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Joint Commission Internationals

International Library of
Measures

Pre-Publication Copy

Joint Commission International


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2011 Joint Commission International


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Last Updated: Version 1.2 January 2011

2011 Joint Commission International



1

Foreword
Joint Commission International (JCI) is very pleased to present this first edition of the Joint
Commission International Library of Measures. The Library is an organized, descriptive
catalogue of 36 selected measures designed to assist health care organizations in choosing a
specific set of measures based on the needs of their populations. The Library will begin to
standardize measurement among organizations by standardizing the measures that are
collected and the details of how they are collected.
Measures provide healthcare professionals and organizations with valuable information about
their performance. Organizations can use this information to make comparisons with other
organizations or with themselves over time. Comparison helps organizations see where they
may be falling short and when processes may be breaking down; thus helping to facilitate
improved performance.
Accreditation programs around the world are moving toward more objective measurements of
quality and patient safety. Over time, the on-site evaluation process will be adjusted to reflect
priority evaluation issues gleaned from measurement data. Accreditation becomes continuous
when a flow of objective data comes to JCI between on-site evaluations. All of this requires
reduction in the variations between organizations in terms of what they collect and how they
collect it. The JCI International Library of Measures is a first step in a multi-year effort to bring
JCI accreditation to the next level. d>:/
improve the quality and safety of patient care around the world.



2011 Joint Commission International

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International Library of Measures


The 4th Edition International Standards for Hospitals (Effective 1 January 2011) require organizations to
select five (5) individual clinical measures from the JCI International Library of Measures (see QPS.3.1).
In addition, the Clinical Care Program Certification requirements include the need for programs to
choose at least two (2) of their four (4) measures from the JCI International Library of Measures. There
are a total of ten (10) measures sets, each containing from two (2) to eight (8) individual measures.

Measure
Code

Measure Description

Acute Myocardial Infarction (AMI)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-AMI-1

Aspirin received within 24 hours of arrival to the hospital for patients having an acute
myocardial infarction (AMI).

I-AMI-2

Aspirin prescribed at discharge for patients who had an acute myocardial infarction.

I-AMI-3

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)


for patients who have LVSD (Left Ventricular Systolic Dysfunction) after having an
acute myocardial infarction.

I-AMI-4

Adult smoking cessation advice/counseling given to patients who had an acute


myocardial infarction.

I-AMI-5

Beta-blocker prescribed at discharge for patients who had an acute myocardial


infarction.

I-AMI-9

Acute myocardial infarction (AMI) patients who expire during the hospital stay

Heart Failure (HF)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-HF-2

Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival, during hospitalization, or is
planned for after discharge

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Measure
Code

Measure Description

I-HF-3

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)


for heart failure patients who have LVSD (Left Ventricular Systolic Dysfunction)

I-HF-4

Adult smoking cessation advice/counseling given to heart failure patients

Stroke (STK)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-STK-2

Patients with ischemic stroke prescribed antithrombotic therapy at discharge

I-STK-3

Patients with atrial fibrillation/flutter receiving anticoagulation therapy

I-STK-8

Stroke patients who were given stroke education during their hospital stay

I-STK-10

Ischemic or hemorrhagic stroke patients who were assessed for rehabilitation services


I-CAC-1

Pediatric asthma patients who received relievers during this hospitalization

I-CAC-2

Pediatric asthma patients who received systemic corticosteroids during hospitalization

Hospital-Based Inpatient Psychiatric Service (HBIPS)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-HBIPS-2

Psychiatric patients who were placed in physical restraints during their inpatient
hospitalization. This measure will determine the total number of hours that patients
were maintained in physical restraints for those admitted to a hospital-based inpatient
psychiatric setting

I-HBIPS-3

Psychiatric patients who were placed in seclusion during their inpatient hospitalization.
This measure will determine the total number of hours that all patients were
maintained in seclusion for those admitted to a hospital-based inpatient psychiatric
setting.

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Measure
Code

Measure Description

Nursing-Sensitive Care (NSC)


Originally developed by the National Quality Forum (NQF)

I-NSC-2

Patients that have hospital-acquired (nosocomial) pressure ulcer(s) (category/stage II)


on the day of the prevalence study.<BR>Note: Please see Appendix E for details on
how to collect this measure.

I-NSC-4

All documented falls with or without injury, experienced by patients in a calendar


month.

I-NSC-5

All documented falls by a patient with an injury level of minor (2) or greater.

Perinatal Care (PC)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-PC-01

Patients with elective vaginal deliveries or elective cesarean sections at >= 37 and < 39
weeks of gestation completed

I-PC-02

Nulliparous women with a term, singleton baby in a vertex position delivered by


cesarean section

I-PC-05

Exclusive breast milk feeding during the newborn's entire hospitalization

Pneumonia (PN)
Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-PN-2

Pneumonia patients, aged 65 and older, who were screened for pneumococcal vaccine
status and were administered the vaccine prior to discharge, if indicated

I-PN-4

Adult smoking cessation advice/counseling given to patients who smoke cigarettes and
who are hospitalized for pneumonia

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Measure
Code
I-PN-7

Measure Description
Pneumonia patients, aged 50 and older, who during the flu season, were screened for
influenza vaccine status and were vaccinated prior to discharge, if indicated

Surgical Care Improvement Project (SCIP)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

Prophylactic antibiotics received one hour prior to surgical incision for hip arthroplasty
I-SCIP-Inf-1d patients
Prophylactic antibiotics received one hour prior to surgical incision for knee
I-SCIP-Inf-1e arthroplasty patients
Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent
I-SCIP-Inf-2d with current guidelines
Surgical patients (knee arthoplasty) who received prophylactic antibiotics consistent
I-SCIP-Inf-2e with current guidelines
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued
I-SCIP-Inf-3d within 24 hours after anesthesia end time
Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued
I-SCIP-Inf-3e within 24 hours after anesthesia end time
Surgical patients (hip/knee arthroplasty) with recommended venous
thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours
I-SCIP-VTE-1 after Anesthesia End Time
Surgical patients who received appropriate venous thromboembolism (VTE)
prophylaxis within 24 hours prior to anesthesia start time to 24 hours after anesthesia
I-SCIP-VTE-2 end time

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Measure
Code

Measure Description

Venous Thromboembolism (VTE)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-VTE-1

Patients who received VTE prophylaxis (or reasons of why this was not done) on the
day of or day after hospital admission or surgery.<BR>Note: This measure applies to
medical and surgical cases that are not included in the SCIP measure population

I-VTE-2

ICU patients who received VTE prophylaxis (or reasons of why this was not done) on
the day of or day after hospital admission or surgery.<BR>Note: This measure applies
to all ICU cases except those included in the SCIP measure population (knee/hip
arthroplasty) who had surgery on the day of or the day after ICU admission or transfer

2011 Joint Commission International



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Acute Myocardial
Infarction (AMI)
Measure Set

2011 Joint Commission International



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Measure
Code

Measure Description

Acute Myocardial Infarction (AMI)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-AMI-1

Aspirin received within 24 hours of arrival to the hospital for patients having an acute
myocardial infarction (AMI).

I-AMI-2

Aspirin prescribed at discharge for patients who had an acute myocardial infarction.

I-AMI-3

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)


for patients who have LVSD (Left Ventricular Systolic Dysfunction) after having an
acute myocardial infarction.

I-AMI-4

Adult smoking cessation advice/counseling given to patients who had an acute


myocardial infarction.

I-AMI-5

Beta-blocker prescribed at discharge for patients who had an acute myocardial


infarction.

I-AMI-9

Acute myocardial infarction (AMI) patients who expire during the hospital stay

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I-AMI 1
Aspirin on Arrival
Measure Overview
I-AMI 1 Aspirin received within 24 hours of arrival to the hospital for patients
having an acute myocardial infarction.
Overview/Details:
Aspirin received within 24 hours of arrival to the hospital for patients having an acute
myocardial infarction (AMI).
Rationale:
The early use of aspirin in patients with acute myocardial infarction results in a
significant reduction in adverse events and subsequent mortality.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Indicator Name: Aspirin on arrival
Numerator: AMI patients who received aspirin within 24 hours before
or after hospital arrival
Denominator: AMI patients who are age >= 18 years

Domains of Performance
Appropriateness

QPS Standards
QPS.3 patient assessments

CCPC
AMI

IPSG
*RDO

Availability
Continuity
Effectiveness

QPS.3 antibiotic and other


medication use

Timeliness
2011 Joint Commission International

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I-AMI 1
Measure Details
Reasons and Implications: The benefits of aspirin therapy on mortality is
comparable to thrombolytic therapy. The combination provides additive benefit for
patients with ST-elevation myocardial infarction and aspirin is also effective in patients
with non-ST-elevation myocardial infarction. Clinical guidelines strongly recommend
aspirin for patients hospitalized with AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who received aspirin within 24 hours before or after hospital
arrival
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Aspirin received within 24 hours before or after hospital arrival
Denominator: AMI patients who are >= 18 years
Data elements:
x Admission Date
x Birthdate
x ICD Principal Diagnosis Code
x Reason for no aspirin on arrival
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice or discontinued care on day of or day
after arrival
x Patients who expired on day of or day after arrival
x Patients with a documented Reason for No Aspirin on Arrival

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I-AMI-1
References
x

x
x

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et
al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). 2004.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et
al. ACC/AHA 2008 performance measures for adults with ST-elevation and
nonST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
Randomized trial of intravenous streptokinase, oral aspirin, both or neither
among 17,187 cases of suspected acute myocardial infarction: ISIS-2. ISIS-2
(Second International Study of Infarct Survival) Collaborative Group. Lancet.
1988 Aug 13;2(8607):349w-60.
Risk of myocardial infarction and death during treatment with low dose aspirin
and intravenous heparin in men with unstable coronary artery disease. The
RISC Group. Lancet. 1990;336(8719):827-830.
Theroux P, Ouimet H, McCans J et al. Aspirin, heparin, or both to treat acute
unstable angina. N Engl J Med. 1988;319(17):1105-1111.

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I-AMI 2
Aspirin Prescribed at Discharge
Measure Overview
I-AMI 2 Aspirin prescribed at discharge for patients who had an
acute myocardial infarction.
Overview/Details:
Aspirin prescribed at discharge for patients who had an acute myocardial
infarction (AMI).
Rationale:
Aspirin therapy in patients who have suffered an acute myocardial infarction reduces
the risk of adverse events and mortality.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
Indicator Name: Aspirin at discharge
Numerator: AMI patients who are prescribed aspirin at hospital discharge
Denominator: AMI patients who are >= 18 years

Domains of Performance
Appropriateness
Continuity

QPS Standards
QPS.3 patient
assessments

CCPC
AMI

IPSG
*RDO

Effectiveness
Prevention/Early
Detection

QPS.3 antibiotic and other


medication use

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I-AMI 2
Measure Details
Reasons and Implications: Studies have demonstrated that aspirin reduces the risk
of adverse events and mortality by 20%. Clinical guidelines strongly recommend longterm aspirin for the secondary prevention of subsequent cardiovascular events in
eligible patients discharged after AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who are prescribed aspirin at hospital discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Aspirin Prescribed at Discharge
Denominator: AMI patients who are >= 18 years
Data elements:
x Birthdate
x ICD Principal Diagnosis Code
x Reason for no aspirin at discharge
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients with a documented Reason for No Aspirin at Discharge

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I-AMI 2
References
x

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et
al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
Antiplatelet Trialists' Collaboration. Collaborative overview of randomized trials of
antiplatelet therapy - I: prevention of death, myocardial infarction, and stroke by
prolonged antiplatelet therapy in various categories of patients. BMJ.
1994;308:81-106.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). 2004.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et
al. ACC/AHA 2008 performance measures for adults with ST-elevation and non
ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC
guidelines for secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130
9. doi:10.1016/j.jacc.2006.04.026.

2011 Joint Commission International



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I-AMI 3
ACEI or ARB for LVSD
Measure Overview
I-AMI 3 ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin
receptor blocker) for patients who have LVSD (Left Ventricular Systolic
Dysfunction) after having an acute myocardial infarction.
Overview/Details:
ACEI or ARB prescribed at discharge for patients with LVSD after having an acute
myocardial infarction (AMI).
NOTE: For the purposes of this measure, LVSD is defined as chart documentation of a
left ventricular ejection fraction (LVEF) less than 40% or a narrative consistent with
moderate or severe systolic dysfunction.
Rationale:
ACEI inhibitors reduce mortality and morbidity in patients with left ventricular systolic
dysfunction (LVSD) after AMI. Clinical trials have also established ARB therapy as an
acceptable alternative to ACEI, especially in patients with heart failure and/or LVSD who
are ACEI intolerant.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services: Medical/Surgical units
Indicator Name: ACEI or ARB for LVSD
Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge
Denominator: AMI patients with LVSD who are >= 18 years
Domains of Performance

QPS Standards

Appropriateness

QPS.3 patient assessments

Continuity

QPS.3 radiology and


diagnostic imaging services

Effectiveness

CCPC
AMI

IPSG
Goal 1

QPS.3 antibiotic and other


medication use
2011 Joint Commission International

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I-AMI 3
Measure Details
Reasons and Implications: Clinical guidelines strongly recommend ACEI for patients
hospitalized with AMI who have either clinical heart failure or LVSD. Guideline
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AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who are prescribed an ACEI or ARB at hospital discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x ACEI Prescribed at Discharge
x ARB Prescribed at Discharge
Denominator: AMI patients with LVSD and who are >= 18 years
Data elements:
x Birthdate
x ICD Principal Diagnosis Code
x LVSD
x Reason for No ACEI and No ARB at Discharge
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1 and chart documentation of LVEF less than
40% or a narrative description of LVS function consistent with moderate or severe
systolic dysfunction
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients with a documented Reason for No ACEI or ARB at Discharge

2011 Joint Commission International



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I-AMI 3
References
x

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et
al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). 2004.
Flather MD, Yusuf S, Kober L et al. Long-term ACE-inhibitor therapy in patients
with heart failure or left-ventricular dysfunction: a systematic overview of data
from individual patients. ACE-Inhibitor Myocardial Infarction Collaborative Group.
Lancet. 2000;355(9215):1575-1581.
Granger CB, McMurray JJ, Yusuf S et al. Effects of candesartan in patients with
chronic heart failure and reduced left-ventricular systolic function intolerant to
angiotensin-converting-enzyme inhibitors: the CHARM-Alternative trial. Lancet.
2003;362:772-776.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et
al. ACC/AHA 2008 performance measures for adults with ST-elevation and non
ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
Pfeffer MA, Braunwald E, Moye LA, Basta L, Brown EJ, Jr., Cuddy TE, et al, for
the SAVE Investigators. Effect of captopril on mortality and morbidity in patients
with left ventricular dysfunction after myocardial infarction. Results of the Survival
and Ventricular Enlargement Trial. N Engl J Med. 1992;327:669-77.
Pfeffer MA, McMurray JJ, Velazquez EJ et al. Valsartan, captopril, or both in
myocardial infarction complicated by heart failure, left ventricular dysfunction, or
both. N Engl J Med. 2003;349:1893-1906.

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Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC
guidelines for secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130
9. doi:10.1016/j.jacc.2006.04.026.

Torp-Pedersen C, Kober L. Effect of ACE inhibitor trandolapril on life expectancy


of patients with reduced left-ventricular function after acute myocardial infarction.
TRACE Study Group. Trandolapril Cardiac Evaluation. Lancet.
1999;354(9172):9-12.
Yusuf S, Pepine CJ, Garces C et al. Effect of enalapril on myocardial infarction
and unstable angina in patients with low ejection fractions. Lancet.
1992;340(8829):1173-1178.

2011 Joint Commission International



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I-AMI 4
Adult Smoking Counseling
Measure Overview
I-AMI 4 Adult smoking cessation advice/counseling given to patients who had
an acute myocardial infarction.
Overview/Details:
Smoking cessation advice/counseling given to patients (cigarette smokers) who had an
acute myocardial infarction (AMI).
NOTE: For the purposes of this measure, a smoker is defined as someone who has
smoked cigarettes anytime during the year prior to hospital arrival.
Rationale:
Smoking cessation reduces mortality and morbidity in all populations. Patients who
receive even brief smoking-cessation advice from their health care providers are more
likely to quit.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
Indicator Name: Adult smoking cessation advice/counseling
Numerator: AMI patients (cigarette smokers) who receive smoking cessation advice or
counseling during the hospital stay
Denominator: AMI patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival who are >= 18 years

Domains of Performance
Appropriateness
Continuity

QPS Standards
QPS.3 patient
assessments

CCPC

IPSG

AMI

Effectiveness
Prevention/Early Detection
2011 Joint Commission International

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I-AMI - 4
Measure Details
Reasons and Implications: Smoking cessation reduces mortality and morbidity in all
populations. Patients who receive even brief smoking-cessation advice from their
health care providers are more likely to quit. Clinical guidelines strongly recommend
smoking cessation counseling for smokers hospitalized with AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients (cigarette smokers) who receive smoking cessation advice or
counseling during the hospital stay
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Adult Smoking Counseling
Denominator: AMI patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival who are >= 18 years
Data elements:
x Adult Smoking History
x Birthdate
x ICD Principal Diagnosis Code
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1 and a history of smoking cigarettes anytime
during the year prior to hospital arrival
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired

2011 Joint Commission International



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I-AMI 4
References
x

x
x

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et
al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). 2004.
Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. May 2008.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et
al. ACC/AHA 2008 performance measures for adults with ST-elevation and non
ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC
guidelines for secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130
9. doi:10.1016/j.jacc.2006.04.026.

2011 Joint Commission International



22

I-AMI 5
Beta Blocker Prescribed at Discharge
Measure Overview
I-AMI 5 Beta-blocker prescribed at discharge for patients who had an acute
myocardial infarction.
Overview/Details:
Acute myocardial infarction (AMI) patients who are prescribed a beta-blocker at hospital
discharge
Rationale:
Long-term use of beta blockers for patients who have suffered an acute myocardial
infarction can reduce mortality and morbidity. Studies have demonstrated that the use
of beta-blockers is associated with a 20% reduction in this risk.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
Indicator Name: Beta-blocker prescribed at discharge
Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge
Denominator: AMI patients who are >= 18 years
Domains of Performance
Appropriateness
Continuity

QPS Standards
QPS.3 patient
assessments

CCPC
AMI

IPSG
*RDO

Effectiveness
Prevention/Early
Detection

QPS.3 antibiotic and


other medication use

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I-AMI - 5
Measure Details
Reasons and Implications: Studies have demonstrated that the use of beta-blockers
is associated with a 20% reduction in risk and there is evidence of effectiveness in
broad populations of patients. Clinical guidelines strongly recommend long-term betablocker therapy for the secondary prevention of subsequent cardiovascular events in
patients discharged after AMI.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: AMI patients who are prescribed a beta-blocker at hospital discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Beta-Blocker Prescribed at Discharge
Denominator: AMI patients who are >= 18 years
Data elements:
x Birthdate
x ICD Principal Diagnosis Code
x Reason for no Beta-blocker at discharge
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients with a documented Reason for No Beta-Blocker at Discharge

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I-AMI 5
References
x

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et
al. ACC/AHA 2007 guidelines for the management of patients with unstable
angina/nonST-elevation myocardial infarction: a report of the American College
of Cardiology/American Heart Association Task Force on Practice Guidelines
(Writing Committee to Revise the 2002 Guidelines for the Management of
Patients With Unstable Angina/NonST-Elevation Myocardial Infarction):
developed in collaboration with the American College of Emergency Physicians,
American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of
Thoracic Surgeons. J Am Coll Cardiol. 2007;50:e1157.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation
myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Committee to Revise the
1999 Guidelines for the Management of Patients With Acute Myocardial
Infarction). 2004.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et
al. ACC/AHA 2008 performance measures for adults with ST-elevation and non
ST-elevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and
NonST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
Krumholz HM, Radford MJ, Wang Y, Chen J, Heiat A, Marciniak TA. National use
and effectiveness of E-blockers for the treatment of elderly patients after acute
myocardial infarction: National Cooperative Cardiovascular Project. JAMA.
1998;280:623-629.
Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC
guidelines for secondary prevention for patients with coronary and other
atherosclerotic vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130
9. doi:10.1016/j.jacc.2006.04.026.
Yusuf S, Wittes J, Friedman L. Overview of results of randomized clinical trials in
heart disease. I. Treatments following myocardial infarction. JAMA. 1988;
260(14):2088:2093.

2011 Joint Commission International



25

I-AMI 9
Inpatient AMI Mortality
Measure Overview
I-AMI 9 Acute myocardial infarction (AMI) patients who expire during hospital
stay
Overview/Details:
Acute myocardial infarction (AMI) patients who expired during the hospital stay
Rationale:
Mortality of patients with AMI represents a significant outcome potentially related to the
quality of care. This rate-based indicator identifies an undesirable outcome of care.
High rates over time may warrant investigation into the quality of care provided.
Outcomes:
Mortality: A decrease in the rate
Improvement noted as: Decrease in rate
Patient Settings/Services
Intensive Care Units
Medical/Surgical units
Indicator Name: Inpatient mortality
Numerator: Inpatient mortality of AMI patients
Denominator: AMI patients who are >= 18 years

Domains of Performance

QPS Standards

Effectiveness

CCPC

IPSG

AMI

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I-AMI 9
Measure Details
Reasons and Implications: Mortality of patients with AMI represents a significant
outcome potentially related to the quality of care. This rate based indicator identifies an
undesirable outcome of care. High rates over time may warrant investigation into the
quality of care provided.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Inpatient mortality of AMI patients
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Discharge status
Denominator: AMI patients who are >= 18 years
Data elements:
x Birthdate
x ICD Principal Diagnosis Code
Inclusions to the population: Patients with ICD-9/ICD-10 principal diagnosis code for
AMI as defined in Appendix A, Table 1.1
Exclusions to the population:
x Patients less than 18 years of age
Note: This measure population does not include deaths that occurred in the
emergency department

2011 Joint Commission International



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I-AMI 9
References
x

Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al.
ACC/AHA guidelines for the management of patients with ST-elevation myocardial
infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Committee to Revise the 1999
Guidelines for the Management of Patients With Acute Myocardial Infarction). 2004.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al.
ACC/AHA 2008 performance measures for adults with ST-elevation and nonSTelevation myocardial infarction: a report of the American College of
Cardiology/American Heart Association Task Force on Performance Measures
(Writing Committee to Develop Performance Measures for ST-Elevation and Non
ST-Elevation Myocardial Infarction). J Am Coll Cardiol. 2008;52:2046 99.
Maggioni AP, et al: Age related increase in mortality among patients with first
myocardial infarctions treated with thrombolysis: the Investigators of the Gruppo
,WDOLDQRSHUOR6WXGLRGHOOD6RSUDYYLYHQ]DQHOO,QIDUWR0LRFDUGLFR *,66,-2). N Engl J
Med. 1993;329:1442-1448.

2011 Joint Commission International



28

Appendix A
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries, ICD-8,
ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in the specific
code utilized by your country to correspond to the ICD-9-CM code description for the
following diagnoses.

Table 1.1 AMI


Acute Myocardial Infarction Codes
ICD-8
ICD-9
ICD-10 ICD-9-CM
Code
Code
Code
Code

Shortened Description

410.00

AMI ANTEROLATERAL,UNSPEC

410.01

AMI ANTEROLATERAL, INIT

410.10

AMI ANTERIOR WALL,UNSPEC

410.11

AMI ANTERIOR WALL, INIT

410.20

AMI INFEROLATERAL,UNSPEC

410.21

AMI INFEROLATERAL, INIT

410.30

AMI INFEROPOST, UNSPEC

410.31

AMI INFEROPOST, INITIAL

410.40

AMI INFERIOR WALL,UNSPEC

410.41

AMI INFERIOR WALL, INIT

410.50

AMI LATERAL NEC, UNSPEC

410.51

AMI LATERAL NEC, INITIAL

410.60

TRUE POST INFARCT,UNSPEC

410.61

TRUE POST INFARCT, INIT

410.70

SUBENDO INFARCT, UNSPEC

410.71

SUBENDO INFARCT, INITIAL

410.80

AMI NEC, UNSPECIFIED

410.81

AMI NEC, INITIAL

410.90

AMI NOS, UNSPECIFIED

410.91

AMI NOS, INITIAL

2011 Joint Commission International



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Heart Failure (HF)


Measure Set

2011 Joint Commission International



30

Measure
Code

Measure Description

Heart Failure (HF)


Originally developed through a collaborative effort between The Joint Commission and the Centers for
Medicare and Medicaid Services (CMS)

I-HF-2

Heart failure patients with documentation in the hospital record that left ventricular
systolic (LVS) function was evaluated before arrival, during hospitalization, or is
planned for after discharge

I-HF-3

ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin receptor blocker)


for heart failure patients who have LVSD (Left Ventricular Systolic Dysfunction)

I-HF-4

Adult smoking cessation advice/counseling given to heart failure patients

2011 Joint Commission International



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I-HF 2
Evaluation of LVS Function
Measure Overview
I-HF 2 Heart failure patients with documentation in the hospital record that left
ventricular systolic (LVS) function was evaluated before arrival, during
hospitalization, or is planned for after discharge
Overview/Details:
Heart failure patients with LVS function evaluation
Rationale:
Appropriate selection of medications to reduce morbidity and mortality in heart failure
requires the identification of patients with impaired left ventricular systolic function.
Clinical guidelines advocate evaluation of left ventricular systolic function as the single
most important diagnostic test in the management of all patients with heart failure.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
Indicator Name: Evaluation of LVS function
Numerator: Heart failure patients with documentation in the hospital record that LVS
function was evaluated before arrival, during hospitalization, or is planned for after
discharge
Denominator: Heart failure patients who are >= 18 years

2011 Joint Commission International



32

Domains of Performance
$SSURSULDWHQHVV
$YDLODELOLW\
&RQWLQXLW\
(IIHFWLYHQHVV

QPS Standards
QPS.3 patient
assessments

CCPC
+)

IPSG
*RDO

QPS.3 radiology and


diagnostic imaging
services

7LPHOLQHVV

2011 Joint Commission International



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I-HF-2
Measure Details
Reasons and Implications:
Clinical guidelines advocate evaluation of left ventricular systolic function as the single
most important diagnostic test in the management of all patients with heart failure.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Heart failure patients with documentation in the hospital record that LVS
function was evaluated before arrival, during hospitalization, or is planned for after
discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x

LVF Assessment

Denominator: Heart failure patients who are >= 18 years


Data elements:
x
x
x

Birthdate
ICD Principal Diagnosis Code
LVF Assessment

Inclusions to the population: Patients with ICD principal diagnosis code for heart
failure as defined in Appendix A, Table 2.1
Exclusions to the population:
x
x
x
x
x

Patients less than 18 years of age


Patients who left against medical advice
Patients who expired
Patients who had a left ventricular assistive device (LVAD) or heart transplant
procedure during hospital stay
Patients with reasons documented for no LVS function evaluation

2011 Joint Commission International



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I-HF-2
References
x

x
x

Bonow RO, Bennett S, Casey DE, Ganiats TG, Hlatky MA, Konstam MA, et al.
ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure: a
report of the American College of Cardiology/American Heart Association Task
Force on Performance Measures (Writing Committee to Develop Heart Failure
Clinical Performance Measures). J Am Coll Cardiol. 2005;46:114478. Available at
http://www.acc.org and http://www.americanheart.org.
Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure
Practice Guideline. J Card Fail. 2006 Feb;12(1):e1-2.
Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al,
writing on behalf of the 2005 Guideline Update for the Diagnosis and
Management of Chronic Heart Failure in the Adult Writing Committee. 2009
focused update: ACCF/AHA guidelines for the diagnosis and management of
heart failure in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2009;53:1343 82.

