthcare Research and Quality (AHRQ)
H-CUPs Medication-Related Adverse Outcomes in U.S. Hospitals and Emergency
Departments
Office of Disease Prevention and Health Promotion
National Action Plan for Adverse Drug Event (ADE) Prevention
Institute for Safe Medication Practices (ISMP)
Improving Medication Safety with Anticoagulant
American Society for Pain Management
American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-
Induced Sedation and Respiratory Depression
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MEASUREMENT: Falls & Immobility
Description and Rationale Falls are the most commonly reported incidents within the healthcare setting and can
increase patient risk for hospital-acquired injuries and/or immobility. If the patient is
immobile, this may prolong hospitalization and decrease the patients’ ability to function.
These measures look at inpatient falls resulting in fracture or dislocation, no injury, minor
injury, moderate injury, major injury, death, count of assisted falls, and fall risk assessment.
See below for more detailed information about each measure.
These measures help to determine how many and how often patients are falling in the
inpatient setting as well as how many are harmed by falls.
Measures
Outcome Measures:
Fall Resulting in Fracture or Dislocation (CMS HAC)
Numerator: Number of Acute Care inpatient discharges with ICD-9/10 fracture or
dislocation code(s) not present on admission
Denominator: Number of Acute Care discharges
Data Source: SID
Baseline: January 2010 to December 2010
*Fall Resulting in No Apparent Injury Rate per Patient Day
Numerator: Number of falls for Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients that have unplanned descent to the floor resulting in no visible sign of
injury, stable vital signs and patient denial or pain or discomfort
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed
and Observation patient days - exclude newborn and respite patients
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012
*Fall Resulting in Minor Injury Rate per Patient Day
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Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients that have unplanned descent to the floor resulting in minor cuts, minor
bleeding, minor skin abrasions, minor swelling and minor contusions or bruising
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed
and Observation patient days - exclude newborn and respite patients
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012
*Fall Resulting in Moderate Injury Rate per Patient Day
Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients that have unplanned descent to the floor resulting in excessive
bleeding, lacerations requiring sutures, temporary loss of consciousness or moderate head
trauma
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed
and Observation patient days - exclude newborn and respite patients
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012
*Fall Resulting in Major Injury Rate per Patient Day
Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients that have unplanned descent to the floor resulting in fracture, subdural
hematoma, other major head trauma, cardiac arrest or patient requiring transfer to ICU or
OR
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed
and Observation patient days - exclude newborn and respite patients
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012
*Fall Resulting in Death Rate per Patient Day
Numerator: Number of for Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients that have unplanned descent to the floor resulting in death
Denominator: Number of patient days for Acute Care, Skilled Nursing Care, Swing Bed
and Observation patient days - exclude newborn and respite patients
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"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012
*Do not include patients assisted or eased to the floor
Count of Assisted Falls
Count: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation events
where the patient is assisted or eased to the floor
Data Source: Self-Reported
Baseline: To be determined
Process Measure:
Fall Risk Assessed on Admission
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed, and Observation
patients assessed for fall risk on admission
Denominator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and
Observation patients admitted
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year
IHC HEN Suggested Resources: IHC HEN Falls-Dislocation Codes
Complete list of ICD-10 Codes for Falls
HRET Top Ten Checklist for Fall Prevention
Checklist to review current or initiate new interventions for fall prevention
CDC Steadi Toolkit
Materials for providers and patients. Checklists, brochures, education, algorithm for fall
assessment and interventions, video for tug test, 30 second chair stand test and 4 stage
balance test.
Institute for Healthcare Improvement
Transforming Care at the Bedside How-to Guide: Reducing Patient Injuries from Falls
(Login required with free access to information)
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CMS Hospital Acquired Conditions
ICD-10 Codes for Falls
Agency for Healthcare Research and Quality (AHRQ)
Bundle of Interventions Targeting High-Risk Patients Reduces Falls and Fall-Related
Injuries on Medical-Surgical Units
AHRQ – Quality Tool
Fall TIPS (Tailoring Interventions for Patient Safety) Morse Fall Scale competency manual,
Fall prevention behavior scale, Fall prevention self-efficacy scale
Medscape – Managing Falls in Older People With Cognitive Impairment
Patient Safety Authority
Hospital Engagement Network Falls Reduction and Prevention Collaboration Self-
Assessment Tool
Falls Prevention Process Measures Audit Tool
Pennsylvania Hospital Engagement Network: Falls Reduction and Prevention
Investigation Tool
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MEASUREMENT: Obstetrical Adverse Events
Description and Rationale Obstetrical adverse events affect mothers and their infants. The events range from perineal
tears to maternal or infant death, leading to extensive hospital admissions and/or neonatal
intensive care. All pregnant women and their infants are at risk during labor and delivery.
These measures focus on the number of early elective deliveries, uncomplicated primary
cesarean delivery rates, peripartum hysterectomy (with and without placenta previa), birth
trauma rates, OB trauma (with and without instrument), timely treatment for hypertension,
and risk assessment for maternal hemorrhage. See below for more detailed information
about each measure.
These measures help to determine how many and how often women are harmed by
obstetrical adverse events.
Measures
Outcome Measures:
Early Elective Delivery
Numerator: Number of elective maternal deliveries between 37-39 weeks gestation with no
medical indication
Denominator: All deliveries between 37-39 weeks gestation
"0" denominator allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year, or January 2015 to
April 2015
Primary Cesarean Delivery Rate, Uncomplicated (AHRQ)
Numerator: Number of maternal inpatients with either MS-DRG code for Cesarean
delivery or any-listed ICD-9/10 procedure code(s) for Cesarean delivery without any-listed
ICD-9/10 procedure code(s) for hysterectomy
Denominator: Number of non-preterm deliveries without previous Cesarean section,
abnormal presentation (breech), fetal death or multiple gestation (see technical
specifications in AHRQ IQI 33 description)
Data Source: SID
Baseline: January 2010 to December 2010, or January 2011 to December 2011
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Peripartum Hysterectomy in Women With Placenta Previa
Numerator: Number of peripartum hysterectomies in women with placenta previa and/or
placenta accreta/percreta
Denominator: Number of deliveries
Data Source: SID
Baseline: January 2010 to December 2010, or January 2011 to December 2011
Peripartum Hysterectomy in Women Without Placenta Previa
Numerator: Number of peripartum hysterectomies in women without placenta previa
and/or placenta accreta/percreta
Denominator: Number of deliveries
Data Source: SID
Baseline: January 2010 to December 2010, or January 2011 to December 2011
Birth Trauma Rate - Injury to Newborn (AHRQ)
Numerator: Number of Newborns with ICD-9/ICD-10 code(s) for birth trauma
Denominator: Number of Newborns excluding preterm infants with birth weight less than
2000 grams, injury to brachial plexus or osteogenesis imperfecta
Data Source: SID
Baseline: January 2010 to December 2010, or January 2011 to December 2011
OB Trauma, Vaginal Deliveries With Instrument (AHRQ)
Numerator: Number of vaginally-delivering, instrument-assisted Moms with ICD-9/ICD-
10 code(s) for 3rd or 4th degree obstetric trauma
Denominator: Number of vaginal deliveries with ICD-9 procedure code(s) for instrument-
assisted delivery
Data Source: SID
Baseline: January 2010 to December 2010, or next oldest calendar year
OB Trauma, Vaginal Deliveries Without Instrument (AHRQ)
Numerator: Number of vaginally-delivering, non instrument-assisted Moms with ICD-
9/ICD-10 code(s) for 3rd or 4th degree obstetric trauma
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Denominator: Number of vaginal deliveries without ICD-9 procedure code(s) for
instrument-assisted delivery
Data Source: SID
Baseline: January 2010 to December 2010, or January 2011 to December 2011
Obstetrical Trauma Composite
*Numerator: Number delivered maternal inpatients with one or more adverse events (see
list below)
Denominator: Number of deliveries
Data Source: SID
Baseline: January 2010 to December 2010, or January 2011 to December 2011
*OB Adverse Events include:
Extended postpartum length of stay (> 3 days for vaginal delivery/> 5 days for
Cesarean delivery)
Transfer to ICU
Transfer to acute care hospital
Acute myocardial infarction
Acute renal failure
Adult respiratory distress syndrome
Amniotic fluid embolism
Aneurysm
Cardiac arrest/ventricular fibrillation
Disseminated intravascular coagulation
Eclampsia
Heart failure during procedure or surgery
Internal injuries of thorax, abdomen or pelvis
Intracranial injuries
Puerperal cerebrovascular disorders
Pulmonary edema
Severe anesthesia complication
Sepsis
Shock
Sickle cell anemia with crisis
Thrombotic embolism
Blood transfusion
Cardio monitoring
Conversion of cardiac rhythm
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Hysterectomy
Operation on heart and pericardium
Temporary tracheostomy
Ventilation
*Source: Callaghan, W. M., Creanga, A. A., & Kuklina, E. V. (2012). Severe maternal morbidity
among delivery and postpartum hospitalizations in the United States. Obstetrics &Gynecology,
V120, 1029-36. http://www.ihconline.org/UserDocs/Pages/Callaghan_et_al.,_2011.pdf
Process Measures:
Risk Assessment for Maternal Hemorrhage
Numerator: Number of maternal inpatients with documented risk assessment for maternal
hemorrhage completed on admission
Denominator: Number of maternal inpatients who have given birth at or greater than 20
weeks completed gestation
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
Timely Treatment for Severe Hypertension
Numerator: Number of maternal inpatients who are treated within 60 minutes with first-
line medications (IV labetalol or IV hydralazine or PO nifedipine if IV access has not been
established)
Denominator: Number of women giving birth ≥20 weeks gestation with a diagnosis of
severe preeclampsia or preeclampsia superimposed on pre-existing hypertension AND who
had severe hypertension
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
IHC HEN Suggested Resources: HRET Top Ten Checklist for OB Harm
Top ten evidence based interventions
Institute for Healthcare Improvement
How-to-Guide: Prevent Obstetrical Adverse Events. Essential elements of prevention,
oxytocin bundles, design strategy, forming the team, PDSA worksheet and measurement.
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The Joint Commission – Specifications Manual National Quality Measures (this is updated
with ICD 10 codes)
Perinatal Care (PC) measure PC-01 Elective Delivery, also located in APPENDIX IX
CDC: Reproductive Health
Severe Maternal Morbidity in the United States (ICD-9 code set for OB Trauma metric),
also found in APPENDIX X. ICD-10 codes not available on this resource page.
CDC: Pregnancy Mortality Surveillance System
Trends in Pregnancy-Related Deaths
National Archives and Records Administration – Office of the Federal Register
Federal Register, Vol. 77, No. 170/Friday, August 31, 2012/Rules and Regulations. Look to
the second column, Page 53528, under (C) “New Chart-abstracted measures: Elective
Delivery…”
The Joint Commission
Joint Commission Performance Measurement FAQs (Click on Performance Measurement
FAQs)
American College of Obstetricians and Gynecologists
Severe Maternal Morbidity Among Delivery and Postpartum Hospitalizations in the United
States, William M. Callaghan, MD Case Study
Agency for Healthcare Research and Quality (AHRQ)
Primary Cesarean Delivery Rate, Uncomplicated Technical Specifications –
Inpatient Quality Indicators #33
Birth Trauma Rate – Injury to Neonate Technical Specifications, Patient Safety
Indicators #17 ICD 9/ICD 10
Obstetric Trauma Rate – Vaginal Delivery With Instrument Technical
Specifications, Patient Safety Indicators #18 ICD 9/ICD 10
Obstetric Trauma Rate – Vaginal Delivery Without Instrument Technical
Specifications, Patient Safety Indicators #19 ICD 9/ICD 10
The American Congress of Obstetricians and Gynecologists (ACOG)
Obstetric Hemorrhage Risk Assessment, bundle and checklist
Severe Hypertension Algorithm, bundle and checklist
Preeclampsia and Hypertension in Pregnancy: Resource Overview Toolkit, resources
for women and patients, task force for hypertension in pregnancy.
