Attach. 2 Q A.pdf

2009 MPSMS Annual Data Report

III. Measure Definitions

Medicare Patient Safety Monitoring System

2009 Annual Data Report

Phase 1, 2 and 3 Measure Definitions and Descriptions Based on PS7 (2009) Data Dictionary

Measures Definition of the Exposure Description of Adverse Events

Definition of Adverse Events Outcomes

MPSMS Annual Data Report: Phase 1, 2 and 3 Measure Definition Descriptions 10/2010 Do not copy, cite or distribute without permission of Qualidigm® Page 1 of 21

Phase 1 Measures Adverse Events Associated with Central Vascular Catheters (CVCs)

Hospitalized patients who had one or more central venous catheters placed during the index hospitalization.

CVC definition (modified from the National Nosocomial Infections Surveillance System (NNIS) 1999: Vascular access device that terminates at, or close to, the heart or in one of the great vessels.

The following are considered great vessels for this measure:

aorta, vena cava, brachiocephalic veins, iliac vein, internal jugular veins, and subclavian veins.

1. One or more mechanical adverse events associated with the placing or replacing of an intra-vascular catheter during the index hospital stay.

2. A blood stream infection (BSI) associated with the placing or replacing of an intra-vascular catheter stay.

1. CVC-associated mechanical adverse events include allergic reactions (only when CPR is administered within 15 minutes of insertion of the catheter), perforation, pneumothorax, hematoma, bleeding, shearing off of the catheter, air embolism, misplaced catheter, venous thrombosis/pulmonary embolism, catheter occlusion, knotting of the pulmonary artery catheter and others as determined by clinical expert review.

2. CVC-associated blood stream infection (BSI) – For a BSI to be associated with a CVC, the patient didn’t have an infection on admission, had no other source of infection, and the first CVC was in place for at least 2 days prior to a positive blood culture for a BSI pathogen (as determined by expert review).

• Length of stay

• In-hospital mortality

• Length of stay

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Note: At least two positive cultures are required to count coagulase negative staphylococcus as a BSI.

Postoperative Pneumonia

Hospitalized patients who had an inpatient surgical procedure as defined by the SCIP major surgical procedure codes listing.

The adverse event of post-operative nosocomial pneumonia during the index hospital stay.

For pneumonia to be associated with the surgical procedure, the patient must not have a diagnosis of pneumonia on admission or evidence of an infiltrate, consolidation or cavitation on chest x-ray prior to the surgical procedure. After the surgical procedure, the patient must have evidence of an infiltrate, consolidation or cavitation on chest x-ray, a physician diagnosis of pneumonia, as well as treatment with an antibiotic for pneumonia.

(This variable was added in 2003).

• Length of stay

• In-hospital mortality

Postoperative Venous Thromboembolic

Hospitalized patients who had an inpatient surgical procedure as defined by the SCIP major surgical procedure codes listing.

(DVT is defined by ICD-9 code 997.2 or 453.4-453.9;

The adverse event of post-operative Deep Vein Thrombosis (DVT) and/or Pulmonary Embolus (PE) during the index hospital stay, or readmission for a DVT/PE within 30 days of

A Venous thrombo-embolism (VTE) is defined as thrombosis or occlusion within the venous system, most commonly of the lower extremities. Only clinically significant DVTs of the lower extremities that occur at or above

• Length of stay

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PE is defined by ICD-9 code 415.11).

the procedure.

If the patient had both a DVT and PE during the index hospital stay, the case is only counted once as a PE.

the popliteal veins (proximal DVT) are included. Therefore, isolated distal DVTs that occur below the popliteal veins or in the deep calf veins are considered clinically insignificant and are excluded.

With a surgical procedure, a physician must diagnosis a DVT following the surgical procedure and the diagnosis must be confirmed by diagnostic study:

Abnormal compression duplex or doppler ultrasonography; abnormal contrast CT scan, abnormal contrast venography; abnormal impedence plethysmography (IPG); or abnormal magnetic resonance venography (MR). In the absence of any of the above test results, physician documentation of a positive test finding is an acceptable alternative.