2011 Joint Commission International



35

I-HF-3
ACEI or ARB for LVSD
Measure Overview
I-HF 3 ACEI (angiotensin converting enzyme inhibitor) or ARB (angiotensin
receptor blocker) for heart failure patients who have LVSD (Left Ventricular
Systolic Dysfunction)
Overview/Details:
Heart failure patients with LVSD who are prescribed and ACEI or ARB at hospital
discharge
NOTE: For the purposes of this measure, LVSD is defined as chart documentation of a
left ventricular ejection fraction (LVEF) less than 40% or a narrative consistent with
moderate or severe systolic dysfunction.
Rationale:
ACEI inhibitors reduce mortality and morbidity in patients with heart failure and left
ventricular systolic dysfunction (LVSD) and are effective in a wide range of patients.
Clinical trials have also established ARB therapy as in acceptable alternative to ACEI,
especially in patients who are ACEI intolerant.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
Indicator Name: ACEI or ARB for LVSD
Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital
discharge
Denominator: Heart failure patients with LVSD who are >= 18 years
2011 Joint Commission International

36

Domains of Performance
$SSURSULDWHQHVV
&RQWLQXLW\
(IIHFWLYHQHVV

QPS Standards
QPS.3 patient
assessments

CCPC
+)

IPSG
*RDO

QPS,3 radiology and


diagnostic imaging
services
QPS.3 antibiotic and
other med use

2011 Joint Commission International



37

I-HF-3
Measure Details
Reasons and Implications: Clinical guidelines strongly recommend ACEI for patients
hospitalized with heart failure and left ventricular systolic dysfunction. Guideline
committees have also supported the inclusLRQRI$5%VLQSHUIRUPDnce measures for
heart failure.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Heart failure patients who are prescribed an ACEI or ARB at hospital
discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x
x

ACEI Prescribed at Discharge or


ARB Prescribed at Discharge

Denominator: Heart failure patients with LVSD who are >= 18 years
Data elements:
x
x
x
x

Birthdate
ICD Principal Diagnosis Code
LVSD
Reason for No ACEI and No ARB at Discharge

Inclusions to the population: Patients with ICD principal diagnosis code for heart
failure as defined in Appendix A, Table 2.1 and chart documentation of LVEF less than
40% or a narrative description of LVS function consistent with moderate or severe
systolic dysfunction
Exclusions to the population:
x
x
x

Patients less than 18 years of age


Patients who left against medical advice
Patients who expired

2011 Joint Commission International



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x
x

Patients who had a left ventricular assistive device (LVAD) or heart transplant
procedure during the hospital stay
Patients with a documented Reason for No ACEI or ARB at Discharge

2011 Joint Commission International



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I-HF-3
References
x

x
x

x
x

x
x

Anderson JL, Adams CD, Antman EM, Bridges CR, Califf RM, Casey DE Jr, et al.
ACC/AHA 2007 guidelines for the management of patients with unstable angina/nonSTelevation myocardial infarction: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the
2002 Guidelines for the Management of Patients With Unstable Angina/NonST-Elevation
Myocardial Infarction): developed in collaboration with the American College of Emergency
Physicians, American College of Physicians, Society for Academic Emergency Medicine,
Society for Cardiovascular Angiography and Interventions, and Society of Thoracic
Surgeons. J Am Coll Cardiol. 2007;50:e1157.
Antman EM, Anbe DT, Armstrong PW, Bates ER, Green LA, Hand M, et al. ACC/AHA
guidelines for the management of patients with ST-elevation myocardial infarction: a report
of the American College of Cardiology/American Heart Association Task Force on Practice
Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients With
Acute Myocardial Infarction). 2004.
Flather MD, Yusuf S, Kober L et al. Long-term ACE-inhibitor therapy in patients with heart
failure or left-ventricular dysfunction: a systematic overview of data from individual patients.
ACE-Inhibitor Myocardial Infarction Collaborative Group. Lancet. 2000;355(9215):15751581.
Granger CB, McMurray JJ, Yusuf S et al. Effects of candesartan in patients with chronic
heart failure and reduced left-ventricular systolic function intolerant to angiotensinconverting-enzyme inhibitors: the CHARM-Alternative trial. Lancet. 2003;362:772-776.
Krumholz HM, Anderson JL, Bachelder BL, Fesmire FM, Fihn SD, Foody JM, et al.
ACC/AHA 2008 performance measures for adults with ST-elevation and nonST-elevation
myocardial infarction: a report of the American College of Cardiology/American Heart
Association Task Force on Performance Measures (Writing Committee to Develop
Performance Measures for ST-Elevation and NonST-Elevation Myocardial Infarction).J
Am Coll Cardiol.2008;52:204699.
Pfeffer MA, Braunwald E, Moye LA, Basta L, Brown EJ, Jr., Cuddy TE, et al, for the SAVE
Investigators. Effect of captopril on mortality and morbidity in patients with left ventricular
dysfunction after myocardial infarction. Results of the Survival and Ventricular Enlargement
Trial. N Engl J Med. 1992;327:669-77.
Pfeffer MA, McMurray JJ, Velazquez EJ et al. Valsartan, captopril, or both in myocardial
infarction complicated by heart failure, left ventricular dysfunction, or both. N Engl J Med.
2003;349:1893-1906.
Smith SC, Allen J, Blair SN, Bonow RO, Brass LM, Fonarow GC, et al. AHA/ACC
guidelines for secondary prevention for patients with coronary and other atherosclerotic
vascular disease: 2006 update. J Am Coll Cardiol. 2006;47:2130 9.
doi:10.1016/j.jacc.2006.04.026.
Torp-Pedersen C, Kober L. Effect of ACE inhibitor trandolapril on life expectancy of patients
with reduced left-ventricular function after acute myocardial infarction. TRACE Study
Group. Trandolapril Cardiac Evaluation. Lancet. 1999;354(9172):9-12.
Yusuf S, Pepine CJ, Garces C et al. Effect of enalapril on myocardial infarction and
unstable angina in patients with low ejection fractions. Lancet. 1992;340(8829):1173-1178.

2011 Joint Commission International



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I-HF-4
Adult Smoking Counseling
Measure Overview
I-HF 4 Adult smoking cessation advice/counseling given to heart failure patients
Overview/Details:
Smoking cessation advice/counseling given to heart failure patients (cigarette smokers)
NOTE: For purposes of this measure, a smoker is defined as someone who has
smoked cigarettes anytime during the year prior to hospital arrival.
Rationale:
Smoking cessation reduces mortality and morbidity in all populations. Patients who
receive even brief smoking-cessation advice from their health care providers are more
likely to quit.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days : Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Medical/Surgical units
Indicator Name: Adult smoking cessation advice/counseling
Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Denominator: Heart failure patients with a history of smoking cigarettes anytime during
the year prior to hospital arrival and who are >= 18 years.

2011 Joint Commission International



41

Domains of Performance
$SSURSULDWHQHVV
&RQWLQXLW\

QPS Standards
QPS.3 patient
assessments

CCPC

IPSG

+)
AMI

(IIHFWLYHQHVV

Asthma

3UHYHQWLRQ(DUO\'HWHFWLRQ

Primary Stroke
Cancer
COPD
Diabetes

2011 Joint Commission International



42

I-HF-4
Measure Details
Reasons and Implications: Smoking cessation reduces mortality and morbidity in all
populations. Patients who receive even brief smoking-cessation advice from their health
care providers are more likely to quit. Clinical guidelines strongly recommend smoking
cessation counseling for cigarette smokers with cardiovascular disease, including heart
failure.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Heart failure patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x

Adult Smoking Counseling

Denominator: Heart failure patients with a history of smoking cigarettes anytime during the
year prior to hospital arrival and who are >= 18 years
Data elements:
x
x
x

Adult Smoking History


Birthdate
ICD Principal Diagnosis Code

Inclusions to the population: Patients with ICD principal diagnosis code for HF as defined
in Appendix A, Table 2.1 and a history of smoking cigarettes anytime during the year prior
to hospital arrival
Exclusions to the population:
x
x
x
x

Patients less than 18 years of age


Patients who left against medical advice
Patients who expired
Patients who had a left ventricular assistive device (LVAD) or heart transplant
procedure during hospital stay

2011 Joint Commission International



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I- HF-4
References
x

x
x
x

Bonow RO, Bennett S, Casey DE, Ganiats TG, Hlatky MA, Konstam MA, et al.
ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure:
a report of the American College of Cardiology/American Heart Association Task
Force on Performance Measures (Writing Committee to Develop Heart Failure
Clinical Performance Measures). J Am Coll Cardiol. 2005;46:114478. Available
at http://www.acc.org and http://www.americanheart.org.
Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and Dependence:
2008 Update. Clinical Practice Guideline. Rockville, MD: U.S. Department of
Health and Human Services. Public Health Service. May 2008.
Heart Failure Society of America. HFSA 2006 Comprehensive Heart Failure
Practice Guideline. J Card Fail. 2006 Feb;12(1):e1-2.
Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, et al,
writing on behalf of the 2005 Guideline Update for the Diagnosis and
Management of Chronic Heart Failure in the Adult Writing Committee. 2009
focused update: ACCF/AHA guidelines for the diagnosis and management of
heart failure in adults: a report of the American College of Cardiology/American
Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol.
2009;53:1343 82.













2011 Joint Commission International

44

Appendix A
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries, ICD-8,
ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in the specific
code utilized by your country to correspond to the ICD-9-CM code description for the
following diagnoses.
Table 2.1
Heart Failure Codes
ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

402.01

MAL HYPERT HRT DIS W HF

402.11

BENIGN HYP HT DIS W HF

402.91

HYP HT DIS NOS W HT FAIL

404.01

MAL HYP HT/KD I-IV W HF

404.03

MAL HYP HT/KD STG V W HF

404.11

BEN HYP HT/KD I-IV W HF

404.13

BEN HYP HT/KD STG V W HF

404.91

HYP HT/KD NOS I-IV W HF

404.93

HYP HT/KD NOS ST V W HF

428.0

CHF NOS

428.1

LEFT HEART FAILURE

428.20

SYSTOLIC HRT FAILURE NOS

428.21

AC SYSTOLIC HRT FAILURE

428.22

CHR SYSTOLIC HRT FAILURE

428.23

AC ON CHR SYST HRT FAIL

2011 Joint Commission International



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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

428.30

DIASTOLC HRT FAILURE NOS

428.31

AC DIASTOLIC HRT FAILURE

428.32

CHR DIASTOLIC HRT FAIL

428.33

AC ON CHR DIAST HRT FAIL

428.40

SYST/DIAST HRT FAIL NOS

428.41

AC SYST/DIASTOL HRT FAIL

428.42

CHR SYST/DIASTL HRT FAIL

428.43

AC/CHR SYST/DIA HRT FAIL

428.9

HEART FAILURE NOS



Table 2.2
Left Ventricular Assistive Device (LVAD) and Heart Transplant
ICD-8
ICD-9
ICD-10
ICD-9Shortened Description
CMCode
Code
Code
Code
33.6

COMB HEART/LUNG TRANSPLA

37.51

HEART TRANSPLANTATION

37.52

IMP TOT INT BI HT RP SYS

37.53

REPL/REP THR UNT TOT HRT

37.54

REPL/REP OTH TOT HRT SYS

37.60

IMP BIVN EXT HRT AST SYS

37.62

INSRT NON-IMPL CIRC DEV

37.63

REPAIR HEART ASSIST SYS

37.65

IMP VENT EXT HRT AST SYS

2011 Joint Commission International



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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

37.66

IMPLANTABLE HRT ASSIST

37.68

PERCUTAN HRT ASSIST SYST

2011 Joint Commission International



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Stroke (STK)
Measure Set

2011 Joint Commission International



48

Measure
Code
Measure Description
Stroke (ST K )
Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

I-STK-2
I-STK-3
I-STK-8
I-STK-10

Patients with ischemic stroke prescribed antithrombotic therapy at


discharge
Patients with atrial fibrillation/flutter receiving anticoagulation
therapy
Stroke patients who were given stroke education during their
hospital stay
Ischemic or hemorrhagic stroke patients who were assessed for
rehabilitation services

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49

I-STK-2
Discharged on Antithrombotic Therapy
Measure Overview
I-STK 2 Patients with ischemic stroke prescribed antithrombotic therapy at
discharge
Overview/Details:
Patients prescribed antithrombotic therapy at discharge after having an ischemic stroke.
Rationale:
Data at this time suggest that antithrombotic therapy should be prescribed at discharge
following acute ischemic stroke to reduce stroke mortality and morbidity as long as no
contraindications exist.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Measure Name: Discharged on Antithrombotic Therapy
Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital
discharge
Denominator: Ischemic stroke patients who are >= 18 years.
Domains of Performance
Appropriateness
Continuity
Effectiveness
Prevention/Early Detection

QPS Standards
QPS.3 patient
assessments

CCPC
Stroke

IPSG
Goal 1

QPS.3 antibiotic and


other medication use

Timeliness
2011 Joint Commission International

50

I-STK-2
Measure Details
Reasons and Implications: The effectiveness of antithrombotic agents in reducing
stroke mortality, stroke related morbidity and recurrence rates has been studied in
several large clinical trials. While the use of these agents for patients with acute
ischemic stroke and transient ischemic attacks continues to be the subject of study,
substantial evidence is available from completed studies. Data at this time suggest
that antithrombotic therapy should be prescribed at discharge following acute
ischemic stroke to reduce mortality and morbidity.
Data Collection:
Retrospective data sources for the required data elements include administrative
data and medical records.
Numerator: Ischemic stroke patients prescribed antithrombotic therapy at hospital
discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Antithrombotic therapy prescribed at discharge
Denominator: Ischemic stroke patients who are > = 18 years.
Data elements:
x Birthdate
x Elective Carotid Intervention
x ICD principal diagnosis code
x Reason for not prescribing antithrombotic therapy at discharge
Inclusions to the population: Patients with ICD principal diagnosis code for
ischemic stroke as defined in Appendix A, Table 8.1
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients admitted for the performance of elective carotid intervention

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I-STK-2
References
x

x
x
x

x
x

Adams HP, del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida
RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH,
Scott PA, Wijdicks E. Guidelines for the Early Management of Adults with Ischemic
Stroke: A Guideline From the American Heart Association/American Stroke Association
Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention
Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care
Outcomes in Research Interdisciplinary Working Groups. Stroke. 2007;38:1655-1711.
Adams H, Adams R, Del Zoppo G, Goldstein LB. Guidelines for the Early Management
of Patients With Ischemic Stroke: Guidelines Update A Scientific Statement From the
Stroke Council of the American Heart Association/American Stroke Association. Stroke
Vol. 36, 2005: 916:923.
Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P. Antithrombotic and
Thrombolytic Therapy for Ischemic Stroke. Chest Vol. 119, 2001: 300-320.
Brott TG, Clark WM, Grotta JC, et al. Stroke the first hours. Guidelines for acute
treatment. Consensus Statement. National Stroke Association. 2000.
Chen ZM, Sandercock P, Pan HC, et al. Indications for early aspirin use in acute
ischemic stroke: a combined analysis of 40,000 randomized patients from the Chinese
acute stroke trial and the international stroke trial. On behalf of the CAST and IST
collaborative groups, Stroke 2000;31:1240-1249.
Coull BM, Williams LS, Goldstein LB, et al. Anticoagulants and Antiplatelet Agents in
Acute Ischemic Stroke. Report of the Joint Stroke Guideline Development Committee of
the American Academy of Neurology and the American Stroke Association (a Division
of the American Heart Association) Stroke. 2002;33:1934 -1942.
Guideline on the Use of Aspirin as Secondary Prophylaxis for Vascular Disease in
Primary Care, Centre for Health Services Research University of Newcastle upon Tyne,
& Centre for Health Economics of York, 1998.
Sacco RL, Adams R, Albers G, Alberts MJ, Benavente O, Furie K, Goldstein LB,
Gorelick P, Halperin J, Harbaugh R, Johnston SC, Katzan I, Kelly-Hayes M, Kenton EJ,
Marks M, Schwamm LH, Tomsick T. Guidelines for Prevention of Stroke in Patients
With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare
Professionals From the American Heart Association/American Stroke Association
Council on Stroke: Co-Sponsored by the Council on Cardiovascular Radiology and
Intervention. Stroke. Vol. 37, 2006:577.

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I-STK-3
Anticoagulation Therapy for Atrial Fibrillation/Flutter
Measure Overview
I-STK 3 Patients with atrial fibrillation/flutter receiving anticoagulation therapy
Overview/Details:
Patients with ischemic stroke with atrial fibrillation/flutter discharged on anticoagulation
therapy.
Rationale:
A prior stroke or transient ischemic attack (TIA) are among a limited number of
predictors of high stroke risk within the population of patients with atrial fibrillation.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Measure Name: Anticoagulation therapy for Atrial Fibrillation/Flutter
Numerator: Ischemic stroke patients prescribed anticoagulation therapy at hospital
discharge
Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter who
are > = 18 years.
Domains of Performance

QPS

CCPC

IPSG

Stroke

Goal 1

Standards
Appropriateness
Continuity
Effectiveness
Prevention/Early Detection
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I-STK-3
Measure Details
Reasons and Implications: Analysis of multiple controlled clinical trials investigating
the efficacy of warfarin in the primary prevention of thromboembolic stroke, found the
relative risk of thromboembolic stroke was reduced by 68% for atrial fibrillation patients
treated with warfarin. The administration of anticoagulation therapy, unless there are
contraindications, is an established effective strategy in preventing recurrent stroke in
high stroke risk-atrial fibrillation patients with TIA or prior stroke.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Ischemic stroke patients prescribed anticoagulation therapy at discharge
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Anticoagulation therapy prescribed at discharge
Denominator: Ischemic stroke patients with documented atrial fibrillation/flutter who
are >= 18 years
Data elements:
x Atrial Fibrillation/Flutter
x Birthdate
x Elective Carotid Intervention
x ICD principal diagnosis code
x Reason for Not Prescribing Anticoagulation Therapy
Inclusions to the population: Patients with ICD principal diagnosis code for ischemic
stroke as defined in Appendix A, Table 8.1.
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients admitted for the performance of elective carotid intervention

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I- STK-3
References
x

x
x
x
x
x
x

Kearon C, Kahn, SR, Agnelli G, Goldhaber S, Raskob, GE, Comerota AJ.


Antithrombotic therapy for venous thromboembolic disease. The Eighth ACCP
Conference on antithrombotic and thrombolytic therapy. Chest. 2008;133: 454S545S.
Sallah S, Thomas DP, Roberts HR. Warfarin and heparin-induced skin necrosis
and the purple toe syndrome: infrequent complications of anticoagulant
treatment. Thromb Haemost. 1997; 78(2): 785-90.
Gallus A, Jackaman J, Tillet J et al. Safety and efficacy of warfarin started early
after submassive venous thrombosis or pulmonary embolism. Lancet. 1986 Dec
6;2(8519):1293-6.
Buller HR, Davidson BL, Decousus DL et al. Subcutaneous fondaparinux versus
intravenous unfractionated heparin in the initial treatment of pulmonary
embolism. N Engl J Med. 2003 Oct 30;349 (18):1695-702.
Buller HR, Davidson BL, Decousas DL et al. Fondaparinux or enoxaparin for the
initial treatment of symptomatic deep venous thrombosis: a randomized trial. Ann
Intern Med. 2004 Jun 1;140(11):867-73.
Ansell J, Hirsch J, Hylek E, Jacobson A, Crowther M, Palareti G. Pharmacology
and management of the vitamin K antagonists: The Eighth ACCP Conference on
Antithrombotic and Thrombolytic Therapy. Chest. 2008 133:160S-198S.
Caprini JA, Tapson VF, Hyers TM et al. NABOR Steering Committee. Treatment
of venous thromboembolism: adherence to guidelines and impact of physician
knowledge, attitudes, and beliefs. J of Vasc Surg. 2005 Oct;42(4):726-33.

2011 Joint Commission International



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I-STK-8 Stroke Education


Measure Overview
I-STK 8 Stroke patients who were given stroke education during their hospital
stay
Overview/Details:
Patients with ischemic stroke or hemorrhagic stroke who are given educational
materials on all of the following; activation of emergency medical system, need for
follow-up after discharge, medications prescribed at discharge, risk factors for stroke,
and warning signs and symptoms of stroke.
Rationale:
Clinical practice guidelines include recommendations for patient and family education
during hospitalization as well as information about resources for social support services.
Some clinical trials have shown measurable benefits in patient and caregiver outcomes
with the application of education and support strategies. The type of stroke experienced
and the resulting outcomes will play a large role in determining not only the course of
treatment but also what education will be required.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Measure Name: Stroke education
Numerator: Ischemic or hemorrhagic stroke patients with documentation that they or
their caregivers were given educational material addressing all of the following:
1. Activation of emergency medical system
2. Follow-up after discharge
3. Medications prescribed at discharge
4. Risk factors for stroke
5. Warning signs and symptoms of stroke
Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home
who are >= 18 years
2011 Joint Commission International

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Domains of Performance QPS Standards

CCPC

Appropriateness

Stroke

QPS.3 clinical assessments

IPSG

Continuity
Effectiveness
Prevention/Early
Detection

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I-STK-8
Measure Details
Reasons and Implications: Clinical practice guidelines include recommendations for
patient and family education during hospitalization as well as information about
resources for social support services. Some clinical trials have shown measurable
benefits in patient and caregiver outcomes with the application of education and
support strategies. The type of stroke experienced and the resulting outcomes will
play a large role in determining not only the course of treatment but also what
education will be required. Patient education should include information about the
event, the role of various medications or strategies, as well as desirable lifestyle
modifications to reduce risk or improve outcomes.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Ischemic or hemorrhagic stroke patients with documentation that they or
their caregivers were given educational material addressing all of the following:
1. Activation of emergency medical system
2. Follow-up after discharge
3. Medications prescribed at discharge
4. Risk factors for stroke
5. Warning signs and symptoms of stroke
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Education Addresses Activation of Emergency Medical System
x Education Addresses Follow-up after Discharge
x Education Addresses Medications Prescribed at Discharge
x Education Addresses Risk Factors for Stroke
x Education Addresses Warning Signs and Symptoms of Stroke
Denominator: Ischemic stroke or hemorrhagic stroke patients discharged home who
are >= 18 years.

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Data elements:
x Elective Carotid Intervention
x Birthdate
x ICD principal diagnosis code
Inclusions to the population: Patients with ICD principal diagnosis code for ischemic
stroke as defined in Appendix A, Table 8.1, or Table 8.2 and who are discharged to
home or home care.
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients admitted for elective carotid intervention

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I-STK-8
References
x
x
x
x
x

Duncan et al, Stroke Rehabilitation Clinical Practice Guidelines Stroke.


2005;36:e100-e143.
Evans RL, Matlock AL, Bishop DS, Stranahan S, Pederson C. Family
intervention after stroke: Does counseling or education help?, Stroke
1988;19:1243-1249.
Kaiser Permanente Clinical Practice Guidelines for Acute Stroke, Kaiser
Permanente Medical Group, 1998.
Lorig KR, Sobel DS, Stewart AL, et al. Evidence suggesting that a chronic
disease self-management program can improve health status while reducing
hospitalization: A randomized trial. Medical Care 1999;37:5-14.
Post Stroke Rehabilitation, Clinical Practice Guideline No.16, Agency for Health
Care Policy and Research (now known as Agency for Healthcare Research and
Quality), 1995.

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I-STK-10 Assessed for Rehabilitation


Measure Overview
I-STK 10 Ischemic or hemorrhagic stroke patients who were assessed for
rehabilitation services
Overview/Details:
Each year hundreds of thousands of people experience a new or recurrent stroke.
Approximately two thirds of these individuals survive and require rehabilitation. Stroke
is a leading course of serious long-term disability in all countries. Many of these
patients are left with moderate functional impairment and some with severe disability.
More than half of patients who have experienced a stroke, or serious injury, have never
received rehabilitation.
Rationale:
Stroke rehabilitation should begin as soon as the diagnosis of stroke is established and
life-threatening problems are under control. Among high priorities for stroke patients
are to mobilize the patient and encourage resumption of self-care activities as soon as
possible. A considerable body of evidence indicates better clinical outcomes when
patients with stroke are treated in a setting that provides coordinated, multidisciplinary
stroke-related evaluation and services.
Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Emergency Services/Department
Intensive Care Units
Medical/Surgical units
Measure Name: Assessed for Rehabilitation
Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received
rehabilitation
Denominator: Ischemic stroke or hemorrhagic stroke patients who are >= 18 years.

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Domains of Performance

QPS Standards

CCPC

Appropriateness

QPS.3 patient assessments Stroke

IPSG
Goal 1

Availability
Continuity
Effectiveness
Prevention/Early Detection
Timeliness

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I-STK-10
Measure Details
Reasons and Implications: A considerable body of evidence indicates better clinical
outcomes when patients with stroke are treated in a setting that provides a coordinated,
multidisciplinary stroke-related evaluation and services. Effective rehabilitation
interventions initiated early following stroke care enhance the recovery process and
minimize functional disability. The primary goal of rehabilitation is to prevent
complications, minimize impairments, and maximize function.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Ischemic or hemorrhagic stroke patients assessed for or who received
rehabilitation services.
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
Assessed for Rehabilitation Services
Denominator: Ischemic stroke or hemorrhagic stroke patients who are > = 18 years
Data elements:
x Birthdate
x Elective Carotid Intervention
x ICD principal diagnosis code
Inclusions to the population: Patients with ICD principal diagnosis code for ischemic
stroke or hemorrhagic stroke as defined in Appendix A, Table 8.1 or Table 8.2.
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients admitted for elective carotid intervention

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STK-10
References
x
x
x

x
x
x
x
x

American Academy of Physical Medicine and Rehabilitation. Rehabilitation Helps


Stroke Patients Recover Skills. AAPM&R Chicago, IL Office: Author.
American Academy of Physical Medicine and Rehabilitation. Urgency Key But
Perseverance Pays Off. AAPM&R Chicago, IL Office: Author.
Bates B, Choi JY, Duncan PW, Glasberg JJ, Graham GD, Katz RC, Lamberty K,
Recker D, Zorowitz R. American Heart Association/American Stroke Associationendorsed practice guideline. Veterans Affairs/Department of Defense clinical
practice guideline for the management of adult stroke rehabilitation care. Stroke.
2005;36:2049. Retrieved August 2, 2007 from World Wide Web.
http://stroke.ahajournals.org/cgi/content/full/36/9/2049.
Management of patients with stroke. Rehabilitation, prevention and management
of complications, and discharge planning, Scottish Intercollegiate network
Guidelines Network (SIGN), 2002.
National Institute of Neurological Disorders. Post-Stroke Rehabilitation Fact
Sheet. National Institute of Neurological Disorders Bethesda, MD Office: Author.
Post Stroke Rehabilitation, Clinical Practice Guideline No.16, Agency for Health
Care Policy and Research (now known as Agency for Healthcare Research and
Quality), 1995.
VA/DoD Clinical Practice Guideline for the Management of Stroke Rehabilitation
in the Primary Care Setting, 2003.
Zorowitz RD, et al, the Post-Stroke Rehabilitation Outcomes Project (PSROP),
Top Stroke Rehabil. 2005 Fall;12(4).

2011 Joint Commission International



64

Appendix A
ICD Code Tables
Stroke Measures
Please Note : Due to the various ICD Code versions used by different countries,
ICD-8, ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in
the specific code utilized by your country to correspond to the ICD-9-CM code
description for the following diagnoses.
Table 8.1
Ischemic Stroke (STK)
ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM
Code

Shortened Description

433.01

OCL BSLR ART W INFRCT

433.10

OCL CRTD ART WO INFRCT

433.11

OCL CRTD ART W INFRCT

433.21

OCL VRTB ART W INFRCT

433.31

OCL MLT BI ART W INFRCT

433.81

OCL SPCF ART W INFRCT

433.91

OCL ART NOS W INFRCT

434.00

CRBL THRMBS WO INFRCT

434.01

CRBL THRMBS W INFRCT

434.11

CRBL EMBLSM W INFRCT

434.91

CRBL ART OCL NOS W INFRC

436

CVA

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Table 8.2
Hemorrhagic Stroke (STK)
ICD-8
ICD-9
ICD-10
Code
Code
Code

ICD-9CM
Code

Shortened Description

430

SUBARACHNOID HEMORRHAGE

431

INTRACEREBRAL HEMORRHAGE

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66

&KLOGUHQV$VWKPD
Care (CAC)
Measure Set

2011 Joint Commission International



67

Measure
Code
Measure Description


Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

I-CAC-1

Pediatric asthma patients who received relievers during this


hospitalization

I-CAC-2

Pediatric asthma patients who received systemic corticosteroids during


hospitalization

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68

I-CAC-1
5HOLHYHUVIRU&KLOGUHQV,QSDWLHQW$VWKPD
Measure Overview
I-CAC-1 5HOLHYHUVIRU&KLOGUHQV,QSDWLHQW$VWKPD
Overview/Details:
Use of relievers in pediatric patients admitted for inpatient treatment of asthma
Rationale:
Asthma is the most common chronic disease in children and a major cause of morbidity
and increased health care expenditures. For children, asthma is one of the most
frequent reasons for admission to hospitals. Under-treatment and/or inappropriate
treatment of asthma are recognized as major contributors to asthma morbidity and
mortality. Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of relievers to gain control of acute asthma exacerbation and
reduce severity as quickly as possible, with step down medication to the least
medication necessary to maintain control.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Pediatric units
Medical/Surgical units (serving pediatric patients)
Free-standing Pediatric hospitals
Measure Name: 5HOLHYHUVIRU&KLOGUHQV,QSDWLHnt Asthma
Numerator: Pediatric asthma inpatients who received relievers during this
hospitalization.
Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were
discharged with a principal diagnosis of asthma
2011 Joint Commission International

69

Domains of Performance
$SSURSULDWHQHVV
$YDLODELOLW\

QPS Standards
QPS.3 patient
assessments

CCPC
$VWKPD

IPSG
*RDO

&RQWLQXLW\
(IIHFWLYHQHVV

QPS.3 antibiotic and other


medication use

3UHYHQWLRQ(DUO\'HWHFWLRQ
7LPHOLQHVV

2011 Joint Commission International



70

I-CAC-1
Measure Details
Reasons and Implications:
Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of relievers to gain control of acute asthma exacerbation and
reduce severity as quickly as possible, with step down medication to the least
medication necessary to maintain control.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Pediatric asthma inpatients who received relievers during this
hospitalization.
Inclusions to the population: Patients who were administered relievers during this
hospitalization.
Exclusions to the population: None
Data elements:
x

Relievers Administered

Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were
discharged with a principal diagnosis of asthma
Data elements:
x
x
x

Birthdate
ICD Principal Diagnosis code
Reason for Not Administering Relievers

Inclusions to the population: Discharges with:


x
x

Patients with ICD principal diagnosis code of asthma as defined in Appendix A,


Table 6.1
An age of 2 through 17 years

Exclusions to the population:


x
x

Patients less than 2 years of age or greater than 18 years of age


Patients with a documented Reason for Not Administering Relievers

2011 Joint Commission International



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I-CAC-1
References
x

x
x
x
x
x
x
x
x

Adams RJ, Fuhlbrigge A, Finkelstein JA, Lozano P, Livingston JM, Weiss KB, and
Weiss ST (2001). Use of Inhaled Anti-inflammatory Medication in Children with
Asthma in Managed Care Settings. Archives of Pediatrics and Adolescent
Medicine, 155, 501-507.
Clinical Practice Guidelines of the American Academy of Pediatrics: A Compendium
of Evidence-Based Research for Pediatric Practice. American Academy of
Pediatrics, 1999.
Crain EF, Weiss KB and Fagan MJ (1995). Pediatric Asthma Care in U.S. Emergency
Departments. Archives of Pediatric and Adolescent Medicine. 149, 893-901.
Gross KM, Ponte CD (1998). New Strategies in the Medical Management of Asthma.
American Family Physician. 58:1
McCormick MC, Kass B, Elixhauser A, Thompson J and Simpson L (2000). Annual
Report on Access to and Utilization of Health Care for Children and Youth in the
United States 1999. Pediatrics, 105:1, 219-230.
Silber JH, Rosenbaum PR, Even-Shoshan O, Shabbout M, Zhang X, Bradlow ET,
and Marsh RR (2003). Length of Stay, Conditional Length of Stay, and Prolonged
Stay in Pediatric Asthma. Health Services Research, 38: 3, 867-886.
Guidelines for the Diagnosis and Management of Asthma (EPR-3) (2007).
http://www.nhlbi.nih.gov
Asthma Management Model System, http://www.nhlbi.nih.gov
National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov

2011 Joint Commission International



72

I-CAC-2
Systemic Corticosteroids for Children Inpatient Asthma
Measure Overview
I-CAC 2 Systemic Corticosteroids for Children Inpatient Asthma
Overview/Details: Use of systemic corticosteroids in pediatric patients admitted for
inpatient treatment of asthma
Rationale:
Asthma is the most common chronic disease in children and a major cause of morbidity
and increased health care expenditures nationally. For children, asthma is one of the
most frequent reasons for admission to hospitals. Under-treatment and/or inappropriate
treatment of asthma are recognized as major contributors to asthma morbidity and
mortality. Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of systemic corticosteroids to gain control of acute asthma
exacerbation and reduce severity as quickly as possible, with step down medication to
the least medication necessary to maintain control.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Pediatric units
Medical/Surgical units (serving pediatric patients)
Free standing Pediatric hospitals
Measure Name: 6\VWHPLFFRUWLFRVWHURLGVIRU&KLOGUHQV,QSDWLHQW$VWKPD
Numerator: Pediatric asthma inpatients who received systemic corticosteroids during
hospitalization.
Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were
discharged with a principal diagnosis of asthma
2011 Joint Commission International

73

Domains of Performance
$SSURSULDWHQHVV
$YDLODELOLW\

QPS Standards
QPS.3 patient
assessments

CCPC
$VWKPD

IPSG
*RDO

&RQWLQXLW\
(IIHFWLYHQHVV

QPS.3 antibiotic and


other medication use

3UHYHQWLRQ(DUO\'HWHFWLRQ
7LPHOLQHVV

2011 Joint Commission International



74

I-CAC-2
Measure Details
Reasons and Implications:
Clinical guidelines for the diagnosis and management of asthma in children,
recommend the use of systemic corticosteroids to gain control of acute asthma
exacerbation and reduce severity as quickly as possible, with step down medication to
the least medication necessary to maintain control.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Pediatric asthma inpatients who received systemic corticosteroids during
hospitalization.
Inclusions to the population: Patients who were administered systemic corticosteroids
during this hospitalization.
Exclusions to the population: None
Data elements:
x

Systemic Corticosteroids Administered

Denominator: Pediatric asthma inpatients (age 2 years through 17 years) who were
discharged with a principal diagnosis of asthma
Data elements:
x
x
x

Birthdate
ICD Principal Diagnosis code
Reason for Not Administering Systemic Corticosteroids

Inclusions to the population: Discharges with:


x
x

Patients with ICD principal diagnosis code of asthma as defined in Appendix A,


Table 6.1
An age of 2 years through 17 years

Exclusions to the population:


x
x

Patients less than 2 years of age or greater than 18 years of age


3DWLHQWVZLWKDGRFXPHQWHG5HDVRQIRU1RW$GPLQLVWHULQJV\VWHPLF
corticosteroids

2011 Joint Commission International



75

I-CAC-2
References
x

x
x
x
x
x
x
x
x

Adams RJ, Fuhlbrigge A, Finkelstein JA, Lozano P, Livingston JM, Weiss KB, and
Weiss ST (2001). Use of Inhaled Anti-inflammatory Medication in Children with
Asthma in Managed Care Settings. Archives of Pediatrics and Adolescent
Medicine, 155, 501-507.
Clinical Practice Guidelines of the American Academy of Pediatrics: A Compendium
of Evidence-Based Research for Pediatric Practice. American Academy of
Pediatrics, 1999.
Crain EF, Weiss KB and Fagan MJ (1995). Pediatric Asthma Care in U.S. Emergency
Departments. Archives of Pediatric and Adolescent Medicine. 149, 893-901.
Gross KM, Ponte CD (1998). New Strategies in the Medical Management of Asthma.
American Family Physician. 58:1
McCormick MC, Kass B, Elixhauser A, Thompson J and Simpson L (2000). Annual
Report on Access to and Utilization of Health Care for Children and Youth in the
United States 1999. Pediatrics, 105:1, 219-230.
Silber JH, Rosenbaum PR, Even-Shoshan O, Shabbout M, Zhang X, Bradlow ET,
and Marsh RR (2003). Length of Stay, Conditional Length of Stay, and Prolonged
Stay in Pediatric Asthma. Health Services Research, 38: 3, 867-886.
Guidelines for the Diagnosis and Management of Asthma (EPR-3) (2007).
http://www.nhlbi.nih.gov
Asthma Management Model System, http://www.nhlbi.nih.gov
National Asthma Education and Prevention Program, http://www.nhlbi.nih.gov

2011 Joint Commission International



76

Appendix A
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries,
ICD-8, ICD-9,and ICD-10 spaces have been left intentionally blank. Please fill in
the specific code utilized by your country to correspond to the ICD-9-CM code
description for the following diagnoses.
Table 6.1
Asthma Codes
ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM Code

Shortened Description

493.00

EXTRINSIC ASTHMA NOS

493.01

EXT ASTHMA W STATUS ASTH

493.02

EXT ASTHMA W(ACUTE) EXAC

493.10

INTRINSIC ASTHMA NOS

493.11

INT ASTHMA W STATUS ASTH

493.12

INT ASTHMA W (AC) EXAC

493.81

EXERCSE IND BRONCHOSPASM

493.82

COUGH VARIANT ASTHMA

493.90

ASTHMA NOS

493.91

ASTHMA W STATUS ASTHMAT

493.92

ASTHMA NOS W (AC) EXAC



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77

Hospital Based
Inpatient Psychiatric
Services (HBIPS)
Measure Sets

2011 Joint Commission International



78

Measure
Code
Measure Description

Hospital-Based Inpatient Psychiatric Service (HBIPS)


Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

I-HBIPS-2

Psychiatric patients who were placed in physical restraints during their


inpatient hospitalization. This measure will determine the total number
of hours that patients were maintained in physical restraints for those
admitted to a hospital-based inpatient psychiatric setting

I-HBIPS-3

Psychiatric patients who were placed in seclusion during their inpatient


hospitalization. This measure will determine the total number of hours
that all patients were maintained in seclusion for those admitted to a
hospital-based inpatient psychiatric setting.

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79

I-HBIPS-2
Hours of physical restraint use
Measure Overview
I-HBIPS 2 Psychiatric patients who were placed in physical restraints during
their inpatient hospitalization. NOTE: This measure will determine the total
number of hours that patients were maintained in physical restraints for those
admitted to a hospital-based inpatient psychiatric setting.
Overview/Details:
Patients who are placed in physical restraint while admitted to a hospital-based inpatient
psychiatric setting.
Rationale:
The use of seclusion and restraint is limited to situations that may present imminent
danger to either the patient and/or staff. The use of restraint is rigorously monitored and
analyzed to prevent future restraint use and to prevent harm.
Measure Related Outcomes:
Reliability: Increased delivery of evidence based care
Improvement noted as: Decrease in rate
Patient Settings/Services
Psychiatric units
Measure Name: Hours of physical restraint use
Numerator: The total number of hours that all psychiatric inpatients were maintained in
physical restraints.
Denominator: Number of psychiatric inpatient days

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80

Domains of Performance

QPS Standards

$SSURSULDWHQHVV
(IIHFWLYHQHVV

CCPC

IPSG
*RDO

QPS.3 patient assessments

3UHYHQWLRQ(DUO\'HWHFWLRQ
6DIHW\

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81

I-HBIPS-2
Measure Details
Reasons and Implications: The use of restraint is limited to situations that may present
imminent danger to either the patient and/or staff. The use of restraint is rigorously
monitored and analyzed to prevent future restraint use and to prevent harm. Providers also
seek to prevent violence or aggression from occurring in their treatment environments by
focusing their attention on prevention activities that have a growing evidence base.
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Numerator: The total number of hours that all psychiatric inpatients were maintained in
physical restraints.
Inclusions to the population: Patients for whom at least one physical restraint event is
reported during the month.
Exclusions to the population: None
Data elements:
x
x
x

Event Date
Event Type
Minutes of Physical Restraint

Denominator: Number of psychiatric inpatient days


Denominator Basis: Per 1,000 hours (psychiatric inpatient)
Data elements:
x
x
x
x

Admission Date
Birthdate
Psychiatric Care Setting
Psychiatric Inpatient days

Inclusions to the population: All psychiatric inpatient days


Exclusions to the population:
x

None

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82

I-HBIPS-2
References
x
x
x
x
x
x

Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of


seclusion and restraint at a public psychiatric hospital. Psychiatric Services.
54(8): 1119-1123.
Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction
programs and their application in a large, urban, state psychiatric hospital.
Journal of Psychiatric Practice, 9(1), 7-15.
Huckshorn, K.A. (2004/September). Reducing seclusion and restraint use in
mental health settings: Core strategies for prevention. Journal of Psychosocial
Nursing and Mental Health Services. 42(9). Pp. 22-31.
Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the
use of restraints with children. Journal of Child and Adolescent Psychiatric
Nursing, 14(3), 141- 151.
Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services,
56 (9), 1104-1142.
Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A
compendium of strategies created by the American Psychiatric Association
(APA), the American Psychiatric Nurses Association (APNA), the National
Association of Psychiatric Health Systems (NAPHS), and the American Hospital
Association Section for Psychiatric and Substance Abuse Services (AHA).
Retrieved from the Internet on February 10, 2010 at http://www.naphs.org

2011 Joint Commission International



83

I-HBIPS-3
Hours of seclusion use
Measure Overview
I-HBIPS 3 Psychiatric patients who were placed in seclusion during their
inpatient hospitalization.
NOTE: This measure will determine the total number of hours that all patients were
maintained in seclusion for those admitted to a hospital-based inpatient psychiatric
setting.
Overview/Details:
Patients who are placed in seclusion while admitted to a hospital-based inpatient
psychiatric setting.
Rationale:
The use of seclusion and restraint is limited to situations that may present imminent
danger to either the patient and/or staff. The use of seclusion is rigorously monitored
and analyzed to prevent future restraint/seclusion use and to prevent harm.
Measure Related Outcomes:
Reliability: Increased delivery of evidence based care
Improvement noted as: Decrease in rate
Patient Settings/Services
Psychiatric units
Measure Name: Hours of seclusion
Numerator: The total number of hours that all psychiatric inpatients were held in
seclusion.
Denominator: Number of psychiatric inpatient days

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84

Domains of Performance
$SSURSULDWHQHVV
(IIHFWLYHQHVV

QPS Standards
QPS.3 patient
assessments

CCPC

IPSG
*RDO

3UHYHQWLRQ(DUO\'HWHFWLRQ
6DIHW\

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85

I-HBIPS-3
Measure Details
Reasons and Implications: The use of seclusion and restraint is limited to situations
that may present imminent danger to either the patient and/or staff. The use of either
restraint or seclusion is rigorously monitored and analyzed to prevent future restraint
use and to prevent harm. Providers also seek to prevent violence or aggression from
occurring in their treatment environments by focusing their attention on prevention
activities that have a growing evidence base.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: The total number of hours that all psychiatric inpatients were held in
seclusion.
Inclusions to the population: Patients for whom at least one seclusion event is
reported during the month.
Exclusions to the population: None
Data elements:
x
x
x

Event Date
Event Type
Minutes of Seclusion

Denominator: Number of psychiatric inpatient days


Denominator Basis: Per 1,000 hours (psychiatric inpatient)
Data elements:
x
x
x
x

Admission Date
Birthdate
Psychiatric Care Setting
Psychiatric Inpatient days

Inclusions to the population: All psychiatric inpatient days


Exclusions to the population: None

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86

I-HBIPS-3
References
x
x
x
x
x

Donat, D. (August, 2003). An analysis of successful efforts to reduce the use of


seclusion and restraint at a public psychiatric hospital. Psychiatric Services.
54(8): 1119-1123.
Fisher, W. A. (2003). Elements of successful restraint and seclusion reduction
programs and their application in a large, urban, state psychiatric hospital.
Journal of Psychiatric Practice, 9(1), 7-15.
Mohr, W. K., & Anderson, J. A. (2001). Faulty assumptions associated with the
use of restraints with children. Journal of Child and Adolescent Psychiatric
Nursing, 14(3), 141- 151.
Special Section on Seclusion and Restraint, (2005, Sept). Psychiatric Services,
56 (9), 1104-1142.
Success Stories and Ideas for Reducing Restraint/Seclusion. (2003). A
compendium of strategies created by the American Psychiatric Association
(APA), the American Psychiatric Nurses Association (APNA), the National
Association of Psychiatric Health Systems (NAPHS), and the American Hospital
Association Section for Psychiatric and Substance Abuse Services (AHA).
Retrieved from the Internet on February 10, 2010 at http://www.naphs.org

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87

Appendix A
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries, ICD-8,
ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in the specific
code utilized by your country to correspond to the ICD-9-CM code description for the
following diagnoses.
Table 10.01
Mental Disorders
ICD-8
ICD-9
Code