ACOG Practice Bulletin
Clinical Management Guidelines for Obstetrician Gynecologists – Postpartum Hemorrhage
Treatments and risk factors
California Maternal Quality Care Collaborative (login in required free information)
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Improving Health Care Response to Obstetric Hemorrhage, Version 2.0 - Toolkit
Parameters for risk assessment, oxytocin as first line for prevention and treatment,
blood replacement recommendations and patient and family support
Improving Health Care Response to Preeclampsia -Toolkit
Tools, Patient care treatment recommendations, algorithms, drills and simulations
and patient education.
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MEASUREMENT: Pressure Ulcers
Description and Rationale Pressure ulcers occur frequently within the hospital setting. Pressure ulcers are staged on
severity and are localized to the skin and tissue.
These measures look at the number of inpatients (Acute Care, Skilled Nursing, Swing Bed)
receiving full preventive care and the number who have a pressure ulcer diagnosis code. See
below for more detailed information about each measure.
These measures help to determine how many patients are harmed by pressure ulcers.
Measures
Outcome Measure:
Stage III, IV or Unstageable Pressure Ulcer (AHRQ)
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients with
ICD-9/10 code(s) for pressure ulcer AND secondary ICD-9/10 diagnosis code(s) for Stage
III, Stage IV or unstageable pressure ulcer, non-POA
Denominator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed
inpatients (refer to AHRQ PSI 3 technical specifications for exclusions)
Data Source: SID
Baseline: January 2010 to December 2010
Process Measure:
At-Risk Patients Receiving Full Pressure Ulcer Preventive Care
Numerator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed
inpatients receiving full pressure ulcer preventative care
Denominator: Number of at-risk Acute Care, Skilled Nursing Facility and Swing Bed
inpatients
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year, or January 2015 to
April 2015
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IHC HEN suggested resources: HRET Top Ten Checklist for Pressure Ulcer
Checklist to review current or initiate new interventions for HAPU prevention
Agency for Healthcare Research and Quality (AHRQ)
Pressure Ulcer Rate Patient Safety Indicators #3
National Pressure Ulcer Advisory Panel
NPUAP Pressure Ulcer Stages/categories
Braden Scale
Instructions and scoring
Institute for Healthcare Improvement
How-to Guide: Prevent Pressure Ulcers (Login required with free access to information),
see APPENDIX XI
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MEASUREMENT: Venous Thromboembolism (VTE)
Description and Rationale Venous Thromboembolism (VTE) refers to conditions in which unwanted blood clots form
in the body. These clots include both Deep Vein Thrombosis (DVT) and Pulmonary
Embolisms (PE).
These measures focus on the number post-operative PE or DVT and utilization of
appropriate VTE prophylaxis. See below for more detailed information about each measure.
These measures help to determine how many and how often patients are harmed by VTE.
Measures
Outcome Measure:
Post-Operative Pulmonary Embolism or Deep Venous Thrombosis (AHRQ)
Numerator: Number of Acute Care surgical inpatients with non-POA secondary ICD-9/10
code(s) for DVT or PE
Denominator: Number of Acute Care surgical inpatient discharges excluding cases where
DVT/PE are present on admission, where a procedure for interruption of vena cava occurs
before or on the same day or any procedure for extracorporeal membrane oxygenation
Data Source: SID
Baseline: January 2010 to December 2010, or next oldest calendar year
Process Measure:
VTE Appropriate Prophylaxis
Numerator: Number of Acute Care, Skilled Nursing Facility, Swing Bed and Observation
patients who received VTE prophylaxis or have documentation why no VTE prophylaxis
was given
Denominator: Number of admissions to Acute Care, Skilled Nursing Facility, Swing Bed
and Observation patients with stays of >48 hours
"0" denominator not allowed
Data Source: Self-Reported
Baseline: January 2012 to December 2012, or next oldest calendar year
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IHC HEN Suggested Resources: HRET Top Ten Checklist for VTE
Top ten evidence based interventions
Agency for Healthcare Research and Quality (AHRQ)
Perioperative Pulmonary Embolism or Deep Vein Thrombosis Rate, PSI #12
AHRQ Preventing Hospital-Acquired Venous Thromboembolism
Framework for improvement, evidence and best practices, VTE prevention protocol and
interventions.
AHRQ Quality Indicators Toolkit
Selected Best Practices and Suggestions for Improvement, PE and DVT see APPENDIX
XII
Joint Commission VTE 1
VTE measure information form
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MEASUREMENT: Clostridium Difficile
Description and Rationale Clostridium difficile (C.diff) is a bacterium that causes infections within the digestive
system, intestines.
This is new to the IHC HEN. Measures focus on hospital-acquired C.diff and hand hygiene
compliance, looking at hand washing technique. See below for more detailed information
about each measure. The current NHSN Manual – Patient Safety Component is utilized for
defining and reporting on these measures. To access the manual, follow this link:
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf.
These measures will help to determine how many and how often patients are harmed by
C.diff.
Measures
Outcome Measure:
Clostridium Difficile Infection Rate
Numerator: Number of hospital onset and community acquired C. diff infections
Denominator: Number of acute care inpatient days
Data Source: NHSN
Baseline: January 2011 to December 2011, or next oldest calendar year, or January 2015 to
April 2015
Clostridium difficile SIRs (Standardized Infection Ratio) will be obtained from NHSN information
conferred to IHC and included in the analysis of statewide and national results for each eligible
facility and all reported units.
Process Measure:
Hand Hygiene Compliance
Numerator: Number of observations where appropriate hand-washing technique was
applied
Denominator: Number of observations
"0" denominator not allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
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IHC HEN Suggested Resources: HRET Top Ten Checklist for CDI
Checklist to review current or initiate new interventions for CDI prevention
Clostridium difficile (CDI) Infections Toolkit
Healthcare-association infection elimination PowerPoint from the U.S. Department of
Health and Human Services, Centers for Disease Control and Prevention.
CDC MDRO and CDI Module
NHSN Multi drug resistant organism & clostridium difficile infection Module
CDC Hand Hygiene in Healthcare Settings
Hand hygiene basics, training, guidelines and measurement
Hand Hygiene Observation Record
This form can be used when performing hand hygiene observations
Institute for Healthcare Improvement
How-to Guide: Improving Hand Hygiene (this is a free resource, sign into IHI to download)
Interventions for improved handwashing, measurement tools
FAQs about Clostridium difficile (CDC)
Fact sheet for patients to have as a resource when they are discharged
World Health Organization (WHO)
Clean Care is Safer Care – Hand Hygiene Tools and Resources
WHO Guidelines on Hand Hygiene in Health Care
Your 5 Moments for Hand Hygiene – Poster
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MEASUREMENT: Sepsis
Description and Rationale Sepsis is an inflammatory response to infection and can be life-threatening. Sepsis is also
referred to as “blood poisoning.”
This is new to the IHC HEN. Measures focus on diagnosis of Sepsis (Postoperative sepsis
and sepsis rate) and severe sepsis and septic shock management bundle compliance. The
current NHSN Manual – Patient Safety Component is utilized for defining and reporting on
these measures. To access the manual, follow this link:
http://www.cdc.gov/nhsn/pdfs/pscmanual/pcsmanual_current.pdf. See below for more
detailed information about each measure.
These measures will help to determine how many and how often patients are harmed by
Sepsis.
Measures
Outcome Measures:
Postoperative Sepsis Rate, (AHRQ PSI 13)
Numerator: Number of Acute Care elective surgical inpatient discharges with any
secondary ICD-9/10 diagnosis code for sepsis
Denominator: Number of Acute Care elective surgical inpatient discharges with any-listed
ICD-9/10 procedure code for an operating room procedure and admission type recorded as
elective
Data Source: SID
Baseline: January 2010 to December 2010, or next oldest calendar year
Sepsis Rate *Suspended February 2016, pending ICD-10 Update
Numerator: Number of Acute Care inpatients with any secondary ICD-9/10 diagnosis code
for sepsis, not POA
Denominator: Number of Acute Care inpatient discharges
Data Source: SID
Baseline: January 2010 to December 2010
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Process Measure:
Severe Sepsis and Septic Shock Management Bundle Compliance (NQF)
Numerator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients
presenting with severe sepsis or septic shock who receive assessment and treatment per
Severe Sepsis and Septic Shock Management 3-hour and 6-hour Bundle
Denominator: Number of Acute Care, Skilled Nursing Facility and Swing Bed inpatients
presenting with severe sepsis or septic shock
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
IHC HEN Suggested Resources: HRET Top Ten Checklist for Sepsis
Checklist to review current or initiate new sepsis mortality reduction interventions
NQF-Endorsed Voluntary Consensus Standard for Hospital Care
Measure information collected for: CMS Voluntary Only – Surgical Care Improvement
Project (SCIP)
Sepsis Bundle Project (SEP) – National Hospital Inpatient Quality Measures
SEP Measure Set Table, last updated version 5.0a. Sepsis initial patient population
algorithm.
Surviving Sepsis Campaign
Updated Bundles in Response to New Evidence
Surviving Sepsis Campaign – Tool
Evaluation for Severe Sepsis Screening Tool
AHRQ Selected Best Practices and Suggestions for Improvement PSI 13: Postoperative
Sepsis
Recommended practices, best processes, and educational recommendations
**IHC HEN 2.0 Sepsis Codes, see APPENDIX XIV
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MEASUREMENT: Worker Safety
Description and Rationale
Worker safety is about the health and safety of staff members. Hospitals are one of the most
hazardous places to work. Patient lifting, repositioning, and transfers represent some of the
most common and preventable sources of injury for employees in the healthcare industry.
This is new to the IHC HEN. Measures focus on work-related back injuries, needle-safety
and ensuring safe patient handling equipment is available for staff. See below for more
detailed information about each measure.
The outcome measures will help to determine how many and how often staff members are
harmed by safety incidents. The process measure will provide hospitals with a checklist to
assist with the ensuring safe patient handling equipment is available, accessible and is in
working order.
Instructions for Measures Outcome measures- The data for these measures may be found within your organizations
employee health department or risk management department.
Process measure- To complete this process measure it is suggested that a sampling of
hospital units (med/surg, medical, ER, radiology) is conducted. The minimal requirement is
at least one unit per month is audited.
Measures
Outcome Measures:
Work-Related Back Injuries
Numerator: Number of work-related back injuries
Denominator: Number of FTEs
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
Needlesticks
Numerator: Number of needlestick events
Denominator: Number of FTEs
"0" denominator allowed
Data Source: Self-Reported
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Baseline: October 2015 to December 2015
Process Measure:
Safe Patient Handling Program Equipment Checklist Compliance
Numerator: Number of units with all checklist items ‘In Place’
Denominator: Number of units assessed
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
*See Appendix XV for the Safe Patient Handling Program Equipment Checklist
IHC HEN Suggested Resources:
OSHA
Worker Safety in Hospitals
Safe patient handling, understanding the problem
Safe Patient Handling- Self-Assessment
Busting the Myths
Understanding lift equipment
Management Support
Management, leadership, implementing and assessments
Training and Education
Training, lift equipment, patient and family, champions and assessments
Knowing the Facts
Learn from the Leaders
Case Studies
Policy and Program Support
How to start a policy and a program
Program Evaluation
Case Studies
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Effectiveness and Cost Savings
Examples, University of Iowa
Safe Patient Handling Program Checklist
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MEASUREMENT: Undue Exposure to Radiation
Description and Rationale Undue exposure to radiation is avoiding unnecessary testing to reduce exposure to radiation
This is new to the IHC HEN. The measures focus on abdomen CT and thorax CT. See
below for more detailed information about each measure.