PE: A PE is defined as an obstruction of the pulmonary artery vasculature usually arising from thrombi in the deep venous system

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For a PE to be associated with a surgical procedure, a physician must diagnosis a PE following the surgical procedure and the diagnosis must be confirmed by diagnostic study: either a high probability ventilation-perfusion (V/Q) scan;

abnormal helical (spiral) computerized tomographic (CT) exam of the pulmonary arteries;

abnormal pulmonary angiography;

abnormal magnetic resonance angiography (MR) exam of the Pulmonary arteries, or a moderate probability V/Q scan in addition to an abnormal duplex US of the lower extremities, abnormal lower extremity venogram, abnormal impedence plethysmography (IPG), or an abnormal magnetic resonance venography (MRI).

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Adverse Events Associated with Hip and Knee Joint Replacement

Hip Joint Replacement – A surgical procedure performed to replace an arthritic or damaged hip joint. Total hip replacement for degenerative conditions (defined by procedure code 81.51) and hip arthroplasty (defined by procedure code 81.52) are considered separately.

Joint prosthesis associated adverse events that occur during the index hospital stay following hip or knee joint replacement surgical procedures, and readmission for a DVT/PE within 30 days of the procedure.

Hip Replacement:

• Post-operative infections include early prosthetic joint and wound infection – acute and early deep hip infection excluding superficial infection; post-operative pneumonia, post-operative catheter-associated urinary tract infection.

• Post-operative deep vein thrombosis or pulmonary embolus.

• Dislocation.

• Wound complications other than infection: dehiscence and necrosis.

• Nerve injury (sciatic or femoral).

• Length of stay

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• Major bleeding/hematoma:

defined as return to the operating room for evacuation and/or to attain hemostasis; hemoglobin drop of more than 2.0 gm/liter compared to the value obtained on the first post-operative day;

or transfusion of 4 or more units of blood postoperatively (not including transfusions received during the procedure). This definition was implemented in 2003.

• Hematoma (a localized collection of blood).

• Cardiovascular complications including MI, CHF or arrhythmia requiring treatment.

• Return to OR (exclude same side revision during the index hospital stay).

• Same side revision during the index hospital stay.

• Periprosthetic fracture (this variable was added in 2003).

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Total Knee Replacement - A surgical procedure performed to replace an arthritic or damaged knee joint (defined by procedure code 81.54).

Knee Replacement:

• Acute or early deep infection.

• Post-operative deep vein thrombosis or pulmonary embolus.

• Wound complications other than infection: dehiscence and necrosis.

• Nerve injury.

• Major bleeding/hematoma:

defined as return to the operating room for evacuation and/or to attain hemostasis; hemoglobin drop of more than 2.0 gm/liter compared to the value obtained on the first post-operative day;

or transfusion of 4 or more units of blood postoperatively (not including transfusions received during the procedure). This definition was implemented in 2003.

• Hematoma (a localized collection of blood).

• Cardiovascular complications including MI, CHF or

• Length of stay

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• Return to OR (exclude same side revision during the index hospital stay).

• Same side revision during the index hospital stay.

• Periprosthetic fracture (This variable was added in Year 2003.)

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Phase 2 Measures Post-operative Cardiac Events

Hospitalized patients who had an inpatient surgical procedure as defined by the SCIP major surgical procedure codes listing.

Experiencing an acute myocardial infarction (AMI), cardiac arrest or death (CPR must have been performed within 24 hours of the death) within 30 days after a surgical procedure.

An acute myocardial infarction (AMI), cardiac arrest or patient death that occurs post-operatively during the index hospital stay (captured by medical record abstraction).

Post-operative

• Length of stay is defined as “the time of the incision until discharge”. If a procedure of interest does not require an incision, the start time of the procedure is used as an alternate.

• In-hospital

Adverse Drug Events

Hospitalized patients, who, stay, received an anticoagulant, hypoglycemic agent, digoxin and/or antibiotic.

Experiencing an adverse drug event(s) associated with specific drugs received during an index hospitalization.

