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  • 1. ___________________________________________Nationally Endorsed Process MeasuresSpecificationsLFG2006 indicates following items taken from current LFG process specs, for consideration this year.IntroductionThe specifications in this document are for auditing and measuring the rate of adherence to processmeasures of quality. Because of the clinical specificity needed, procedure and condition definitionsDIFFER from those used to count volume of procedures elsewhere in the survey and should not be usedfor that purpose.Every effort has been made to harmonize these process measures with national performancemeasurement systems such as JCAHO, CMS, Vermont Oxford Network (VON) or National Quality Forum(NQF) Endorsed Measure Sets, to reduce the reporting burden on survey respondents. The measureidentifies if the specifications are from a national measure set or a NQF endorsed measure set. If themeasure is from a national performance measurement system (such as STS, ACC, ACS) data reported tothose organizations consistent with their specifications can and should be used to report hospitalperformance for these indicators in the Leapfrog Survey. In some cases, measures used for anotherdiagnosis are adapted to a procedure associated with that diagnosis (e.g., PCI and AMI—there were no“identified” measure sets that were attached to the procedure PCI; but there were measure sets (JCAHO-AMI) that measured PCI within that diagnostic group (AMI).General Instructions1. If your hospital has • measured adherence to the process-of-care quality indicator, • reported the results to JCAHO, CMS or VON • for a one-year period ending not more than 12 months prior to survey submission. Use data as reported for that measure in responding to the survey. To the extent any specifications below differ from the specifications for reporting the data to those organizations, rely on the specifications of that organization.2. For those indicators not measured and reported to JCAHO, CMS or VON for a recent period (i.e., a one-year period ending not more than 12 months prior to survey submission), you should measure adherence to the process-of-care quality indicator and use those results in responding to the survey. See also the Frequently Asked Questions at the end related to measuring these indicators.3. In either case #1 or #2, we ask that you report the number of cases in the denominator and that you report the number of cases where there was adherence to the measurement standard (numerator). Note: in order to attain credit you will need to have 80% or more adherence to a minimum of two process measures within the procedure you are submitting, except in the case of high risk delivery, where there is only one process measure included in the survey.Links throughout this document to JCAHO Appendices and measures can be located atwww.jointcommission.org/PerformanceMeasurement/PerformanceMeasurement/Current+NHQM+Manual.htmOctober 26, 2006 1v4.0a 2007 Survey DRAFT
  • 2. ___________________________________________Nationally Endorsed Process MeasuresSpecificationsMeasurement Guidelines for Coronary Artery Bypass Graft (CABG) Indicators CABG-1: Anti-platelet medication at discharge Source: STS NQF Endorsed Numerator: Number of patients who were discharged on aspirin/safety-coated aspirin or clopidogrel after isolated CABG. Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization Exclusions: per JCAHO-CMS • <18 years of age • Transferred to another acute care hospital • Expired • Left against medical advice • Discharged to hospice • One or more of the following aspirin contraindications/reasons for not prescribing aspirin documented in the medical record: o Aspirin allergy o Active bleeding on arrival or during hospital stay o Warfarin/Coumadin prescribed at discharge, or o Other reasons documented by physician, nurse practitioner, or physician assistant for not prescribing at discharge CABG-2: Isolated CABG using internal mammary artery Source: CMS-NQF Endorsed Numerator: Number of isolated CABG patients who received an IMA graft ICD9 procedure codes 36.15 and 36.16 Denominator: Number of surgical patients with isolated CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularizationOctober 26, 2006 2v4.0a 2007 Survey DRAFT
  • 3. ___________________________________________Nationally Endorsed Process MeasuresSpecifications Exclusions: • Other heart procedures (ICD-9 procedure codes 37.32; 37.34; 37.35; 36.2; 35.0-35.99) • Repeat CABG (ICD-9 status code V45.81) • Patient <20 LFG2006: Exclusion criteria1,2 for IMA grafting = Documentation of one or more of the following • The Left Anterior Descending (LAD) artery is not suitable for LIMA grafting (eg, donor or target vessels <1.5 mm in size) • Calcified or diffuse coronary disease in the LAD • Subclavian stenosis • Previous thoracic surgery • Previous radiation • Current use of immunosuppressive agents (eg, Prednisone, Imuran, or other) • Coagulation disorder • Myocardial infarction within 7 days prior to the procedure • Chronic renal insufficiency • Require emergent operation • Require concomitant surgery (eg. aneurysm resection, valve replacement) • Morbid obesity • Other reasons as documented by physician, nurse practitioner, or physician assistant CABG-3: Pre-operative beta blockade for isolated CABG surgery LFG2006: Beta-blocker within 24 hours after surgery Source: STS-NQF endorsed Numerator: Number of patients coming to isolated CABG with documented pre-operative (24 hours) beta blockade Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization Exclusions: Patient <20 LFG2006:1 Sethi GK, Copeland JG, Moritz T, Henderson W, Zadina K, Goldman S. Comparison of postoperative complicationsbetween saphenous vein and IMA grafts to left anterior descending coronary artery. Ann Thorac Surg 1991;51: 733-738.2 Berger PB, Alderman EL, Nadel A, Schaff HV. Frequency of early occlusion and stenosis in a left internal mammaryartery to left anterior descending artery bypass graft after surgery through a median sternotomy on conventionalbypass: benchmark for minimally invasive direct coronary artery bypass. Circulation 1999; 100: 2353-2358.October 26, 2006 3v4.0a 2007 Survey DRAFT