These measures will help to determine how many and how often patients are exposed to
undue radiation.
Measures
Outcome Measures:
Abdomen CT - Use of Contrast Material (CMS)
Numerator: Number of outpatient abdomen CT studies with and without contrast
('combined studies')
Denominator: Number of outpatient abdomen CT studies performed (with, without OR
both with and without contrast)
Data Source: SID
Baseline: January 2010 to December 2010, or next oldest calendar year
Thorax CT - Use of Contrast Material (CMS)
Numerator: Number of outpatient thorax CT studies with and without contrast ('combined
studies')
Denominator: Number of outpatient abdomen CT studies performed (with, without OR
both with and without contrast)
Data Source: SID
Baseline: January 2010 to December 2010, or next oldest calendar year, or January 2015 to
April 2015
Process Measures:
Total CT Dose Capture Compliance - DLP
Numerator: Total number of CTs in which the total DLP is recorded
Denominator: Total number of CTs
"0" denominator allowed
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Data Source: Self-Reported
Baseline: October 2015 to December 2015
Total CT Dose Capture Compliance – CTDIvol
Numerator: Total number of CTs in which the total CTDIvol is recorded
Denominator: Total number of CTs
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
Total CT Dose Capture Compliance – SSDE
Numerator: Total number of CTs in which the total SSDE is recorded
Denominator: Total number of CTs
"0" denominator allowed
Data Source: Self-Reported
Baseline: October 2015 to December 2015
IHC HEN Suggested Resources:
HRET Top Ten Checklist for Radiation Safety
American Academy of Pediatrics
Choosing Wisely Campaign – AAP Identifies List of Commonly Used Tests and Treatments
to Question
Choosing Wisely – American Academy of Pediatrics
Five things physicians and patients should question, see 3-5
Radiological Society of North America (RSNA)
“How I Do It: Managing Radiation Dose in CT” Mayo-Smith, W. W., Hara, A. K., Mahesh,
M., Sahani, D. V., & Pavlicek, W. (2014).
Radiology Today
Choosing Wisely, Imaging Procedures on the Latest List of Ones ‘Patients and physicians
should question’
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MEASUREMENT: Safety Across the Board
Description and Rationale Safety across the board (SAB) is the focus on all causes of harm within the inpatient setting,
to improve patient safety.
This is new to the IHC HEN. The measures will focus on the weighted average of the
adjusted observed to expected ratios for multiple patient safety components, and the number
of acute care surgical deaths. See below for more detailed information about each measure.
These measures will help to determine how many patients have been harmed in the inpatient
setting.
Measures
Outcome Measures:
Patient Safety Indicator 90 (AHRQ) *Suspended February 2016, pending ICD-10 Update
Ratio: Weighted Average of the Reliability-Adjusted Observed-to-Expected Ratios for
component indicators: PSI 03, 06, 07, 08, 09, 10, 11, 12, 13, 14, 15
Data Source: SID
Baseline: October 2015 to December 2015
Death Rate Among Surgical Inpatients With Serious Treatable Complications (AHRQ)
Numerator: Number of Acute Care surgical inpatients with non-POA secondary ICD-9/10
code(s) for DVT or PE
Denominator: Number of Acute Care surgical inpatient discharges
Data Source: SID
Baseline: October 2015 to December 2015
IHC HEN Suggested Resources: Healthcare and Patient Partnership Institute
Safety Across the Board Guides including healthcare provider staff, in-hospital trainer,
patient advocates, and hospital leadership focused guides.
The Partnership for Patients Campaign
Guide to Safety Across the Board
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Appendices
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Appendix I State Action on Avoidable Re-hospitalizations – STAAR model
http://www.ihi.org/offerings/Initiatives/PastStrategicInitiatives/STAAR/Pages/Measures
Results.aspx
Process Measures: (Source information)
Enhanced admission assessment for post-hospital needs
Percent of admissions where patients and family caregivers are included in assessing post
discharge needs
Percent of admissions where community providers (e.g., home care providers, primary care
providers and nurses and staff in skilled nursing facilities) are included in assessing post
discharge needs
Effective teaching and enhanced learning
Percent of observations of nurses teaching patient or other identified learner where Teach
Back is used to assess understanding
Percent of observations of doctors teaching patient or other identified learner where Teach
Back is used to assess understanding
Real-time patient- and family- centered handoff communication
Percent of patients discharged who receive a customized care plan written in patient-friendly
language at the time of discharge
Percent of time critical information in transmitted at the time of discharge to the next site of
care (e.g., home health, long term care facility, rehab care, physician office)
Post-hospital care follow up
Percent of patients discharged who had a follow-up visit scheduled before being discharged
in accordance with their risk assessment
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Appendix II
The hospital-wide (all-condition) unplanned 30-day readmission measure displays observed
readmission rates using the CMS (Yale) methodology). Acute-to-acute readmissions to any hospital
counts are produced when applying methodology to the all-payer statewide database. Credit for
developing the ability to return results for this measure goes to the Wisconsin Hospital Association
in conjunction with the Iowa Hospital Association.
Denominator: Index admission counts determine denominator populations. Exclusions to inclusion
as an index acute admission include: 1) cancer discharges; 2) psychiatric discharges; 3) distinct unit
medical rehab discharges; 4) planned procedures; and 5) patients transferred to another acute care
facility (Patient Discharge Status 02 or 66); 7) patients who have in-hospital death; 8) patients
discharged against medical advice and 9) pediatric patients (<18 y/o).
Numerator: Readmission records are scanned for inclusion/exclusion to determine if a planned
procedure is documented as part of the return to any hospital. See below for a list of planned
procedures.
Exclusions for planned procedures include:
Insertion/replacement/removal of extracranial ventricular shunt
Laminectomy
Thyroidectomy
Lobectomy or pneumonectomy
Heart valve procedures
CABG
PTCA
Pacemaker insertion
Endarterectomy
Aortic resection
Peripheral bypass
Embolectomy of lower limbs
Bone marrow transplant
Gastrectomy
Small bowel, colon resection
Appendectomy
Cholecystectomy
Inguinal and femoral hernia repair
Nephrotomy/nephrectomy
TURP
Prostatectomy
Oophorectomy
Hysterectomy
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Treatment of fracture/dislocation
Arthroplasties
Hip
Spinal fusion
Lumpectomy
Mastectomy
Organ transplant
Therapeutic radiology for cancer
There are differences between how CMS vs IHC HEN apply the Yale methodology. IHC is unable
to risk stratify due to the absence of access to all claims or the ability to determine insurance
eligibility. This methodology is being applied to all payers and all participating IHC HEN hospitals
(including CAHs) where data is available from Iowa hospitals.
Readmission records may be counted as index admissions if criteria are met for inclusion.
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Appendix III
Institute for Healthcare Improvement – IHI How-to Guide: Prevent Catheter-Associated Urinary
Tract Infections, page 24.
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCatheterAssociated
UrinaryTractInfection.aspx
Process Measure 1: Unnecessary urinary catheters (Urinary catheters not meeting criteria for
appropriate insertion)
Numerator includes:
Number of new indwelling urinary catheters inserted without appropriate indication
documented at time of insertion
Criteria should include at a minimum:
o Perioperative use for selected surgical procedures
o Urine output monitoring in critically ill patients
o Management of acute urinary retention and urinary obstruction
o Assistance in pressure ulcer healing for incontinent patients
o As an exception, at patient request to improve comfort (SHEA-IDSA) or for comfort
during end-of-life care (CDC)
Hospitals may add to or modify these criteria for local needs; criteria may be defined in
policies or procedures
Denominator includes:
Number of records reviewed of patients with new indwelling urinary catheters
Sampling & Measurement Tips:
Frequency
Monthly at minimum
Weekly reporting may be helpful during improvement effort
Start by collecting data for patients on unit where improvement efforts are focused or
urinary catheter usage is high
Collect random samples by reviewing records of all patients on the unit with new indwelling
urinary catheters on one day each week. Vary the day and time of review.
Review records only for patients admitted recently (such as prior 72 hours or since last
review) to ensure patients are not counted more than once.
Specify a timeframe in which documentation of indication must be noted in order to count
in numerator (e.g., within four hours of insertion time). Ideally, indication should be
documented at the time of insertion. Do not include indications documented after the day of
insertion.
Include all patients with new indwelling urinary catheters in the denominator, whether or
not indication for insertion is documented. Those without documented appropriate
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indication will not be included in the numerator and represent opportunities for
improvement.
If insertion of indwelling urinary catheters in the ED is high, consider measuring this
separately for that area to determine the percent of unnecessary insertions in the ED.
This measure can also be reported in the converse, i.e., Appropriate indwelling urinary
catheter usage, where the numerator is the percent of patients with an indication documented
at insertion that meets criteria.
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Appendix IV
CDC Checklist for Prevention of Central Line Associated Blood Stream Infections
http://www.cdc.gov/HAI/pdfs/bsi/checklist-for-CLABSI.pdf
Follow Proper Insertion Practices
1. Perform hand hygiene before insertion
2. Adhere to aseptic technique
3. Use maximal sterile barrier precautions (i.e., mask, cap, gown, sterile gloves, and sterile
full-body drape)
4. Perform skin antisepsis with >0.5% chlorhexidine with alcohol
5. Choose the best site to minimize infections and mechanical complications
6. Avoid femoral site in adult patients
7. Cover the site with sterile gauze or sterile, transparent, semipermeable dressings
Handle and Maintain Central Lines Appropriately
1. Comply with hand hygiene requirements
2. Scrub the access port or hub immediately prior to each use with an appropriate antiseptic
(e.g., chlorhexidine, povidone iodine, an iodophor, or 70% alcohol)
3. Access catheters only with sterile devices
4. Replace dressings that are wet, soiled, or dislodged
5. Perform dressing changes under aseptic technique using clean or sterile gloves
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Appendix V CDC Procedure-associated Module for Surgical Site Infection (SSI) Event
http://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf
This module includes information on the codes below.