Code

ICD-10
Code

ICD-9CMCode

Shortened Description

290.0

SENILE DEMENTIA UNCOMP

290.10

PRESENILE DEMENTIA

290.11

PRESENILE DELIRIUM

290.12

PRESENILE DELUSION

290.13

PRESENILE DEPRESSION

290.20

SENILE DELUSION

290.21

SENILE DEPRESSIVE

290.3

SENILE DELIRIUM

290.40

VASCULAR DEMENTIA,UNCOMP

290.41

VASC DEMENTIA W DELIRIUM

290.42

VASC DEMENTIA W DELUSION

290.43

VASC DEMENTIA W DEPRESSN

290.8

SENILE PSYCHOSIS NEC

290.9

SENILE PSYCHOT COND NOS

291.0

DELIRIUM TREMENS

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

291.1

ALCOHOL AMNESTIC DISORDR

291.2

ALCOHOL PERSIST DEMENTIA

291.3

ALCOH PSY DIS W HALLUCIN

291.4

PATHOLOGIC ALCOHOL INTOX

291.5

ALCOH PSYCH DIS W DELUS

291.81

ALCOHOL WITHDRAWAL

291.82

ALCOH INDUCE SLEEP DISOR

291.89

ALCOHOL MENTAL DISOR NEC

291.9

ALCOHOL MENTAL DISOR NOS

292.0

DRUG WITHDRAWAL

292.11

DRUG PSYCH DISOR W DELUS

292.12

DRUG PSY DIS W HALLUCIN

292.2

PATHOLOGIC DRUG INTOX

292.81

DRUG-INDUCED DELIRIUM

292.82

DRUG PERSISTING DEMENTIA

292.83

DRUG PERSIST AMNESTC DIS

292.84

DRUG-INDUCED MOOD DISORD

292.85

DRUG INDUCED SLEEP DISOR

292.89

DRUG MENTAL DISORDER NEC

292.9

DRUG MENTAL DISORDER NOS

293.0

DELIRIUM D/T OTHER COND

293.1

SUBACUTE DELIRIUM

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

293.81

PSY DIS W DELUS OTH DIS

293.82

PSY DIS W HALLUC OTH DIS

293.83

MOOD DISORDER OTHER DIS

293.84

ANXIETY DISORDER OTH DIS

293.89

TRANSIENT MENTAL DIS NEC

293.9

TRANSIENT MENTAL DIS NOS

294.0

AMNESTIC DISORD OTH DIS

294.10

DEMENTIA W/O BEHAV DIST

294.11

DEMENTIA W BEHAVIOR DIST

294.8

MENTAL DISOR NEC OTH DIS

294.9

MENTAL DISOR NOS OTH DIS

295.00

SIMPL SCHIZOPHREN-UNSPEC

295.01

SIMPL SCHIZOPHREN-SUBCHR

295.02

SIMPLE SCHIZOPHREN-CHR

295.03

SIMP SCHIZ-SUBCHR/EXACER

295.04

SIMPL SCHIZO-CHR/EXACERB

295.05

SIMPL SCHIZOPHREN-REMISS

295.10

HEBEPHRENIA-UNSPEC

295.11

HEBEPHRENIA-SUBCHRONIC

295.12

HEBEPHRENIA-CHRONIC

295.13

HEBEPHREN-SUBCHR/EXACERB

295.14

HEBEPHRENIA-CHR/EXACERB

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

295.15

HEBEPHRENIA-REMISSION

295.20

CATATONIA-UNSPEC

295.21

CATATONIA-SUBCHRONIC

295.22

CATATONIA-CHRONIC

295.23

CATATONIA-SUBCHR/EXACERB

295.24

CATATONIA-CHR/EXACERB

295.25

CATATONIA-REMISSION

295.30

PARANOID SCHIZO-UNSPEC

295.31

PARANOID SCHIZO-SUBCHR

295.32

PARANOID SCHIZO-CHRONIC

295.33

PARAN SCHIZO-SUBCHR/EXAC

295.34

PARAN SCHIZO-CHR/EXACERB

295.35

PARANOID SCHIZO-REMISS

295.40

SCHIZOPHRENIFORM DIS NOS

295.41

SCHIZOPHRENIC DIS-SUBCHR

295.42

SCHIZOPHREN DIS-CHRONIC

295.43

SCHIZO DIS-SUBCHR/EXACER

295.44

SCHIZOPHR DIS-CHR/EXACER

295.45

SCHIZOPHRENIC DIS-REMISS

295.50

LATENT SCHIZOPHREN-UNSP

295.51

LAT SCHIZOPHREN-SUBCHR

295.52

LATENT SCHIZOPHREN-CHR

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

295.53

LAT SCHIZO-SUBCHR/EXACER

295.54

LATENT SCHIZO-CHR/EXACER

295.55

LAT SCHIZOPHREN-REMISS

295.60

SCHIZOPHR DIS RESID NOS

295.61

SCHIZOPH DIS RESID-SUBCH

295.62

SCHIZOPHR DIS RESID-CHR

295.63

SCHIZO RESID SUBCHR/EXAC

295.64

SCHIZOPH RESID-CHRO/EXAC

295.65

SCHIZOPH DIS RESID-REMIS

295.70

SCHIZOAFFECTIVE DIS NOS

295.71

SCHIZOAFFECTV DIS-SUBCHR

295.72

SCHIZOAFFECTIVE DIS-CHR

295.73

SCHIZOAFF DIS-SUBCH/EXAC

295.74

SCHIZOAFFTV DIS-CHR/EXAC

295.75

SCHIZOAFFECTVE DIS-REMIS

295.80

SCHIZOPHRENIA NEC-UNSPEC

295.81

SCHIZOPHRENIA NEC-SUBCHR

295.82

SCHIZOPHRENIA NEC-CHR

295.83

SCHIZO NEC-SUBCHR/EXACER

295.84

SCHIZO NEC-CHR/EXACERB

295.85

SCHIZOPHRENIA NEC-REMISS

295.90

SCHIZOPHRENIA NOS-UNSPEC

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

295.91

SCHIZOPHRENIA NOS-SUBCHR

295.92

SCHIZOPHRENIA NOS-CHR

295.93

SCHIZO NOS-SUBCHR/EXACER

295.94

SCHIZO NOS-CHR/EXACERB

295.95

SCHIZOPHRENIA NOS-REMISS

296.00

BIPOL I SINGLE MANIC NOS

296.01

BIPOL I SINGLE MANC-MILD

296.02

BIPOL I SINGLE MANIC-MOD

296.03

BIPOL I SING-SEV W/O PSY

296.04

BIPO I SIN MAN-SEV W PSY

296.05

BIPOL I SING MAN REM NOS

296.06

BIPOL I SINGLE MANIC REM

296.10

RECUR MANIC DIS-UNSPEC

296.11

RECUR MANIC DIS-MILD

296.12

RECUR MANIC DIS-MOD

296.13

RECUR MANIC DIS-SEVERE

296.14

RECUR MANIC-SEV W PSYCHO

296.15

RECUR MANIC-PART REMISS

296.16

RECUR MANIC-FULL REMISS

296.20

DEPRESS PSYCHOSIS-UNSPEC

296.21

DEPRESS PSYCHOSIS-MILD

296.22

DEPRESSIVE PSYCHOSIS-MOD

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

296.23

DEPRESS PSYCHOSIS-SEVERE

296.24

DEPR PSYCHOS-SEV W PSYCH

296.25

DEPR PSYCHOS-PART REMISS

296.26

DEPR PSYCHOS-FULL REMISS

296.30

RECURR DEPR PSYCHOS-UNSP

296.31

RECURR DEPR PSYCHOS-MILD

296.32

RECURR DEPR PSYCHOS-MOD

296.33

RECUR DEPR PSYCH-SEVERE

296.34

REC DEPR PSYCH-PSYCHOTIC

296.35

RECUR DEPR PSYC-PART REM

296.36

RECUR DEPR PSYC-FULL REM

296.40

BIPOL I CURRNT MANIC NOS

296.41

BIPOL I CURNT MANIC-MILD

296.42

BIPOL I CURRNT MANIC-MOD

296.43

BIPOL I MANC-SEV W/O PSY

296.44

BIPOL I MANIC-SEV W PSY

296.45

BIPOL I CUR MAN PART REM

296.46

BIPOL I CUR MAN FULL REM

296.50

BIPOL I CUR DEPRES NOS

296.51

BIPOL I CUR DEPRESS-MILD

296.52

BIPOL I CUR DEPRESS-MOD

296.53

BIPOL I CURR DEP W/O PSY

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

296.54

BIPOL I CURRNT DEP W PSY

296.55

BIPOL I CUR DEP REM NOS

296.56

BIPOL I CURRNT DEP REMIS

296.60

BIPOL I CURRNT MIXED NOS

296.61

BIPOL I CURRNT MIX-MILD

296.62

BIPOL I CURRNT MIXED-MOD

296.63

BIPOL I CUR MIX W/O PSY

296.64

BIPOL I CUR MIXED W PSY

296.65

BIPOL I CUR MIX-PART REM

296.66

BIPOL I CUR MIXED REMISS

296.7

BIPOLOR I CURRENT NOS

296.80

BIPOLAR DISORDER NOS

296.81

ATYPICAL MANIC DISORDER

296.82

ATYPICAL DEPRESSIVE DIS

296.89

BIPOLAR DISORDER NEC

296.90

EPISODIC MOOD DISORD NOS

296.99

EPISODIC MOOD DISORD NEC

297.0

PARANOID STATE, SIMPLE

297.1

DELUSIONAL DISORDER

297.2

PARAPHRENIA

297.3

SHARED PSYCHOTIC DISORD

297.8

PARANOID STATES NEC

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

297.9

PARANOID STATE NOS

298.0

REACT DEPRESS PSYCHOSIS

298.1

EXCITATIV TYPE PSYCHOSIS

298.2

REACTIVE CONFUSION

298.3

ACUTE PARANOID REACTION

298.4

PSYCHOGEN PARANOID PSYCH

298.8

REACT PSYCHOSIS NEC/NOS

298.9

PSYCHOSIS NOS

299.00

AUTISTIC DISORD-CURRENT

299.01

AUTISTIC DISORD-RESIDUAL

299.10

CHILDHD DISINTEGR-ACTIVE

299.11

CHILDHD DISINTEGR-RESID

299.80

PERVASV DEV DIS-CUR NEC

299.81

PERVASV DEV DIS-RES NEC

299.90

PERVASV DEV DIS-CUR NOS

299.91

PERVASV DEV DIS-RES NOS

300.00

ANXIETY STATE NOS

300.01

PANIC DIS W/O AGORPHOBIA

300.02

GENERALIZED ANXIETY DIS

300.09

ANXIETY STATE NEC

300.10

HYSTERIA NOS

300.11

CONVERSION DISORDER

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

300.12

DISSOCIATIVE AMNESIA

300.13

DISSOCIATIVE FUGUE

300.14

DISSOCIATVE IDENTITY DIS

300.15

DISSOCIATIVE REACT NOS

300.16

FACTITIOUS DIS W SYMPTOM

300.19

FACTITIOUS ILL NEC/NOS

300.20

PHOBIA NOS

300.21

AGORAPHOBIA W PANIC DIS

300.22

AGORAPHOBIA W/O PANIC

300.23

SOCIAL PHOBIA

300.29

ISOLATED/SPEC PHOBIA NEC

300.3

OBSESSIVE-COMPULSIVE DIS

300.4

DYSTHYMIC DISORDER

300.5

NEURASTHENIA

300.6

DEPERSONALIZATION DISORD

300.7

HYPOCHONDRIASIS

300.81

SOMATIZATION DISORDER

300.82

UNDIFF SOMATOFORM DISRDR

300.89

SOMATOFORM DISORDERS NEC

300.9

NONPSYCHOTIC DISORD NOS

301.0

PARANOID PERSONALITY

301.10

AFFECTIV PERSONALITY NOS

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

301.11

CHRONIC HYPOMANIC PERSON

301.12

CHR DEPRESSIVE PERSON

301.13

CYCLOTHYMIC DISORDER

301.20

SCHIZOID PERSONALITY NOS

301.21

INTROVERTED PERSONALITY

301.22

SCHIZOTYPAL PERSON DIS

301.3

EXPLOSIVE PERSONALITY

301.4

OBSESSIVE-COMPULSIVE DIS

301.50

HISTRIONIC PERSON NOS

301.51

CHR FACTITIOUS ILLNESS

301.59

HISTRIONIC PERSON NEC

301.6

DEPENDENT PERSONALITY

301.7

ANTISOCIAL PERSONALITY

301.81

NARCISSISTIC PERSONALITY

301.82

AVOIDANT PERSONALITY DIS

301.83

BORDERLINE PERSONALITY

301.84

PASSIVE-AGGRESSIV PERSON

301.89

PERSONALITY DISORDER NEC

301.9

PERSONALITY DISORDER NOS

302.0

EGO-DYSTONIC SEX ORIENT

302.1

ZOOPHILIA

302.2

PEDOPHILIA

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98


ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

302.3

TRANSVESTIC FETISHISM

302.4

EXHIBITIONISM

302.50

TRANS-SEXUALISM NOS

302.51

TRANS-SEXUALISM, ASEXUAL

302.52

TRANS-SEXUAL, HOMOSEXUAL

302.53

TRANS-SEX, HETEROSEXUAL

302.6

GENDR IDENTITY DIS-CHILD

302.70

PSYCHOSEXUAL DYSFUNC NOS

302.71

HYPOACTIVE SEX DESIRE

302.72

INHIBITED SEX EXCITEMENT

302.73

FEMALE ORGASMIC DISORDER

302.74

MALE ORGASMIC DISORDER

302.75

PREMATURE EJACULATION

302.76

DYSPAREUNIA, PSYCHOGENIC

302.79

PSYCHOSEXUAL DYSFUNC NEC

302.81

FETISHISM

302.82

VOYEURISM

302.83

SEXUAL MASOCHISM

302.84

SEXUAL SADISM

302.85

GEND IDEN DIS, ADOL/ADULT

302.89

PSYCHOSEXUAL DIS NEC

302.9

PSYCHOSEXUAL DIS NOS

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

306.0

PSYCHOGEN MUSCULSKEL DIS

306.1

PSYCHOGENIC RESPIR DIS

306.2

PSYCHOGEN CARDIOVASC DIS

306.3

PSYCHOGENIC SKIN DISEASE

306.4

PSYCHOGENIC GI DISEASE

306.50

PSYCHOGENIC GU DIS NOS

306.51

PSYCHOGENIC VAGINISMUS

306.52

PSYCHOGENIC DYSMENORRHEA

306.53

PSYCHOGENIC DYSURIA

306.59

PSYCHOGENIC GU DIS NEC

306.6

PSYCHOGEN ENDOCRINE DIS

306.7

PSYCHOGENIC SENSORY DIS

306.8

PSYCHOGENIC DISORDER NEC

306.9

PSYCHOGENIC DISORDER NOS

307.0

STUTTERING

307.1

ANOREXIA NERVOSA

307.20

TIC DISORDER NOS

307.21

TRANSIENT TIC DISORDER

307.22

CHR MOTOR/VOCAL TIC DIS

307.23

TOURETTE'S DISORDER

307.3

STEREOTYPIC MOVEMENT DIS

307.40

NONORGANIC SLEEP DIS NOS

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100


ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

307.41

TRANSIENT INSOMNIA

307.42

PERSISTENT INSOMNIA

307.43

TRANSIENT HYPERSOMNIA

307.44

PERSISTENT HYPERSOMNIA

307.45

NONORGANIC CIRCADIAN RHY

307.46

SLEEP AROUSAL DISORDER

307.47

SLEEP STAGE DYSFUNC NEC

307.48

REPETIT SLEEP INTRUSION

307.49

NONORGANIC SLEEP DIS NEC

307.50

EATING DISORDER NOS

307.51

BULIMIA NERVOSA

307.52

PICA

307.53

RUMINATION DISORDER

307.54

PSYCHOGENIC VOMITING

307.59

EATING DISORDER NEC

307.6

ENURESIS

307.7

ENCOPRESIS

307.80

PSYCHOGENIC PAIN NOS

307.81

TENSION HEADACHE

307.89

PSYCHOGENIC PAIN NEC

307.9

SPECIAL SYMPTOM NEC/NOS

308.0

STRESS REACT, EMOTIONAL

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101


ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

308.1

STRESS REACTION, FUGUE

308.2

STRESS REACT, PSYCHOMOT

308.3

ACUTE STRESS REACT NEC

308.4

STRESS REACT, MIXED DIS

308.9

ACUTE STRESS REACT NOS

309.0

ADJUSTMNT DIS W DEPRESSN

309.1

PROLONG DEPRESSIVE REACT

309.21

SEPARATION ANXIETY

309.22

EMANCIPATION DISORDER

309.23

ACADEMIC/WORK INHIBITION

309.24

ADJUSTMENT DIS W ANXIETY

309.28

ADJUST DIS W ANXIETY/DEP

309.29

ADJ REACT-EMOTION NEC

309.3

ADJUST DISOR/DIS CONDUCT

309.4

ADJ DIS-EMOTION/CONDUCT

309.81

POSTTRAUMATIC STRESS DIS

309.82

ADJUST REACT-PHYS SYMPT

309.83

ADJUST REACT-WITHDRAWAL

309.89

ADJUSTMENT REACTION NEC

309.9

ADJUSTMENT REACTION NOS

310.0

FRONTAL LOBE SYNDROME

310.1

PERSONALITY CHG OTH DIS

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

310.2

POSTCONCUSSION SYNDROME

310.8

NONPSYCHOT BRAIN SYN NEC

310.9

NONPSYCHOT BRAIN SYN NOS

311

DEPRESSIVE DISORDER NEC

312.00

UNSOCIAL AGGRESS-UNSPEC

312.01

UNSOCIAL AGGRESSION-MILD

312.02

UNSOCIAL AGGRESSION-MOD

312.03

UNSOCIAL AGGRESS-SEVERE

312.10

UNSOCIAL UNAGGRESS-UNSP

312.11

UNSOCIAL UNAGGRESS-MILD

312.12

UNSOCIAL UNAGGRESS-MOD

312.13

UNSOCIAL UNAGGR-SEVERE

312.20

SOCIAL CONDUCT DIS-UNSP

312.21

SOCIAL CONDUCT DIS-MILD

312.22

SOCIAL CONDUCT DIS-MOD

312.23

SOCIAL CONDUCT DIS-SEV

312.30

IMPULSE CONTROL DIS NOS

312.31

PATHOLOGICAL GAMBLING

312.32

KLEPTOMANIA

312.33

PYROMANIA

312.34

INTERMITT EXPLOSIVE DIS

312.35

ISOLATED EXPLOSIVE DIS

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

312.39

IMPULSE CONTROL DIS NEC

312.4

MIX DIS CONDUCT/EMOTION

312.81

CNDCT DSRDR CHLDHD ONST

312.82

CNDCT DSRDR ADLSCNT ONST

312.89

OTHER CONDUCT DISORDER

312.9

CONDUCT DISTURBANCE NOS

313.0

OVERANXIOUS DISORDER

313.1

MISERY & UNHAPPINESS DIS

313.21

SHYNESS DISORDER-CHILD

313.22

INTROVERTED DIS-CHILD

313.23

SELECTIVE MUTISM

313.3

RELATIONSHIP PROBLEMS

313.81

OPPOSITION DEFIANT DISOR

313.82

IDENTITY DISORDER

313.83

ACADEMIC UNDERACHIEVMENT

313.89

EMOTIONAL DIS CHILD NEC

313.9

EMOTIONAL DIS CHILD NOS

314.00

ATTN DEFIC NONHYPERACT

314.01

ATTN DEFICIT W HYPERACT

314.1

HYPERKINET W DEVEL DELAY

314.2

HYPERKINETIC CONDUCT DIS

314.8

OTHER HYPERKINETIC SYND

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CMCode

Shortened Description

314.9

HYPERKINETIC SYND NOS

315.00

READING DISORDER NOS

315.01

ALEXIA

315.02

DEVELOPMENTAL DYSLEXIA

315.09

READING DISORDER NEC

315.1

MATHEMATICS DISORDER

315.2

OTH LEARNING DIFFICULTY

315.31

EXPRESSIVE LANGUAGE DIS

315.32

RECP-EXPRES LANGUAGE DIS

315.34

SPEECHDEL D/T HEAR LOSS

315.39

SPEECH/LANGUAGE DIS NEC

315.4

DEVEL COORDINATION DIS

315.5

MIXED DEVELOPMENT DIS

315.8

DEVELOPMENT DELAYS NEC

315.9

DEVELOPMENT DELAY NOS

316

PSYCHIC FACTOR W OTH DIS

317

MILD MENTAL RETARDATION

318.0

MOD MENTAL RETARDATION

318.1

SEVERE MENTAL RETARDAT

318.2

PROFOUND MENTAL RETARDAT

319

MENTAL RETARDATION NOS


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Nursing Sensitive
Care (NSC)
Measure Set

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Measure
Code
Measure Description

Nursing-Sensitive Care (NSC)


Originally developed by the National Quality Forum (NQF)

I-NSC-2

Patients that have hospital-acquired (nosocomial) pressure ulcer(s)


(category/stage II) on the day of the prevalence study.<BR>Note: Please
see Appendix E for details on how to collect this measure.

I-NSC-4

All documented falls with or without injury, experienced by patients in


a calendar month.

I-NSC-5

All documented falls by a patient with an injury level of minor (2) or


greater.

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I-NSC-2
Pressure Ulcer Prevalence (Hospital-Acquired)
Measure Overview
I-NSC 2 Patients that have hospital-acquired (nosocomial) pressure ulcer(s)
(category/stage II) on the day of the prevalence study.
Overview/Details:
The total number of patients that have hospital-acquired (nosocomial) category/stage II
or greater pressure ulcer(s) on the day of the prevalence study.
Note: Please see Attachment E for details on how to collect this measure.
Rationale: The incidence of hospitalized patients developing pressure ulcers has been
reported to range from 2.7 percent to 29.5 percent in various clinical studies. Certain
circumstances (e.g., immobility, incontinence, impaired nutritional status ,critical illness,
etc.) further increase the risk for selected patients. The development of hospital
acquired pressure ulcers (HAPU) places the patient at risk for other adverse events and
may lead to increased lengths of stay. HAPUs also increase resource consumption and
costs. In most vulnerable patients, reducing risk factors and implementing
preventive/treatment measures will reduce the incidence of new pressure ulcer
development and prevent the worsening of existing ulcers. Recommendations from the
clinical guidelines include the individuals at risk and early intervention with a goal of
maintaining and improving tissue tolerance in order to prevent injury. In most vulnerable
patients, reducing risk factors and implementing preventive/treatment measures will
reduce the incidence of new pressure ulcer development and prevent the worsening of
existing ulcers. Nurses and nursing-care interventions play an important role in
pressure ulcer prevention and management. The use of this prevalence measure allows
organizations to monitor this important patient outcome at points in time and examine
institutional processes.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: A decrease in rate
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Patient Settings/Services:
Medical/surgical units
Intensive Care units/Critical care units
Measure Name: Pressure Ulcer Prevalence (Hospital-Acquired)
Numerator: Patients that have at least one category/stage II or greater
hospital-acquired pressure ulcer(s) on the day of the prevalence study.
Denominator: All patients surveyed for the study who are > = 18 years.

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2011 Joint Commission International



109

I-NSC-2
Measure Details
Reasons and Implications: Certain circumstances (e.g., immobility, incontinence,
impaired nutritional status, critical illness, etc.) further increase the risk for selected
patients. The development of hospital acquired pressure ulcers (HAPU) places the
patient at risk for other adverse events and may lead to increased lengths of stay. In
most vulnerable patients, reducing risk factors and implementing preventive/treatment
measures will reduce the incidence of new pressure ulcer development and prevent the
worsening of existing ulcers. Recommendations from the clinical guidelines include
identifying the individuals at risk and early intervention with a goal of maintaining and
improving tissue tolerance in order to prevent injury. In most vulnerable patients,
reducing risk factors and implementing preventive/ treatment measures will reduce the
incidence of new pressure ulcer development and prevent the worsening of existing
ulcers. Nurses and nursing-care interventions play an important role in pressure ulcer
prevention and management. The use of this prevalence measure allows organizations
to monitor this important patient outcome at points in time and examine institutional
processes.
Data Collection:
Concurrent for observed data elements (pressure ulcer).
Numerator: Patients that have at least one category/stage II or greater
hospital-acquired pressure ulcer(s) on the day of the prevalence study.
Inclusions to the population: Hospital-acquired pressure ulcers (ulcers discovered or
documented after the first 24 hours from the time of inpatient admission)
x
x
x

Category/stage II or greater pressure ulcers


Unstageable/unclassified pressure ulcers
Suspected deep tissue injury

Exclusions to the population: None


Data elements:
x
x
x

Observed Pressure Ulcer


Observed Pressure Ulcer Hospital-Acquired
Observed Pressure Ulcer Category/stage

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Denominator: All patients surveyed for the study who are > = 18 years.
Data elements:
x
x
x
x

Admission Date
Birthdate
Sex
Type of unit

Exclusions to the population:


x
x
x
x
x

Patients less than 18 years of age


Patients who refuse to be assessed
Patients who are off the unit at the time of the prevalence study, i.e.
surgery, x-ray, physical therapy, etc.
Patients who are medically unstable at the time of the study for whom
assessment would be contraindicated at the time of the study, i.e., unstable
blood pressure, uncontrolled pain, or fracture waiting repair.
Patients who are actively dying and pressure ulcer prevention is no longer a
treatment goal.

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I-NSC-2
References
x
x
x
x
x
x

x
x
x
x
x
x

AHRQ, Agency for Healthcare Quality and Research (2006). Numbers of patients
with pressure sores increasing. ttp://hcup.ahrq.gov/HCUPnet.asp
Allman, R. (1997). Pressure ulcer prelavence, incidence and risk factors and
impact. Clinics in Geriatric Medicine, 13(3), 421-436.
Allman, R. (2001). Pressure ulcers: Using what we know to improve quality of
care. Journal of the American Geriatric Society, 49, 996-997.
Allman, R., Goode, P., Burst, N., Bartolucci, A., & Thomas, D. (1999) Pressure
ulcer, hospital complications, and disease severity: Impact on hospital costs and
length of stay. Advances in Wound Care, 12(1), 22-30.
Anderson, C. & Rappl, L. (2004). Lateral rotation mattresses for wound healing.
Ostomy/Wound Management, 50(4), 50-62.
Baumgarten M, Margolis DJ, Localio AR, Kagan SH, Lowe RA, Kinosian B,
Holmes JH, Abbuhl SB, Kavesh W, Ruffin A. Pressure ulcers among elderly
patients early in the hospital stay. J Gerontol A Biol Sci Med Sci. 2006
Jul;61(7):749-54.
Black J, Baharestani M, Cuddigan J, Dorner B, Edsberg L, Langemo D,
Posthauer ME, Ratliff C, Taler G; National Pressure Ulcer Advisory
Panel.National Pressure Ulcer Advisory Panel's updated pressure ulcer
staging/categorizing system. Dermatol Nurs. 2007 Aug;19(4):343-9; quiz 350.
Braden BJ, Maklebust J. Preventing pressure ulcers with the Braden scale: An
update on this easy-to-XVHWRROWKDWDVVHVVHVDSDWLHQWVULVN$P-1XUV
2005;105:70-72.
Dale, M.C., Burns, A., Panter, L., & Morris, J. (2001). Factors affecting survival of
elderly nursing home residents. Internal Journal of Geriatric Psychiatry. 16, 7076.
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory
Panel. Prevention and treatment of pressure ulcers: quick reference guide.
Washington DC: National Pressure Ulcer Advisory Panel; 2009.
Fogerty MD, Abumrad NN, Nanney L, Arbogast PG, Poulose B, Barbul A. Risk
factors for pressure ulcers in acute care hospitals. Wound Repair Regen. 2008
Jan- Feb;16(1):11-8.
Hart S, Bergquist S, Gajewski B, Dunton N. Reliability testing of the National
Database of Nursing Quality Indicators pressure ulcer indicator. J Nurs Care
Qual. 2006 Jul-Sep;21(3):256-65.
Hopkins, A., Dealey, C., Bale, S., Defloor, T., & Worboys, F. (2006). Patient
stories of living with a pressure ulcer. Journal of Advanced Nursing, 56(4), 345353.

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x
x
x
x
x
x
x
x
x
x
x

x
x
x
x
x

Horn SD, Bender SA, Ferguson ML, Smout RJ, Bergstrom N, Taler G, Cook AS,
Sharkey SS, Voss AC. The National Pressure Ulcer Long-Term Care
Study:pressure ulcer development in long-term care residents. J Am Geriatr Soc.
2004 Mar;52(3):359-67.
IOM (Institute of Medicine) (1999). To error is human: Building a safer health
system. Washington D.C: National Academy of Sciences.
Kottner J, Tannen A, Halfens R, Dassen T.Does the number of raters influence
the pressure ulcer prevalence rate? Appl Nurs Res. 2009 Feb;22(1):68-72.
Langemo, K.K., Melland, H., Hanson, K., Olson, B., & Hunter, S. (2000). The
lived experience of having a pressure ulcer: A qualitative analysis. Advances in
Skin and Wound Care, 13(5), 225-235.
Maklebust, J. (2005). Pressure ulcers: The great insult. Nursing Clinics of North
America, 40, 365-389.
Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Lopez-Medina IM, Alvarez-Nieto C.
Risk assessment scales for pressure ulcer prevention: a systematic review. J
Adv Nurs. 2006 Apr;54(1):94-110.
Pressure Ulcers in Adults: Prediction and Prevention (AHCPR, 1992). URL:
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.chapter.4409
Adults: Prediction and Prevention. Clinical Practice
Guideline Number 3. AHCPR Pub. No. 92-0047:May 1992
Rastinehad, D. (2006). Pressure ulcer pain. Journal of Wound, Ostomy &
Continence Nursing, 33, 252-257.
Reddy M, Gill SS, Kalkar SR, Wu W, Anderson PJ, Rochon PA.Treatment of
pressure ulcers: a systematic review. JAMA. 2008 Dec 10;300(22):2647-62.
Redelings, M.D., Lee, N.E., Sorvillo, F. (2005). Pressure ulcers: More lethal than
we thought? Advances in Skin and Wound Care, 18, 367-372.
Stechmiller JK, Cowan L, Whitney JD, Phillips L, Aslam R, Barbul A, Gottrup
F,Gould L, Robson MC, Rodeheaver G, Thomas D, Stotts N. Guidelines for the
prevention of pressure ulcers. Wound Repair Regen. 2008 Mar-Apr;16(2):15168.
Whitney J, Phillips L, Aslam R, Barbul A, Gottrup F, Gould L, Robson
MC,Rodeheaver G, Thomas D, Stotts N. Guidelines for the treatment of pressure
ulcers. Wound Repair Regen. 2006 Nov-Dec;14(6):663-79.
Whittington KT, Briones R. National Prevalence and Incidence Study: 6-year
sequential acute care data. Adv Skin Wound Care. 2004 Nov-Dec;17(9):490-4
Wound, Ostomy and Continence Nurses Society. (2003) Guideline for Prevention
and Management of Pressure Ulcers. WOCN: Glenview, IL
Zulkowski, K., Langemo, D., Posthauer, M.E., & the National Pressure Ulcer
Advisory Panel. (2005). Coming to consensus on deep tissue injury. Advances in
Skin & Wound Care, 18(1), 28-29.

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I-NSC-4
Patient Falls
Measure Overview
I-NSC 4 All documented falls with or without injury, experienced by patients in a
calendar month.
Overview/Details:
All documented falls with or without injury, experienced by patients in a calendar month.
Rationale: Patient falls occurring during hospitalization can result in serious and even
potentially life threatening consequences for many patients. Efforts to reduce this
adverse event have included the development of tools to assess and identify patients at
risk of falling and the implementation of fall prevention protocols. More recently,
research has suggested that staffing on patient care units, specifically the number of
professional nurses, may impact the incidence of this patient outcome. Nurses are
responsible for identifying patients who are at risk for falls and for developing a plan of
care to minimize that risk. High performance measure rates may suggest the need to
examine clinical and organizational processes related to the identification of, and care
for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: A decrease in rate
Patient Settings/Services:
Medical/surgical units
Intensive Care units/Critical care units
Measure Name: Patient Falls
Numerator: Total number of patient falls (with or without injury to the
patient) during the calendar month.
Denominator: Patient days by Type of Unit during the calendar month.
2011 Joint Commission International

114

Domains of
Performance
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2011 Joint Commission International



115

I-NSC-4
Measure Details
Reasons and Implications: Patient falls occurring during hospitalization can result in
serious and even potentially life threatening consequences for many patients. Efforts to
reduce this adverse event have included the development of tools to assess and identify
patients at risk of falling and the implementation of fall prevention protocols. More
recently, research has suggested that staffing on patient care units, specifically the
number of professional nurses, may impact the incidence of this patient outcome.
Nurses are responsible for identifying patients who are at risk for falls and for developing
a plan of care to minimize that risk. High performance measure rates may suggest the
need to examine clinical and organizational processes related to the identification of, and
care for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Total number of patient falls (with or without injury to the (patient) during the
calendar month.
Inclusions to the population:
x
x
x

Patient falls occurring while on an eligible reporting unit


Assisted falls
Repeat falls

Exclusions to the population: Falls by:


x
x
x
x
x

Visitors
Students
Staff members
Patients from eligible reporting units, however patient was not on unit at
time of fall (e.g., patients falls in radiology department)
Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)

Data elements:
x
x
x
x

Month
Number of Injury Falls
Type of Unit
Year

2011 Joint Commission International



116

Denominator Statement: Patient days by Type of Unit during the calendar month.
Included Populations:
x
x
x

Inpatients, short stay patients, observation patients and same day surgery
patients who receive care on eligible in-patient units for all or part of a day.
Adult critical care, step-down, medical, surgical, medical-surgical
combined, and mixed acuity units.
Any age patient on an eligible reporting unit is included in the patient day count.

Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, etc)
Data Elements:
x
x
x
x

Month
Patient Days
Type of Unit
Year

2011 Joint Commission International



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I-NSC-4
References
x
x
x
x
x
x
x
x
x

x
x
x

American Nurses Association. National Database of Nursing Quality Indicators.


(NDNQI) ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington, DC. American Nurses Publishing. 1996.
Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic
Value of Professional Nursing. Medical Care 47(1): 97-104.
Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on
acute care hospital units. Nursing Outlook. 2004; 53:53-59.
Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality
of care on nursing units. Nursing Management.
Dunton, N., Gajewski, B., Klaus, S., Pierson, B. (2007). The relationship of
nursing workforce characteristics to patient outcomes. OJIN: Online Journal of
Issues in Nursing, 12(3), Manuscript 4.
Hendrich, A.L., Bender, P.S. & Myhuis, A. Validation of the Hendrich II fall risk
model: a large concurrent case/control study of hospitalized patients. Applied
Nursing Research. 2005 (16(1)): 9-12.
McCollam, M.E. Evaluation and Implementation of a research-based falls
assessment innovation. Nursing Clinics of North America. 1995;30(3):507-514.
Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone
patient. Canadian Journal of Aging. 1989; (8):366-377.
Savitz, Lucy A., Jones, Cheryl B., Bernard, Shulamit. Advances in Patient Safety:
From Research to Implementation Advances in Patient Safety: From Research to
Implementation Volume 4. Programs, Tools, and Products Quality Indicators
Sensitive to Nurse Staffing in Acute Care Settings. 2005.
Schmid, N. A. 1989 Federal Nursing Service Award Winner. Reducing patient
falls: a research-based comprehensive fall prevention program. Military Medicine.
1990; 155(5):202-207.
Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care.
2003; 41(1):142-152.
Yang KP. Relationships between nurse staffing and patient outcomes. Journal of
Nursing Research. 2003; 11(3):149-158.

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I-NSC-5
Patient Falls with Injury
Measure Overview
I-NSC 5 All documented falls by a patient with an injury level of minor (2) or
greater.
Overview/Details:
All documented falls with a minor (2) or greater injury level
1. None - patient had no injuries
2. Minor - resulted in application of a dressing, ice, cleaning of a wound, limb
elevation, topical medication, bruise or abrasion
3. Moderate - resulted in suturing, application of steristrips/skin glue, splinting,
or muscle or joint strain
4. Major - resulted in surgery, casting, traction, fracture, or required consultation
for neurological or internal injury
5. Death - the patient died as a result of injuries sustained from the fall
6. UTD Unable to Determine from the documentation
Rationale: Patient falls occurring during hospitalization can result in serious and even
potentially life threatening consequences for many patients. Nurses are responsible for
identifying patients who are at risk for falls and for developing a plan of care to minimize
that risk. Short staffing, nurse inexperience and inadequate nurse knowledge could
place patients at risk for injury. High performance measure rates may suggest the need
to examine clinical and organizational processes related to the identification of, and care
for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: A decrease in rate

2011 Joint Commission International



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Patient Settings/Services:
Medical/surgical units
Intensive Care units/Critical care units
Measure Name: Patient Falls with injury
Numerator: Number of patient falls with an injury level of minor or greater during the
calendar month.
Denominator: Patient days by Type of Unit during the calendar month.

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Performance
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2011 Joint Commission International



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I-NSC-5
Measure Details
Reasons and Implications: Patient falls occurring during hospitalization can result in
serious and even potentially life threatening consequences for many patients. Nurses are
responsible for identifying patients who are at risk for falls and for developing a plan of care
to minimize that risk. Short staffing, nurse inexperience and inadequate nurse knowledge
could place patients at risk for injury. High performance measure rates may suggest the
need to examine clinical and organizational processes related to the identification of, and
care for, patients at risk of falling, and possibly staffing effectiveness on the unit.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Number of patient falls with an injury level of minor or greater during the
calendar month
Inclusions to the population:
x
x

Patient falls occurring while on an eligible reporting unit


Falls with Fall Injury Level RIPLQRU
1. None - patient had no injuries
2. Minor - resulted in application of a dressing, ice, cleaning of a wound, limb
elevation, topical medication, bruise or abrasion
3. Moderate - resulted in suturing, application of steristrips/skin glue,
splinting, or muscle or joint strain
4. Major - resulted in surgery, casting, traction, fracture, or
required consultation for neurological or internal injury
5. Death - the patient died as a result of injuries sustained from the fall
6. UTD Unable to Determine from the documentation

Exclusions to the population: Falls by:


x
x
x

Visitors
Students
Staff members

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x
x
x

Patients from eligible reporting units, however patient was not on unit at
time of fall (e.g., patients falls in radiology department)
Falls on other unit types (e.g., pediatric, obstetrical, rehab, etc)
Falls with Fall Injury Level RIQRQH

Data elements:
x
x

Number of Injury Falls


Type of Unit

Denominator Statement: Patient days by Type of Unit during the calendar month.
Included Populations:
x
x

Inpatients, short stay patients, observation patients and same day surgery patients
who receive care on eligible in-patient units for all or part of a day.
Adult critical care, step-down, medical, surgical, medical-surgical
combined, and mixed acuity units.

Excluded Populations: Other unit types (e.g., pediatric, obstetrical, rehab, and the like)
Data Elements:
x
x
x
x

Month
Patient Days
Type of Unit
Year

Data Accuracy:
x
x
x
x

,QMXU\OHYHO-when the initial fall report is written by the nursing staff, the extent of
the injury may not yet be known. A method to follow-XSRQWKHSDWLHQWVFRQGLWLRQDW
least 24 hours later should be established.
A fall injury level of level of death may be selected only if the fall caused the death of
the patient, not if dying caused the fall.
Eligible reporting unit(s) will calculate and report fall data by calendar month. In
addition, each unit that reports fall data must also collect patient day data for the
same month in order to calculate fall with injury rates.
Fall rate is calculated by multiplying the numerator by 1,000 and then dividing by the
denominator.

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I-NSC-5
References
x
x
x
x
x
x
x
x
x

x
x
x

American Nurses Association. National Database of Nursing Quality Indicators.


(NDNQI) ANA. Nurse Staffing and Patient Outcomes in the Inpatient Setting.
Washington, DC. American Nurses Publishing. 1996.
Dall, T., Yaozhu, J., Seifert, R., Maddox, P., & Hogan, P. (2009). The Economic
Value of Professional Nursing. Medical Care 47(1): 97-104.
Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on
acute care hospital units. Nursing Outlook. 2004; 53:53-59.
Dunton, N. (April 2008). Take a cue from the NDNQI: Demonstrating the quality
of care on nursing units. Nursing Management.
Dunton, N., Gajewski, B., Klaus, S., Pierson, B. (2007). The relationship of
nursing workforce characteristics to patient outcomes. OJIN: Online Journal of
Issues in Nursing, 12(3), Manuscript 4.
Hendrich, A.L., Bender, P.S. & Myhuis, A. Validation of the Hendrich II fall risk
model: a large concurrent case/control study of hospitalized patients. Applied
Nursing Research. 2005 (16(1)): 9-12.
McCollam, M.E. Evaluation and Implementation of a research-based falls
assessment innovation. Nursing Clinics of North America. 1995;30(3):507-514.
Morse, J.M., Morse, et al. Development of a scale to identify the fall-prone
patient. Canadian Journal of Aging. 1989; (8):366-377.
Savitz, Lucy A., Jones, Cheryl B., Bernard, Shulamit. Advances in Patient Safety:
From Research to Implementation Advances in Patient Safety: From Research to
Implementation Volume 4. Programs, Tools, and Products Quality Indicators
Sensitive to Nurse Staffing in Acute Care Settings. 2005.
Schmid, N. A. 1989 Federal Nursing Service Award Winner. Reducing patient
falls: a research-based comprehensive fall prevention program. Military Medicine.
1990; 155(5):202-207.
Unruh L. Licensed nurse staffing and adverse events in hospitals. Medical Care.
2003; 41(1):142-152.
Yang KP. Relationships between nurse staffing and patient outcomes. Journal of
Nursing Research. 2003; 11(3):149-158.

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Appendix E
Nursing Sensitive Care
Prevalence Study Methodology
General Information
The time and staff required to do a prevalence study depends on the size of the hospital
DQGWKHXQLWVDVZHOODVWKHVWXG\WHDPVH[SHULHQFHLQ conducting the observation,
extracting required data elements from the clinical record and documenting the
information. Experienced sites have indicated that the prevalence study process
requires some learning at first and benefits from a core group of staff that is very skilled
in the study area. This greatly improves the validity and reliability of the data. Other
suggestions include the pairing of less experienced staff with experts, in teams, to
provide a rich teaching/learning experience and as a valuable competency development
strategy. It is also important that the study team(s) has (have) at least one
planning/training session prior to the day on which the study is conducted.
For those organizations that are members of a multi-hospital system, it may be
beneficial to consider the development of an expert team to travel between hospitals. In
this way, the expertise and efficiency of the prevalence study is maximized. Another
suggestion is to have sites mentor one another so if this is your organizatLRQVILUVW
prevalence study, consider observing, first hand, another site conduct their prevalence
study. The insight and experience gained can then be applied as your organization
plans and conducts its own first study. Finally, some hospitals have found it convenient
to conduct the pressure ulcer and restraint prevalence studies at the same time.
Prevalence Study Procedures
1) Assign a coordinator
A coordinator should be selected who has organizational, problem-solving and
leadership skills. Responsibilities of the coordinator include communications,
selecting the study date, finalizing the data collection tool, training the data
collectors, managing questions/concerns, and assuring the data are collated. The
coordinator should ensure that all observers are trained in the study methodology
and observation techniques. The coordinator should also monitor Inter-rater
(interobserver) reliability as an important component of data quality assessment.

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2) Determine Who Will Conduct the Study


a. Pressure Ulcer Prevalence: A combination of exempt nurses with current
clinical skills (e.g., ET nurses, clinical nurse specialists, educators, and unit
managers) and staff nurse experts should be considered for the inspection team.
Chart review may be conducted concurrently by other staff with skill in reading
GRFXPHQWDWLRQ8VLQJDWHDPIRUWKHREVHUYDWLRQSRUWLRQRIWKHVWXG\PD\EH
helpful for conducting skin inspection (e.g., to help turn immobile patients for
inspection). To help decrease the likelihood of bias in observation, consider
assigning observation team members to study units other than their regularly
assigned work unit. Resources required will vary based on the efficiency of the
teams and the amount of data desired by the facility.
b. Restraint Use Prevalence: To help decrease the likelihood of bias in
observation, consider assigning observation team members to study units other
than their regularly assigned work unit. Resources required will vary based on
the efficiency of the teams and the amount of data desired by the facility.
3) Train Those Who Will Conduct the Study
a. Pressure Ulcer Prevalence: Training in skin inspection and pressure ulcer
staging/categorization is required prior to study participation. One option would
be to have an ET nurse or clinical expert organize a training session on the
EPUAP/NPUAP Pressure Ulcer Guidelines.
b. Restraint Use Prevalence: Not applicable.
4) Observation
a. Pressure Ulcer Prevalence: Inspect all bony prominences including the
traditional areas such as the coccyx but also areas such as heels, elbows, ears,
and posterior cranium on bedridden patients. If using teams, be sure one person
is a skin expert. Any pressure ulcers found are staged/categorized and recorded
on the data collection tool. Facilities may opt to also measure/photograph ulcers
for their quality programs.
b. Restraint Use Prevalence: Each patient on the assigned unit is observed (i.e.,
observations are not to be referred by staff for those patients thought to be
restrained).