  • 4. ___________________________________________Nationally Endorsed Process MeasuresSpecifications Contraindications to beta-blockers (as per JCAHO for beta-blockers in AMI) = Documentation of one or more of the following [NOTE: Patients having one or more of the following contraindications may still potentially be eligible to receive the medication.] • Allergy to beta-blockers • Bradycardia (heart rate < 60 beats/min) on day of discharge or the previous day, while not on a beta-blocker • Systolic blood pressure < 90 mm Hg on day of discharge or the previous day, while not on a beta-blocker • Second- or third-degree AV heart block at any time during hospitalization or on admission, if no pacemaker • Other reasons as documented by physician, nurse practitioner, or physician assistant LFG2006: Definitions: Beta-blockers = oral beta-blockers as specified by JCAHO beta-blockers in AMI (Appendix C: Medication Tables) CABG-4: Beta-blockers prescribed at discharge Source: STS-NQF endorsed Numerator: Number of isolated CABG patients discharged on beta blockers Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization Exclusions: Patient <20 LFG2006: Contraindications to beta-blockers (as per JCAHO for beta-blockers in AMI) = Documentation of one or more of the following [NOTE: Patients having one or more of the following contraindications may still potentially be eligible to receive the medication.] • Allergy to beta-blockers • Bradycardia (heart rate < 60 beats/min) on day of discharge or the previous day, while not on a beta-blocker • Systolic blood pressure < 90 mm Hg on day of discharge or the previous day, while not on a beta-blocker • Second- or third-degree AV heart block at any time during hospitalization or on admission, if no pacemaker • Other reasons as documented by physician, nurse practitioner, or physician assistant LFG2006:October 26, 2006 4v4.0a 2007 Survey DRAFT
  • 5. ___________________________________________Nationally Endorsed Process MeasuresSpecifications Definitions: Beta-blockers = oral beta-blockers as specified by JCAHO beta-blockers in AMI (Appendix C: Medication Tables) CABG-5: Lipid-lowering regimen prescribed at discharge Source: STS-NQF endorsed Numerator: Number of isolated CABG patients discharged on a statin or other pharmacologic lipid- lowering regimen Denominator: Total number of surgical patients with CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization LFG2006: 1. An LDL level > 100 mg/dL as determined by lipid profile test before the surgery Exclusions: Patient <20 LFG2006: Contraindications to lipid-lowering agents3,4 = Documentation of one or more of the following [NOTE: Patients having one or more of the following contraindications may still potentially be eligible to receive the medication.] • Allergy to any of the lipid lowering products mentioned in # 3 • Complete biliary obstruction • Preexisting gallbladder disease • Active liver disease • Unexplained persistent elevated liver function tests • Severe renal dysfunction • Severe biliary cirrhosis • Other reasons as documented by physician, nurse practitioner, or physician assistant LFG2006: Definitions: Lipid-lowering agents = (Lovastatin, Simvastatin, Pravastatin, Fluvastatin, Atorvastatin, Cerivastatin,3 The Post Coronary Artery Bypass Graft Trial Investigators (Post- CABG). The effect of aggressive lowering of lowdensity lipoprotein cholesterol levels and low dose anticoagulation on obstructive changes in saphenous veincoronary bypass grafts. N Engl J Med 1997; 336: 153-162.4 Pitt B, Waters D, Brown WV, van Boven AJ, Schwartz L, Title LM, Eisenberg D, Shurzinske L, McCormick LS.Aggressive lipid- lowering therapy compared with angioplasty in stable coronary artery disease (AVERT). N Engl JMed 1999; 341: 70-76.October 26, 2006 5v4.0a 2007 Survey DRAFT
  • 6. ___________________________________________Nationally Endorsed Process MeasuresSpecifications Colestipol, Cholestyramine, Colesevelam, Gemfibrozil, Fenofibrate, Nicotinic Acid, (Clofibrate, Dextrothyroxine – these two agents are not commonly used as antihyperlipidemics) and Zetia®2 (ezetimibe) CABG-6: Prophylactic antibiotic selection for surgical patients -- isolated CABG Source: JCAHO-CMS (SCIP-Inf-2b); see JCAHO specifications manual Numerator: Number of isolated CABG surgery patients who received prophylactic antibiotics recommended for CABG surgery: cefazolin, cefuroxime, cefarnandole, or vancomycin* (see approved list JCAHO) need JCAHO link or reference Denominator: Total number of surgical patients with CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization Exclusions: • Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases (from Appendix A, Table 5.09 for ICD-9-CM codes) need JCAHO link or reference Principal or admission diagnosis really? suggestive of pre-operative infectious disease: o Infectious diseases 001.0-139.8 o Meningitis 320.0-326 o Ear Infection 380.0-380.23; 382.0-382.20 o Endocarditis 421.0-422.99 o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1 o Digestive 540-542; 575.0 o Renal 590-590.9; 595.0 o Prostate 601.0-601.9 o Gynecologic 614-614.9 ; 616-616.4 o Skin 680-686.9 o Musculo-skeletal 711.9-711.99; 730.0-730.99 o Fever of unknown origin 780.6 o Septic Shock 785.59 o Bacteremia 790.7 o Viremia 790.8 OR • Patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics) • Patients who were receiving antibiotics more than 24 hours prior to surgery (except colon surgery patients taking oral prophylactic antibiotics) • Patients less than 18 years of age • Patients with physician documented infection prior to surgical procedure of interestOctober 26, 2006 6v4.0a 2007 Survey DRAFT