Table Name Code Shortened Description
Abdominal
Hysterectomy
0UT90ZZ RESECTION UTERUS OPEN
Abdominal
Hysterectomy
0UT94ZZ RESECTION UTERUS PERCUTANEOUS ENDO
Colon Surgery 0D1907L BYPASS DUODENUM TRANS COLON AUTO OP
Colon Surgery 0D190JL BYPASS DUODENUM TRANS COLON SYN OP
Colon Surgery 0D190KL BYPASS DUODENUM TRNS COLON NAUTO OP
Colon Surgery 0D190ZL BYPASS DUODENUM TRANS COLON OPEN
Colon Surgery 0D1947L BYPASS DUOD TRNS COLON AUTO PC ENDO
Colon Surgery 0D194JL BYPASS DUOD TRANS COLON SYN PC ENDO
Colon Surgery 0D194KL BYPASS DUOD TRN COLON NAUTO PC ENDO
Colon Surgery 0D194ZL BYPASS DUOD TRANS COLON PERQ ENDO
Colon Surgery 0D1A07H BYPASS JEJUNUM CECUM AUTO TISS OP
Colon Surgery 0D1A07K BYPASS JEJUNUM ASCEND COLON AUTO OP
Colon Surgery 0D1A07L BYPASS JEJUNUM TRANS COLON AUTO OP
Colon Surgery 0D1A07M BYPASS JEJUNUM DESC COLON AUTO OP
Colon Surgery 0D1A07N BYPASS JEJUNUM SIG COLON AUTO OP
Colon Surgery 0D1A0JH BYPASS JEJUNUM CECUM SYNTH SUBST OP
Colon Surgery 0D1A0JK BYPASS JEJUNUM ASCEND COLON SYN OP
Colon Surgery 0D1A0JL BYPASS JEJUNUM TRANS COLON SYN OP
Colon Surgery 0D1A0JM BYPASS JEJUNUM DESC COLON SYN OP
Colon Surgery 0D1A0JN BYPASS JEJUNUM SIG COLON SYN SUB OP
Colon Surgery 0D1A0KH BYPASS JEJUNUM CECUM NONAUTO SUB OP
Colon Surgery 0D1A0KK BYPASS JEJUNUM ASC COLON NAUTO OP
Colon Surgery 0D1A0KL BYPASS JEJUNUM TRANS COLON NAUTO OP
Colon Surgery 0D1A0KM BYPASS JEJUNUM DESC COLON NAUTO OP
Colon Surgery 0D1A0KN BYPASS JEJUNUM SIG COLON NAUTO OP
Colon Surgery 0D1A0ZH BYPASS JEJUNUM CECUM OPEN APPROACH
Colon Surgery 0D1A0ZK BYPASS JEJUNUM ASCENDING COLON OP
Colon Surgery 0D1A0ZL BYPASS JEJUNUM TRANSVERSE COLON OP
Colon Surgery 0D1A0ZM BYPASS JEJUNUM DESCENDING COLON OP
Colon Surgery 0D1A0ZN BYPASS JEJUNUM SIGMOID COLON OP
Colon Surgery 0D1A47H BYPASS JEJUNUM CECUM AUTO PC ENDO
Colon Surgery 0D1A47K BYPASS JEJUN ASC COLON AUTO PC ENDO
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Table Name Code Shortened Description
Colon Surgery 0D1A47L BYPASS JEJUN TRN COLON AUTO PC ENDO
Colon Surgery 0D1A47M BYPASS JEJUN DES COLON AUTO PC ENDO
Colon Surgery 0D1A47N BYPASS JEJUN SIG COLON AUTO PC ENDO
Colon Surgery 0D1A4JH BYPASS JEJUNUM CECUM SYN PC ENDO
Colon Surgery 0D1A4JK BYPASS JEJUN ASC COLON SYN PC ENDO
Colon Surgery 0D1A4JL BYPASS JEJUN TRNS COLON SYN PC ENDO
Colon Surgery 0D1A4JM BYPASS JEJUN DESC COLON SYN PC ENDO
Colon Surgery 0D1A4JN BYPASS JEJUN SIG COLON SYN PC ENDO
Colon Surgery 0D1A4KH BYPASS JEJUNUM CECUM NAUTO PC ENDO
Colon Surgery 0D1A4KK BYPASS JEJ ASC COLON NAUTO PC ENDO
Colon Surgery 0D1A4KL BYPASS JEJ TRNS COLON NAUTO PC ENDO
Colon Surgery 0D1A4KM BYPASS JEJ DES COLON NAUTO PC ENDO
Colon Surgery 0D1A4KN BYPASS JEJ SIG COLON NAUTO PC ENDO
Colon Surgery 0D1A4ZH BYPASS JEJUNUM CECUM PERQ ENDO
Colon Surgery 0D1A4ZK BYPASS JEJUNUM ASC COLON PERQ ENDO
Colon Surgery 0D1A4ZL BYPASS JEJUNUM TRNS COLON PERQ ENDO
Colon Surgery 0D1A4ZM BYPASS JEJUNUM DESC COLON PERQ ENDO
Colon Surgery 0D1A4ZN BYPASS JEJUNUM SIG COLON PERQ ENDO
Colon Surgery 0D1B07H BYPASS ILEUM CECUM AUTO TISS SUB OP
Colon Surgery 0D1B07K BYPASS ILEUM ASCEND COLON AUTO OP
Colon Surgery 0D1B07L BYPASS ILEUM TRANS COLON AUTO OP
Colon Surgery 0D1B07M BYPASS ILEUM DESCEND COLON AUTO OP
Colon Surgery 0D1B07N BYPASS ILEUM SIGMOID COLON AUTO OP
Colon Surgery 0D1B0JH BYPASS ILEUM CECUM SYNTH SUBST OPN
Colon Surgery 0D1B0JK BYPASS ILEUM ASCENDING COLON SYN OP
Colon Surgery 0D1B0JL BYPASS ILEUM TRANS COLON SYN SUB OP
Colon Surgery 0D1B0JM BYPASS ILEUM DESCEND COLON SYN OP
Colon Surgery 0D1B0JN BYPASS ILEUM SIGMOID COLON SYN OP
Colon Surgery 0D1B0KH BYPASS ILEUM CECUM NONAUTO SUB OP
Colon Surgery 0D1B0KK BYPASS ILEUM ASC COLON NAUTO SUB OP
Colon Surgery 0D1B0KL BYPASS ILEUM TRANS COLON NAUTO OP
Colon Surgery 0D1B0KM BYPASS ILEUM DESCEND COLON NAUTO OP
Colon Surgery 0D1B0KN BYPASS ILEUM SIG COLON NAUTO SUB OP
Colon Surgery 0D1B0ZH BYPASS ILEUM TO CECUM OPEN APPROACH
Colon Surgery 0D1B0ZK BYPASS ILEUM ASCENDING COLON OPEN
Colon Surgery 0D1B0ZL BYPASS ILEUM TRANSVERSE COLON OPEN
Colon Surgery 0D1B0ZM BYPASS ILEUM DESCENDING COLON OPEN
Colon Surgery 0D1B0ZN BYPASS ILEUM SIGMOID COLON OPEN
Colon Surgery 0D1B47H BYPASS ILEUM CECUM AUTO PC ENDO
Colon Surgery 0D1B47K BYPASS ILEUM ASC COLON AUTO PC ENDO
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Table Name Code Shortened Description
Colon Surgery 0D1B47L BYPASS ILEUM TRN COLON AUTO PC ENDO
Colon Surgery 0D1B47M BYPASS ILEUM DES COLON AUTO PC ENDO
Colon Surgery 0D1B47N BYPASS ILEUM SIG COLON AUTO PC ENDO
Colon Surgery 0D1B4JH BYPASS ILEUM CECUM SYN SUB PC ENDO
Colon Surgery 0D1B4JK BYPASS ILEUM ASC COLON SYN PC ENDO
Colon Surgery 0D1B4JL BYPASS ILEUM TRNS COLON SYN PC ENDO
Colon Surgery 0D1B4JM BYPASS ILEUM DESC COLON SYN PC ENDO
Colon Surgery 0D1B4JN BYPASS ILEUM SIG COLON SYN PC ENDO
Colon Surgery 0D1B4KH BYPASS ILEUM CECUM NAUTO PC ENDO
Colon Surgery 0D1B4KK BYPASS ILEUM A COLON NAUTO PC ENDO
Colon Surgery 0D1B4KL BYPAS ILEUM TRN COLON NAUTO PC ENDO
Colon Surgery 0D1B4KM BYPASS ILEUM D COLON NAUTO PC ENDO
Colon Surgery 0D1B4KN BYPASS ILEUM S COLON NAUTO PC ENDO
Colon Surgery 0D1B4ZH BYPASS ILEUM CECUM PERQ ENDO APPR
Colon Surgery 0D1B4ZK BYPASS ILEUM ASC COLON PERQ ENDO
Colon Surgery 0D1B4ZL BYPASS ILEUM TRANS COLON PERQ ENDO
Colon Surgery 0D1B4ZM BYPASS ILEUM DESC COLON PERQ ENDO
Colon Surgery 0D1B4ZN BYPASS ILEUM SIG COLON PERQ ENDO
Colon Surgery 0D1H074 BYPASS CECUM CUT AUTO TISS SUB OP
Colon Surgery 0D1H0J4 BYPASS CECUM CUTANEOUS SYN SUBST OP
Colon Surgery 0D1H0K4 BYPASS CECUM CUT NAUTO TISS SUB OP
Colon Surgery 0D1H0Z4 BYPASS CECUM CUT OPEN APPROACH
Colon Surgery 0D1H474 BYPASS CECUM CUT AUTO SUB PC ENDO
Colon Surgery 0D1H4J4 BYPASS CECUM CUT SYN SUB PERQ ENDO
Colon Surgery 0D1H4K4 BYPASS CECUM CUT NAUTO SUB PC ENDO
Colon Surgery 0D1H4Z4 BYPASS CECUM CUTANEOUS PERQ ENDO
Colon Surgery 0D1K074 BYPASS ASC COLON CUT AUTO TISS OP
Colon Surgery 0D1K0J4 BYPASS ASCEND COLON CUT SYN SUB OP
Colon Surgery 0D1K0K4 BYPASS ASC COLON CUT NAUTO SUB OPEN
Colon Surgery 0D1K0Z4 BYPASS ASCENDING COLON CUTANEOUS OP
Colon Surgery 0D1K474 BYPASS ASC COLON CUT AUTO PC ENDO
Colon Surgery 0D1K4J4 BYPASS ASC COLON CUT SYN PC ENDO
Colon Surgery 0D1K4K4 BYPASS ASC COLON CUT NAUTO PC ENDO
Colon Surgery 0D1K4Z4 BYPASS ASCENDING COLON CUT PC ENDO
Colon Surgery 0D1L074 BYPASS TRANS COLON CUT AUTO SUB OP
Colon Surgery 0D1L0J4 BYPASS TRANS COLON CUTANEOUS SYN OP
Colon Surgery 0D1L0K4 BYPASS TRANS COLON CUT NAUTO SUB OP
Colon Surgery 0D1L0Z4 BYPASS TRANS COLON CUTANEOUS OPEN
Colon Surgery 0D1L474 BYPASS TRANS COLON CUT AUTO PC ENDO
Colon Surgery 0D1L4J4 BYPASS TRANS COLON CUT SYN PC ENDO
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Table Name Code Shortened Description
Colon Surgery 0D1L4K4 BYPASS TRNS COLON CUT NAUTO PC ENDO
Colon Surgery 0D1L4Z4 BYPASS TRANSVERSE COLON CUT PC ENDO
Colon Surgery 0D1M074 BYPASS DESCENDING COLON CUT AUTO OP
Colon Surgery 0D1M0J4 BYPASS DESCEND COLON CUT SYN SUB OP
Colon Surgery 0D1M0K4 BYPASS DESCEND COLON CUT NAUTO OP