An adverse drug event is a harm (temporary or permanent impairment of physical or psychological

Anticoagulants Warfarin:

Adverse events associated with warfarin are defined as the following symptoms, laboratory results or treatments noted within the time period of 2 days prior to the first INR ≥ 4.0 , stop/hold of warfarin, the administration of

• Length of stay

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Vitamin K, FFP or blood transfusion to 2 days after the last INR ≥ 4.0 , stop/hold of warfarin, the administration of Vitamin K, FFP or blood transfusion:

• Death

• Cardiac arrest/emergency measures to sustain life

• Gastrointestinal bleeding

• Genitourinary bleeding

• Hematocrit drop of three points

(48 hours after arrival)

• Intracranial bleed (subdural hematoma)

• New hematoma

• Other types of bleeding

• Pulmonary bleeding, or

1) An abrupt cessation/hold of Warfarin with one or more of the above symptoms, or

2) Administration of Vitamin K or fresh frozen plasma with one or more of the above symptoms, or

3) A transfusion absent a surgical procedure with one or more of the above symptoms

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Heparin:

Adverse events associated with IV heparin are defined as:

1) A PTT > 100 sec. with one or more of the following symptoms:

• Cardiac arrest/emergency measures to sustain life

• Death

• Gastrointestinal bleeding

• Genitourinary bleeding

• Hematocrit drop of three points.

(48 hours after arrival)

• Intracranial bleed (subdural hematoma)

• New hematoma

• Other types of bleeding

• Pulmonary bleeding; or

2) An abrupt cessation/hold of heparin with one or more of the above symptoms, or

3) Administration of protamine or fresh frozen plasma with one or more of the above symptoms or,

4) A transfusion absent a surgical procedure with one or more of the above symptoms.

• Length of stay

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Low Molecular Weight Heparin and Factor Xa:

Adverse events associated with low molecular weight heparin (LMHW) are defined as:

1) An abrupt cessation/hold of LMWH and one or more of the following symptoms:

• Cardiac arrest/emergency measures to sustain life.

• Gastrointestinal bleeding.

• Death.

• Genitourinary bleeding.

• Hematocrit drop of three points

(48 hours after arrival).

• Intracranial bleed (ex. subdural hematoma).

• New hematoma.

• Other types of bleeding.

• Pulmonary bleeding, or

2) An abrupt cessation/hold of heparin with one or more of the above symptoms, or

3) Administration of protamine or fresh frozen plasma with one or more of the above symptoms or,

4) A transfusion absent a surgical procedure with one or more of the above symptoms.

• Length of stay

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Hypoglycemic Agents (Insulin/Oral Hypoglycemics/Combination of both) Adverse events associated with hypoglycemic agents are defined as:

1) A serum glucose ≤ 70 mg/dl and one or more of the following symptoms or interventions:

• Administration of D 50

• Administration of glucagons

• Administration of juice and/or sugar

• Anxiety

• Code Blue/CPR

• Confused

• Death

• Drowsiness

• Sweating

• Weakness

• Trembling

• Increased heart rate

• Irritability

• Seizure

• Stroke

• TIA

• Myocardial Infarction

• Coma/loss of consciousness

• Length of stay

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Digoxin Adverse events associated with Digoxin are defined as:

1) A digoxin level ≥ 2.5 mg/ml and one or more of the following symptoms:

• Ventricular tachycardia

• Premature ventricular contraction

• Bradycardia

• AV Block

• PR prolongation

• Ventricular Fib.

• Code Blue/CPR

• Death

• Administration of Digibind or,

2) A digoxin level > 1.5 mg/ml and < 2.5 mg/ml and a potassium <

3.5 mEq/L, and one or more of the above symptoms.

• Length of stay

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Antibiotic Associated C. Diff Adverse event associated with Clostridium difficile is defined as:

1. A positive C. Diff. toxin assay

> 2 days after arrival and

2. The patient received an antibiotic during the hospital stay and at least one day before the C. difficile toxin assay was ordered.

• Length of stay

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Hospital Acquired Pressure Ulcers

Hospitalized patients who are discharged from the hospital.

Acquiring one or more pressure ulcers during the index hospital stay.

A pressure ulcer is defined as a lesion caused by persistent pressure on a bony site that obstructs capillary flow leading to tissue necrosis

One or more new pressure ulcers not present in the same anatomical region as a pressure ulcer documented on admission.

Synonyms/Inclusions for “pressure ulcer”:

• Bedsore

• Blister

• Boggy tissue

• Breakdown

• Decubitus Ulcer

• Deep crater with or without visible bone

• Erythema

• Full thickness skin loss involving damage or exposure of subcutaneous tissue, muscle, ligaments or tendons

• Open area over bony prominence

• Partial thickness skin loss involving the epidermis

• Length of stay

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• Partial skin loss involving dermis

• Pressure sore

• Reddened area

• Stage I, II, III, IV

Anatomical Regions

I Coccyx/Sacrum II Hip and Buttock III Heel IV Ankle V Elbow

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Phase 3 Measures Catheter Associated Urinary Tract Infection (UTI)

Hospitalized patients who had an indwelling urinary catheter or straight catheter inserted during the index hospital stay.