  • 7. ___________________________________________Nationally Endorsed Process MeasuresSpecifications • Patients whose procedure of interest occurred prior to date of admission * Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactarn, then vancomycin or clindarnycin is an acceptable substitute but vancomycin on list, always acceptable? CABG-7: Prophylactic antibiotic received within 1 hour prior to surgical incision -- CABG Source: JCAHO-CMS; NQF-Endorsed (SCIP-Inf-1b); see JCAHO specifications manual Numerator: Number of isolated CABG surgical patients who received prophylactic antibiotics within one hour of surgical incision (two hours if receiving vancomycin or fluouroqinolone). Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization Exclusions: • Principal or admission diagnosis really? suggestive of pre-operative infectious disease: o Infectious diseases 001.0-139.8 o Meningitis 320.0-326 o Ear Infection 380.0-380.23; 382.0-382.20 o Endocarditis 421.0-422.99 o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1 o Digestive 540-542; 575.0 o Renal 590-590.9; 595.0 o Prostate 601.0-601.9 o Gynecologic 614-614.9 ; 616-616.4 o Skin 680-686.9 o Musculo-skeletal 711.9-711.99; 730.0-730.99 o Fever of unknown origin 780.6 o Septic Shock 785.59 o Bacteremia 790.7 o Viremia 790.8 OR • Patients who were receiving antibiotics at time of admission • Medical records do not include antibiotic start date/time or incision date/time • Patients receiving antibiotics more than 24 hours prior to surgery • Age? CABG-8: Prophylactic antibiotics discontinued within 24 hours after surgery end -- CABGOctober 26, 2006 7v4.0a 2007 Survey DRAFT
  • 8. ___________________________________________Nationally Endorsed Process MeasuresSpecifications Source: JCAHO-CMS (SCIP-Inf-3b); see JCAHO specifications manual Numerator: Number of isolated CABG patients who received prophylactic antibiotics within 24 hours after surgery end time. Denominator: Total number of surgical patients with isolated CABG ICD-9-CM procedure codes below: 36.10 Aortocoronary bypass for heart revascularization, NOS 36.11 Aortocoronary bypass for one coronary artery 36.12 Aortocoronary bypass for two coronary arteries 36.13 Aortocoronary bypass for three coronary arteries 36.15 Single internal mammnary-coronary bypass 36.16 Souble internal mammary-coronary bypass 36.19 Other bypass anastamosis for heart revascularization Exclusions: • Principal or admission diagnosis really? suggestive of pre-operative infectious disease: o Infectious diseases 001.0-139.8 o Meningitis 320.0-326 o Ear Infection 380.0-380.23; 382.0-382.20 o Endocarditis 421.0-422.99 o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1 o Digestive 540-542; 575.0 o Renal 590-590.9; 595.0 o Prostate 601.0-601.9 o Gynecologic 614-614.9 ; 616-616.4 o Skin 680-686.9 o Musculo-skeletal 711.9-711.99; 730.0-730.99 o Fever of unknown origin 780.6 o Septic Shock 785.59 o Bacteremia 790.7 o Viremia 790.8 OR • Patients who were receiving antibiotics at time of admission • Medical records do not include antibiotic start date/time or incision date/time • Patients receiving antibiotics more than 24 hours prior to surgery • No antibiotics received before or during surgery, or within 24 hours after surgery end-time (i.e., the patient did not receive antibiotics) • Diagnosed with and treated for infections within two days after surgery date • No antibiotics received during the hospitalization • Age?October 26, 2006 8v4.0a 2007 Survey DRAFT
  • 9. ___________________________________________Nationally Endorsed Process MeasuresSpecificationsMeasurement Guidelines for Percutaneous Coronary Intervention (PCI) PCI-1: PCI received within 90 minutes of hospitalization Source: JCAHO (AMI-8a) Numerator: AMI patients whose time from hospital arrival to PCI is 90 minutes or less. Denominator: Total number of AMI patients who have undergone PCIPrincipal discharge diagnosis of AMI determined using the following ICD-9 diagnsosis codes for AMI(Appendix A: AMI Codes from JCAHO website): 410.01 Anterolateral wall, acute myocardial infarction-initial episode 410.11 Other anterior wall, acute myocardial infarction-initial episode 410.21 Inferolateral wall, acute myocardial infarction-initial episode 410.31 Inferoposterior wall, acute myocardial infarction-initial episode 410.41 Other inferior wall, acute myocardial infarction-initial episode 410.51 Other lateral wall, acute myocardial infarction-initial episode 410.61 True posterior wall, acute myocardial infarction-initial episode 410.71 Subendocardial, acute myocardial infarction 410.81 Other specified sites, acute myocardial infarction-initial episode 410.91 Unspecified site, acute myocardial infarction-initial episodeAndPCI determined using the following ICD-9 procedure codes as principal or secondary procedure: 00.66 Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy (code effective 10/1/2005) 36.01 Single vessel percutaneous transluminal coronary angioplasty without mention of thrombolytics (code discontinued 10/1/2005) 36.02 Single vessel percutaneous transluminal coronary angioplasty with mention of thrombolytics (code discontinued 10/1/2005) 36.05 Multiple vessel PTCA at the same session with or without mention of thrombolytics (code discontinued 10/1/2005) 36.06 Insertion of coronary artery stents 36.07 Insertion of drug-eluting coronary artery stent(s) LFG2006: Eligible = Patients with acute myocardial infarction (AMI) and • ST-segment elevation or • new or presumed new left bundle branch block5 Exclusions: (As per JCAHO for aspirin in AMI) • Age < 20 years • Transferred to another acute care hospital • Expired during hospitalization • Left against medical advice • Discharge to hospice5 Upon review with comparable JCAHO measure AMI-8a, we are consistent in our definition of patient eligibility.October 26, 2006 9v4.0a 2007 Survey DRAFT