Colon Surgery 0D1M0Z4 BYPASS DESCEND COLON CUTANEOUS OPEN
Colon Surgery 0D1M474 BYPASS DESC COLON CUT AUTO PC ENDO
Colon Surgery 0D1M4J4 BYPASS DESC COLON CUT SYN PC ENDO
Colon Surgery 0D1M4K4 BYPASS DESC COLON CUT NAUTO PC ENDO
Colon Surgery 0D1M4Z4 BYPASS DESCEND COLON CUT PERQ ENDO
Colon Surgery 0D1N074 BYPASS SIG COLON CUT AUTO TISS OP
Colon Surgery 0D1N0J4 BYPASS SIGMOID COLON CUT SYN SUB OP
Colon Surgery 0D1N0K4 BYPASS SIGMOID COLON CUT NAUTO OP
Colon Surgery 0D1N0Z4 BYPASS SIGMOID COLON CUTANEOUS OPEN
Colon Surgery 0D1N474 BYPASS SIG COLON CUT AUTO PC ENDO
Colon Surgery 0D1N4J4 BYPASS SIG COLON CUT SYN PC ENDO
Colon Surgery 0D1N4K4 BYPASS SIG COLON CUT NAUTO PC ENDO
Colon Surgery 0D1N4Z4 BYPASS SIGMOID COLON CUT PERQ ENDO
Colon Surgery 0D5E0ZZ DESTRUCTION LARGE INTESTINE OPEN
Colon Surgery 0D5F0ZZ DESTRUCTION RT LARGE INTESTINE OPEN
Colon Surgery 0D5G0ZZ DESTRUCTION LT LARGE INTESTINE OPEN
Colon Surgery 0D5H0ZZ DESTRUCTION OF CECUM OPEN APPROACH
Colon Surgery 0D5K0ZZ DESTRUCTION ASCENDING COLON OPEN
Colon Surgery 0D5L0ZZ DESTRUCTION TRANSVERSE COLON OPEN
Colon Surgery 0D5M0ZZ DESTRUCTION DESCENDING COLON OPEN
Colon Surgery 0D5N0ZZ DESTRUCTION SIGMOID COLON OP
Colon Surgery 0D9E00Z DRAIN LG INTEST DRAIN DEVC OPN APPR
Colon Surgery 0D9E0ZX DRAIN LG INTESTINE OPEN APPROACH DX
Colon Surgery 0D9E0ZZ DRAIN LARGE INTESTINE OPEN APPROACH
Colon Surgery 0D9E40Z #N/A
Colon Surgery 0D9E4ZX DRAIN LG INTEST PERQ ENDO APPR DX
Colon Surgery 0D9E4ZZ DRAIN LG INTEST PERQ ENDO APPROACH
Colon Surgery 0D9F0ZX DRAIN RT LG INTEST OPEN APPROACH DX
Colon Surgery 0D9G0ZX DRAINAGE LT LG INTESTINE OPEN DX
Colon Surgery 0D9H0ZX DRAINAGE CECUM OPEN APPROACH DX
Colon Surgery 0D9H4ZX DRAIN CECUM PERQ ENDO APPROACH DX
Colon Surgery 0D9K0ZX DRAINAGE ASCEND COLON OPEN APPR DX
Colon Surgery 0D9L0ZX DRAINAGE TRNS COLON OPEN APPR DX
Colon Surgery 0D9M0ZX DRAINAGE DESCEND COLON OPEN APPR DX
Colon Surgery 0D9N0ZX DRAINAGE SIGMOID COLON OPEN APPR DX
Reporting Toolkit
Version 2.4
71
Table Name Code Shortened Description
Colon Surgery 0DBE0ZX EXCISION OF LARGE INTESTINE OPEN DX
Colon Surgery 0DBE0ZZ EXCISION OF LARGE INTESTINE OPEN
Colon Surgery 0DBE4ZX EXCISION LG INTESTINE PERQ ENDO DX
Colon Surgery 0DBE4ZZ EXCISION LARGE INTESTINE PERQ ENDO
Colon Surgery 0DBF0ZX EXCISION RT LARGE INTESTINE OPEN DX
Colon Surgery 0DBF0ZZ EXCISION RIGHT LARGE INTESTINE OPEN
Colon Surgery 0DBF4ZZ EXCISION RT LG INTESTINE PERQ ENDO
Colon Surgery 0DBG0ZX EXCISION LT LG INTESTINE OPN APP DX
Colon Surgery 0DBG0ZZ EXCISION LT LG INTESTINE OPEN APPR
Colon Surgery 0DBG4ZZ EXCISION LT LG INTEST PC ENDO APPR
Colon Surgery 0DBH0ZX EXCISION CECUM OPEN APPROACH DX
Colon Surgery 0DBH0ZZ EXCISION OF CECUM OPEN APPROACH
Colon Surgery 0DBH4ZX EXCISION CECUM PERQ ENDO APPR DX
Colon Surgery 0DBH4ZZ EXCISION CECUM PERQ ENDO APPROACH
Colon Surgery 0DBK0ZX EXCISION ASCEND COLON OPEN APPR DX
Colon Surgery 0DBK0ZZ EXCISION ASCENDING COLON OPEN APPR
Colon Surgery 0DBK4ZZ EXCISION ASC COLON PERQ ENDO APPR
Colon Surgery 0DBL0ZX EXCISION TRNS COLON OPEN APPR DX
Colon Surgery 0DBL0ZZ EXCISION TRANSVERSE COLON OPEN APPR
Colon Surgery 0DBL4ZZ EXCISION TRNS COLON PERQ ENDO APPR
Colon Surgery 0DBM0ZX EXC DESCEND COLON OPEN APPROACH DX
Colon Surgery 0DBM0ZZ EXCISION DESCEND COLON OPEN APPR
Colon Surgery 0DBM4ZZ EXC DESCEND COLON PERQ ENDO APPR
Colon Surgery 0DBN0ZX EXCISION SIGMOID COLON OPEN APPR DX
Colon Surgery 0DBN0ZZ EXCISION SIGMOID COLON OPEN APPR
Colon Surgery 0DBN4ZX EXC SIGMOID COLON PERQ ENDO APPR DX
Colon Surgery 0DBN4ZZ EXC SIGMOID COLON PERQ ENDO APPR
Colon Surgery 0DCE0ZZ EXTIRPAT MATTER LG INTEST OPN APPR
Colon Surgery 0DCE4ZZ EXTIRPAT MATTER LG INTEST PERQ ENDO
Colon Surgery 0DCF0ZZ EXTIRPAT MATTER RT LG INTEST OPN
Colon Surgery 0DCF4ZZ EXTIRPAT MATTR RT LG INTEST PC ENDO
Colon Surgery 0DCG0ZZ EXTIRPAT MATTER LT LG INTEST OPN
Colon Surgery 0DCG4ZZ EXTIR MATTR LT LG INTEST PERQ ENDO
Colon Surgery 0DCH0ZZ EXTIRPATION MATTER FROM CECUM OPEN
Colon Surgery 0DCH4ZZ EXTIRPAT MATTER CECUM PERQ ENDO
Colon Surgery 0DCK0ZZ EXTIRPAT MATTER ASC COLON OPN APPR
Colon Surgery 0DCK4ZZ EXTIRPAT MATTER ASC COLON PERQ ENDO
Colon Surgery 0DCL0ZZ EXTIRPAT MATTER TRNS COLON OPN APPR
Colon Surgery 0DCL4ZZ EXTIRPAT MATTR TRNS COLON PC ENDO
Colon Surgery 0DCM0ZZ EXTIRPAT MATTER DESC COLON OPN APPR
Reporting Toolkit
Version 2.4
72
Table Name Code Shortened Description
Colon Surgery 0DCM4ZZ EXTIRPAT MATTER DESC COLON PC ENDO
Colon Surgery 0DCN0ZZ EXTIRPAT MATTER SIG COLON OPEN APPR
Colon Surgery 0DCN4ZZ EXTIRPAT MATTER SIG COLON PERQ ENDO
Colon Surgery 0DPD00Z REMV DRN DEVC LOW INTEST TRACT OPEN
Colon Surgery 0DPD02Z REMV MON DEVC LOW INTEST TRACT OPEN
Colon Surgery 0DPD03Z REMV INFUS DEVC LW INTEST TRACT OPN
Colon Surgery 0DPD07Z REMV AUTO SUB LOW INTEST TRACT OPEN
Colon Surgery 0DPD0CZ REMV EXTRALUM DEV L INTEST TRACT OP
Colon Surgery 0DPD0DZ REMV INTRALUM DEV L INTEST TRACT OP
Colon Surgery 0DPD0JZ REMV SYNTH SUBST L INTEST TRACT OPN
Colon Surgery 0DPD0KZ REMV NAUTO SUB LOW INTEST TRACT OPN
Colon Surgery 0DPD0UZ REMV FEED DEVC LOW INTEST TRACT OPN
Colon Surgery 0DPD40Z REMOVAL DRN LW INTEST TRACT PC ENDO
Colon Surgery 0DPD42Z REMOVAL MON LW INTEST TRACT PC ENDO
Colon Surgery 0DPD43Z REMOVAL INF LW INTEST TRACT PC ENDO
Colon Surgery 0DPD47Z REMV AUTO SUB LW INTST TRCT PC ENDO
Colon Surgery 0DPD4CZ REMV EL DEV LW INTEST TRACT PC ENDO
Colon Surgery 0DPD4DZ REMV IL DEV LW INTEST TRACT PC ENDO
Colon Surgery 0DPD4JZ REMV SYN SUB L INTEST TRACT PC ENDO
Colon Surgery 0DPD4KZ REMV NAUTO SUB LW INTST TRCT PC END
Colon Surgery 0DPD4UZ REMV FD DEV LW INTEST TRACT PC ENDO
Colon Surgery 0DQE0ZZ REPAIR LARGE INTESTINE OPEN APPR
Colon Surgery 0DQE4ZZ REPAIR LG INTESTINE PERQ ENDO APPR
Colon Surgery 0DQF0ZZ REPAIR RT LARGE INTESTINE OPEN APPR
Colon Surgery 0DQF4ZZ REPR RT LG INTEST PERQ ENDO APPR
Colon Surgery 0DQG0ZZ REPR LT LG INTESTINE OPEN APPROACH
Colon Surgery 0DQG4ZZ REPAIR LT LG INTEST PERQ ENDO APPR
Colon Surgery 0DQH0ZZ REPAIR / CECUM / OPEN APPROACH
Colon Surgery 0DQH4ZZ REPAIR CECUM PERQ ENDO APPROACH
Colon Surgery 0DQK0ZZ REPAIR ASCENDING COLON OPEN APPR
Colon Surgery 0DQK4ZZ REPAIR ASC COLON PERQ ENDO APPROACH
Colon Surgery 0DQL0ZZ REPAIR TRNS COLON OPEN APPROACH
Colon Surgery 0DQL4ZZ REPR TRNS COLON PERQ ENDO APPROACH
Colon Surgery 0DQM0ZZ REPAIR DESCEND COLON OPEN APPROACH
Colon Surgery 0DQM4ZZ REPAIR DESC COLON PERQ ENDO APPR
Colon Surgery 0DQN0ZZ REPAIR SIGMOID COLON OPEN APPROACH
Colon Surgery 0DQN4ZZ REPR SIG COLON PERQ ENDO APPROACH
Colon Surgery 0DTE0ZZ RESECTION OF LARGE INTESTINE OPEN
Colon Surgery 0DTE4ZZ RESECTION LARGE INTESTINE PERQ ENDO
Colon Surgery 0DTF0ZZ RESECTION RIGHT LARGE INTESTINE OPN
Reporting Toolkit
Version 2.4
73
Table Name Code Shortened Description
Colon Surgery 0DTF4ZZ RESECTION RT LG INTESTINE PERQ ENDO
Colon Surgery 0DTG0ZZ RESECTION LEFT LARGE INTESTINE OPEN
Colon Surgery 0DTG4ZZ RESECTION LT LG INTESTINE PERQ ENDO
Colon Surgery 0DTH0ZZ RESECTION OF CECUM OPEN APPROACH