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5) Chart Review
a. Pressure Ulcer Prevalence: (DFKSDWLHQWVFKDUWLVDOVRUHYLHZHGIRU
demographic data, documentation relative to risk assessment and, if the Braden
Scale is used, Total and Subscale Scores on admission for all patients with
stage/category I or greater ulcers. Sites may also decide to inspect
documentation related to skin care or other standards. Various other quality
management studies may be combined with the prevalence study and data
specific to those may also be included in the chart review.
b. Restraint Use Prevalence: (DFKSDWLHQWVFKDUWLVDOVRUHYLHZHGIRU
documentation relative to the clinical justification for use of a restraint or sitter.
$GGLWLRQDOLQIRUPDWLRQVXFKDVRWKHULQWHUYHQWLRQVSDWLHQWVFRQGLWLRQDQGOHQJWK
of time in restraints may be useful to collect for additional analysis.
6) Data Collection Tools
a. Pressure Ulcer Prevalence: Data should be recorded (whether or not pressure
ulcers were noted) for each patient whose skin is observed during the prevalence
study. These data include both the patient observation findings and the chart
review findings. If different team members are doing the observing and chart
review, it is helpful to have the data collection tool divided into distinct portions
(each with a patient identifier) and two systems for tracking which patients have
been completed (observers and chart reviewers proceed at different paces).
b. Restraint Use Prevalence: Data should be recorded (whether or not restraints
were noted) for each patient. These data include both the observation findings
and chart review findings. If different team members are doing the observing and
chart review, it is helpful to have the data collection tool divided into distinct
portions (each with a patient identifier) and two systems for tracking which
patients have been completed (observers and chart reviewers proceed at
different paces).
7) Data Submission
a. Pressure Ulcer Prevalence: After the chart review and patient observation
have been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure for internal analysis or following procedures as defined for external
data submission.

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b. Restraint Use Prevalence: After the chart review and patient observation have
been completed, data collection tools should be checked for accuracy, and
completeness. Completed study data should be submitted using a defined
procedure developed for internal analysis or following procedures as defined for
external data submission.
8) Important Notes
a. Definition: A pressure ulcer is localized injury to the skin and/or underlying
tissue usually over a bony prominence, as a result of pressure, or pressure in
combination with shear and/or friction. (National Pressure Ulcer Advisory Panel,
NPUAP, 2009)
b. Hospital-acquired pressure ulcers are ulcers discovered or documented after
the first 24 hours from the time of inpatient admission.
c. Skin breakdown due to arterial occlusion, venous insufficiency, diabetes
related neuropathy or incontinence dermatitis are not pressure ulcers and should
not be reported in the prevalence study.
d. Healing/Closed or Healed Pressure Ulcers: Pressure ulcers that are healing
should not be reverse staged; rather they should be staged based on the
maximum anatomic depth of tissue damage that was recorded LQWKHSDWLHQWV
record. Pressure ulcers that have closed/healed are not counted as pressure
ulcers.
e. Patient consent NOT required: A prevalence study is NOT a research study
for which you must obtain patient consent. It is a Quality Improvement activity like
many others in your facility. The examination is the same as the mandatory skin
examinations your nurses perform on a regular basis. Thus all your nurses need
to do is let patients know that you are examining all patients as part of your
quality procedures. Of course, if they absolutely refuse, you do exclude them.
f. Actively dying and medically unstable patients: 7KHWHUPVDFWLYHO\G\LQJ
DQGPHGLFDOO\XQVWDEOHDUHWHUPVXVHGWRFKDUDFWHUL]HSDWLHQWVZho cannot
safely be turned for physiological reasons. Active dying is considered the last few
days of life when blood flow to organs (e.g., brain, heart, kidneys) is decreasing,
respiratory distress is increasing, and physiological instability is apparent, making
WXUQLQJXQUHDOLVWLF0HGLFDOO\XQVWDEOHSHRSOHPD\KDYHSRRUKHPRG\QDPLF
profiles or distress so severe that they cannot safely be turned for examination of
the back, sacrum scapula, ischea, back of head, etc. The nature of the instability
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will vary e.g., some will require upright position to breathe, others cannot tolerate
movement because of changes in hemodynamics (reduction) or intracranial
pressure (increase).
g. A patient with a very long length of stay, who was surveyed previously, should
be counted and surveyed again as long as they remain a patient in your facility.
h. Mucous membrane ulcers are tissue disruption on mucous membranes due to
ischemic pressure from medical devices. Mucous membranes do not have skin
on them so the staging system for pressure ulcers cannot be used to stage
mucosal pressure ulcers. Do NOT report mucous membrane ulcers.
Source: Collaborative Alliance for Nursing Outcomes (CALNOC)

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Perinatal Care (PC)


Measure Set

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Measure
Code
Measure Description

Perinatal Care (PC)


Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

I-PC-01

Patients with elective vaginal deliveries or elective cesarean sections at


>= 37 and < 39 weeks of gestation completed

I-PC-02

Nulliparous women with a term, singleton baby in a vertex position


delivered by cesarean section

I-PC-05

Exclusive breast milk feeding during the newborn's entire


hospitalization

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I-PC-01
Elective Delivery
Measure Overview
I-PC 01 Patients with elective vaginal deliveries or elective cesarean sections at
>= 37 and < 39 weeks of gestation completed
Overview/Details:
Patients who had an elective vaginal delivery or elective cesarean section performed
at greater than or equal to 37 weeks and less than 39 weeks gestation completed.
Rationale:
Clinical guidelines have had in place a standard requiring 39 completed weeks
gestation prior to ELECTIVE delivery, either vaginal or operative. Studies have
determined that elective delivery or elective cesarean section prior to the gestational
age of 39 weeks may result in significant short term neonatal morbidity (neonatal
intensive care unit admission rates of 13-21%).
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement Noted: Decrease in rate
Patient Settings/Services
Obstetric/Maternal units
Medical/Surgical units
Measure Name: Elective Delivery
Numerator: Patients with elective deliveries
Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation
completed
Domains of Performance
Appropriateness
Effectiveness
Prevention/Early Detection
Timeliness

QPS Standards
QPS.3 patient
assessments

CCPC

IPSG
Goal 1
Goal 4

QPS.3 surgical
procedure

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I-PC-01
Measure Details
Clinical guidelines have had in place a standard requiring 39 completed weeks
gestation prior to ELECTIVE delivery, either vaginal or operative. Studies have
determined that elective delivery or elective cesarean section prior to the
gestational age of 39 weeks may result in significant short term neonatal
morbidity (neonatal intensive care unit admission rates of 13-21%).
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Patients with elective deliveries
Inclusions to the population: ICD principal code for one or more of the following:
x Medical induction of labor (Appendix A Table 11.05)
x Cesarean section as defined in Appendix A, Table 11.06 while not in active labor,
or experiencing spontaneous rupture of membranes
Exclusions to the population: None
Data elements:
x Active Labor
x ICD Principal/Other Procedure code
x Spontaneous Rupture of Membranes
Denominator: Patients delivering newborns with >= 37 and < 39 weeks of gestation
completed
Data elements:
x Admission Date
x Birthdate
x Gestational age
x ICD principal/other diagnosis code
Inclusions to the population: Not applicable
Exclusions to the population:
x ICD Principal Diagnosis code for conditions possibly justifying elective delivery
prior to 39 weeks gestation as defined in Appendix A, Table 11.07
x Patients less than 8 years of age
x Patients greater than or equal to 65 years of age
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I-PC-01
References
x
x
x
x
x

American Academy of Family Physicians. (2000). Tips from Other Journals:


Elective induction doubles cesarean delivery rate, 61, 4.Retrieved December 29,
2008 at: http://www.aafp.org/afp/20000215/tips/39.html.
American College of Obstetricians and Gynecologists. (November 1996). ACOG
Educational Bulletin.
Clark, S., Miller, D., Belfort, M., Dildy, G., Frye, D., & Meyers, J. (2009). Neonatal
and maternal outcomes associated with elective delivery. [Electronic Version].
Am J Obstet Gynecol. 200:156.e1-156.e4.
Glantz, J. (Apr.2005). Elective induction vs. spontaneous labor associations and
outcomes. [Electronic Version]. J Reprod Med. 50(4):235-40.
Tita, A., Landon, M., Spong, C., Lai, Y., Leveno, K., Varner, M, et al. (2009).
Timing of elective repeat cesarean delivery at term and neonatal outcomes.
[Electronic Version]. NEJM. 360:2, 111-120.

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I-PC-02
Cesarean Section
Measure Overview
I-PC 02 Nulliparous women with a term, singleton baby in a vertex position
delivered by cesarean section
Overview/Details:
Patients, during their first pregnancy who presented with a single fetus in a normal
(vertex position) who were delivered by cesarean section at 37 or more weeks of
gestation completed.
Rationale:
Studies have demonstrated that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor admission rates.
Clinical studies have shown if labor was forced when the cervix was not ready, the
outcomes were poorer. Studies have also shown the use of that labor and delivery
guidelines can make a difference in labor outcomes.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted: Decrease in rate
Patient Settings/Services
Labor and Delivery units
Medical/Surgical units
Measure Name: Cesarean Section
Numerator: Patients with cesarean sections
Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex
presentation
Domains of Performance
Appropriateness
Effectiveness
Prevention/Early Detection
Timeliness

QPS Standards
QPS.3 patient
assessments

CCPC

IPSG
Goal 1
Goal 4

QPS.3 surgical
procedures

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I-PC-02
Measure Details
Clinical studies found that over 60% of the variation among hospitals can be
attributed to first birth labor induction rates and first birth early labor admission
rates. The results have shown if labor was forced when the cervix was not ready,
the outcomes were poorer. Many authors have shown that physician factors,
rather than patient characteristics or obstetric diagnoses are the major driver for
the difference in rates within a hospital.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Patients with cesarean sections
Inclusions to the population: ICD Principal Procedure Code or ICD Other Procedure
Codes for cesarean section as defined in Appendix A, Table 11.06
Exclusions to the population: None
Data elements:
x ICD principal/other procedure Code
Denominator: Nulliparous patients delivered of a live term singleton newborn in vertex
presentation.
Data elements:
x Admission Date
x Birthdate
x Gestational age
x ICD other diagnosis code
x ICD other procedure code
x ICD principal diagnosis code
x ICD procedure code
x Parity

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Inclusions to the population: Nulliparous patients with ICD Principal Diagnosis Code
or ICD Other Diagnosis Codes for outcome of delivery as defined in Appendix A, Table
11.08 and with a delivery of a newborn with 37 weeks or more of gestation completed
Exclusions to the population:
x ICD Principal Diagnosis Code or ICD Other Diagnosis Codes, for
contraindications to vaginal delivery as defined in Appendix A, Table 11.09
x Patients less than 8 years of age
x Patients greater than or equal to 65 years of age

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I-PC-02
References
x

x
x

x
x

x
x
x

x
x

Agency for Healthcare Research and Quality. (2002). AHRQ Quality Indicators
Guide to Inpatient Quality Indicators: Quality of Care in HospitalsVolume,
Mortality, and Utilization. Revision 4 (December 22, 2004). AHRQ Pub. No. 02RO204.
Alfirevic, Z., Edwards, G., & Platt, M.J. (2004). The impact of delivery suite
JXLGHOLQHVRQLQWUDSDUWXPFDUHLQVWDQGDUGSULPLJUDYLGD(XU-2EVWHW*\QHFRO
Reprod Biol.115:28-31.
American College of Obstetricians and Gynecologists. (2000). Task Force on
Cesarean Delivery Rates. Evaluation of Cesarean Delivery. (Developed under
the direction of the Task Force on Cesarean Delivery Rates, Roger K. Freeman,
MD, Chair, Arnold W. Cohen, MD, Richard Depp III, MD, Fredric D. Frigoletto Jr,
MD, Gary D.V. Hankins, MD, Ellice Lieberman, MD, DrPH, M. Kathryn Menard,
MD, David A. Nagey, MD, Carol W. Saffold, MD, Lisa Sams, RNC, MSN and
ACOG Staff: Stanley Zinberg, MD, MS, Debra A. Hawks, MPH, and Elizabeth
Steele).
Bailit, J.L., Garrett, J.M., Miller, W.C., McMahon, M.J., & Cefalo, R.C. (2002).
Hospital primary cesarean delivery rates and the risk of poor neonatal outcomes.
Am J Obstet Gynecol. 187(3):721-7.
Bailit, J. & Garrett, J. (2003). Comparison of risk-adjustment methodologies. Am
J Obstet Gynecol.102:45-51. * Bailit, J.L., Love, T.E., & Dawson, N.V. (2006).
Quality of obstetric care and risk-adjusted primary cesarean delivery rates. Am J
Obstet Gynecol.194:402.
Bailit, J.L. (2007). Measuring the quality of inpatient obstetrical care. Ob Gyn Sur.
62:207-213.
Berkowitz, G.S., Fiarman, G.S., Mojica, M.A., et al. (1989). Effect of physician
characteristics on the cesarean birth rate. Am J Obstet Gynecol. 161:146-9.
California Office of Statewide Hospital Planning and Development. (2006).
Utilization Rates for Selected Medical Procedures in California Hospitals,
Retrieved from the Internet on February 11, 2010 at:
http://www.oshpd.ca.gov/HID/Products/PatDischargeData/ResearchReports/Hos
pIPQualInd/Vol-Util_IndicatorsRpt/2007Util.pdf
Cleary, R., Beard, R.W., Chapple, J., Coles, J., Griffin, M., & Joffe, M. (1996).
The standard primipara as a basis for inter-unit comparisons of maternity care. Br
J Obstet Gynecol. 103:223-9.
Coonrod, D.V., Drachman, D., Hobson, P., & Manriquez, M. (2008). Nulliparous
term singleton vertex cesarean delivery rates: institutional and individual level
predictors. Am J Obstet Gynecol. 694-696.

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x
x
x
x
x
x
x

x
x
x
x

DiGiuseppe, D.L., Aron, D.C., Payne, S.M., Snow, R.J., Dieker, L., & Rosenthal,
G.E. (2001). Risk adjusting cesarean delivery rates: a comparison of hospital
profiles based on medical record and birth certificate data. Health Serv
Res.36:959-77.
Gould, J., Danielson, B., Korst, L., Phibbs, R., Chance, K.,& Main, E.K., et al.
(2004). Cesarean delivery rate and neonatal morbidity in a low-risk population.
Am J Obstet Gynecol, 104:11-19.
Goyert, G.L., Bottoms, F.S., Treadwell, M.C., et al. (1989). The physician factor
in cesarean birth rates. N Engl J Med.320:706-9.
Le Ray, C., Carayol, M., Zeitlin, J., Berat, G., & Goffinet, F. (2006). Level of
perinatal care of the maternity unit and rate of cesarean in low-risk nulliparas. Am
J Obstet Gynecol. 107:1269-77.
Luthy, D.A., Malmgren, J.A., Zingheim, R.W., & Leininger, C.J. (2003). Physician
contribution to a cesarean delivery risk model. Am J Obstet Gynecol.188:157985.
Main, E.K. (1999). Reducing cesarean birth rates with data-driven quality
improvement activities. Peds. 103: 374-383.
Main E.K., Bloomfield, L., & Hunt, G. (2004). Development of a large-scale
obstetric quality-improvement program that focused on the nulliparous patient at
term. Am J Obstet Gynecol.190:1747-58.
Main, E.K., Moore, D., Farrell, B., Schimmel, L.D., Altman, R.J., Abrahams, C., et
al., (2006). Is there a useful cesarean birth measure? Assessment of the
nulliparous term singleton vertex cesarean birth rate as a tool for obstetric quality
improvement. Am J Obstet Gynecol. 194:1644-51.
Menacker, F. (2005).Trends in cesarean rates for first births and repeat cesarean
rates for low-risk women: United States, 1990-2003. Nat Vital Stat Rep. 54(4): 15.
Romano, P.S., Yasmeen, S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M.
(2005). Coding of perineal lacerations and other complications of obstetric care in
hospital discharge data. Am J Obstet Gynecol.106:717-25.
U.S. Department of Health and Human Services. (2000). Healthy People 2010:
Understanding and Improving Health. 2nd ed. Washington, DC: U.S.
Government Printing Office. Measure 16-9.
Yasmeen, S., Romano, P.S., Schembri, M.E., Keyzer, J.M., & Gilbert, W.M.
(2006). Accuracy of obstetric diagnoses and procedures in hospital discharge
data. Am J Obstet Gynecol. 194:992-1001.

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I-PC-05
Exclusive Breast Milk Feeding
Measure Overview
I-PC 05 Exclusive breast milk feeding during the newborn's entire
hospitalization
Overview/Details:
([FOXVLYHEUHDVWPLONIHHGLQJGXULQJWKHQHZERUQVHQWLUHKRVSLWDOL]DWLRQ
Rationale:
Exclusive breast milk feeding for the first 6 months of neonatal life has long been the
expressed goal of World Health Organization (WHO) and other authorities of women
and child health care. A recent study substantiates the benefits of exclusively feeding a
newborn infant breast milk.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Labor and Delivery units
Measure Name: Exclusive Breast Milk Feeding
Numerator: Newborns that were fed breast milk only since birth
Denominator: Term newborns discharged from the hospital
Domains of Performance

QPS
Standards

CCPC

IPSG

Appropriateness
Prevention/Early
Detection
Timeliness

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I-PC-05
Measure Details
Exclusive breast milk feeding for the first 6 months of neonatal life has long been the
expressed goal of World Health Organization (WHO) and other authorities of women and
child health care. A recent study substantiates the benefits of exclusively feeding
QHZERUQLQIDQWVEUHDVWPLON
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Newborns that were fed breast milk only since birth
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Exclusive Breast Milk Feeding
Denominator: Term newborns discharged from the hospital
.
Data elements:
x Admission Date
x Birthdate
x ICD other diagnosis code
x ICD other procedure code
x ICD principal diagnosis code
x ICD procedure code
x Reason for Not Exclusively Feeding Breast Milk
Inclusions to the population: Live-born newborns
Exclusions to the population:
x Infants admitted to the Neonatal Intensive Care Unit (NICU) during this
hospitalization
x ICD Principal Diagnosis Code or ICD Other Diagnosis Codes, for galactosemia
Table Appendix A, Table 11.21
x ICD Principal Procedure Code or ICD Other Procedure Codes for parenteral
infusion as defined in Appendix A, Table 11.22
x Newborns who die at birth
x Documented reason for Not Exclusively Feeding Breast Milk
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I-PC-05
References
x American Academy of Pediatrics. (2005). Section on Breastfeeding. Policy
Statement: Breastfeeding and the Use of Human Milk. Pediatrics.115:496 506.
x American College of Obstetricians and Gynecologists. (Feb. 2007). Committee
on Obstetric Practice and Committee on Health Care for Underserved
Women.Breastfeeding: Maternal and Infant Aspects. ACOG Committee Opinion
361.
x California Department of Public Health. (2006). Genetic Disease Branch.
California In-Hospital Breastfeeding as Indicated on the Newborn Screening Test
Form, Statewide, County and Hospital of Occurrence: Available at:
http://www.cdph.ca.gov/data/statistics/Pages/BreastfeedingStatistics.aspx.
x Centers for Disease Control and Prevention. (Aug 3, 2007). Breastfeeding trends
and updated national health objectives for exclusive breastfeeding--United States
birth years 2000-2004. MMWR - Morbidity & Mortality Weekly Report.
56(30):760-3.
x Centers for Disease Control and Prevention. (2007). Division of Nutrition,
Physical Activity and Obesity. Breastfeeding Report Card. Available at:
http://www.cdc.gov/breastfeeding/data/report_card2.htm.
x Ip, S., Chung, M., Raman, G., et al. (2007). Breastfeeding and maternal and
infant health outcomes in developed countries. Rockville, MD: US Department of
Health and Human Services. Available at:
http://www.ahrq.gov/downloads/pub/evidence/pdf/brfout/brfout.pdf
x Kramer, M.S. & Kakuma, R. (2002).Optimal duration of exclusive breastfeeding.
[107 refs] Cochrane Database of Systematic Reviews. (1):CD003517.
x Petrova, A., Hegyi, T., & Mehta, R. (2007). Maternal race/ethnicity and onemonth exclusive breastfeeding in association with the in-hospital feeding
modality. Breastfeeding Medicine. 2(2):92-8.
x Shealy, K.R., Li, R., Benton-Davis, S., & Grummer-Strawn, L.M. (2005).The CDC
guide to breastfeeding interventions. Atlanta, GA: US Department of Health and
Human Services, CDC. Available at:
http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf.
x Taveras, E.M., Li, R., Grummer-Strawn, L., Richardson, M., Marshall, R., Rego,
V.H., Miroshnik, I., & Lieu, T.A. (2004). Opinions and practices of clinicians
associated with continuation of exclusive breastfeeding. Pediatrics. 113(4):e28390.
x US Department of Health and Human Services. (2007). Healthy People 2010
Midcourse Review. Washington, DC: US Department of Health and Human
Services. Available at: http://www.healthypeople.gov/data/midcourse.
x World Health Organization. (1991). Indicators for assessing breastfeeding
practices. Geneva, Switzerland: World Health Organization. Available at:
http://www.who.int/childadolescenthealth/new_publications/nutrition/who_cdd_se
r_91.14.pdf.
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Appendix A
Perinatal Care ICD Code Tables
ICD Codes
Please Note : Due to the various ICD Code versions used by different countries,
ICD-8, ICD-9,and ICD-10 spaces have been left intentionally blank. Please fill in
the specific code utilized by your country to correspond to the ICD-9-CM code
description for the following diagnoses.
Table 11.05
Medical Induction of Labor Codes
ICD-8
ICD-9
ICD-10
ICD-9Shortened Description
Code
Code
Code
CMCode
73.01
INDUCT LABOR-RUPT MEMB

Table 11.06
Cesarean Section
ICD-8
ICD-9
Code
Code

ICD-10
Code

73.1

SURG INDUCT LABOR NEC

73.4

MEDICAL INDUCTION LABOR

ICD-9Shortened Description
CMCode
74.0
CLASSICAL C-SECTION
74.1

LOW CERVICAL SECTION

74.2

EXTRAPERITONEAL C-SECTION

74.4

CESAREAN SECTION NEC

74.99

CESAREAN SECTION NOS

Table 11.07
Conditions Justifying Elective Delivery
ICD-8
ICD-9
ICD-10
ICD-9Shortened Description
Code
Code
Code
CMCode
641.01 PLACENTA PREVIA-DELIVER
641.11

PLACENTA PREV HEM-DELIV

641.21

PREM SEPAR PLACEN-DELIV

641.31

COAG DEF HEMORR-DELIVER

641.81

ANTEPARTUM HEM NEC-DELIV

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9Shortened Description
CMCode
641.91 ANTEPARTUM HEM NOS-DELIV
642.01

ESSEN HYPERTEN-DELIVERED

642.02

ESSEN HYPERTEN-DEL W P/P

642.11

RENAL HYPERTEN PG-DELIV

642.12

RENAL HYPERTEN-DEL P/P

642.21

OLD HYPERTEN NEC-DELIVER

642.22

OLD HYPERTEN-DELIV W P/P

642.31

TRANS HYPERTEN-DELIVERED

642.32

TRANS HYPERTEN-DEL W P/P

642.41

MILD/NOS PREECLAMP-DELIV

642.42

MILD PREECLAMP-DEL W P/P

642.51

SEVERE PREECLAMP-DELIVER

642.52

SEV PREECLAMP-DEL W P/P

642.61

ECLAMPSIA-DELIVERED

642.62

ECLAMPSIA-DELIV W P/P

642.71

TOX W OLD HYPERTEN-DELIV

642.72

TOX W OLD HYP-DEL W P/P

642.91

TOX W OLD HYP-DEL W P/P

642.92

HYPERTENS NOS-DEL W P/P

645.11

POST TERM PREG-DEL

645.21

PROLONGED PREG-DEL

646.21

RENAL DIS NOS-DELIVERED

646.22

RENAL DIS NOS-DEL W P/P

646.71

LIVER DISORDER-DELIVERED

648.02

DIABETES-DELIVERED W P/P

648.51

CONGEN CV DIS-DELIVERED

648.52

CONGEN CV DIS-DEL W P/P

648.61

CV DIS NEC PREG-DELIVER

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143

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9Shortened Description
CMCode
648.62 CV DIS NEC-DELIVER W P/P
648.81

ABN GLUCOSE TOLER-DELIV

648.82

ABN GLUCOSE-DELIV W P/P

649.31

COAGULATION DEF-DELIV

649.32

COAGULATN DEF-DEL W P/P

649.73

CERVICAL SHORTENING-ANTE

651.01

TWIN PREGNANCY-DELIVERED

651.11

TRIPLET PREGNANCY-DELIV

651.21

QUADRUPLET PREG-DELIVER

651.31

TWINS W FETAL LOSS-DEL

651.41

TRIPLETS W FET LOSS-DEL

651.51

QUADS W FETAL LOSS-DEL

651.61

MULT GES W FET LOSS-DEL

651.71

MULT GEST-FET REDUCT DEL

651.81

MULTI GESTAT NEC-DELIVER

651.91

MULT GESTATION NOS-DELIV

652.01

UNSTABLE LIE-DELIVERED

652.11

CEPHALIC VERS NOS-DELIV

652.21

BREECH PRESENTAT-DELIVER

652.31

TRANSVER/OBLIQ LIE-DELIV

652.41

FACE/BROW PRESENT-DELIV

652.51

HIGH HEAD AT TERM-DELIV

652.61

MULT GEST MALPRES-DELIV

654.31

RETROVERT UTERUS-DELIVER

654.32

RETROVERT UTER-DEL W P/P

655.01

FETAL CNS MALFORM-DELIV

655.11

FETAL CHROMOSO ABN-DELIV

655.31

FET DAMG D/T VIRUS-DELIV

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9Shortened Description
CMCode
655.41 FET DAMG D/T DIS-DELIVER
655.51

FET DAMAG D/T DRUG-DELIV

656.61

EXCESS FETAL GRTH-DELIV

656.01

FETAL-MATERNAL HEM-DELIV

656.11

RH ISOIMMUNIZAT-DELIV

656.21

ABO ISOIMMUNIZAT-DELIV

656.41

INTRAUTER DEATH-DELIV

656.51

POOR FETAL GROWTH-DELIV

657.01

POLYHYDRAMNIOS-DELIV

658.01

OLIGOHYDRAMNIOS-DELIV

658.11

PREM RUPT MEMBRAN-DELIV

658.21

PROLONG RUPT MEMB-DELIV

V27.1

DELIVER- SINGLE-STILLBORN

Table 11.08 Outcome of Delivery


ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
V27.0

Shortened Description
DELIVER-SINGLE LIVEBORN

Table 11.09 Contraindications to Vaginal Delivery


ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode

Shortened Description

644.20

EARLY ONSET DELIV-UNSPEC

644.21

EARLY ONSET DELIVERY-DEL

651.00

TWIN PREGNANCY-UNSPEC

651.01

TWIN PREGNANCY-DELIVERED

651.03

TWIN PREGNANCY-ANTEPART

651.10

TRIPLET PREGNANCY-UNSPEC

651.11

TRIPLET PREGNANCY-DELIV

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode

Shortened Description

651.13

TRIPLET PREG-ANTEPARTUM

651.20

QUADRUPLET PREG-UNSPEC

651.21

QUADRUPLET PREG-DELIVER

651.23

QUADRUPLET PREG-ANTEPART

651.30

TWINS W FETAL LOSS-UNSP

651.31

TWINS W FETAL LOSS-DEL

651.33

TWINS W FETAL LOSS-ANTE

651.40

TRIPLETS W FET LOSS-UNSP

651.41

TRIPLETS W FET LOSS-DEL

651.43

TRIPLETS W FET LOSS-ANTE

651.50

QUADS W FETAL LOSS-UNSP

651.51

QUADS W FETAL LOSS-DEL

651.53

QUADS W FETAL LOSS-ANTE

651.60

MULT GES W FET LOSS-UNSP

651.61

MULT GES W FET LOSS-DEL

651.63

MULT GES W FET LOSS-ANTE

651.80

MULTI GESTAT NEC-UNSPEC

651.81

MULTI GESTAT NEC-DELIVER

651.83

MULTI GEST NEC-ANTEPART

651.90

MULTI GESTAT NOS-UNSPEC

651.91

MULT GESTATION NOS-DELIV

651.93

MULTI GEST NOS-ANTEPART

652.20

BREECH PRESENTAT-UNSPEC

652.21

BREECH PRESENTAT-DELIVER

652.23

BREECH PRESENT-ANTEPART

652.30

TRANSV/OBLIQ LIE-UNSPEC

652.31

TRANSVER/OBLIQ LIE-DELIV

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode

Shortened Description

652.33

TRANSV/OBLIQ LIE-ANTEPAR

652.40

FACE/BROW PRESENT-UNSPEC

652.41

FACE/BROW PRESENT-DELIV

652.43

FACE/BROW PRES-ANTEPART

652.60

MULT GEST MALPRESEN-UNSP

652.61

MULT GEST MALPRES-DELIV

652.63

MULT GES MALPRES-ANTEPAR

654.20

PREV C-DELIVERY UNSPEC

654.21

PREV C-DELIVERY-DELIVRD

654.23

PREV C-DELIVERY-ANTEPART

656.40

INTRAUTERINE DEATH-UNSPEC

656.41

INTRAUTER DEATH-DELIV

656.43

INTRAUTER DEATH-ANTEPART

660.50

LOCKED TWINS-UNSPECIFIED

660.51

LOCKED TWINS-DELIVERED

660.53

LOCKED TWINS-ANTEPARTUM

662.30

DELAY DEL 2ND TWIN-UNSP

662.31

DELAY DEL 2ND TWIN-DELIV

662.33

DELAY DEL 2 TWIN-ANTEPAR

669.60

BREECH EXTR NOS-UNSPEC

669.61

BREECH EXTR NOS-DELIVER

761.5

MULT PREGNANCY AFF NB

V27.1

DELIVER SINGLE-STILLBORN

V27.2

DELIVER-TWINS, BOTH LIVE

V27.3

DEL-TWINS, 1 NB, 1 SB

V27.4

DELIVER-TWINS, BOTH SB

V27.5

DEL-MULT BIRTH, ALL LIVE

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147

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode

Shortened Description

V27.6

DEL-MULT BIRTH, SOME LIVE

V27.7

DEL-MULT BIRTH, ALL SB

Table 11.20.1 Term Gestation


ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
765.29

Shortened Description
37+ Comp WKS GESTATION

Table 11.21 Galactosemia


ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
271.1

Shortened Description
GALACTOSEMIA

Table 11.22 Parenteral Infusion


ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
99.15

Shortened Description
PARENT INFUS NUTRIT SUB

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Pneumonia (PN)
Measure Set

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149

Measure
Code
Measure Description

Pneumonia (PN)
Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

I-PN-2

Pneumonia patients, aged 65 and older, who were screened for


pneumococcal vaccine status and were administered the vaccine prior
to discharge, if indicated

I-PN-4

Adult smoking cessation advice/counseling given to patients who


smoke cigarettes and who are hospitalized for pneumonia

I-PN-7

Pneumonia patients, aged 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to
discharge, if indicated

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150

I-PN-2
Pneumococcal Vaccination
Measure Overview
I-PN 2 Pneumonia patients, aged 65 and older, who were screened for
pneumococcal vaccine status and were administered the vaccine prior to
discharge, if indicated
Overview/Details:
Patients (aged 65 and older) who were diagnosed with pneumonia, and who received
pneumococcal vaccine prior to discharge from the hospital.
Rationale:
Pneumococcal vaccination is indicated for persons 65 years of age and older because it
is up to 75% effective in preventing pneumococcal bacteremia and meningitis. It is also
an important vaccine due to increasing antibiotic resistance among pneumocci.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: Increase in rate
Patient Settings/Services
Intensive Care Units
Medical/Surgical units
Measure Name: Pneumococcal Vaccination
Numerator: Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if indicated.
Denominator: Pneumonia patients 65 years of age and older.