  • 10. ___________________________________________Nationally Endorsed Process MeasuresSpecifications LFG2006: • Transferred from another acute care hospital Exclusion criteria for primary PCI = Documentation of one or more of the following (Exclusion criteria for invasive cardiac procedure in settings without full-support services from the ACC/AHA guideline) • NYHA class III or IV heart failure • Acute, intermediate, or high risk ischemic syndromes • Recent myocardial infarction with post infarction ischemia • Pulmonary edema felt to be caused by ischemia • Markedly abnormal non-invasive test indicating a high likelihood of left main or multivessel coronary disease • Known left main coronary disease • Severe valvular dysfunction especially in the setting of depressed LV performance • Other reasons as documented by physician, nurse practitioner, or physician assistant Definitions: PCI < 90 minutes = As time (in minutes) from hospital arrival to percutaneous transluminal coronary angioplasty (PTCA) PCI-2: Aspirin at arrival Source: JCAHO (AMI-1) Numerator: Number of AMI patients who underwent PCI and who received aspirin (or aspirin/dipyridamole; if aspirin allergic, clopidogrel or ticlopidine) upon arrival.Denominator: Total number of AMI patients who have undergone PCI and have no contraindications toany of the above agents.Principal discharge diagnosis of AMI determined using the following ICD-9 diagnsosis codes for AMI(Appendix A: AMI Codes from JCAHO website): 410.01 Anterolateral wall, acute myocardial infarction-initial episode 410.11 Other anterior wall, acute myocardial infarction-initial episode 410.21 Inferolateral wall, acute myocardial infarction-initial episode 410.31 Inferoposterior wall, acute myocardial infarction-initial episode 410.41 Other inferior wall, acute myocardial infarction-initial episode 410.51 Other lateral wall, acute myocardial infarction-initial episode 410.61 True posterior wall, acute myocardial infarction-initial episode 410.71 Subendocardial, acute myocardial infarction 410.81 Other specified sites, acute myocardial infarction-initial episode 410.91 Unspecified site, acute myocardial infarction-initial episodeAndPCI determined using the following ICD-9 procedure codes as principal or secondary procedure:October 26, 2006 10v4.0a 2007 Survey DRAFT
  • 11. ___________________________________________Nationally Endorsed Process MeasuresSpecifications 00.66 Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy (code effective 10/1/2005) 36.01 Single vessel percutaneous transluminal coronary angioplasty without mention of thrombolytics (code discontinued 10/1/2005) 36.02 Single vessel percutaneous transluminal coronary angioplasty with mention of thrombolytics (code discontinued 10/1/2005) 36.05 Multiple vessel PTCA at the same session with or without mention of thrombolytics (code discontinued 10/1/2005) 36.06 Insertion of coronary artery stents 36.07 Insertion of drug-eluting coronary artery stent(s) Exclusions: (as per JCAHO for aspirin in AMI) • Age < 18 years • Transferred to another acute care hospital • Expired during hospitalization • Left against medical advice • Discharge to hospice • Contraindications to aspirin, documentation of one or more of the following: [NOTE: Patients having one or more of the following contraindications may still potentially be eligible to receive the medication.] >Allergy to aspirin >Active bleeding on admission or during hospitalization > Warfarin prescribed upon discharge • Other reasons as documented by physician, nurse practitioner, or physician Definitions: Aspirin = oral aspirin and aspirin-containing medications as specified by JCAHO for aspirin in AMI (Appendix C: Medication Tables from JCAHO website) Upon discharge = As part of the discharge medications list PCI-3: Aspirin prescribed at discharge Source: JCAHO AMI-2 Numerator: Number of AMI patients who underwent PCI and who received aspirin (or aspirin/dipyridamole; if aspirin allergic, clopidogrel or ticlopidine) upon hospital discharge. Denominator: Total number of AMI patients who have undergone PCI and have no contraindications toany of the above agents.Principal discharge diagnosis of AMI determined using the following ICD-9 diagnsosis codes for AMI(Appendix A: AMI Codes from JCAHO website):October 26, 2006 11v4.0a 2007 Survey DRAFT
  • 12. ___________________________________________Nationally Endorsed Process MeasuresSpecifications 410.01 Anterolateral wall, acute myocardial infarction-initial episode 410.11 Other anterior wall, acute myocardial infarction-initial episode 410.21 Inferolateral wall, acute myocardial infarction-initial episode 410.31 Inferoposterior wall, acute myocardial infarction-initial episode 410.41 Other inferior wall, acute myocardial infarction-initial episode 410.51 Other lateral wall, acute myocardial infarction-initial episode 410.61 True posterior wall, acute myocardial infarction-initial episode 410.71 Subendocardial, acute myocardial infarction 410.81 Other specified sites, acute myocardial infarction-initial episode 410.91 Unspecified site, acute myocardial infarction-initial episodeAndPCI determined using the following ICD-9 procedure codes as principal or secondary procedure: 00.66 Percutaneous transluminal coronary angioplasty [PTCA] or coronary atherectomy (code effective 10/1/2005) 36.01 Single vessel percutaneous