Colon Surgery 0DTH4ZZ RESECTION CECUM PERQ ENDOSCOPIC
Colon Surgery 0DTK0ZZ RESECTION ASCENDING COLON OPEN APPR
Colon Surgery 0DTK4ZZ RESECTION ASCENDING COLON PERQ ENDO
Colon Surgery 0DTL0ZZ RESECTION TRANSVERSE COLON OPEN
Colon Surgery 0DTL4ZZ RESECTION TRNS COLON PERQ ENDO APPR
Colon Surgery 0DTM0ZZ RESECTION DESCENDING COLON OPEN
Colon Surgery 0DTM4ZZ RESECT DESCENDING COLON PERQ ENDO
Colon Surgery 0DTN0ZZ RESECTION SIGMOID COLON OPEN APPR
Colon Surgery 0DTN4ZZ RESECT SIGMOID COLON PERQ ENDO APPR
Colon Surgery 0DWD00Z REV DRN DEV LW INTEST TRACT OPN
Colon Surgery 0DWD02Z REV MON DEV LW INTEST TRACT OPN
Colon Surgery 0DWD03Z REV INFUS DEV LW INTEST TRACT OPN
Colon Surgery 0DWD07Z REV AUTO SUB LW INTEST TRACT OPN
Colon Surgery 0DWD0CZ REV EXTRALUM DEV L INTEST TRACT OPN
Colon Surgery 0DWD0DZ REV INTRALUM DEV L INTEST TRACT OPN
Colon Surgery 0DWD0JZ REV SYNTH SUBST LW INTEST TRACT OPN
Colon Surgery 0DWD0KZ REV NAUTO SUB LW INTEST TRACT OPN
Colon Surgery 0DWD0UZ REV FD DEV LW INTEST TRACT OPN APPR
Colon Surgery 0DWD40Z REV DRN DEV LW INTEST TRACT PC ENDO
Colon Surgery 0DWD42Z REV MON DEV LW INTEST TRACT PC ENDO
Colon Surgery 0DWD43Z REV INF DEV LW INTEST TRACT PC ENDO
Colon Surgery 0DWD47Z REV AUTO SUB L INTEST TRACT PC ENDO
Colon Surgery 0DWD4CZ REV EL DEV LOW INTEST TRACT PC ENDO
Colon Surgery 0DWD4DZ REV IL DEV LOW INTEST TRACT PC ENDO
Colon Surgery 0DWD4JZ REV SYN SUB LW INTEST TRACT PC ENDO
Colon Surgery 0DWD4KZ REV NAUTO SUB LW INTST TRCT PC ENDO
Colon Surgery 0DWD4UZ REV FD DEV L INTEST TRACT PERQ ENDO
Colon Surgery 0DWE07Z REV AUTO TISS SUBST LG INTEST OPEN
Colon Surgery 0DWE0JZ REV SYNTH SUBST LG INTEST OPN APPR
Colon Surgery 0DWE0KZ REV NONAUTO TISS SUBST LG INTEST OP
Colon Surgery 0DWE47Z REV AUTO SUB LG INTEST PC ENDO APPR
Colon Surgery 0DWE4JZ REV SYNTH SUBST LG INTEST PERQ ENDO
Colon Surgery 0DWE4KZ REV NAUTO SUB LG INTESTINE PC ENDO
Hip Arthroplasty 0SR9019 REPL RT HIP JOINT MEATL CEMENT OPEN
Hip Arthroplasty 0SR901A REPL R HIP JOINT METL UNCEMENT OPEN
Hip Arthroplasty 0SR901Z REPLACEMENT RT HIP JOINT METAL OPEN
Reporting Toolkit
Version 2.4
74
Table Name Code Shortened Description
Hip Arthroplasty 0SR9029 REPL R HIP JNT METL POLY CMENT OPEN
Hip Arthroplasty 0SR902A REPL R HIP JNT METL POLY UNCMNT OPN
Hip Arthroplasty 0SR902Z REPL RT HIP JOINT METAL POLY OPEN
Hip Arthroplasty 0SR9039 REPL RT HIP JOINT CERAM CMENT OPEN
Hip Arthroplasty 0SR903A REPL RT HIP JNT CERAM UNCEMENT OPEN
Hip Arthroplasty 0SR903Z REPLACE RT HIP JOINT CERAMIC OPEN
Hip Arthroplasty 0SR9049 REPL R HIP JNT CERAM POLY CMENT OPN
Hip Arthroplasty 0SR904A REPL R HIP JNT CERAM PLY UCMENT OPN
Hip Arthroplasty 0SR904Z REPL RT HIP JOINT CERAM POLY OPEN
Hip Arthroplasty 0SR907Z REPL RT HIP JNT AUTO TISS SUBST OPN
Hip Arthroplasty 0SR90J9 REPL R HIP JOINT SYNTH CEMENT OPEN
Hip Arthroplasty 0SR90JA REPL R HIP JOINT SYNTH CEMENT OPEN
Hip Arthroplasty 0SR90JZ REPL RT HIP JOINT SYNTH SUBST OPEN
Hip Arthroplasty 0SR90KZ REPL RT HIP JOINT NAUTO SUB OPEN
Hip Arthroplasty 0SRA009 REPL R HIP JNT ACE POLY CMENTD OPEN
Hip Arthroplasty 0SRA00A REPL R HIP JNT ACE POLY UNCMENT OPN
Hip Arthroplasty 0SRA00Z REPL RT HIP JOINT ACETAB POLY OPEN
Hip Arthroplasty 0SRA019 REPL R HIP JNT ACE METL CMENTD OPEN
Hip Arthroplasty 0SRA01A REPL R HIP JNT ACE METL UNCMENT OPN
Hip Arthroplasty 0SRA01Z REPL RT HIP JOINT ACETAB METAL OPEN
Hip Arthroplasty 0SRA039 REPL R HIP JNT ACE CERMC CMENTD OPN
Hip Arthroplasty 0SRA03A REPL R HIP JNT ACE CERMC UNCMNT OPN
Hip Arthroplasty 0SRA03Z REPL RT HIP JOINT ACETAB CERMC OPEN
Hip Arthroplasty 0SRA07Z REPL RT HIP JOINT ACTB AUTO SUB OPN
Hip Arthroplasty 0SRA0J9 REPL R HIP JNT ACE SYNTH CMENTD OPN
Hip Arthroplasty 0SRA0JA REPL R HIP JNT ACE SYNT UNCMENT OPN
Hip Arthroplasty 0SRA0JZ REPL RT HIP JOINT ACTB SURF SYN OPN
Hip Arthroplasty 0SRA0KZ REPL RT HIP JNT ACTB NAUTO SUB OPN
Hip Arthroplasty 0SRB019 REPL LT HIP JOINT METAL CEMENT OPEN
Hip Arthroplasty 0SRB01A REPL LT HIP JOINT METL UNCMENT OPEN
Hip Arthroplasty 0SRB01Z REPLACEMENT LT HIP JOINT METAL OPEN
Hip Arthroplasty 0SRB029 REPL L HIP JNT METL POLY CMENT OPEN
Hip Arthroplasty 0SRB02A REPL L HIP JNT METL POLY UCMENT OPN
Hip Arthroplasty 0SRB02Z REPL LT HIP JOINT METAL POLY OPEN
Hip Arthroplasty 0SRB039 REPL LT HIP JOINT CERAM CEMENT OPEN
Hip Arthroplasty 0SRB03A REPL LT HIP JNT CERAM UNCEMENT OPEN
Hip Arthroplasty 0SRB03Z REPLACE LT HIP JOINT CERAMIC OPEN
Hip Arthroplasty 0SRB049 REPL L HIP JNT CERAM POLY CMENT OPN
Hip Arthroplasty 0SRB04A REPL L HIP JNT CERAM PLY UCMENT OPN
Hip Arthroplasty 0SRB04Z REPL LT HIP JOINT CERAMIC POLY OPEN
Reporting Toolkit
Version 2.4
75
Table Name Code Shortened Description
Hip Arthroplasty 0SRB07Z REPL LT HIP JNT AUTO TISS SUBST OPN
Hip Arthroplasty 0SRB0J9 REPL LT HIP JOINT SYNTH CMENTD OPEN
Hip Arthroplasty 0SRB0JA REPL L HIP JNT SYNTH UNCEMENTD OPEN
Hip Arthroplasty 0SRB0JZ REPL LT HIP JOINT SYNTH SUBST OPEN
Hip Arthroplasty 0SRB0KZ REPL LT HIP JOINT NAUTO SUB OPEN
Hip Arthroplasty 0SRE009 REPL L HIP JNT ACE POLY CMENTED OPN
Hip Arthroplasty 0SRE00A REPL L HIP JNT ACE POLY UCMENTD OPN
Hip Arthroplasty 0SRE00Z REPL LT HIP JOINT ACETAB POLY OPEN
Hip Arthroplasty 0SRE019 REPL L HIP JNT ACE METL CMENTD OPEN
Hip Arthroplasty 0SRE01A REPL L HIP JNT ACE METL UCMENTD OPN
Hip Arthroplasty 0SRE01Z REPL LT HIP JOINT ACETAB METAL OPEN
Hip Arthroplasty 0SRE039 REPL L HIP JNT ACE CERMC CMENTD OPN
Hip Arthroplasty 0SRE03A REPL L HIP JNT ACE CERMC UCMENT OPN
Hip Arthroplasty 0SRE03Z REPL LT HIP JOINT ACE CERAMIC OPEN
Hip Arthroplasty 0SRE07Z REPL LT HIP JOINT ACTB AUTO SUB OPN
Hip Arthroplasty 0SRE0J9 REPL L HIP JNT ACE SYN CMENTD OPEN
Hip Arthroplasty 0SRE0JA REPL L HIP JNT ACE SYN UCMENTD OPEN
Hip Arthroplasty 0SRE0JZ REPL LT HIP JOINT ACTB SURF SYN OPN
Hip Arthroplasty 0SRE0KZ REPL LT HIP JOINT ACTB NAUTO SUB OP
Hip Arthroplasty 0SRR019 REPL R HIP JNT FEMR METL CMENTD OPN
Hip Arthroplasty 0SRR01A REPL R HIP JNT FEMR METL UCMENT OPN
Hip Arthroplasty 0SRR01Z REPL RT HIP JOINT FEMORL METAL OPEN
Hip Arthroplasty 0SRR039 REPL R HIP JNT FEMR CERMC CMNTD OPN
Hip Arthroplasty 0SRR03A REPL R HIP JNT FEMR CERMC UCMNTD OP
Hip Arthroplasty 0SRR03Z REPL RT HIP JOINT FEMOR CERMC OPEN
Hip Arthroplasty 0SRR07Z RPL RT HIP JNT FEM SURF AUTO SUB OP
Hip Arthroplasty 0SRR0J9 REPL R HIP JNT FEMR SYNTH CMNTD OPN
Hip Arthroplasty 0SRR0JA REPL R HIP JNT FEMR SNTH UCMNTD OPN
Hip Arthroplasty 0SRR0JZ REPL RT HIP JNT FEM SURF SYN SUB OP
Hip Arthroplasty 0SRR0KZ REPL RT HIP JNT FEM NAUTO SUB OP
Hip Arthroplasty 0SRS019 REPL L HIP JNT FEMR METL CMNTD OPEN
Hip Arthroplasty 0SRS01A REPL L HIP JNT FEMR METL CMNTD OPEN
Hip Arthroplasty 0SRS01Z REPL L HIP JOINT FEMORAL METAL OPEN
Hip Arthroplasty 0SRS039 REPL L HIP JNT FEMR CERMC CMNTD OPN
Hip Arthroplasty 0SRS03A REPL L HIP JNT FEMR CERMC UCMNTD OP
Hip Arthroplasty 0SRS03Z REPL LT HIP JOINT FEMORL CERMC OPEN
Hip Arthroplasty 0SRS07Z RPL LT HIP JNT FEM SURF AUTO SUB OP
Hip Arthroplasty 0SRS0J9 REPL L HIP JNT FEMR SYNTH CMNTD OPN