Acquiring a urinary tract infection (UTI) during the index hospitalization after an indwelling catheter is placed or a straight catherization is performed.

An in-hospital catheter-associated urinary tract infection is defined as a physician diagnosis of UTI at least one day following insertion of an indwelling or a straight urinary during the hospital stay as well as a physician order for an antibiotic to treat the UTI.

• Length of stay

• In-hospital mortality

In-hospital Patient Fall

Hospitalized patients who are discharged from the hospital.

A patient experiencing, at least one, “fall” to the floor during the index hospital stay.

A “fall” is defined as documentation of a “fall” or specific descriptive statements that are indicative of a fall.

• Length of stay

• In-hospital mortality

Methicillin Resistant Staphylococcus Aureus (MRSA)

Hospitalized patients who are discharged from the hospital.

Acquiring MRSA during the index hospital stay.

For Methicillin-resistant Staphylococcus Aureus (MRSA) to be considered as Hospital-acquired, the patient must not be documented as a “carrier” of MRSA or have a positive culture and sensitivity for MRSA on admission, and have a positive culture and sensitivity for MRSA obtained from a sterile site1 more than 2 days after arrival to the hospital.

1 Sterile Sites: blood, cerebrospinal

• Length of stay

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Vancomycin Resistant Enterococcus (VRE)

Hospitalized patients who are discharged from the hospital.

Acquiring VRE during the index hospital stay.

For Vancomycin-resistant Enterbcoccus (VRE) to be considered as Hospital-acquired, the patient must not be documented as a “carrier” of VRE or have a positive culture and sensitivity for VREon admission, and have a positive culture and sensitivity for VRE obtained from a sterile site1 more than 2 days after arrival to the hospital.

1 Sterile Sites: blood, cerebrospinal fluid, joint aspirates, pleural fluid, peritoneal/ascites fluid.

• Length of stay

Adverse Events Associated with Femoral Artery Puncture for Angiographic Procedures

Hospitalized patients who, during the index hospital stay, had a catheter angiographic procedure through a femoral artery puncture.

Experiencing an adverse event post-catheter angiographic procedure through a femoral artery puncture.

Adverse events include:

• Hematoma at puncture site ≥ 6 cm,

• Femoral arteriorraphy or femoral artery repair,

• Post-procedure bleeding at the insertion site requiring additional intervention,

• Retroperitoneal hematoma,

• Arterial compromise

• Length of stay

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(stenosis, occlusion, embolization, surgical device removal),

• False aneurysm or arteriovenous fistula (clinically manifested, requiring treatment),

• New clinical evidence of poor femoral artery blood flow on side of puncture1.

• Local infection2,

• Other adverse events as indicated by clinical expert review.

Note: An adverse event is counted if it is on the same side as the femoral puncture.

1 “Clinical evidence of poor femoral artery blood flow” is defined as loss of pulse, mottled toes, cold foot, purple foot, black foot, or painful leg.

2“Local infection” is cellulitis, warmth, erythema, and/or redness surrounding puncture site, or

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Contrast Nephropathy Associated with Catheter Angiography

Hospitalized patients who had a catheter angiography (contrast dye) during the index hospital stay.

Acquiring contrast nephropathy after a catheter angiography.

Contrast Nephropathy is defined as an absolute increase in serum creatinine of more than 0.5 mg/dL or a relative increase in serum creatinine of more than 25% of its level before administration of contrast medium within seven days post-procedure.

• Length of stay

• In-hospital mortality

Ventilator Associated Pneumonia

Hospitalized patients who experienced intubation/ventilator exposure during the index hospital stay for > 2 days without prior evidence of pneumonia.

Acquiring pneumonia after intubation or ventilator exposure during the index hospital stay.

Ventilator associated pneumonia is determined by evidence in the medical record of new infiltrate, consolidation, or cavitations noted on chest X-ray at least 2 days after intubation, and documentation of a physician-ordered antibiotic to treat the pneumonia.

• Length of stay