transluminal coronary angioplasty without mention of thrombolytics (code discontinued 10/1/2005) 36.02 Single vessel percutaneous transluminal coronary angioplasty with mention of thrombolytics (code discontinued 10/1/2005) 36.05 Multiple vessel PTCA at the same session with or without mention of thrombolytics (code discontinued 10/1/2005) 36.06 Insertion of coronary artery stents 36.07 Insertion of drug-eluting coronary artery stent(s) Exclusions: LFG2006: Exclusions: (As per JCAHO for aspirin in AMI) • Age < 20 years • Transferred to another acute care hospital • Expired during hospitalization • Left against medical advice • Discharge to hospice • One or more of the following aspirin contraindications/reasons for not prescribing aspirin documented in the medical record: o Aspirin allergy o Active bleeding on arrival or during hospital stay o Warfarin/Coumadin prescribed at discharge, or o Other reasons documented by physician, nurse practitioner, or physician assistant for not prescribing at discharge Definitions: Aspirin = oral aspirin and aspirin-containing medications as specified by JCAHO for aspirin in AMI (Appendix C: Medication Tables from JCAHO website) Upon discharge = As part of the discharge medications listOctober 26, 2006 12v4.0a 2007 Survey DRAFT
  • 13. ___________________________________________Nationally Endorsed Process MeasuresSpecificationsMeasurement Guidelines for Aortic Valve Replacement SurgeryJCAHO SCIP-Ind-#c measures are for Other Cardiac Surgery, not AVR, so why AVR procedure codes? AVS-1: Prophylactic antibiotic selection for other cardiac surgical patients Source: JCAHO-CMS; NQF Endorsed (SCIP-Inf-2c); see JCAHO specifications manual Numerator: Number of patients with isolated aortic valve replacement (AVR) surgery who received prophylactic antibiotics recommended for CABG surgery: cefazolin, cefuroxime, cefarnandole, or vancomycin* (see approved list JCAHO) Denominator: Total number of patients with isolated AVR with the following ICD-9-CM Procedure Codes: 35.21 Replacement of aortic valve with tissue graft 35.22 Other replacement of aortic valve Exclusions: • Patients who had a principal or admission diagnosis suggestive of preoperative infectious diseases (from Appendix A, Table 5.09 for ICD-9-CM codes) need JCAHO link or reference Principal or admission diagnosis really? suggestive of pre-operative infectious disease: o Infectious diseases 001.0-139.8 o Meningitis 320.0-326 o Ear Infection 380.0-380.23; 382.0-382.20 o Endocarditis 421.0-422.99 o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1 o Digestive 540-542; 575.0 o Renal 590-590.9; 595.0 o Prostate 601.0-601.9 o Gynecologic 614-614.9 ; 616-616.4 o Skin 680-686.9 o Musculo-skeletal 711.9-711.99; 730.0-730.99 o Fever of unknown origin 780.6 o Septic Shock 785.59 o Bacteremia 790.7 o Viremia 790.8 OR • Patients who were receiving antibiotics within 24 hours prior to arrival (except colon surgery patients taking oral prophylactic antibiotics) • Patients less than 20 years of age • Patients with physician documented infection prior to surgical procedure of interest • Patients whose procedure of interest occurred prior to date of admission *Special consideration: For cardiac and vascular surgery, if patient is allergic to b-lactarn, then vancomycin or clindarnycin is an acceptable substitute but vancomycin on list, always acceptable? AVS-2: Prophylactic antibiotic received within 1 hour prior to surgical incision – other cardiac surgery Source: JCAHO-CMS-NQF Endorsed (SCIP-Inf-1c); see JCAHO specifications manual Numerator: Number of patients with isolated isolated aortic valve replacement (AVR) surgery whoOctober 26, 2006 13v4.0a 2007 Survey DRAFT
  • 14. ___________________________________________Nationally Endorsed Process MeasuresSpecifications received prophylactic antibiotics within one hour of surgical incision (two hours if receiving vancomycin or fluouroqinolone) Denominator: Total number of patients with isolated AVR with the following ICD-9-CM procedure codes: 35.21 Replacement of aortic valve with tissue graft 35.22 Other replacement of aortic valve Exclusions: • Principal or admission diagnosis really? suggestive of pre-operative infectious disease: o Infectious diseases 001.0-139.8 o Meningitis 320.0-326 o Ear Infection 380.0-380.23; 382.0-382.20 o Endocarditis 421.0-422.99 o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1 o Digestive 540-542; 575.0 o Renal 590-590.9; 595.0 o Prostate 601.0-601.9 o Gynecologic 614-614.9 ; 616-616.4 o Skin 680-686.9 o Musculo-skeletal 711.9-711.99; 730.0-730.99 o Fever of unknown origin 780.6 o Septic Shock 785.59 o Bacteremia 790.7 o Viremia 790.8 OR • Receiving antibiotics at time of admission • Medical records do not include antibiotic start date/time or incision date/time • Receiving antibiotics more than 24 hours prior to surgery • Patients < 20 AVS-3: Prophylactic antibiotics discontinued within 24 hours after surgery end time – other cardiac surgery Source: JCAHO (SCIP-Inf-3c); see JCAHO specifications manual Numerator: Number of patients with isolated aortic valve replacement (AVR) surgery whose prophylactic antibiotics were discontinued within 24 hours after surgery end. Denominator: Total number of patients with isolated AVR with the following ICD-9-CM procedure codes: 35.21 Replacement of aortic valve with tissue graft 35.22 Other replacement of aortic valve • Principal or admission diagnosis really? suggestive of pre-operative infectious disease: o Infectious diseases 001.0-139.8 o Meningitis 320.0-326 o Ear Infection 380.0-380.23; 382.0-382.20October 26, 2006 14v4.0a 2007 Survey DRAFT