Hip Arthroplasty 0SRS0JA REPL L HIP JNT FEMR SYNTH UCMNTD OP
Hip Arthroplasty 0SRS0JZ REPL LT HIP JNT FEM SURF SYN SUB OP
Reporting Toolkit
Version 2.4
76
Table Name Code Shortened Description
Hip Arthroplasty 0SRS0KZ REPL LT HIP JOINT FEM NAUTO SUB OP
Hip Arthroplasty 0SU907Z SUPPL RT HIP JNT AUTO TISS SUBST OP
Hip Arthroplasty 0SU909Z SUPPLEMENT RT HIP JOINT W/LINER OPN
Hip Arthroplasty 0SU90BZ SUPPL RT HIP JOINT RESURFACING OPN
Hip Arthroplasty 0SU90KZ SUPPL RT HIP JOINT NAUTO SUB OPEN
Hip Arthroplasty 0SUA09Z SUPPL RT HIP JNT ACTB SURF LINER OP
Hip Arthroplasty 0SUA0BZ SUPPL RT HIP JNT ACTB SURF RSRF OP
Hip Arthroplasty 0SUB07Z SUPPL LT HIP JNT AUTO TISS SUBST OP
Hip Arthroplasty 0SUB09Z SUPPL LT HIP JOINT W/LINER OPN APPR
Hip Arthroplasty 0SUB0BZ SUPPL LT HIP JNT W/RESURFACING OPEN
Hip Arthroplasty 0SUB0KZ SUPPL LT HIP JOINT NONAUTO SUB OPEN
Hip Arthroplasty 0SUE09Z SUPPL LT HIP JNT ACTB SURF LINER OP
Hip Arthroplasty 0SUE0BZ SUPPL LT HIP JNT ACTB SURF RSRF OPN
Hip Arthroplasty 0SUR09Z SUPPL RT HIP JNT FEM SURF LINER OPN
Hip Arthroplasty 0SUR0BZ SUPPL RT HIP JNT FEM SURF RESURF OP
Hip Arthroplasty 0SUS09Z SUPPL LT HIP JNT FEM SURF LINER OPN
Hip Arthroplasty 0SUS0BZ SUPPL LT HIP JNT FEM SURF RESURF OP
Hip Arthroplasty 0SW904Z REV IF DEVC RT HIP JNT OPN APPROACH
Hip Arthroplasty 0SW907Z REV AUTO TISS SUBST RT HIP JNT OPN
Hip Arthroplasty 0SW90JZ REV SYNTH SUBST RT HIP JNT OPN APPR
Hip Arthroplasty 0SW90KZ REV NONAUTO SUB RT HIP JNT OPN APPR
Hip Arthroplasty 0SW944Z REV IF DEV RT HIP JNT PERQ ENDO
Hip Arthroplasty 0SW947Z REV AUTO SUB RT HIP JNT PC ENDO
Hip Arthroplasty 0SW94JZ REV SYNTH SUBST RT HIP JNT PC ENDO
Hip Arthroplasty 0SW94KZ REV NAUTO SUB RT HIP JNT PC ENDO
Hip Arthroplasty 0SWB04Z REV IF DEVC LT HIP JNT OPN APPROACH
Hip Arthroplasty 0SWB07Z REV AUTO TISS SUBST LT HIP JNT OPN
Hip Arthroplasty 0SWB0JZ REV SYNTH SUBST LT HIP JNT OPN APPR
Hip Arthroplasty 0SWB0KZ REV NONAUTO SUB LT HIP JNT OPN APPR
Hip Arthroplasty 0SWB44Z REV IF DEV LT HIP JNT PERQ ENDO
Hip Arthroplasty 0SWB47Z REV AUTO SUB LT HIP JNT PC ENDO
Hip Arthroplasty 0SWB4JZ REV SYNTH SUBST LT HIP JNT PC ENDO
Hip Arthroplasty 0SWB4KZ REV NAUTO SUB LT HIP JNT PC ENDO
Knee Arthroplasty 0QRD0JZ REPL RIGHT PATELLA SYNTH SUBST OPEN
Knee Arthroplasty 0QRD4JZ REPL RT PAT SYNTH SUBST PERQ ENDO
Knee Arthroplasty 0QRF0JZ REPL LEFT PATELLA SYNTH SUBST OPEN
Knee Arthroplasty 0QRF4JZ REPL LEFT PAT SYNTH SUBST PERQ ENDO
Knee Arthroplasty 0QUD0JZ SUPPLEMENT RT PAT SYNTH SUBST OPEN
Knee Arthroplasty 0QUD4JZ SUPPL RT PAT SYNTH SUBST PERQ ENDO
Knee Arthroplasty 0QUF0JZ SUPPL LEFT PATELLA SYNTH SUBST OP
Reporting Toolkit
Version 2.4
77
Table Name Code Shortened Description
Knee Arthroplasty 0QUF4JZ SUPPL LT PAT SYNTH SUBST PERQ ENDO
Knee Arthroplasty 0SRC07Z REPL RT KNEE JNT AUTO TISS SUB OPN
Knee Arthroplasty 0SRC0J9 REPL R KNEE JOINT SYNTH CMENTD OPEN
Knee Arthroplasty 0SRC0JA REPL R KNEE JNT SYNTH UNCMENTD OPEN
Knee Arthroplasty 0SRC0JZ REPL RT KNEE JOINT SYNTH SUBST OPEN
Knee Arthroplasty 0SRC0KZ REPL RT KNEE JOINT NONAUTO SUB OPEN
Knee Arthroplasty 0SRD07Z REPL LT KNEE JNT AUTO TISS SUB OPN
Knee Arthroplasty 0SRD0J9 REPL L KNEE JOINT SYNTH CMENTD OPEN
Knee Arthroplasty 0SRD0JA REPL L KNEE JNT SYNTH UNCMENTD OPEN
Knee Arthroplasty 0SRD0JZ REPL LT KNEE JOINT SYNTH SUBST OPEN
Knee Arthroplasty 0SRD0KZ REPL LT KNEE JOINT NONAUTO SUB OPEN
Knee Arthroplasty 0SRT07Z REPL RT KN JNT FEM SURF AUTO SUB OP
Knee Arthroplasty 0SRT0J9 REPL RT KN JNT FEMR SYNTH CMNTD OPN
Knee Arthroplasty 0SRT0JA REPL R KN JNT FEMR SYNTH UCMNTD OPN
Knee Arthroplasty 0SRT0JZ REPL RT KN JNT FEM SURF SYN SUB OPN
Knee Arthroplasty 0SRT0KZ RPL RT KN JNT FEM SURF NAUTO SUB OP
Knee Arthroplasty 0SRU07Z REPL LT KN JNT FEM SURF AUTO SUB OP
Knee Arthroplasty 0SRU0J9 REPL LT KN JNT FEMR SYNTH CMNTD OPN
Knee Arthroplasty 0SRU0JA REPL L KN JNT FEMR SYNTH UCMNTD OPN
Knee Arthroplasty 0SRU0JZ REPL LT KN JNT FEM SURF SYN SUB OPN
Knee Arthroplasty 0SRU0KZ RPL LT KN JNT FEM SURF NAUTO SUB OP
Knee Arthroplasty 0SRV07Z REPL RT KN JNT TIB SURF AUTO SUB OP
Knee Arthroplasty 0SRV0J9 REPL RT KN JNT TIB SYNTH CMNTED OPN
Knee Arthroplasty 0SRV0JA REPL RT KN JNT TIB SYNTH UCMNTD OPN
Knee Arthroplasty 0SRV0JZ REPL RT KN JNT TIB SURF SYN SUB OPN
Knee Arthroplasty 0SRV0KZ RPL RT KN JNT TIB SURF NAUTO SUB OP
Knee Arthroplasty 0SRW07Z REPL LT KN JNT TIB SURF AUTO SUB OP
Knee Arthroplasty 0SRW0J9 REPL LT KN JNT TIB SYNTH CMNTED OPN
Knee Arthroplasty 0SRW0JA REPL LT KN JNT TIB SYNTH UNCMNTD OP
Knee Arthroplasty 0SRW0JZ REPL LT KN JNT TIB SURF SYN SUB OPN
Knee Arthroplasty 0SRW0KZ RPL LT KN JNT TIB SURF NAUTO SUB OP
Knee Arthroplasty 0SUC07Z SUPPL RT KNEE JNT AUTO TISS SUB OPN
Knee Arthroplasty 0SUC09C SUPPL RT KNEE JNT LINER PAT SURF OP
Knee Arthroplasty 0SUC0JZ SUPPL RT KNEE JOINT SYNTH SUBST OPN
Knee Arthroplasty 0SUC0KZ SUPPL RT KNEE JOINT NAUTO SUB OPEN
Knee Arthroplasty 0SUC47Z SUPPL RT KNEE JNT AUTO SUB PC ENDO
Knee Arthroplasty 0SUC4JZ SUPPL RT KNEE JNT SYNTH SUB PC ENDO
Knee Arthroplasty 0SUC4KZ SUPPL RT KNEE JNT NAUTO SUB PC ENDO
Knee Arthroplasty 0SUD07Z SUPPL LT KN JNT AUTO TISS SUBST OPN
Knee Arthroplasty 0SUD09C SUPPL LT KNEE JNT LINER PAT SURF OP
Reporting Toolkit
Version 2.4
78
Table Name Code Shortened Description
Knee Arthroplasty 0SUD0JZ SUPPL LT KNEE JOINT SYNTH SUBST OPN
Knee Arthroplasty 0SUD0KZ SUPPL LT KNEE JOINT NAUTO SUB OPEN
Knee Arthroplasty 0SUD47Z SUPPL LT KNEE JNT AUTO SUB PC ENDO
Knee Arthroplasty 0SUD4JZ SUPPL LT KNEE JNT SYNTH SUB PC ENDO
Knee Arthroplasty 0SUD4KZ SUPPL LT KNEE JNT NAUTO SUB PC ENDO
Knee Arthroplasty 0SUT09Z SUPPL RT KNEE JNT FEM SURF LINER OP
Knee Arthroplasty 0SUU09Z SUPPL LT KNEE JNT FEM SURF LINER OP
Knee Arthroplasty 0SUV09Z SUPPL RT KNEE JNT TIB SURF LINER OP
Knee Arthroplasty 0SUW09Z SUPPL LT KNEE JNT TIB SURF LINER OP
Knee Arthroplasty 0SWC04Z REV IF DEVC RT KN JNT OPEN APPROACH
Knee Arthroplasty 0SWC07Z REV AUTO TISS SUBST RT KN JNT OPN
Knee Arthroplasty 0SWC0JZ REV SYNTH SUBST RT KN JNT OPN APPR
Knee Arthroplasty 0SWC0KZ REV NONAUTO TISS SUBST RT KN JNT OP
Knee Arthroplasty 0SWC44Z REV IF DEV RT KN JNT PERQ ENDO APPR
Knee Arthroplasty 0SWC47Z REV AUTO SUB RT KN JNT PC ENDO APPR
Knee Arthroplasty 0SWC4JZ REV SYNTH SUBST RT KN JNT PERQ ENDO
Knee Arthroplasty 0SWC4KZ REV NAUTO SUB RT KN JNT PC ENDO
Knee Arthroplasty 0SWD04Z REV IF DEVC LT KN JNT OPEN APPROACH
Knee Arthroplasty 0SWD07Z REV AUTO TISS SUBST LT KN JNT OPN
Knee Arthroplasty 0SWD0JZ REV SYNTH SUBST LT KN JNT OPN APPR
Knee Arthroplasty 0SWD0KZ REV NONAUTO TISS SUBST LT KN JNT OP
Knee Arthroplasty 0SWD44Z REV IF DEV LT KN JNT PERQ ENDO APPR
Knee Arthroplasty 0SWD47Z REV AUTO SUB LT KN JNT PC ENDO APPR
Knee Arthroplasty 0SWD4JZ REV SYNTH SUBST LT KN JNT PERQ ENDO
Knee Arthroplasty 0SWD4KZ REV NAUTO SUB LT KN JNT PC ENDO
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Appendix VI
PAGE 27. Institute for Healthcare Improvement – IHI How-to Guide: Prevent Ventilator-
Associated Pneumonia.