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Domains of
Performance

QPS

Appropriateness

QPS.3 patient
assessments

Availability
Continuity
Effectiveness
Prevention/Early
Detection

CCPC

IPSG

AMI

Goal 1

Standards
HF

Stroke
QPS.3 infection
Diabetes (Type I/II)
prevention and control,
ESRD
surveillance and
reporting
Traumatic

Timeliness

Brain Injury
HIV/AIDS
Asthma
COPD

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I-PN-2
Measure Details
Reasons and Implications: Pneumococcal vaccination is indicated for persons 65
years of age and older because it is up to 75% effective in preventing pneumococcal
bacteremia and meningitis. It is also an important vaccine due to increasing
antibiotic resistance for pneumococcal infection. Inpatient vaccine screening and
administration are recommended, and hospitalization is an underutilized opportunity
for adult vaccination.
Data Collection:
Retrospective data sources for the required data elements include administrative
data and medical records.
Numerator: Patients with pneumonia, age 65 and older, who were screened for
pneumococcal vaccine status and were vaccinated prior to discharge, if indicated.
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Pneumococcal Vaccination Status
Denominator: Pneumonia patients 65 years of age and older.
Data elements:
x Admission Date
x Birthdate
x Chest X-ray
x ICD principal or other diagnosis code
Inclusions to the population: Patients with ICD principal diagnosis code of
pneumonia as defined in Appendix A, Table 3.1 or an other diagnosis code of
pneumonia (Appendix A, Table 3.1)
Exclusions to the population:
x Patients less than 65 years of age
x Patients who left against medical advice
x Patients who had no chest x-ray or CT scan that indicated abnormal findings
within 24 hours prior to or during this hospital stay
x Patients who expired
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I-PN-2
References
x
x

x
x

x
x

Bratzler DW, Houck PM, Jiang H, et al. Failure to vaccinate Medicare


inpatients: a missed opportunity. Arch Intern Med 2002;162:23492356.
Centers for Disease Control and Prevention. General
recommendations on immunization. Recommendations of the Advisory
Committee on Immunization Practices (ACIP) and the American
Academy of Family Physicians (AAFP). MMWR. 2002;51(RR02):1-36.
Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and
SQHXPRFRFFDOYDFFLQDWLRQ6XWWRQV/DZDSSOLHGWRSUHYHQWLRQInfect
Control Hosp Epi. 2000;21:692-699.
Fine MF, Smith MAA, Carson CA, Meffe P, Sankery SS, Weissfeld LA,
Detsky AS, Kapoor WN. Efficacy of pneumococcal vaccination in
adults: a meta-analysis of randomized controlled trials. Arch Intern
Med. 1994(December); 154:2666-2677.
Kissam S, Gifford DR, Patry G, et al. Is signed consent for influenza or
pneumococcal polysaccharide vaccination required? Arch Intern Med
2004; 164:13-16.
Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious
Diseases Society of America; American Thoracic Society. Infectious
Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
Sisk JE, Moskowitz AJ, Whang W, et al. Cost-effectiveness of
vaccination against pneumococcal bacteremia among elderly people.
JAMA, 1997; 278:1333-1339.

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154

I-PN 4
Adult Smoking Counseling
Measure Overview
I-PN 04 Adult smoking cessation advice/counseling given to patients who
smoke cigarettes and who are hospitalized for pneumonia.
Overview/Details:
Smoking cessation advice/counseling given to patients who had pneumonia.
NOTE: For the purposes of this measure, a smoker is defined as someone who has
smoked cigarettes anytime during the year prior to hospital arrival.
Rationale:
Smoking cessation reduces mortality and morbidity in all populations. Patients who
receive even brief smoking-cessation advice from their health care providers are more
likely to quit than those who receive no counseling whatsoever.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement Noted as: An increase in the rate
Patient Settings/Services: Medical/Surgical units
Measure Name: Adult smoking cessation advice/counseling
Numerator: Pneumonia patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Denominator: Pneumonia patients 18 years of age and older with a history of smoking
cigarettes anytime during the year prior to hospital arrival
Domains of Performance

QPS Standards

CCPC

Appropriateness

QPS.3 patient
assessments

HF

Continuity

IPSG

Stroke

Effectiveness

Diabetes

Prevention/Early Detection

Traumatic Brain Injury


Asthma
COPD

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I-PN 4
Measure Details
Reasons and Implications: Smoking cessation may reduce mortality and morbidity in
all populations. Patients who receive even brief smoking-cessation advice from their
health care providers are more likely to quit. Clinical guidelines strongly recommend
smoking cessation counseling for smokers. Hospitalization can be an ideal opportunity
IRUDSDWLHQWWRVWRSVPRNLQJDQGVPRNLQJFHVVDWLRQPD\SURPRWHWKHSDWLHQWV
medical recovery.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Pneumonia patients (cigarette smokers) who receive smoking cessation
advice or counseling during the hospital stay
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Adult Smoking Counseling
Denominator: Pneumonia patients 18 years of age and older with a history of
smoking cigarettes anytime during the year prior to hospital arrival
Data elements:
x Adult Smoking History
x Birthdate
x ICD Principal Diagnosis Code or Other
x Chest X-ray
Inclusions to the population: Patients with ICD principal diagnosis code for
pneumonia as defined in Appendix A, Table 3.1 and a history of smoking cigarettes
anytime during the year prior to hospital arrival
Exclusions to the population:
x Patients less than 18 years of age
x Patients who left against medical advice
x Patients who expired
x Patients who had no chest x-ray or CT scan that indicated abnormal findings
within 24 hours prior to or during this hospital stay
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I-PN-4
References
x

x
x

x
x

Fiore MC, Jan CR, Baker TB, et al. Treating Tobacco Use and
Dependence: 2008 Update. Clinical Practice Guideline. Rockville, MD:
U.S. Department of Health and Human Services. Public Health
Service. May 2008.
HXGPRQ.6+HPEHUJHU..&RUHOOL5/HWDO7KHSKDUPDFLVWVUROHLQ
smoking cessation counseling: perceptions of users of nonprescription
nicotine replacement therapy. J Am Pharm Assoc 2003; 43(5):573582.
Kikano GE, et al: The value of brief, targeted smoking-cessation
advice. Family Practice Management. pp. 50-2000.
Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious
Diseases Society of America; American Thoracic Society. Infectious
Diseases Society of America/American Thoracic Society consensus
guidelines on the management of community-acquired pneumonia in
adults. Clin Infect Dis. 2007 March 1;44 Suppl 2:S27-72.
Sheahan SL. How to help older adults quit smoking. Nurse Pract 2002;
27:27-33.
The Smoking Cessation Clinical Practice Guideline Panel and Staff:
The Agency for Health Care Policy and Research. Smoking Cessation
Clinical Practice Guideline. JAMA, 275:1270-1280, 1996.

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157

I-PN 7
Influenza Vaccination
Measure Overview
I-PN 07 Pneumonia patients, aged 50 and older, who during the flu season, were
screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated
Overview/Details:
Patients (aged 50 and older) who were diagnosed with pneumonia (during the flu
season), and who received influenza vaccine prior to discharge from the hospital.
Rationale:
Pneumococcal vaccination is indicated for persons 50 years of age and older because it
is highly effective in preventing influenza-related pneumonia.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement Noted as: An increase in rate/score/number of occurrences
Patient Settings/Services
Intensive Care Units
Medical/Surgical units
Measure Name: Influenza Vaccination
Numerator: Patients with pneumonia, age 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated.
Denominator: Pneumonia patients 50 years and older (during the flu season)

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158

Domains of Performance

QPS Standards

CCPC

IPSG

Appropriateness

QPS.3 patient
assessments

AMI

*RDO

Availability

HF

Continuity

Stroke
QPS.3

infection
Effectiveness
Diabetes (Type I/II)
prevention and
Prevention/Early Detection control, surveillance, Traumatic Brain Injury
and reporting
Timeliness
Asthma
COPD

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159

I-PN 7
Measure Details
Reasons and Implications: Influenza vaccination is indicated for persons 50 years of
age and older because it is highly effective in preventing influenza related pneumonia,
hospitalization and death. Inpatient vaccine screening and administration are
recommended especially during the flu season, and hospitalization is an underutilized
opportunity to provide vaccination to adults.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Patients with pneumonia, age 50 and older, who during the flu season,
were screened for influenza vaccine status and were vaccinated prior to discharge, if
indicated.
Inclusions to the population: Not Applicable
Exclusions to the population: None
Data elements:
x Influenza Vaccination Status
Denominator: Pneumonia patients 50 years of age and older (during the flu season)
Data elements:
x Admission Date
x Birthdate
x Chest X-ray
x ICD principal or other diagnosis code
Inclusions to the population: Patients with ICD principal diagnosis code of pneumonia
as defined in Appendix A, Table 3.1 or an other diagnosis code of pneumonia
(Appendix A, Table 3.1)
Exclusions to the population:
x Patients less than 50 years of age
x Patients who left against medical advice
x Patients who had no chest x-ray or CT scan that indicated abnormal findings
within 24 hours prior to or during this hospital stay
x Patients who expired
x Patients with a secondary diagnosis of influenza pneumonia
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I-PN - 7
References
x
x
x
x

Centers for Disease Control. Prevention of Influenza. Recommendations of the


Advisory Committee on Immunization Practices (ACIP). MMWR. April
2002;51(No.RR-02):1-36.
Fedson DS, Houck PM, Bratzler D. Hospital-based influenza and pneumococcal
YDFFLQDWLRQ6XWWRQV/DZDSSOLHGWRSUHYHQWLRQInfect Control Hosp Epi.
2000;21:692-699.
Kissam S, Gifford DR, Patry G, et al. Is signed consent for influenza or
pneumococcal polysaccharide vaccination required? Arch Intern Med 2004; 164:1316.
Mandell LA, Wunderink RG, Anzueta A, Bartlett JG, Infectious Diseases Society of
America; American Thoracic Society. Infectious Diseases Society of
America/American Thoracic Society consensus guidelines on the management of
community-acquired pneumonia in adults. Clin Infect Dis. 2007 March 1;44 Suppl
2:S27-72.

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161

Appendix A
ICD Codes
Please Note: Due to the various ICD Code versions used by different countries, ICD-8,
ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in the specific
code utilized by your country to correspond to the ICD-9-CM code description for the
following diagnoses.

Table 3.1
Pneumonia (PN)
ICD-8
ICD-9
Code
Code

ICD-10
Code

ICD-9Shortened Description
CMCode
481
PNEUMOCOCCAL PNEUMONIA
482.0

K. PNEUMONIAE PNEUMONIA

482.1

PSEUDOMONAL PNEUMONIA

482.2

H.INFLUENZAE PNEUMONIA

482.30

STREPTOCOCCAL PNEUMN NOS

482.31

PNEUMONIA STRPTOCOCCUS A

482.32

PNEUMONIA STRPTOCOCCUS B

482.39

PNEUMONIA OTH STREP

482.40

STAPHYLOCOCCAL PNEU NOS

482.41

METH SUS PNEUM D/T STAPH

482.42

METH RES PNEU D/T STAPH

482.49

STAPH PNEUMONIA NEC

482.82

PNEUMONIA E COLI

482.83

PNEUMO OTH GRM-NEG BACT

482.84

LEGIONNAIRES' DISEASE

482.89

PNEUMONIA OTH SPCF BACT

482.9

BACTERIAL PNEUMONIA NOS

483.0

PNEU MYCPLSM PNEUMONIAE

483.1

PNEUMONIA D/T CHLAMYDIA

483.8

PNEUMON OTH SPEC ORGNSM

485

BRONCHOPNEUMONIA ORG NOS

486

PNEUMONIA, ORGANISM NOS

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162

Surgical Care
Improvement Project
(SCIP)
Measure Set

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163

Measure
Code
Measure Description

Surgical Care Improvement Project (SCIP)


Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

Prophylactic antibiotics received one hour prior to surgical incision for


I-SCIP-Inf-1d hip arthroplasty patients
Prophylactic antibiotics received one hour prior to surgical incision for
I-SCIP-Inf-1e knee arthroplasty patients
Surgical patients (hip arthroplasty) who received prophylactic
I-SCIP-Inf-2d antibiotics consistent with current guidelines
Surgical patients (knee arthoplasty) who received prophylactic
I-SCIP-Inf-2e antibiotics consistent with current guidelines
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were
I-SCIP-Inf-3d discontinued within 24 hours after anesthesia end time
Surgical patients (knee arthroplasty) whose prophylactic antibiotics
I-SCIP-Inf-3e were discontinued within 24 hours after anesthesia end time
Surgical patients (hip/knee arthroplasty) with recommended venous
thromboembolism (VTE) prophylaxis ordered anytime from hospital
I-SCIP-VTE-1 arrival to 24 hours after Anesthesia End Time
Surgical patients who received appropriate venous thromboembolism
(VTE) prophylaxis within 24 hours prior to anesthesia start time to 24
I-SCIP-VTE-2 hours after anesthesia end time

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164

I-SCIP-Inf-1d
Prophylactic Antibiotic Received
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 1d Prophylactic antibiotics received within one hour prior to surgical
incision for hip arthroplasty patients.
Overview/Details:
Surgical patients (hip arthroplasty) with prophylactic antibiotics initiated within one hour
prior to surgical incision.
Note: Patients who received vancomycin or a fluroquinolone for prophylactic antibiotics should
have the antibiotics initiated within two hours prior to a surgical incision. Due to the longer
infusion time required for vancomycin or a fluroquinolone, it is acceptable to start these
antibiotics within two hours prior to incision time.

Rationale:
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels
at the time of skin incision. Clinical studies have demonstrated that a common reason
for failure of prophylaxis was delay of antibiotic administration until after the operation.
In a comprehensive study, it was found that the lowest incidence of post-operative
infection was associated with antibiotic administration during the one hour prior to
surgery. The risk of infection increased progressively with greater time intervals
between administration and skin incision. Therefore, opportunities to improve care have
been demonstrated and timely administration has been recommended.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services:
Medical/surgical units
Measure Name: Prophylactic antibiotic received within one hour prior to surgical
incision for hip arthroplasty.
Numerator: Number of surgical patients (hip arthroplasty) with prophylactic antibiotics
initiated within one hour prior to surgical incision
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection and who are > = 18 years.
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Domains of Performance QPS

CCPC

IPSG

Joint
Replacement

*RDO

Standards
Appropriateness
Availability

QPS.3 surgical
procedures

Continuity
Effectiveness
Prevention/Early
Detection
Timeliness

Goal 4
Goal 5

QPS.3 antibiotics and


other mediation use
QPS.3 infection,
prevention and control,
surveillance and reporting

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166

I-SCIP-Inf-1d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to establish bactericidal
tissue and serum levels at the time of skin incision. Clinical studies have demonstrated that
a common reason for failure of prophylaxis was delay of antibiotic administration until after
the operation. In a comprehensive study, it was found that the lowest incidence of postoperative infection was associated with antibiotic administration during the one hour prior to
surgery. The risk of infection increased progressively with greater time intervals between
administration and skin incision. Therefore, opportunities to improve care have been
demonstrated and timely administration has been recommended.
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Numerator: Number of surgical patients (hip arthroplasty) with prophylactic antibiotics
initiated within one hour prior to surgical incision
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Anesthesia start date
x Antibiotic administration date
x Antibiotic administration time
x Surgical incision time
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection and who are >= 18 years.
Data elements:
x Admission date
x Anesthesia start date
x Antibiotic name
x Antibiotic received
x Antibiotic administration route
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure Code
x Infection prior to anesthesia
x Other surgeries
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167

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04).
Exclusions to the population:
x Patients less than 18 years of age
x Patients who had a previous diagnosis suggestive of preoperative infectious disease
(as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to the surgical procedure of interest (hip
arthroplasty)
x Patients who had other procedures requiring general or spinal anesthesia that
occurred within 3 days prior to or after the procedure of interest (during separate
surgical episodes) during this hospital stay
x Patients who were receiving antibiotics within 24 hours prior to arrival
x Patients who were receiving antibiotics more than 24 hours prior to surgery

2011 Joint Commission International



168

I-SCIP-Inf-1d
References
x

x
x
x
x
x
x
x
x
x
x

Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):17061715.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in
selected inpatient surgical procedures. Am J Surg. 1996;171:548-552.
Larsen RA, Evans RS, Burke JP, et al. Improved perioperative antibiotic use and
reduced surgical wound infections through use of computer decision analysis.
Infect Control Hosp Epidemiol. 1989;10:316-320.
Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic
prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097.
Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care:
administration of preoperative antibiotics in the operating room. Am Surg.
1997;63:500-503.
Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients
undergoing common surgical procedures in a community teaching hospital: the
chaos continues. World J Surg. 1999;23:429-432.
Bernard HR, Cole WR. The prophylaxis of surgical infections: the effect of
prophylactic antimicrobial drugs on the incidence of infection following potentially
contaminated operations. Surgery. 1964;56:151-157.
Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of
determinant factors and prevention. Surgery. 1969;66:97-103.
Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary,
and colonic surgery. Ann Surg. 1976;184:443-452.
American College of Obstetricians and Gynecologists (ACOG) Committee on
Practice Bulletins ACOG Practice Bulletin No 104 Antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol May 2009; 113(5) : 1180-1189.

2011 Joint Commission International



169

I-SCIP-Inf-1e
Prophylactic Antibiotics Received
(Knee arthroplasty)
Measure Overview
I-SCIP-Inf 1e Prophylactic antibiotics received within one hour prior to surgical
incision for knee arthroplasty patients.
Overview/Details:
Surgical patients (knee arthroplasty) with prophylactic antibiotics initiated within one
hour prior to surgical incision.
Note: Patients who received vancomycin or a fluroquinolone for prophylactic antibiotics should
have the antibiotics initiated within two hours prior to a surgical incision. Due to the longer
infusion time required for vancomycin or a fluroquinolone, it is acceptable to start these
antibiotics within two hours prior to incision time.

Rationale:
A goal of prophylaxis with antibiotics is to establish bactericidal tissue and serum levels
at the time of skin incision.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services:
Medical/surgical units
Measure Name: Prophylactic antibiotic received within one hour prior to surgical
incision.
Numerator: Number of surgical patients (knee arthroplasty) with prophylactic antibiotics
initiated within one hour prior to surgical incision
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of
prior infection and > = 18 years.

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170

Domains of
Performance

QPS

Availability
Effectiveness

IPSG

Joint
Replacement

*RDO

Standards

Appropriateness QPS.3 surgical procedures


Continuity

CCPC

QPS.3 antibiotics and other


mediation use

Goal 4
Goal 5

Prevention/Early
Detection
Timeliness

QPS.3 infection, prevention


and control, surveillance and
reporting

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171

I-SCIP-Inf-1e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to establish
bactericidal tissue and serum levels at the time of skin incision. Clinical studies have
demonstrated that a common reason for failure of prophylaxis was delay of antibiotic
administration until after the operation. In a comprehensive study, it was found that the
lowest incidence of post-operative infection was associated with antibiotic administration
during the one hour prior to surgery. The risk of infection increased progressively with
greater time intervals between administration and skin incision. Therefore, opportunities to
improve care have been demonstrated and timely administration has been recommended.
Data Collection:
Retrospective data sources for the required data elements include administrative data and
medical records.
Numerator: Number of surgical patients (knee arthroplasty) with prophylactic antibiotics
initiated within one hour prior to surgical incision
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Anesthesia start date
x Antibiotic administration date
x Antibiotic administration time
x Surgical incision time
Denominator: All selected surgical patients (knee arthoplasty) with no evidence of prior
infection and who are >= 18 years.
Data elements:
x Admission date
x Anesthesia start date
x Antibiotic name
x Antibiotic received
x Antibiotic administration route
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Infection prior to anesthesia
x Other surgeries
2011 Joint Commission International

172

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.05).
Exclusions to the population:
x Patients less than 18 years of age
x Patients who had a previous diagnosis suggestive of preoperative infectious disease
(as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest (knee
arthroplasty)
x Patients who were receiving antibiotics within 24 hours prior to arrival
x Patients who had other procedures requiring general or spinal anesthesia that
occurred within 3 days prior to or after the procedure of interest (during separate
surgical episodes) during this hospital stay
x Patients who were receiving antibiotics more than 24 hours prior to surgery
x Patients who were receiving antibiotics within 24 hours prior to arrival.

2011 Joint Commission International



173

I-SCIP-Inf-1e
References
x

x
x
x
x
x
x
x
x
x
x

Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):17061715.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
Silver A, Eichorn A, Kral J, et al. Timeliness and use of antibiotic prophylaxis in
selected inpatient surgical procedures. Am J Surg. 1996;171:548-552.
Larsen RA, Evans RS, Burke JP, et al. Improved perioperative antibiotic use and
reduced surgical wound infections through use of computer decision analysis.
Infect Control Hosp Epidemiol. 1989;10:316-320.
Finkelstein R, Reinhertz G, Embom A. Surveillance of the use of antibiotic
prophylaxis in surgery. Isr J Med Sci. 1996;32:1093-1097.
Matuschka PR, Cheadle WG, Burke JD, et al. A new standard of care:
administration of preoperative antibiotics in the operating room. Am Surg.
1997;63:500-503.
Gorecki P, Schein M, Rucinski JC, et al. Antibiotic administration in patients
undergoing common surgical procedures in a community teaching hospital: the
chaos continues. World J Surg. 1999;23:429-432.
Bernard HR, Cole WR. The prophylaxis of surgical infections: the effect of
prophylactic antimicrobial drugs on the incidence of infection following potentially
contaminated operations. Surgery. 1964;56:151-157.
Polk HC, Lopez-Mayor JF. Postoperative wound infection: a prospective study of
determinant factors and prevention. Surgery. 1969;66:97-103.
Stone HH, Hooper CA, Kolb LD, et al. Antibiotic prophylaxis in gastric, biliary,
and colonic surgery. Ann Surg. 1976;184:443-452.
American College of Obstetricians and Gynecologists (ACOG) Committee on
Practice Bulletins ACOG Practice Bulletin No 104 Antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol May 2009; 113(5) : 1180-1189.

2011 Joint Commission International



174

I-SCIP-Inf-2d
Prophylactic Antibiotic Selection
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 2d Prophylactic antibiotic selection for surgical patients (hip
arthroplasty).
Overview/Details:
Surgical patients (hip arthroplasty) who received prophylactic antibiotics consistent with
current guidelines.
Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, costeffective, and has a spectrum of action that covers most of the probable intraoperative
contaminants for the operation. First or second-generation cephalosporins satisfy these
criteria for most operations, although anaerobic coverage is needed for colon surgery.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services: Medical/surgical units
Measure Name: Prophylactic antibiotic selection for surgical patients (hip arthroplasty)
Numerator: Number of surgical patients (hip arthroscopy) who received prophylactic
antibiotics recommended for their specific surgical procedure.
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection who are >= 18 years.

2011 Joint Commission International



175

Domains of
Performance

QPS

Appropriateness

QPS.3 surgical procedures

Effectiveness

IPSG

Joint
Replacement

*RDO

Standards

Availability
Continuity

CCPC

QPS.3 antibiotics and other


mediation use

Goal 4
Goal 5

Prevention/Early
Detection

QPS.3 infection, prevention


and control, surveillance and
reporting

2011 Joint Commission International



176

I-SCIP-Inf-2d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to use an agent
that is safe, cost-effective, and has a spectrum of action that covers most of the
probable intraoperative contaminants for the operation. First or second-generation
cephalosporins satisfy these criteria for most operations, although anaerobic coverage
is needed for colon surgery. Vancomycin is not recommended for routine use because
of the potential for development of antibiotic resistance, but is acceptable if a patient is
allergic to beta-lactams, as are fluoroquinolones and clindamycin in selected situations.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Number of surgical patients (hip arthroplasty) who received prophylactic
antibiotics recommended for their specific surgical procedure.
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Antibiotic Administration Route
x Antibiotic Allergy
x Antibiotic Name
x Vancomycin
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of
prior infection and are >= 18 years.
Data elements:
x Admission date
x Antibiotic administration date
x Antibiotic administration time
x Antibiotic received
x Antibiotic admission route
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Infection prior to anesthesia
x Surgical Incision time
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177

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04.)
Exclusions to the population:
x Patients less than 18 years of age
x Patients who had a previous diagnosis suggestive of preoperative infectious
disease (as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest (hip
arthroplasty)
x Patients who were receiving antibiotics within 24 hours prior to arrival
x Patients who were receiving antibiotics more than 24 hours prior to surgery
x Patients who did not receive any antibiotics before or during surgery, or within
24 hours after Anesthesia End time (i.e., patient did not receive prophylactic
antibiotics)
x Patients who did not receive any antibiotics during this hospitalization

2011 Joint Commission International



178

I-SCIP-Inf-2d
References
x

x
x
x
x
x
x

Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):17061715.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
American Society of Health-System Pharmacists. ASHP therapeutic guidelines
on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:18391888.
No author listed. The Medical letter. Antimicrobial prophylaxis for Surgery. Med
Lett Drugs Ther. 2009; 82: 47-52.
Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial
prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427.
Gilbert DN, Moellering RC Jr., Elipoulos GM, Chamber HF, Saag MS, eds. The
Sanford Guide to Antimicrobial Therapy 2009. 39st ed. Sperryville, VA:
Antimicrobial Therapy, Inc; 2009.
Itani KMF, Wilson SE, Awad SS, Jensen EH, Finn TS, Abramson MA. Ertapenem
versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 2006
Dec 21; 355 (25): 2640-2651.
Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical
wounds. Arch Surg. 1993;128:79-88.
American College of Obstetricians and Gynecologists (ACOG) Committee on
Practice Bulletins ACOG Practice Bulletin No 104 Antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol May 2009; 113(5) : 1180-1189.