  • 15. ___________________________________________Nationally Endorsed Process MeasuresSpecifications o Endocarditis 421.0-422.99 o Respiratory 460.0-466.19; 472-476.1; 480.0-487.8; 490-491.9; 510-511.9; 513-513.1 o Digestive 540-542; 575.0 o Renal 590-590.9; 595.0 o Prostate 601.0-601.9 o Gynecologic 614-614.9 ; 616-616.4 o Skin 680-686.9 o Musculo-skeletal 711.9-711.99; 730.0-730.99 o Fever of unknown origin 780.6 o Septic Shock 785.59 o Bacteremia 790.7 o Viremia 790.8 OR • Receiving antibiotics at time of admission • Medical records do not include antibiotic start date/time or incision date/time • Receiving antibiotics more than 24 hours prior to surgery • Patients < 20 How about these? • No antibiotics received before or during surgery, or within 24 hours after surgery end-time (i.e., the patient did not receive antibiotics) • Diagnosed with and treated for infections within two days after surgery date • No antibiotics received during the hospitalizationMeasurement Guidelines for Elective Abdominal Aortic Aneurysm (AAA) repair AAA-1: Beta-blocker agent prior to induction Source: Zynx measure Numerator: Number of patients undergoing elective AAA who received beta-blockers prior to the time of induction Denominator: Total number of patients who underwent elective AAA repair and have no contraindications to beta-blockers Principal or secondary discharge diagnosis of Elective AAA Repair determined using the following: ICD-9 PROCEDURE CODES for non-ruptured AAA 38.24 Resection of aorta with anastomosis 38.44 Resection of aorta, abdominal, with replacement 38.64 Excision of aorta 39.71 Endovascular implantation of graft in abdominal aorta AND ICD-9 DIAGNOSIS CODES for unruptured AAA 441.4 Aortic aneurysm without mention of rupture 441.5 Aortic aneurysm of unspecified site without mention of ruptureOctober 26, 2006 15v4.0a 2007 Survey DRAFT
  • 16. ___________________________________________Nationally Endorsed Process MeasuresSpecifications Exclusions: (as per JCAHO for beta-blockers in AMI) • <18 years of age • Transferred to or from another acute care hospital • Expired • Left against medical advice • Discharged to hospice • One or more of the following beta blocker contraindications/reasons for not prescribing a beta blocker documented in the medical record: o Beta blocker allergy; o Bradycardia (heart rate <60 beats per minute) on day of discharge or day prior to discharge while not on a beta blocker; o Second or third degree heart block on ECG on arrival or during hospital stay and does not have a pacemaker; o Systolic blood pressure <90 mm Hg on day of admission or the previous day, while not on a beta blocker; or o Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing a beta blocker at discharge Definitions: Beta-blockers = oral or IV (given immediately pre-operative or intra-operative) beta-blockers as specified by JCAHO for beta-blockers in AMI (Appendix C: Medication Tables from JCAHO website) Prior to induction = Followed usual treatment regimen if chronic beta-blocker user (eg, taking an oral a.m. dose of the drug on the day of surgery) or as part of the medication history list on the day of surgery of in anesthesia record from OR AAA-2: Beta-blockers prescribed at discharge Source: Zynx measure Numerator: Number of patients who underwent AAA repair who received beta-blockers upon hospital discharge Denominator: Total number of patients who underwent AAA repair and have no contraindications to beta-blockers. Principal or secondary procedure of AAA Repair determined using the following ICD-9 PROCEDURE CODES 38.24 Resection of aorta with anastomosis 38.44 Resection of aorta, abdominal, with replacement 38.64 Excision of aorta 39.71 Endovascular implantation of graft in abdominal aorta Exclusions: (as per JCAHO for beta-blockers in AMI) • <18 years of age • Transferred to another acute care hospitalOctober 26, 2006 16v4.0a 2007 Survey DRAFT
  • 17. ___________________________________________Nationally Endorsed Process MeasuresSpecifications • Expired • Left against medical advice • Discharged to hospice • One or more of the following beta blocker contraindications/reasons for not prescribing a beta blocker documented in the medical record: o Beta blocker allergy; o Bradycardia (heart rate <60 beats per minute) on day of discharge or day prior to discharge while not on a beta blocker; o Second or third degree heart block on ECG on arrival or during hospital stay and does not have a pacemaker; o Systolic blood pressure <90 mm Hg on day of discharge or day prior to discharge, while not on a beta blocker; or o Other reasons documented by a physician, nurse practitioner, or physician assistant for not prescribing a beta blocker at discharge Definitions: Beta-blockers = oral beta-blockers as specified by JCAHO for beta-blockers in AMI (Appendix C: Medication Tables from JCAHO website) Upon discharge = As part of the discharge medications listMeasurement Guidelines for High-Risk Deliveries NICU-1: Antenatal steroids Source: Vermont Oxford Network; see Manual of Operations Numerator: The number of mothers receiving antenatal steroids prior to birth of a very low birthweight infant6 or of an infant admitted to the NICU immediately (on day 0) following “in-born” birth. LFG2006: Numerator: Number of inborn mothers delivering VLBW infants at 24 through 33 6/7 weeks gestational age with no contraindications to antenatal steroids and who received at least one dose of antenatal steroids Denominator: Total number of mothers delivering either Very Low Birthweight Infants or “in-born” infants admitted to the NICU immediately (on day 0). LFG2006: Denominator: Total number of eligible inborn mothers delivering VLBW infants at 24 through 33 6/7 weeks gestational age and have no contraindications Very Low Birthweight Infants = Any infant who is born at your hospital and whose birth weight is between 401 and 1500 grams OR whose gestational age is between 22 weeks 0 days and 29 weeks 6 days (inclusive) is eligible, regardless of where in your hospital the infant receives care. See Tables6 VON Manual of Operations 2006, version 10.2, Published Oct 2005, Revised March 9, 2006 andRevised July 11, 2006.October 26, 2006 17v4.0a 2007 Survey DRAFT