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventVAP.aspx
Ventilator Bundle Compliance
In our experience, teams begin to demonstrate improvement in outcomes when they provide all five
components of the Ventilator Bundle. Therefore, we choose to measure compliance with the entire
Ventilator Bundle, not just parts of the bundle.
On a given day, select all the ventilated patients and assess them for compliance with the Ventilator
Bundle. If even one bundle component is missing, the case is not in compliance with the bundle.
For example, if there are 7 ventilated patients, and 6 patients have all 5 bundle elements completed,
then 6/7 (86%) is the compliance with the Ventilator Bundle. If all 7 ventilated patients had all 5
elements completed, compliance would be 100%. If all 7 were missing even a single element,
compliance would be 0%.
No. ventilated patients receiving ALL 5 Ventilator Bundle elements = Reliability of ventilator
bundle compliance
No. patients on ventilators for the day of the sample.
PAGE 10-20: Institute for Healthcare Improvement – IHI How-to Guide: Prevent Ventilator-
Associated Pneumonia.
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventVAP.aspx
Preventing Ventilator-Associated Pneumonia:
Five components of Care:
1. Elevation of the Head
a. Recommended elevation is between 30 and 45 degrees
2. Daily Sedative Interruption and Daily Assessment of Readiness to Extubate
3. Peptic Ulcer Disease Prophylaxis
4. Deep Venous Thrombosis Prophylaxis
5. Daily Oral Care with Chlorhexidine
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Appendix VII
Medication Therapy Intervention & Safety Documentation Program User Manual (v 7.0), pages 8-9
Adverse Drug Reaction (ADR) definition
http://www.ihconline.org/UserDocs/Pages/USC-Medication-Therapy-Intervention-and-
Documentation-Manual--Updated-4-6-2012.pdf
Adverse Drug Reaction (ADR)
An ADR is harm directly caused by a drug at normal doses during normal use. ADRs are side
effects, but the term “side effects” tends to minimize the importance of the reaction and, therefore,
ADR is the preferred terminology. These reactions may not necessarily be severe. Adverse drug
reaction can be augmented pharmacologic effects, idiosyncratic effects, chronic effects, delayed
effects, end-of-treatment effects, or failure of therapy.
Example:
Lower extremity edema from Norvasc 10mg daily for HTN
Tylenol with Codeine #3 1-2 tabs q4-6h prn pain leading to severe drowsiness or
constipation
Cough from ACEi therapy
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Appendix VIII How-to Confer NHSN Rights to IHC
IHC is encouraging the reporting of CAUTI, CLABSI, VAE, SSI and CDI data through NHSN. In
order to simplify reporting to IHC for the HEN metrics, we’re encouraging hospitals using NHSN
to confer rights to IHC for their NHSN data – this will help avoid duplication of effort between the
IHC HEN data entry system and NHSN. Below are the steps you can follow to confer rights to
IHC. Let me know if you have any questions.
1. First, of course, enroll in NHSN. Information on enrollment steps can be found on the
CDC’s NHSN website http://www.cdc.gov/nhsn
2. Once enrollment in NHSN is complete, log into NHSN/SAMs. Once logged into NHSN,
you may come to a “Landing Page” where you will select your facility.
3. On the navigation bar on the left side of the page, click on “Group” and select “Join”. The
Memberships screen will appear. Note: The decision to confer rights to a group is a decision
made by the NHSN facility administrator – the individual in your facility with enrollment
privileges in NHSN who can grant this access.
4. Enter the 'Group ID' and 'Group Joining Password' in their respective places. For IHC, the
Group ID is ‘14184’. Group Joining Password is ‘IHC-IOWA’.
5. Click "Join Group". A pop-up box will appear that indicates CDC is not accountable for
how the group you join uses your data. To join the IHC group, you must select “OK”. You
will then come to the Confer Rights screen, with a message at the top indicating that you’ve
successfully joined the group
6. Note the confer rights template is pre-populated with the specific NHSN metrics IHC is to
receive from your facility. Please do not alter the template. If you do so we may not have the
ability to pull data necessary to update your HEN reports (such as numerator or denominator
data, events, etc.) Please remember we do not receive ANY patient identifiers.
Thanks very much for your support of IHC’s work. Please let me know if you have any questions.
Jennifer Brockman
Clinical Coordinator – HAI Strategies
Iowa Healthcare Collaborative
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Appendix IX
The Joint Commission – Perinatal Care (PC) measure PC-01 Elective Delivery
https://manual.jointcommission.org/releases/TJC2015B2/MIF0166.html
Numerator: Patients with elective deliveries
Included populations: ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure
Codes for one or more of the following:
Medical induction of labor as defined in Appendix A, Table 11.05 while not in Labor prior to the
procedure
Cesarean birth as defined in Appendix A, Table 11.06 and all of the following:
o not in Labor
o no history of a Prior Uterine Surgery
Excluded Populations: None
Data Elements:
ICD-10-PCS Other Procedure Codes
ICD-10-PCS Principal Procedure Code
Labor
Prior Uterine Surgery
Denominator: Patients delivering newborn with >= 37 and < 39 weeks of gestation completed
Included populations:
ICD-10-PCS Principal Procedure Code or ICD-10-PCS Other Procedure Codes for delivery as
defined in Appendix A, Table 11.01.1
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for planned
cesarean birth in labor as defined in Appendix A, Table 11.06.1 Excluded Populations:
ICD-10-CM Principal Diagnosis Code or ICD-10-CM Other Diagnosis Codes for conditions
possibly justifying elective delivery prior to 39 weeks gestation as defined in Appendix A, Table
11.07
Less than 8 years of age
Greater than or equal to 65 years of age
Length of stay > 120 days
Enrolled in clinical trials
Gestational Age < 37 or >= 39 weeks or UTD Data Elements:
Admission Date
Birthdate
Clinical Trial
Discharge Date
Gestational Age
ICD-10-CM Other Diagnosis Codes
ICD-10-CM Principal Diagnosis Code
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Appendix X
CDC: Severe Maternal Morbidity in the United States (ICD-9 code set for OB Trauma metric)
ICD-9 DIAGNOSIS CODES
ICD-9
PROCEDURE
CODES
Acute myocardial infarction 410.xx
Acute renal failure 584.x, 669.3x
Adult respiratory distress syndrome 518.5, 518.81, 518.82,
518.84, 799.1
Amniotic fluid embolism 673.1x
Aneurysm 441.xx
Cardiac arrest/ventricular fibrillation 427.41, 427.42, 427.5
Disseminated intravascular coagulation 286.6, 286.9, 666.3x
Eclampsia 642.6x
Heart failure during procedure or surgery 669.4x, 997.1
Internal injuries of thorax, abdomen or pelvis 860.xx - 869.xx
Intracranial injuries 800.xx, 801.xx, 803.xx,
804.xx, 851.xx - 854.xx
Puerperal cerebrovascular disorders
430, 431, 432.x, 433.xx,
434.xx, 436, 437.x, 671.5x,
674.0x, 997.2, 999.2
Pulmonary edema 428.1, 518.4
Severe anesthesia complication 668.0x, 668.1x, 668.2x
Sepsis 038.xx, 995.91, 995.92
ICD-9 DIAGNOSIS CODES
ICD-9
PROCEDURE
CODES
Shock 669.1x, 785.5x, 995.0,
995.4, 998.0
Sickle cell anemia with crisis 282.62, 282.64, 282.69
Thrombotic embolism 415.1x, 673.0x, 673.2x,
673.3x, 673.8x
Blood transfusion 99.0x
Cardio monitoring 89.6x
Conversion of cardiac rhythm 99.6x
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http://www.cdc.gov/reproductivehealth/MaternalInfantHealth/SevereMaternalMorbidity.html
Hysterectomy 68.3x - 68.9
Operation on heart and pericardium 35.xx, 36.xx,
37.xx, 39.xx
Temporary tracheostomy 31.1
Ventilation
93.90, 96.01 -
96.05, 96.7x
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Appendix XI
Institute for Healthcare Improvement – IHI How-to Guide: Prevent Pressure Ulcers
http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventPressureUlcers.aspx
CALCULATION DETAILS:
Numerator Definition: Number of patients identified as at risk for pressure ulcers for which all
components of proper pressure ulcer care were performed and documented in the calendar day prior
to review. If a component of care is not applied due to a documented contraindication, count it as
appropriately performed for the purposes of this measure.
Proper pressure ulcer care includes the following six components:
Conduct a pressure ulcer admission assessment for all patients
Reassess risk for all patients daily
Inspect skin daily
Manage moisture: keep the patient dry and moisturize the skin
Optimize nutrition and hydration
Minimize pressure
o Turn/Reposition every two hours
o Use pressure-redistribution surfaces
Numerator Exclusions: None
Denominator Definition: Total number of patients identified as being at risk for pressure ulcers
Denominator Exclusions: Patients admitted on current day or prior calendar day
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Appendix XII
AHRQ Quality Indicators Toolkit – Selected Best Practice for Improvement - VTE
http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/hospital/qitoolkit/d4b-dvt-
bestpractices.pdf
Risk Factors:
Age over 60 years
Critical care admission
Dehydration
Known thrombophilias
Obesity
One or more significant medical comorbidities (heart disease, metabolic, endocrine or
respiratory pathologies; acute infectious diseases; inflammatory conditions)
History of VTE
Use of hormone replacement therapy
Use of estrogen-containing contraceptive therapy
Varicose veins with associated phlebitis
Fracture of pelvis/hip/lower extremity
Active cancer or cancer treatment
Indwelling central venous catheter
Immobility
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Appendix XIII All Measures Information – Break down of the measures
Follow this link to view the HEN Measure set and additional measure resources:
http://www.ihconline.org/aspx/publicreporting/reportyourdata.aspx
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Appendix XIV
*Suspended February 2016, pending ICD-10 Update
HEN 2.0 Sepsis Codes
Severe sepsis is a common and costly problem. Although consistently defined clinically by
consensus conference since 1991, there have been several different implementations of the severe
sepsis definition using ICD-9-CM codes for research. IHC has elected to adopt the “Angus”
implementation for identifying cases with severe sepsis. Records will be counted as meeting criteria
for either presenting with or acquiring severe sepsis and shock as demonstrated by any diagnosis of
septicemia or septic shock/sepsis OR a combination of any diagnosis of infection in conjunction
with the presence of a body system failure diagnosis.
To view all Sepsis codes, click the following link:
http://www.ihconline.org/UserDocs/HEN_2_0_Sepsis_Codes.pdf
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Appendix XV Safe Patient Handling Program Equipment Checklist
https://www.osha.gov/dsg/hospitals/documents/3.2_SPH_checklist_508.pdf