2011 Joint Commission International



179

I-SCIP-Inf-2e
Prophylactic Antibiotic Selection
(Knee arthroplasty)
Measure Overview
I-SCIP-Inf 2e Prophylactic antibiotic selection for surgical patients (knee
arthoplasty).
Overview/Details:
Surgical patients (knee arthroplasty) who received prophylactic antibiotics consistent
with current guidelines.
Rationale: A goal of prophylaxis with antibiotics is to use an agent that is safe, costeffective, and has a spectrum of action that covers most of the probable intraoperative
contaminants for the operation. First or second-generation cephalosporins satisfy these
criteria for most operations, although anaerobic coverage is needed for colon surgery.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services: Medical/surgical units
Measure Name: Prophylactic antibiotic selection for surgical patients (knee
arthroplasty).
Numerator: Number of surgical patients (knee arthroplasty) who received prophylactic
antibiotics recommended for their specific surgical procedure.
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of
prior infection who are >= 18 years.
Domains of Performance

QPS Standards

Appropriateness

QPS.3 surgical procedures

Availability
Continuity

CCPC

Joint
QPS.3 antibiotics and other Replacement
mediation use

IPSG
*RDO
Goal 4
Goal 5

QPS.3 infection, prevention


and control, surveillance and
Prevention/Early Detection reporting
Effectiveness

2011 Joint Commission International



180

I-SCIP-Inf-2e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to use an agent
that is safe, cost-effective, and has a spectrum of action that covers most of the
probable intraoperative contaminants for the operation. First or second-generation
cephalosporins satisfy these criteria for most operations, although anaerobic
coverage is needed for colon surgery. Vancomycin is not recommended for routine
use because of the potential for development of antibiotic resistance, but is
acceptable if a patient is allergic to beta-lactams, as are fluoroquinolones and
clindamycin in selected situations.
Data Collection:
Retrospective data sources for the required data elements include administrative
data and medical records.
Numerator: Number of surgical patients (knee arthroplasty) who received
prophylactic antibiotics recommended for their specific surgical procedure.
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Antibiotic administration route
x Antibiotic allergy
x Antibiotic name
x Vancomycin
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of
prior infection and are >= 18 years.
Data elements:
x Admission date
x Antibiotic administration date
x Antibiotic administration time
x Antibiotic Received
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Infection prior to anesthesia
x Surgical Incision time
2011 Joint Commission International

181

Inclusions to the population: ICD Principal Procedure Code of selected surgeries


(as defined in Appendix A, Table 5.05).
Exclusions to the population:
x Patients less than 18 years of age
x Patients who had a previous diagnosis suggestive of preoperative infectious
disease (as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest
(knee arthroplasty)
x Patients who were receiving antibiotics within 24 hours prior to arrival
x Patients who were receiving antibiotics more than 24 hours prior to surgery
x Patients who did not receive any antibiotics before or during surgery, or within
24 hours after Anesthesia End time (i.e., patient did not receive prophylactic
antibiotics)
x Patients who did not receive any antibiotics during this hospitalization

2011 Joint Commission International



182

I-SCIP-Inf-2e
References
x

x
x
x
x
x
x

Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):17061715.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
American Society of Health-System Pharmacists. ASHP therapeutic guidelines
on antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 1999;56:18391888.
No author listed. The Medical letter. Antimicrobial prophylaxis for Surgery. Med
Lett Drugs Ther. 2009; 82: 47-52.
Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial
prophylaxis in surgical procedures. Clin Infect Dis. 1994;18:422-427.
Gilbert DN, Moellering RC Jr., Elipoulos GM, Chamber HF, Saag MS, eds. The
Sanford Guide to Antimicrobial Therapy 2009. 39st ed. Sperryville, VA:
Antimicrobial Therapy, Inc; 2009.
Itani KMF, Wilson SE, Awad SS, Jensen EH, Finn TS, Abramson MA. Ertapenem
versus cefotetan prophylaxis in elective colorectal surgery. N Engl J Med. 2006
Dec 21; 355 (25): 2640-2651.
Page CP, Bohnen JM, Fletcher JR, et al. Antimicrobial prophylaxis for surgical
wounds. Arch Surg. 1993;128:79-88.
American College of Obstetricians and Gynecologists (ACOG) Committee on
Practice Bulletins ACOG Practice Bulletin No 104 Antibiotic prophylaxis for
gynecologic procedures. Obstet Gynecol May 2009; 113(5) : 1180-1189.

2011 Joint Commission International



183

I-SCIP-Inf-3d
Prophylactic Antibiotics Discontinued within
24 Hours After Surgery End Time
(Hip arthroplasty)
Measure Overview
I-SCIP-Inf 3d Prophylactic antibiotics discontinued within 24 Hours after surgery
end time (Hip arthroplasty)
Overview/Details:
Surgical patients (hip arthroplasty) whose prophylactic antibiotics were discontinued
within 24 hours after anesthesia end time.
Rationale: It is important to maintain therapeutic serum and tissue levels throughout
the operation. Intraoperative re-dosing may be needed for long operations.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services: Medical/surgical units
Measure Name: Prophylactic antibiotic discontinued within 24 hours after surgery end
time (hip arthroplasty).
Numerator: Number of surgical patients (hip arthroplasty) whose prophylactic
antibiotics were discontinued within 24 hours after Anesthesia End Time
Denominator: All selected surgical patients (hip arthroplasty) with no evidence of prior
infection who are >= 18 years

2011 Joint Commission International



184

Domains of
Performance

QPS

Appropriateness

QPS.3 surgical procedures

Effectiveness

IPSG

Joint
Replacement

*RDO

Standards

Availability
Continuity

CCPC

QPS.3 antibiotics and other


mediation use

Goal 4
Goal 5

Prevention/Early
Detection
Timeliness

QPS.3 infection, prevention


and control, surveillance and
reporting

2011 Joint Commission International



185

I-SCIP-Inf-3d
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to provide benefit to the
patient with as little risk as possible. It is important to maintain therapeutic serum and tissue
levels throughout the operation. Intraoperative re-dosing may be needed for long
operations. However, administration of antibiotics for more than a few hours after the
incision is closed offers no additional benefit to the surgical patient. Prolonged
administration does increase the risk of Clostridium difficile infection and the development of
antimicrobial resistant pathogens.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Number of surgical patients (hip arthroplasty) whose prophylactic antibiotics
were discontinued within 24 hours after Anesthesia End Time
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Anesthesia end date
x Anesthesia end time
x Antibiotic administration date
x Antibiotic administration time
Denominator: All selected surgical patients (hip arthroscopy) with no evidence of prior
infection and who are >= 18 years.
Data elements:
x Admission date
x Anesthesia start date
x Antibiotic administration route
x Antibiotic name
x Antibiotic received
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Infection prior to anesthesia
x Other surgeries
x Reason to extend antibiotics
x Surgical incision time
2011 Joint Commission International

186

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04.)
Exclusions to the population:
x Patients less than 18 years of age
x Patients who had other procedures requiring general or spinal anesthesia that
occurred within 3 days prior to or after the procedure of interest (during separate
surgical episodes) during this hospital stay
x Patients who had a previous diagnosis suggestive of preoperative infectious disease
(as defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest (hip
arthroplasty)
x Patients who were receiving antibiotics more than 24 hours prior to arrival
x Patients who were receiving antibiotics more than 24 hours prior to surgery
x Patients who did not receive any antibiotics during this hospitalization
x Patients with reasons to extend antibiotics

2011 Joint Commission International



187

I-SCIP-Inf-3d
References
x

x
x
x
x
x

Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):17061715.
Crabtree TD, Pelletier SJ, Gleason TG, et al. Clinical characteristics and
antibiotic utilization in surgical patients with Clostridium difficile-associated
diarrhea. Am Surg. 1999;65:507-511.
Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of
Thoracic Surgeons Practice Guideline Series: Antibiotic prophylaxis in cardiac
surgery, Part I: Duration, 2006. Ann Thoracic Surg 2006; 81: 397-404.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
McDonald M, Grabsch E, Marshall C, et al. Single- versus multiple-dose
antimicrobial prophylaxis for major surgery: a systemic review. Aust N Z J Surg.
1988;68:388-396.
Scher KS. Studies on the duration of antibiotic administration for surgical
prophylaxis. Am Surg. 1997;63:59-62.

2011 Joint Commission International



188

I-SCIP-Inf-3e
Prophylactic Antibiotics Discontinued within
24 Hours After Surgery End Time
(Knee Arthroplasty)
Measure Overview
I-SCIP-Inf 3e Prophylactic antibiotics discontinued within 24 hours after
surgery end time (knee arthroplasty).
Overview/Details:
Surgical patients (knee arthroplasty) whose prophylactic antibiotics were discontinued
within 24 hours after anesthesia end time.
Rationale: It is important to maintain therapeutic serum and tissue levels throughout
the operation. Intraoperative re-dosing may be needed for long operations.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services:
Medical/surgical units
Measure Name: Prophylactic antibiotic discontinued within 24 hours after surgery end
time (knee arthroplasty)
Numerator: Number of surgical patients (knee arthroplasty) whose prophylactic
antibiotics were discontinued within 24 hours after Anesthesia End Time
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of
prior infection who are >= 18 years.

2011 Joint Commission International



189

Domains of
Performance

QPS

Appropriateness

QPS.3 surgical
procedures

Availability

Prevention/Early
Detection
Timeliness

IPSG

Joint
Replacement

*RDO

Standards

Continuity
Effectiveness

CCPC

Goal 4
Goal 5

QPS.3 antibiotics and


other mediation use
QPS.3 infection,
prevention and control,
surveillance and reporting

2011 Joint Commission International



190

I-SCIP-Inf-3e
Measure Details
Reasons and Implications: A goal of prophylaxis with antibiotics is to provide benefit to the
patient with as little risk as possible. It is important to maintain therapeutic serum and tissue
levels throughout the operation. Intraoperative re-dosing may be needed for long operations.
However, administration of antibiotics for more than a few hours after the incision is closed
offers no additional benefit to the surgical patient. Prolonged administration does increase the
risk of Clostridium difficile infection and the development of antimicrobial resistant pathogens.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Number of surgical patients (knee arthroplasty) whose prophylactic antibiotics
were discontinued within 24 hours after Anesthesia End Time
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Anesthesia End Date
x Anesthesia End Time
x Antibiotic Administration Date
x Antibiotic Administration Time
Denominator: All selected surgical patients (knee arthroplasty) with no evidence of prior
infection and who are >= 18 years.
Data elements:
x Admission date
x Anesthesia start date
x Antibiotic administration route
x Antibiotic name
x Antibiotic received
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Infection prior to anesthesia
x Other surgeries
x Reason to extend antibiotics
x Surgical incision time
2011 Joint Commission International

191

Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as defined
in Appendix A, Table 5.05)
Exclusions to the population:
x Patients less than 18 years of age
x Patients who had other procedures requiring general or spinal anesthesia that occurred
within 3 days prior to or after the procedure of interest (during separate surgical
episodes) during this hospital stay
x Patients who had a previous diagnosis suggestive of preoperative infectious disease (as
defined in Appendix A, Table 5.09)
x Patients with a documented infection prior to surgical procedure of interest (knee
arthroplasty)
x Patients who were receiving antibiotics more than 24 hours prior to arrival
x Patients who were receiving antibiotics more than 24 hours prior to surgery
x Patients who did not receive any antibiotics during this hospitalization
x Patients with reasons to extend antibiotics

2011 Joint Commission International



192

I-SCIP- Inf-3e
References
x

x
x
x
x
x

Bratzler DW, Houck PM, for the Surgical Infection Prevention Guidelines Writers
Group. Antimicrobial prophylaxis for surgery: An advisory statement from the
National Surgical Infection Prevention Project. CID. 2004:38(15 June):17061715.
Crabtree TD, Pelletier SJ, Gleason TG, et al. Clinical characteristics and
antibiotic utilization in surgical patients with Clostridium difficile-associated
diarrhea. Am Surg. 1999;65:507-511.
Edwards FH, Engelman RM, Houck P, Shahian DM, Bridges CR. The Society of
Thoracic Surgeons Practice Guideline Series: Antibiotic prophylaxis in cardiac
surgery, Part I: Duration, 2006. Ann Thoracic Surg 2006; 81: 397-404.
Mangram AJ, Horan TC, Pearson ML, et al. Guidelines for prevention of surgical
site infection, 1999. Infect Control Hosp Epidemiol. 1999;20:247-280.
McDonald M, Grabsch E, Marshall C, et al. Single- versus multiple-dose
antimicrobial prophylaxis for major surgery: a systemic review. Aust N Z J Surg.
1988;68:388-396.
Scher KS. Studies on the duration of antibiotic administration for surgical
prophylaxis. Am Surg. 1997;63:59-62.

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I-SCIP-VTE-1
Surgical Patients (hip/knee arthroplasty) with Recommended
Venous Thromboembolism (VTE) Prophylaxis Ordered
Measure Overview
I=SCIP-VTE 1 Surgical patients (hip/knee arthroplasty) with recommended
venous thromboembolism (VTE) prophylaxis ordered
Overview/Details:
Surgical patients (hip/knee arthroplasty who received venous thromboembolism (VTE)
prophylaxis ordered anytime from hospital arrival to 24 hours after Anesthesia End
Time.
Rationale: Despite the evidence that VTE is one of the most common postoperative
complications and prophylaxis is the most effective strategy to reduce morbidity and
mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and
duration of surgery, patient risk factors, duration and extent of postoperative
immobilization, and use or nonuse of prophylaxis.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services:
Medical/surgical units
Measure Name: Surgery patients (hip/knee arthroplasty) with recommended venous
thromboembolism (VTE) prophylaxis ordered
Numerator: Surgery patients (hip/knee arthroplasty) with recommended venous
thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours
after Anesthesia End Time
Denominator: All selected (hip/knee arthoroplasty) patients who are >= 18 years.

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Domains of Performance

QPS

CCPC

IPSG

Joint
Replacement

*RDO

Standards
Appropriateness
Availability

QPS.3 patient
assessments

Continuity
Effectiveness
Prevention/Early
Detection
Timeliness

QPS.3 surgical
procedures
QPS.3 antibiotics and
other mediation use

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I-SCIP-VTE-1
Measure Details
Reasons and Implications: Despite the evidence that VTE is one of the most common
postoperative complications and prophylaxis is the most effective strategy to reduce morbidity
and mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and duration of
surgery, patient risk factors, duration and extent of postoperative immobilization, and use or
nonuse of prophylaxis. According to clinical trials, surgery was associated with over a twentyfold increase in the odds of being diagnosed with VTE. Studies have shown that appropriately
used thromboprophylaxis has a positive risk/benefit ratio and is cost effective. Prophylaxis
recommendations for this measure are based on clinical practice guidelines.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Surgery patients (hip/knee arthroplasty) with recommended venous
thromboembolism (VTE) prophylaxis ordered anytime from hospital arrival to 24 hours after
Anesthesia End Time
Denominator: All selected (hip/knee arthoroplasty) patients who are >= 18 years.
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Anesthesia type
x VTE Prophylaxis
Denominator: All selected surgical patients (hip/knee arthroplasty).
Data elements:
x Admission date
x Anesthesia end date
x Anesthesia end time
x Anesthesia start date
x Anesthesia start time
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Preadmission Warfarin
x Reason for Not Administering VTE Prophylaxis
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Inclusions to the population: ICD Principal Procedure Code of selected surgeries (as
defined in Appendix A, Table 5.04, 5.05.)
Exclusions to the population:
x Patients less than 18 years of age
x Patients with hospital stay of less than or equal to 3 calendar days
x Patients who are on warfarin prior to admission
x Patients whose total surgery time is less than or equal to 60 minutes
x Patients with reasons for not administering both mechanical and pharmocolgical
prophylaxis

Elective Total Hip


Replacement
5B

Elective Total Knee


Replacement
6B

Elective Total Hip


Replacement with a
reason for not
administering
pharmacological
prophylaxis

Any of the following started within 24 hours of surgery:


x
Low molecular weight heparin (LMWH)
x
Factor Xa Inhibitor (Fondaparinux)
x
Warfarin
x
Oral Factor Xa Inhibitor (Rivaroxaban)
Any of the following:
x Low molecular weight heparin (LMWH)
x Factor Xa Inhibitor (Fondaparinux)
x Warfarin
x Intermittent pneumatic compression devices (IPC)
x Venous foot pump (VFP)
x Oral Factor Xa Inhibitor (Rivaroxaban)
Any of the following:
x Intermittent pneumatic compression devices (IPC)
x Venous foot pump (VFP)

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I-SCIP-VTE-1
References
x
x

x
x
x

x
x

x
x
x

x
x

Chapter 31 of Making Healthcare Safer: A Critical Analysis of Patient Safety


Practices. Prepared for Agency for Healthcare Research and Quality, Contract No.
290-97-0013. Prevention of Venous Thromboembolism. PMID: 00000.
Stratton MA, Anderson FA, Bussey HI, Caprini J. Prevention of venous
thromboembolism: adherence to the 1995 American College of Chest Physicians
Consensus Guidelines for Surgical Patients. Arch Intern Med. 2000;160:334-3.
PMID: 10668835.
Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein
thrombosis. The Cochrane Library. Issue1, 2001. PMID: 10908501.
Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for prevention
of venous thromboembolism in neurosurgery: a meta-analysis. Arch Intern Med.
2000;160:2327-2332. PMID: 10927730.
Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism
among hospitalized patients at Brigham and Women's Hospital is caused more
often by prophylaxis failure than by withholding treatment. Chest. 2000;118:16801684. PMID: 11115458.
2'RQQHOO0:HLW]-,7KURPERSURSK\OD[LVLQVXUJLFDOSDWLHQWVCan J Surg. 2003;
46(2): 129-135. PMID: 12691354.
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest 2008; 133:381S-453S. PMID:
18574271.
Janku GV, Paiement GD, Green HD. Prevention of venous thromboembolism in
orthopaedics in the United States. Clin Ortho & Related Research. 1996:313-321.
PMID: 8998892.
Koch A, Bouges S, Ziegler S, et al. Low molecular weight heparin and
infractionated heparin in thrombosis prophylaxis after major surgical intervention:
update of previous meta-analyses. Br J Surg. 1997;84:750-759. PMID: 9189079.
Palmer AJ, Schramm W, Kirchhof B, et al. Low molecular weight heparin and
unfractionated heparin for prevention of thrombo-embolism in general surgery: a
meta-analysis of randomised clinical trials. Haemostasis. 1997;27:65-74. PMID:
9212354.
Bratzler DW, Raskob GE, Murray CK, et al. Underuse of venous thromboembolism
prophylaxis for general surgery patients: physician practices in the community
hospital setting. Arch Intern Med. 1998;158:1909-1912. PMID: 9759687.
Vanek VW. Meta-analysis of effectiveness of intermittent pneumatic compression
devices with a comparison of thigh-high to knee-high sleeves. American Surgeon.
1998;64:1050-1058. PMID: 9798767.
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x
x
x
x

Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of lowmolecular-weight heparin prophylaxis against venous thromboembolism in patients
undergoing elective hip replacement. Arch Intern Med. 1999;159:137-141. PMID:
9927095.
Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ, III. Risk
factors for deep vein thrombosis and pulmonary embolism: a population-based
case-control study. Arch Intern Med 2000;160:809-815.
Abrams PJ, Emerson CR. Rivaroxaban: a novel, oral, direct factor Xa Inhibitor. Pub
Med. Feb.2009; 167-81
Borris LC, Rivaroxaban, a new, oral direct factor Xa inhibitor for
thromboprophylaxis after major joint arthroplasty. Pub Med. April 2009; 10 6):10838.
Eriksson BI, Kakkar AK, Turpie AG, Gent M, Bandel TJ, Homering M, Misselwitz F,
Lassen MR. Oral rivaroxaban for the prevention of symptomatic venous
thromboembolism after elective hip and knee replacement. Pub Med. May
2009;91(5):636-44.
Turpie AG, Lassen MR, Davidson BL, et. Al. Rivaroxaban versus Enoxaparin for
thromboprophylaxis after total knee arthroplasty (RECORD4): a randomized trial.
Pub Med. May 16;373(9676):1673-80. Equb 2009 Mat 4.

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I-SCIP-VTE-2
Surgical Patients (hip/knee arthorplasty) who Received
appropriate Venous Thromboembolism (VTE) Prophylaxis
within 24 hours prior to Anesthesia Start Time to 24 hours
after Anesthesia End Time.
Measure Overview
I=SCIP_VTE 2 Surgical patients (hip/knee arthroplasty) who received
appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to
anesthesia start time to 24 hours after anesthesia end time.
Overview/Details:
Surgical patients (hip/knee arthroplasty) who received appropriate venous
thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start time to 24
hours after anesthesia end time.
Rationale: Despite the evidence that VTE is one of the most common postoperative
complications and prophylaxis is the most effective strategy to reduce morbidity and
mortality, it is often underused. The frequency of Venous Thromboembolism (VTE), that
includes deep vein thrombosis and pulmonary embolism, is related to the type and
duration of surgery, patient risk factors, duration and extent of postoperative
immobilization, and use or nonuse of prophylaxis. According to a clinical study, surgery
was associated with over a twenty-fold increase in the odds of being diagnosed with
VTE. Studies have shown that appropriately used thromboprophylaxis has a positive
risk/benefit ratio and is cost effective.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services:
Medical/surgical units
Measure Name: Surgery Patients (hip/knee arthroplasty) Who Received Appropriate
Venous Thromboembolism Prophylaxis Within 24 Hours Prior to Anesthesia Start Time
to 24 Hours After Anesthesia Start Time

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Numerator: Surgery patients (hip/knee arthroplasty) who received appropriate Venous


Thromboembolism (VTE) prophylaxis within 24 hours prior to Anesthesia Start Time to
24 hours after Anesthesia End Time.
Denominator: All selected (hip/knee arthroplasty) patients who are > = 18 years.

Domains of Performance QPS

CCPC

IPSG

Joint
Replacement

*RDO

Standards
Appropriateness
Availability

QPS.3 patient
assessments

Continuity
Effectiveness
Prevention/Early
Detection
Timeliness

QPS.3 surgical
procedures
QPS.3 antibiotics and
other mediation use

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I-SCIP-VTE-2
Measure Details
Reasons and Implications: Timing of prophylaxis is based on the type of procedure,
prophylaxis selection, and clinical judgment regarding the impact of patient risk
factors. The optimal start of pharmacologic prophylaxis in surgical patients varies and
must be balanced with the efficacy-versus-bleeding potential. Due to the inherent
variability related to the initiation of prophylaxis for surgical procedures, 24 hours prior
to surgery to 24 hours post surgery was recommended for use in this measure set in
order to establish a timeframe that would encompass most procedures.
Data Collection:
Retrospective data sources for the required data elements include administrative data
and medical records.
Numerator: Surgery patients (hip/knee arthroplasty) who received appropriate
venous thromboembolism (VTE) prophylaxis within 24 hours prior to anesthesia start
time to 24 hours after anesthesia end time
Denominator: All selected (hip/knee arthroplasty) patients who are >= 18 years.
Inclusions to the population: Not applicable
Exclusions to the population: None
Data elements:
x Anesthesia type
x VTE Prophylaxis
x VTE Timely
Denominator: All selected surgical patients (hip/knee arthroplasty).
Data elements:
x Admission date
x Anesthesia start date
x Anesthesia start time
x Anesthesia end date
x Anesthesia end time
x Birthdate
x ICD principal diagnosis code
x ICD principal procedure code
x Preadmission warfarin
x Reason for not administering VTE prophylaxis
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Inclusions to the population: ICD Principal Procedure Code of selected surgeries


(as defined in Appendix A, Table 5.04, 5.05).
Exclusions to the population:
x Patients less than 18 years of age
x Patients with length of stay less than or equal to 3 calendar days
x Patients who are on warfarin prior to admission
x Patients whose total surgery time is less than or equal to 60 minutes
x Patients with reasons for not administering both mechanical and
pharmocolgical prophylaxis
x Patients who did not receive VTE Prophylaxis

Su

Surgery Type
Elective Total Hip
Replacement
5B

Elective Total Knee


Replacement
6B

Elective Total Hip


Replacement with a
reason for not
administering
pharmacological
prophylaxis

VTE Prophylaxis Options for Surgery


Recommended Prophylaxis Options
Any of the following started within 24 hours of surgery:
x
Low molecular weight heparin (LMWH)
x
Factor Xa Inhibitor (Fondaparinux)
x
Warfarin
x
Oral Factor Xa Inhibitor (Rivaroxaban)
Any of the following:
x Low molecular weight heparin (LMWH)
x Factor Xa Inhibitor (Fondaparinux)
x Warfarin
x Intermittent pneumatic compression devices (IPC)
x Venous foot pump (VFP)
x Oral Factor Xa Inhibitor (Rivaroxaban)
Any of the following:
x Intermittent pneumatic compression devices (IPC)
x Venous foot pump (VFP)

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I-SCIP-VTE-2
References
x
x
x

x
x
x

x
x
x
x

Chapter 31 of Making Healthcare Safer: A Critical Analysis of Patient Safety


Practices. Prepared for Agency for Healthcare Research and Quality, Contract
No. 290-97-0013. Prevention of Venous Thromboembolism. PMID: 00000.
Anderson FA, Wheeler HB, Goldberg RJ, et al. Physician practices in the
prevention of VTE. Ann Intern Med. 1991;115-591-595. PMID: 1892330.
Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest 2008; 133:381S-453S. PMID:
18574271.
Stratton MA, Anderson FA, Bussey HI, Caprini J. Prevention of venous
thromboembolism: adherence to the 1995 American College of Chest Physicians
Consensus Guidelines for Surgical Patients. Arch Intern Med. 2000;160:334-3.
PMID: 10668835.
Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep vein
thrombosis. The Cochrane Library, Issue1, 2001. PMID: 10908501.
Iorio A, Agnelli G. Low-molecular-weight and unfractionated heparin for
prevention of venous thromboembolism in neurosurgery: a meta-analysis. Arch
Intern Med. 2000;160:2327-2332. PMID: 10927730.
Goldhaber SZ, Dunn K, MacDougall RC. New onset of venous thromboembolism
among hospitalized patients at Brigham and Women's Hospital is caused more
often by prophylaxis failure than by withholding treatment. Chest. 000;118:16801684. PMID: 11115458.
2'RQQHOO0:HLW]-,7KURPERSURSK\OD[LVLQVXUJLFDOSDWLHQWVCan J Surg.
2003; 46(2): 129-135. PMID: 12691354.
Janku GV, Paiement GD, Green HD. Prevention of venous thromboembolism in
orthopaedics in the United States. Clin Ortho & Related Research. 1996:313321. PMID: 8998892.
Koch A, Bouges S, Ziegler S, et al. Low molecular weight heparin and
infractionated heparin in thrombosis prophylaxis after major surgical intervention:
update of previous meta-analyses. Br J Surg. 1997;84:750-759. PMID: 9189079.
Palmer AJ, Schramm W, Kirchhof B, et al. Low molecular weight heparin and
unfractionated heparin for prevention of thrombo-embolism in general surgery: a
meta-analysis of randomised clinical trials. Haemostasis. 1997;27:65-74. PMID:
9212354.
Bratzler DW, Raskob GE, Murray CK, et al. Underuse of venous
thromboembolism prophylaxis for general surgery patients: physician practices in
the community hospital setting. Arch Intern Med. 1998;158:1909-1912. PMID:
9759687.

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x
x

x
x
x
x
x

Vanek VW. Meta-analysis of effectiveness of intermittent pneumatic compression


devices with a comparison of thigh-high to knee-high sleeves. American
Surgeon. 1998;64:1050-1058. PMID: 9798767.
Hull RD, Brant RF, Pineo GF, et al. Preoperative vs postoperative initiation of
low-molecular-weight heparin prophylaxis against venous thromboembolism in
patients undergoing elective hip replacement. Arch Intern Med. 1999;159:137141. PMID: 9927095.
Raskob GE, Hirsh J. Controversies in timing of the first dose of anticoagulant
prophylaxis against venous thromboembolism after major orthopedic surgery.
Chest. 2003 Dec;124(6 Suppl):379S-385S.
Heit JA, Silverstein MD, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ, III.
Risk factors for deep vein thrombosis and pulmonary embolism: a
population-based case-control study. Arch Intern Med 2000;160:809-815.
Abrams PJ, Emerson CR. Rivaroxaban: a novel, oral, direct factor Xa Inhibitor.
Pub Med. Feb.2009; 167-81
Borris LC, Rivaroxaban, a new, oral direct factor Xa inhibitor for
thromboprophylaxis after major joint arthroplasty. Pub Med. April 2009; 10
6):1083-8.
Eriksson BI, Kakkar AK, Turpie AG, Gent M, Bandel TJ, Homering M, Misselwitz
F, Lassen MR. Oral rivaroxaban for the prevention of symptomatic venous
thromboembolism after elective hip and knee replacement. Pub Med. May
2009;91(5):636-44.
Turpie AG, Lassen MR, Davidson BL, et. Al. Rivaroxaban versus Enoxaparin for
thromboprophylaxis after total knee arthroplasty (RECORD4): a randomized trial.
Pub Med. May 16;373(9676):1673-80. Equb 2009 Mat 4.