  • 18. ___________________________________________Nationally Endorsed Process MeasuresSpecifications 4.10, 4.10.1, and 4.11. Vermont Oxford Manual of Operations (see link below) OR Any infant whose birth weight is over 1500 grams and who is admitted to a Neonatal intensive care unit (NICU) in your hospital within the first 28 days of life, regardless of gestational age. A NICU is any location within the hospital in which newborn infants can receive continuous positive airway pressure (CPAP) or intermittent ventilation (IMV). See Tables 4.12, and 4.13. VON Manual of Operations 2006, version 10.2, Published Oct 2005, Revised March 9, 2006 and Revised July 11, 2006. www.vtoxford.org/tools/2006ManualofOperationsver10_2.pdf LFG2006: Principal or secondary discharge diagnosis of Delivery <1500 grams and <32 weeks gestation = Determined using the following ICD-9 DIAGNOSIS CODES: 764.01-764.05 Light for dates without mention of malnutrition--< 500 gms. - 1499 gms. 764.11-764.15 Light for dates with signs of fetal malnutrition--< 500 gms. - 1499 gms. 764.21-764.25 Fetal malnutrition without mention of light for dates--< 500 gms. - 1499 gms. 764.91-764.95 Fetal growth retardation, unspecified--< 500 gms. - 1499 gms. 765.0x Extreme immaturity (usually BW < 1000 gms. or gestation < 28 weeks) 765.10-765.15 Other preterm infants, --< 500 gms. – 1499 gms. AND 765.21-765.26 Gestation age < 33 weeks Eligible mothers = Mothers of very low birthweight infants (500 – 1500g) who were delivered between 24 and 33 6/7 weeks gestational age, as per the Vermont Oxford Network definition.7 Exclusions: Total number of mothers delivering either Very Low Birthweight Infants or “in-born” infants admitted to the NICU immediately (on day 0). other than premies/low weight? why steroids for mom? Babies are “in-born”, not moms; transferred moms should be excluded anyway? LFG2006: o Mother’s age < 18 years o Mother expired during hospitalization o Transfers in or out o Contraindications8,9 to administer antenatal steroids to mothers = Documentation of one or more of the following [NOTE: Patients having one or more of the following contraindications may still potentially be eligible to receive the medication in which case they should not be excluded as contraindications.] • Maternal thyrotoxicosis • Maternal cardiomyopathy • Active maternal infection or chorioamnionitis • Ruptured membrane and imminent delivery 6-12 hours • Fetal demise • Mother with tuberculosis • Other reasons as documented by physician, nurse practitioner, or physician7 1999 VON Database Manual of Operations. Release 3.5. VON. Burlington, VT.8 American College of Obstetricians and Gynecologists. Antenatal steroid corticosteroid therapy for fetalmaturation. Committee Opinion 147. Washington, D.C.: ACOG, 1994.9 Steer P, Flint C. ABC of labour care: preterm labour and premature rupture of membranes. BMJ 1999; 318(7190):1059-1062.October 26, 2006 18v4.0a 2007 Survey DRAFT
  • 19. ___________________________________________Nationally Endorsed Process MeasuresSpecifications assistant LFG2006: Antenatal steroids10 = Betamethasone, Dexamethasone. If either agent is not available, hydrocortisone may help to reduce the incidence of respiratory distress syndrome11,1210 NIH Consensus Statement 1994 Feb 28-Mar 2;12(2):1-24.11 Morrison JC, Whybrew WD, Bucovaz ET, Schneider JM. Injection of corticosteroids into mother to prevent neonatalrespiratory distress syndrome. Am J Obstet Gynecol 1978; 131: 358-366.12 Morrison JC, Schneider JM, Whybrew WD, Bucovaz ET. Effect of corticosteroids and Fetomaternal disorders onthe L:S ratio. Obstet Gynecol 1980; 56: 583-590.October 26, 2006 19v4.0a 2007 Survey DRAFT
  • 20. ___________________________________________Nationally Endorsed Process MeasuresFrequently Asked QuestionsFrequently Asked Questions re: Measuring Adherence for Indicators NOT Reported Nationally1. I have fewer than 60 cases? Should I measure and report adherence for the indicator(s)? Yes. Use all the cases that meet the criteria.2. What is the method that should be used to draw the sample of 60 cases? Hospitals will need to pull a random sample of more than 60 cases, since some cases will be eliminated based on the exclusion criteria. The exclusion criteria differ from indicator to indicator, so you’ll need additional cases for that reason as well. Start by pulling a random sample of cases in excess of 60. If you need additional cases to make 60 because of the exclusion criteria, just do another random sample. Hospitals with fewer than 60 cases in total for any procedure should review all cases. To sample cases randomly, use a technique that ensures that individual eligible cases in a population for the entire time period have an equal chance of being selected. Consider using methods similar to those described by JCAHO. (See JCAHO Sampling Methods)3. Does this mean that each indicator within the clinical groups will have its own sample of 60? All will start with a sample size of 60, if at least 60 patients were hospitalized with that condition. Additional patients may be required depending the number of patients who meet the inclusionary and exclusionary criteria per indicator.4. Does this mean that all cases will need to be screened for contraindications and then a random sample is selected from the remaining records? (Ex. 131 mothers with deliveries at 24-34 weeks, all charts are reviewed and patients with contraindications to steroids are eliminated. A random sample of 60 is then selected from the remaining cases.) 60 consecutive cases are to be selected, if at least 60 patients were hospitalized with that condition. Because some of these patients may meet the exclusionary criteria for each indicator, additional patients may be required to end with 60 patients per indicator who satisfy the inclusionary and exclusionary criteria. If 60 patients who meet the inclusionary and exclusionary criteria cannot be identified, please use the total number of eligible patients during that calendar year.5. Do the inclusion/exclusion criteria apply to both numerator and denominator? Yes. In fact, for each indicator, you should apply all inclusion/criteria to establish cases in the denominator first, either all cases meeting those criteria or a sample of 60 if more than 60 meet all the criteria. The numerator is simply those cases from the denominator that meet the clinical guideline, and the numerator never includes cases not in the denominator.CABG – Indicator 6 (early extubation)6. Virtually all of our patients have at least one of these contraindications to early extubation, so we won’t have any observations in our denominator. Not all indicators are appropriate for every hospital. We expect that many patients will meet exclusionary criteria for early extubation and potentially other indicators.Percutaneous Coronary Intervention – Indicator 3 (aspirin at discharge)7. Should expired patients be excluded from the denominator? Yes.October 26, 2006 20v4.0a 2007 Survey DRAFT
  • 21. ___________________________________________Nationally Endorsed Process MeasuresFrequently Asked QuestionsPercutaneous Coronary Intervention – Indicator 2 (door-to-balloon time)8. Should transfers from another facility be excluded from the denominator and numerator? (JCAHO core measures excludes transfers.) Yes9. Would the Expert Panelists convened by Zynx consider redefining its indicators to be consistent with JCAHO Core Measures (or CMS, AHA measures?) e.g. AAA repair contraindications are these defined same as Core Measures? The panelists attempted to be consistent with JCAHO Clinical Core Measure. AAA repair is not a JCAHO Clinical Core Measure.10. Can the expert panel indicator for PTCA balloons/average hours turnaround for AMI be “synchronized” with the JCAHO/CMS/AMA definitions? The expert panel has attempted to be consistent with JCAHO/CMS definitions for the door-to-balloon time. (See the Leapfrog-Zynx document of definitions and operational guidelines for the Expert Panel-Endorsed Process Measures.)AAA – Indicator 1 (beta-blockers before anesthesia induction)11. Should transfers from another facility be excluded from the denominator and numerator? (JCAHO core measures excludes transfers) Yes12. The numerator is defined as the number of patients undergoing elective AAA repair who received beta-blockers “by the time” of induction. What is the defined time period for “by the time” of induction? Prior to induction = Followed usual treatment regimen if a chronic beta-blocker user (e.g., taking an oral a.m. dose of the drug on the day of surgery) or as part of the medication history list on the day of surgery. If the patient is a chronic user of beta-blockers, that patient should then receive the regular dose at the normal period of administration, regardless if the dose should fall on the night prior to surgery or in the morning before surgery. If the patient is not a chronic user, that patient should then receive beta-blockers at any time prior to the induction of anesthetics.13. We counted patients as a yes who took their regular AM dose at home before coming in for surgery. Is this correct? Yes.14. What is the defined time period for “by the time” of induction? Prior to induction = Followed usual treatment regimen if chronic beta-blocker user (e.g., taking an oral a.m. dose of the drug on the day of surgery) or as part of the medication history list on the day of surgery. If the patient is a chronic user of beta-blockers, that patient should then receive the regular dose at the normal period of administration, regardless if the dose should fall on the night prior to surgery or in the morning before surgery. If the patient is not a chronic user, that patient should then receive beta-blockers at any time prior to the induction of anesthetics.October 26, 2006 21v4.0a 2007 Survey DRAFT
  • 22. ___________________________________________Nationally Endorsed Process MeasuresFrequently Asked QuestionsAAA – Indicator 2 (beta blocker at discharge)15. Should expired patients be excluded from the denominator? Yes.Neonatal intensive care – Indicator 1 (pre-natal steroids for early-term mother)16. How do we count a patient transferred here from another facility where they received the steroids at the other facility? Is this patient excluded from our data since we did not administer the steroids? Yes, the patient is excluded from your data.17. Do we only look at the admission that the patient delivers on? Some preterm patients receive steroids and are then sent home. They then return at a later date and deliver. Does this count as a yes? Yes.18. We pulled records based on the gestational age at the time of delivery not the age at the time the steroids were given. Yes, that is correct.19. What is the definition for rupture of membranes? Any breakage of the amniotic sac.20. Some patients have prolonged premature rupture of membranes and still receive steroids. Are these patients then excluded? No. Only patients with premature rupture with imminent delivery within 6-8 hours should be excluded.21. Some patients who have contraindications still get the steroids. Do we then exclude these patients from our counts? Yes.October 26, 2006 22v4.0a 2007 Survey DRAFT

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