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Appendix A
ICD Codes
Surgical Care Improvement Project (SCIP)
Please Note : Due to the various ICD Code versions used by different countries,
ICD-8, ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in
the specific code utilized by your country to correspond to the ICD-9-CM code
description for the following diagnoses.
Table 5.04
Hip Arthroplasty
ICD-8
ICD-9
Code
Code

ICD-10
Code

ICD-9Shortened Description
CMCode
81.51
TOTAL HIP REPLACEMENT
81.52
PARTIAL HIP REPLACEMENT

Table 5.05
Knee Arthroplasty
ICD-8
ICD-9
Code
Code

ICD-10
Code

ICD-9Shortened Description
CMCode
81.54
TOTAL KNEE REPLACEMENT

Table 5.09
Infection Codes
ICD-8
ICD-9
Code
Code

ICD-10
Code

ICD-9CMCode
Code
001.0
001.1
001.9
002.0
002.1
002.2
002.3
002.9
003.0
003.1
003.20
003.21
003.22

Shortened Description
Shortened Description
CHOLERA D/T VIB CHOLERAE
CHOLERA D/T VIB EL TOR
CHOLERA NOS
TYPHOID FEVER
PARATYPHOID FEVER A
PARATYPHOID FEVER B
PARATYPHOID FEVER C
PARATYPHOID FEVER NOS
SALMONELLA ENTERITIS
SALMONELLA SEPTICEMIA
LOCAL SALMONELLA INF NOS
SALMONELLA MENINGITIS
SALMONELLA PNEUMONIA

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
003.23
003.24
003.29
003.8
003.9
004.0
004.1
004.2
004.3
004.8
004.9
006.0
006.1
006.2
006.3
006.4
006.5
006.6
006.8
006.9
007.1
008.00
008.01
008.02
008.03
008.04
008.09
008.1
008.2
008.3
008.41
008.42
008.43
008.44
008.45
008.46
008.47
008.49
008.5

Shortened Description
SALMONELLA ARTHRITIS
SALMONELLA OSTEOMYELITIS
LOCAL SALMONELLA INF NEC
SALMONELLA INFECTION NEC
SALMONELLA INFECTION NOS
SHIGELLA DYSENTERIAE
SHIGELLA FLEXNERI
SHIGELLA BOYDII
SHIGELLA SONNEI
SHIGELLA INFECTION NEC
SHIGELLOSIS NOS
AC AMEBIASIS W/O ABSCESS
CHR AMEBIASIS W/O ABSCES
AMEBIC NONDYSENT COLITIS
AMEBIC LIVER ABSCESS
AMEBIC LUNG ABSCESS
AMEBIC BRAIN ABSCESS
AMEBIC SKIN ULCERATION
AMEBIC INFECTION NEC
AMEBIASIS NOS
GIARDIASIS
INTEST INFEC E COLI NOS
INT INF E COLI ENTRPATH
INT INF E COLI ENTRTOXGN
INT INF E COLI ENTRNVSV
INT INF E COLI ENTRHMRG
INT INF E COLI SPCF NEC
ARIZONA ENTERITIS
AEROBACTER ENTERITIS
PROTEUS ENTERITIS
STAPHYLOCOCC ENTERITIS
PSEUDOMONAS ENTERITIS
INT INFEC CAMPYLOBACTER
INT INF YRSNIA ENTRCLTCA
INT INF CLSTRDIUM DFCILE
INTES INFEC OTH ANEROBES
INT INF OTH GRM NEG BCTR
BACTERIAL ENTERITIS NEC
BACTERIAL ENTERITIS NOS

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
008.8
009.0
009.1
009.2
009.3
020.0
020.1
020.2
020.3
020.4
020.5
020.8
020.9
021.0
021.1
021.2
021.3
021.8
021.9
022.0
022.1
022.2
022.3
022.8
022.9
023.0
023.1
023.2
023.3
023.8
023.9
024
025
026.0
026.1
026.9
027.0
027.1
027.2

Shortened Description
VIRAL ENTERITIS NOS
INFECTIOUS ENTERITIS NOS
ENTERITIS OF INFECT ORIG
INFECTIOUS DIARRHEA NOS
DIARRHEA OF INFECT ORIG
BUBONIC PLAGUE
CELLULOCUTANEOUS PLAGUE
SEPTICEMIC PLAGUE
PRIMARY PNEUMONIC PLAGUE
SECONDARY PNEUMON PLAGUE
PNEUMONIC PLAGUE NOS
OTHER TYPES OF PLAGUE
PLAGUE NOS
ULCEROGLANDUL TULAREMIA
ENTERIC TULAREMIA
PULMONARY TULAREMIA
OCULOGLANDULAR TULAREMIA
TULAREMIA NEC
TULAREMIA NOS
CUTANEOUS ANTHRAX
PULMONARY ANTHRAX
GASTROINTESTINAL ANTHRAX
ANTHRAX SEPTICEMIA
OTHER ANTHRAX MANIFEST
ANTHRAX NOS
BRUCELLA MELITENSIS
BRUCELLA ABORTUS
BRUCELLA SUIS
BRUCELLA CANIS
BRUCELLOSIS NEC
BRUCELLOSIS NOS
GLANDERS
MELIOIDOSIS
SPIRILLARY FEVER
STREPTOBACILLARY FEVER
RAT-BITE FEVER NOS
LISTERIOSIS
ERYSIPELOTHRIX INFECTION
PASTEURELLOSIS

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
027.8
027.9
030.0
030.1
030.2
030.3
030.8
030.9
031.0
031.1
031.2
031.8
031.9
032.0
032.1
032.2
032.3
032.81
032.82
032.83
032.84
032.85
032.89
032.9
033.0
033.1
033.8
033.9
034.0
034.1
035
036.0
036.1
036.2
036.3
036.40
036.41
036.42
036.43

Shortened Description
ZOONOTIC BACT DIS NEC
ZOONOTIC BACT DIS NOS
LEPROMATOUS LEPROSY
TUBERCULOID LEPROSY
INDETERMINATE LEPROSY
BORDERLINE LEPROSY
LEPROSY NEC
LEPROSY NOS
PULMONARY MYCOBACTERIA
CUTANEOUS MYCOBACTERIA
DMAC BACTEREMIA
MYCOBACTERIAL DIS NEC
MYCOBACTERIAL DIS NOS
FAUCIAL DIPHTHERIA
NASOPHARYNX DIPHTHERIA
ANT NASAL DIPHTHERIA
LARYNGEAL DIPHTHERIA
CONJUNCTIVAL DIPHTHERIA
DIPHTHERITIC MYOCARDITIS
DIPHTHERITIC PERITONITIS
DIPHTHERITIC CYSTITIS
CUTANEOUS DIPHTHERIA
DIPHTHERIA NEC
DIPHTHERIA NOS
BORDETELLA PERTUSSIS
BORDETELLA PARAPERTUSSIS
WHOOPING COUGH NEC
WHOOPING COUGH NOS
STREP SORE THROAT
SCARLET FEVER
ERYSIPELAS
MENINGOCOCCAL MENINGITIS
MENINGOCOCC ENCEPHALITIS
MENINGOCOCCEMIA
MENINGOCOCC ADRENAL SYND
MENINGOCOCC CARDITIS NOS
MENINGOCOCC PERICARDITIS
MENINGOCOCC ENDOCARDITIS
MENINGOCOCC MYOCARDITIS

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
036.81
036.82
036.89
036.9
037
038.0
038.10
038.11
038.12
038.19
038.2
038.3
038.40
038.41
038.42
038.43
038.44
038.49
038.8
038.9
039.0
039.1
039.2
039.3
039.4
039.8
039.9
040.0
040.1
040.2
040.3
040.81
040.82
040.89
041.00
041.01
041.02
041.03
041.04

Shortened Description
MENINGOCOCC OPTIC NEURIT
MENINGOCOCC ARTHROPATHY
MENINGOCOCCAL INFECT NEC
MENINGOCOCCAL INFECT NOS
TETANUS
STREPTOCOCCAL SEPTICEMIA
STAPHYLCOCC SEPTICEM NOS
METH SUSC STAPH AUR SEPT
MRSA SEPTICEMIA
STAPHYLCOCC SEPTICEM NEC
PNEUMOCOCCAL SEPTICEMIA
ANAEROBIC SEPTICEMIA
GRAM-NEG SEPTICEMIA NOS
H. INFLUENAE SEPTICEMIA
E COLI SEPTICEMIA
PSEUDOMONAS SEPTICEMIA
SERRATIA SEPTICEMIA
GRAM-NEG SEPTICEMIA NEC
SEPTICEMIA NEC
SEPTICEMIA NOS
CUTANEOUS ACTINOMYCOSIS
PULMONARY ACTINOMYCOSIS
ABDOMINAL ACTINOMYCOSIS
CERVICOFAC ACTINOMYCOSIS
MADURA FOOT
ACTINOMYCOSIS NEC
ACTINOMYCOSIS NOS
GAS GANGRENE
RHINOSCLEROMA
WHIPPLE'S DISEASE
NECROBACILLOSIS
TROPICAL PYOMYOSITIS
TOXIC SHOCK SYNDROME
BACTERIAL DISEASES NEC
STREPTOCOCCUS UNSPECF
STREPTOCOCCUS GROUP A
STREPTOCOCCUS GROUP B
STREPTOCOCCUS GROUP C
ENTEROCOCCUS GROUP D

2011 Joint Commission International



210

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
041.05
041.09
041.10
041.11
041.12
041.19
041.2
041.3
041.4
041.5
041.6
041.7
041.81
041.82
041.83
041.84
041.85
041.86
041.89
041.9
051.2
073.0
073.7
073.8
073.9
076.0
076.1
076.9
078.2
078.3
078.4
078.6
078.88
079.88
079.98
082.40
082.41
082.49
082.8

Shortened Description
STREPTOCOCCUS GROUP G
OTHER STREPTOCOCCUS
STAPHYLOCOCCUS UNSPCFIED
MTH SUS STPH AUR ELS/NOS
MRSA ELSEWHERE/NOS
OTHER STAPHYLOCOCCUS
PNEUMOCOCCUS INFECT NOS
KLEBSIELLA PNEUMONIAE
E. COLI INFECT NOS
H. INFLUENZAE INFECT NOS
PROTEUS INFECTION NOS
PSEUDOMONAS INFECT NOS
MYCOPLASMA
BACTEROIDES FRAGILIS
CLOSTRIDIUM PERFRINGENS
OTHER ANAEROBES
OTH GRAM NEGATV BACTERIA
HELICOBACTER PYLORI
OTH SPECF BACTERIA
BACTERIAL INFECTION NOS
CONTAGIOUS PUSTULAR DERM
ORNITHOSIS PNEUMONIA
ORNITHOSIS COMPLICAT NEC
ORNITHOSIS COMPLICAT NOS
ORNITHOSIS NOS
TRACHOMA, INITIAL STAGE
TRACHOMA, ACTIVE STAGE
TRACHOMA NOS
SWEATING FEVER
CAT-SCRATCH DISEASE
FOOT & MOUTH DISEASE
HEM NEPHROSONEPHRITIS
OTH SPEC DIS CHLAMYDIAE
OTH SPCF CHLAMYDIAL INFC
CHLAMYDIAL INFECTION NOS
EHRLICHIOSIS NOS
EHRLICHIOSIS CHAFEENSIS
EHRLICHIOSIS NEC
TICK-BORNE RICKETTS NEC

2011 Joint Commission International



211

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
082.9
083.2
083.8
083.9
088.0
088.81
090.0
090.1
090.2
090.3
090.40
090.41
090.42
090.49
090.5
090.6
090.7
090.9
091.0
091.1
091.2
091.3
091.4
091.50
091.51
091.52
091.61
091.62
091.69
091.7
091.81
091.82
091.89
091.9
092.0
092.9
093.0
093.1
093.20

Shortened Description
TICK-BORNE RICKETTS NOS
RICKETTSIALPOX
RICKETTSIOSES NEC
RICKETTSIOSIS NOS
BARTONELLOSIS
LYME DISEASE
EARLY CONG SYPH SYMPTOM
EARLY CONGEN SYPH LATENT
EARLY CONGEN SYPH NOS
SYPHILITIC KERATITIS
JUVENILE NEUROSYPH NOS
CONGEN SYPH ENCEPHALITIS
CONGEN SYPH MENINGITIS
JUVENILE NEUROSYPH NEC
LATE CONGEN SYPH SYMPTOM
LATE CONGEN SYPH LATENT
LATE CONGEN SYPH NOS
CONGENITAL SYPHILIS NOS
PRIMARY GENITAL SYPHILIS
PRIMARY ANAL SYPHILIS
PRIMARY SYPHILIS NEC
SECONDARY SYPH SKIN
SYPHILITIC ADENOPATHY
SYPHILITIC UVEITIS NOS
SYPHILIT CHORIORETINITIS
SYPHILITIC IRIDOCYCLITIS
SYPHILITIC PERIOSTITIS
SYPHILITIC HEPATITIS
SECOND SYPH VISCERA NEC
SECOND SYPHILIS RELAPSE
ACUTE SYPHIL MENINGITIS
SYPHILITIC ALOPECIA
SECONDARY SYPHILIS NEC
SECONDARY SYPHILIS NOS
EARLY SYPH LATENT RELAPS
EARLY SYPHIL LATENT NOS
AORTIC ANEURYSM, SYPHIL
SYPHILITIC AORTITIS
SYPHIL ENDOCARDITIS NOS

2011 Joint Commission International



212

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
093.21
093.22
093.23
093.24
093.81
093.82
093.89
093.9
094.0
094.1
094.2
094.3
094.81
094.82
094.83
094.84
094.85
094.86
094.87
094.89
094.9
095.0
095.1
095.2
095.3
095.4
095.5
095.6
095.7
095.8
095.9
096
097.0
097.1
097.9
098.0
098.10
098.11
098.12

Shortened Description
SYPHILITIC MITRAL VALVE
SYPHILITIC AORTIC VALVE
SYPHIL TRICUSPID VALVE
SYPHIL PULMONARY VALVE
SYPHILITIC PERICARDITIS
SYPHILITIC MYOCARDITIS
CARDIOVASCULAR SYPH NEC
CARDIOVASCULAR SYPH NOS
TABES DORSALIS
GENERAL PARESIS
SYPHILITIC MENINGITIS
ASYMPTOMAT NEUROSYPHILIS
SYPHILITIC ENCEPHALITIS
SYPHILITIC PARKINSONISM
SYPH DISSEM RETINITIS
SYPHILITIC OPTIC ATROPHY
SYPH RETROBULB NEURITIS
SYPHIL ACOUSTIC NEURITIS
SYPH RUPT CEREB ANEURYSM
NEUROSYPHILIS NEC
NEUROSYPHILIS NOS
SYPHILITIC EPISCLERITIS
SYPHILIS OF LUNG
SYPHILITIC PERITONITIS
SYPHILIS OF LIVER
SYPHILIS OF KIDNEY
SYPHILIS OF BONE
SYPHILIS OF MUSCLE
SYPHILIS OF TENDON/BURSA
LATE SYMPT SYPHILIS NEC
LATE SYMPT SYPHILIS NOS
LATE SYPHILIS LATENT
LATE SYPHILIS NOS
LATENT SYPHILIS NOS
SYPHILIS NOS
ACUTE GC INFECT LOWER GU
GC (ACUTE) UPPER GU NOS
GC CYSTITIS (ACUTE)
GC PROSTATITIS (ACUTE)

2011 Joint Commission International



213

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
098.13
098.14
098.15
098.16
098.17
098.19
098.2
098.30
098.31
098.32
098.33
098.34
098.35
098.36
098.37
098.39
098.40
098.41
098.42
098.43
098.49
098.50
098.51
098.52
098.53
098.59
098.6
098.7
098.81
098.82
098.83
098.84
098.85
098.86
098.89
099.0
099.1
099.2
099.3

Shortened Description
GC ORCHITIS (ACUTE)
GC SEM VESICULIT (ACUTE)
GC CERVICITIS (ACUTE)
GC ENDOMETRITIS (ACUTE)
ACUTE GC SALPINGITIS
GC (ACUTE) UPPER GU NEC
CHR GC INFECT LOWER GU
CHR GC UPPER GU NOS
GC CYSTITIS, CHRONIC
GC PROSTATITIS, CHRONIC
GC ORCHITIS, CHRONIC
GC SEM VESICULITIS, CHR
GC CERVICITIS, CHRONIC
GC ENDOMETRITIS, CHRONIC
GC SALPINGITIS (CHRONIC)
CHR GC UPPER GU NEC
GONOCOCCAL CONJUNCTIVIT
GONOCOCCAL IRIDOCYCLITIS
GONOCOCCAL ENDOPHTHALMIA
GONOCOCCAL KERATITIS
GONOCOCCAL EYE NEC
GONOCOCCAL ARTHRITIS
GONOCOCCAL SYNOVITIS
GONOCOCCAL BURSITIS
GONOCOCCAL SPONDYLITIS
GC INFECT JOINT NEC
GONOCOCCAL INFEC PHARYNX
GC INFECT ANUS & RECTUM
GONOCOCCAL KERATOSIS
GONOCOCCAL MENINGITIS
GONOCOCCAL PERICARDITIS
GONOCOCCAL ENDOCARDITIS
GONOCOCCAL HEART DIS NEC
GONOCOCCAL PERITONITIS
GONOCOCCAL INF SITE NEC
CHANCROID
LYMPHOGRANULOMA VENEREUM
GRANULOMA INGUINALE
REITER'S DISEASE

2011 Joint Commission International



214

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
099.40
099.41
099.49
099.50
099.51
099.52
099.53
099.54
099.55
099.56
099.59
099.8
099.9
100.0
100.81
100.89
100.9
101
102.0
102.1
102.2
102.3
102.4
102.5
102.6
102.7
102.8
102.9
103.0
103.1
103.2
103.3
103.9
104.0
104.8
104.9
130.0
130.1
130.2

Shortened Description
UNSPCF NONGNCCL URETHRTS
CHLMYD TRACHOMATIS URETH
NONGC URTH OTH SPF ORGSM
OTH VD CHLM TRCH UNSP ST
OTH VD CHLM TRCH PHARYNX
OTH VD CHLM TRCH ANS RCT
OTH VD CHLM TRCH LOWR GU
OTH VD CHLM TRCH OTH GU
OT VD CHLM TRCH UNSPF GU
OT VD CHLM TRCH PRTONEUM
OTH VD CHLM TRCH SPCF ST
VENEREAL DISEASE NEC
VENEREAL DISEASE NOS
LEPTOSPIROS ICTEROHEM
LEPTOSPIRAL MENINGITIS
LEPTOSPIRAL INFECT NEC
LEPTOSPIROSIS NOS
VINCENT'S ANGINA
INITIAL LESIONS YAWS
MULTIPLE PAPILLOMATA
EARLY SKIN YAWS NEC
HYPERKERATOSIS OF YAWS
GUMMATA AND ULCERS, YAWS
GANGOSA
YAWS OF BONE & JOINT
YAWS MANIFESTATIONS NEC
LATENT YAWS
YAWS NOS
PINTA PRIMARY LESIONS
PINTA INTERMED LESIONS
PINTA LATE LESIONS
PINTA MIXED LESIONS
PINTA NOS
NONVENEREAL ENDEMIC SYPH
SPIROCHETAL INFECT NEC
SPIROCHETAL INFECT NOS
TOXOPLASM MENINGOENCEPH
TOXOPLASM CONJUNCTIVITIS
TOXOPLASM CHORIORETINIT

2011 Joint Commission International



215

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
130.3
130.4
130.5
130.7
130.8
131.00
131.01
131.02
131.03
131.09
131.8
131.9
320.0
320.1
320.2
320.3
320.7
320.81
320.82
320.89
320.9
322.9
323.1
324.0
324.1
324.9
380.10
380.11
380.12
380.13
380.14
380.15
380.16
380.21
380.22
380.23
382.00
382.01
382.02

Shortened Description
TOXOPLASMA MYOCARDITIS
TOXOPLASMA PNEUMONITIS
TOXOPLASMA HEPATITIS
TOXOPLASMOSIS SITE NEC
MULTISYSTEM TOXOPLASMOS
UROGENITAL TRICHOMON NOS
TRICHOMONAL VAGINITIS
TRICHOMONAL URETHRITIS
TRICHOMONAL PROSTATITIS
UROGENITAL TRICHOMON NEC
TRICHOMONIASIS NEC
TRICHOMONIASIS NOS
HEMOPHILUS MENINGITIS
PNEUMOCOCCAL MENINGITIS
STREPTOCOCCAL MENINGITIS
STAPHYLOCOCC MENINGITIS
MENING IN OTH BACT DIS
ANAEROBIC MENINGITIS
MNINGTS GRAM-NEG BCT NEC
MENINGITIS OTH SPCF BACT
BACTERIAL MENINGITIS NOS
MENINGITIS NOS
RICKETTSIAL ENCEPHALITIS
INTRACRANIAL ABSCESS
INTRASPINAL ABSCESS
CNS ABSCESS NOS
INFEC OTITIS EXTERNA NOS
ACUTE INFECTION OF PINNA
ACUTE SWIMMERS' EAR
AC INFECT EXTERN EAR NEC
MALIGNANT OTITIS EXTERNA
CHR MYCOT OTITIS EXTERNA
CHR INF OTIT EXTERNA NEC
CHOLESTEATOMA EXTERN EAR
ACUTE OTITIS EXTERNA NEC
CHR OTITIS EXTERNA NEC
AC SUPP OTITIS MEDIA NOS
AC SUPP OM W DRUM RUPT
AC SUPP OM IN OTH DIS

2011 Joint Commission International



216

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
382.1
382.2
421.0
421.1
421.9
422.0
422.90
422.91
422.92
422.93
422.99
462
463
464.00
464.01
464.10
464.11
464.20
464.21
464.30
464.31
464.50
464.51
475
476.0
476.1
481
482.0
482.1
482.2
482.30
482.31
482.32
482.39
482.40
482.41
482.42
482.49
482.81

Shortened Description
CHR TUBOTYMPAN SUPPUR OM
CHR ATTICOANTRAL SUP OM
AC/SUBAC BACT ENDOCARD
AC ENDOCARDIT IN OTH DIS
AC/SUBAC ENDOCARDIT NOS
AC MYOCARDIT IN OTH DIS
ACUTE MYOCARDITIS NOS
IDIOPATHIC MYOCARDITIS
SEPTIC MYOCARDITIS
TOXIC MYOCARDITIS
ACUTE MYOCARDITIS NEC
ACUTE PHARYNGITIS
ACUTE TONSILLITIS
AC LARYNGITIS W/O OBST
AC LARYNGITIS W OBSTRUCT
AC TRACHEITIS NO OBSTRUC
AC TRACHEITIS W OBSTRUCT
AC LARYNGOTRACH NO OBSTR
AC LARYNGOTRACH W OBSTR
AC EPIGLOTTITIS NO OBSTR
AC EPIGLOTTITIS W OBSTR
SUPRAGLOTTIS W/O OBS NOS
SUPRAGLOTTIS W OBSTR NOS
PERITONSILLAR ABSCESS
CHRONIC LARYNGITIS
CHR LARYNGOTRACHEITIS
PNEUMOCOCCAL PNEUMONIA
K. PNEUMONIAE PNEUMONIA
PSEUDOMONAL PNEUMONIA
H.INFLUENZAE PNEUMONIA
STREPTOCOCCAL PNEUMN NOS
PNEUMONIA STRPTOCOCCUS A
PNEUMONIA STRPTOCOCCUS B
PNEUMONIA OTH STREP
STAPHYLOCOCCAL PNEU NOS
METH SUS PNEUM D/T STAPH
METH RES PNEU D/T STAPH
STAPH PNEUMONIA NEC
PNEUMONIA ANAEROBES

2011 Joint Commission International



217

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
482.82
482.83
482.84
482.89
482.9
483.0
483.1
483.8
484.1
484.3
484.5
484.6
484.7
484.8
485
486
487.0
487.1
487.8
490
491.0
491.1
491.20
491.21
491.22
491.8
491.9
510.0
510.9
513.0
513.1
540.0
540.1
540.9
541
542
562.01
562.11
562.13

Shortened Description
PNEUMONIA E COLI
PNEUMO OTH GRM-NEG BACT
LEGIONNAIRES' DISEASE
PNEUMONIA OTH SPCF BACT
BACTERIAL PNEUMONIA NOS
PNEU MYCPLSM PNEUMONIAE
PNEUMONIA D/T CHLAMYDIA
PNEUMON OTH SPEC ORGNSM
PNEUM W CYTOMEG INCL DIS
PNEUMONIA IN WHOOP COUGH
PNEUMONIA IN ANTHRAX
PNEUM IN ASPERGILLOSIS
PNEUM IN OTH SYS MYCOSES
PNEUM IN INFECT DIS NEC
BRONCHOPNEUMONIA ORG NOS
PNEUMONIA, ORGANISM NOS
INFLUENZA WITH PNEUMONIA
FLU W RESP MANIFEST NEC
FLU W MANIFESTATION NEC
BRONCHITIS NOS
SIMPLE CHR BRONCHITIS
MUCOPURUL CHR BRONCHITIS
OBST CHR BRONC W/O EXAC
OBS CHR BRONC W(AC) EXAC
OBS CHR BRONC W AC BRONC
CHRONIC BRONCHITIS NEC
CHRONIC BRONCHITIS NOS
EMPYEMA WITH FISTULA
EMPYEMA W/O FISTULA
ABSCESS OF LUNG
ABSCESS OF MEDIASTINUM
AC APPEND W PERITONITIS
ABSCESS OF APPENDIX
ACUTE APPENDICITIS NOS
APPENDICITIS NOS
OTHER APPENDICITIS
DVRTCLI SML INT W/O HMRG
DVRTCLI COLON W/O HMRHG
DVRTCLI COLON W HMRHG

2011 Joint Commission International



218

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
566
567.21
567.22
567.23
567.29
567.31
567.38
567.39
567.81
567.82
567.89
567.9
569.5
569.61
575.0
590.00
590.01
590.10
590.11
590.2
590.3
590.80
590.81
590.9
595.0
599.0
601.0
601.1
601.2
601.3
601.4
601.8
601.9
614.0
614.1
614.2
614.3
614.4
614.5

Shortened Description
ANAL & RECTAL ABSCESS
PERITONITIS (ACUTE) GEN
PERITONEAL ABSCESS
SPONTAN BACT PERITONITIS
SUPPURAT PERITONITIS NEC
PSOAS MUSCLE ABSCESS
RETROPERITON ABSCESS NEC
RETROPERITON INFECT NEC
CHOLEPERITONITIS
SCLEROSING MESENTERITIS
PERITONITIS NEC
PERITONITIS NOS
INTESTINAL ABSCESS
COLOSTY/ENTEROST INFECTN
ACUTE CHOLECYSTITIS
CHR PYELONEPHRITIS NOS
CHR PYELONEPH W MED NECR
AC PYELONEPHRITIS NOS
AC PYELONEPHR W MED NECR
RENAL/PERIRENAL ABSCESS
PYELOURETERITIS CYSTICA
PYELONEPHRITIS NOS
PYELONEPHRIT IN OTH DIS
INFECTION OF KIDNEY NOS
ACUTE CYSTITIS
URIN TRACT INFECTION NOS
ACUTE PROSTATITIS
CHRONIC PROSTATITIS
ABSCESS OF PROSTATE
PROSTATOCYSTITIS
PROSTATITIS IN OTH DIS
PROSTATIC INFLAM DIS NEC
PROSTATITIS NOS
AC SALPINGO-OOPHORITIS
CHR SALPINGO-OOPHORITIS
SALPINGO-OOPHORITIS NOS
ACUTE PARAMETRITIS
CHRONIC PARAMETRITIS
AC PELV PERITONITIS-FEM

2011 Joint Commission International



219

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
614.7
616.2
616.3
616.4
639.0
646.60
646.61
646.62
646.63
646.64
670.00
670.02
670.04
674.30
674.32
674.34
680.0
680.1
680.2
680.3
680.4
680.5
680.6
680.7
680.8
680.9
681.00
681.01
681.02
681.10
681.11
681.9
682.0
682.1
682.2
682.3
682.4
682.5
682.6

Shortened Description
CHR PELV PERITON NEC-FEM
BARTHOLIN'S GLAND CYST
BARTHOLIN'S GLND ABSCESS
ABSCESS OF VULVA NEC
POSTABORTION GU INFECT
GU INFECT IN PREG- UNSPEC
GU INFECTION-DELIVERED
GU INFECTION-DELIV W P/P
GU INFECTION-ANTEPARTUM
GU INFECTION-POSTPARTUM
MAJ PUERP INF NOS-UNSP
MAJ PUER INF NOS-DEL P/P
MAJOR PUERP INF NOS-P/P
OB SURG COMPL NEC-UNSPEC
OB SURG COMPL-DEL W P/P
OB SURG COMP NEC- POSTPAR
CARBUNCLE OF FACE
CARBUNCLE OF NECK
CARBUNCLE OF TRUNK
CARBUNCLE OF ARM
CARBUNCLE OF HAND
CARBUNCLE OF BUTTOCK
CARBUNCLE OF LEG
CARBUNCLE OF FOOT
CARBUNCLE, SITE NEC
CARBUNCLE NOS
CELLULITIS, FINGER NOS
FELON
ONYCHIA OF FINGER
CELLULITIS, TOE NOS
ONYCHIA OF TOE
CELLULITIS OF DIGIT NOS
CELLULITIS OF FACE
CELLULITIS OF NECK
CELLULITIS OF TRUNK
CELLULITIS OF ARM
CELLULITIS OF HAND
CELLULITIS OF BUTTOCK
CELLULITIS OF LEG

2011 Joint Commission International



220

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
682.7
682.8
682.9
683
684
685.0
685.1
686.00
686.01
686.09
686.1
686.8
686.9
711.90
711.91
711.92
711.93
711.94
711.95
711.96
711.97
711.98
711.99
730.00
730.01
730.02
730.03
730.04
730.05
730.06
730.07
730.08
730.09
730.10
730.11
730.12
730.13
730.14
730.15

Shortened Description
CELLULITIS OF FOOT
CELLULITIS, SITE NEC
CELLULITIS NOS
ACUTE LYMPHADENITIS
IMPETIGO
PILONIDAL CYST W ABSCESS
PILONIDAL CYST W/O ABSC
PYODERMA NOS
PYODERMA GANGRENOSUM
PYODERMA NEC
PYOGENIC GRANULOMA
LOCAL SKIN INFECTION NEC
LOCAL SKIN INFECTION NOS
INF ARTHRITIS NOS-UNSPEC
INF ARTHRITIS NOS-SHLDER
INF ARTHRITIS NOS-UP/ARM
INF ARTHRIT NOS-FOREARM
INF ARTHRIT NOS-HAND
INF ARTHRIT NOS-PELVIS
INF ARTHRIT NOS-L/LEG
INF ARTHRIT NOS-ANKLE
INF ARTHRIT NOS-OTH SITE
INF ARTHRITIS NOS-MULT
AC OSTEOMYELITIS-UNSPEC
AC OSTEOMYELITIS-SHLDER
AC OSTEOMYELITIS-UP/ARM
AC OSTEOMYELITIS-FOREARM
AC OSTEOMYELITIS-HAND
AC OSTEOMYELITIS-PELVIS
AC OSTEOMYELITIS-L/LEG
AC OSTEOMYELITIS-ANKLE
AC OSTEOMYELITIS NEC
AC OSTEOMYELITIS-MULT
CHR OSTEOMYELITIS-UNSP
CHR OSTEOMYELIT-SHLDER
CHR OSTEOMYELIT-UP/ARM
CHR OSTEOMYELIT-FOREARM
CHR OSTEOMYELIT-HAND
CHR OSTEOMYELIT-PELVIS

2011 Joint Commission International



221

ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
730.16
730.17
730.18
730.19
730.20
730.21
730.22
730.23
730.24
730.25
730.26
730.27
730.28
730.29
730.30
730.31
730.32
730.33
730.34
730.35
730.70
730.71
730.72
730.73
730.74
730.75
730.76
730.77
730.78
730.79
730.80
730.81
730.82
730.83
730.84
730.85
730.86
730.87
730.88

Shortened Description
CHR OSTEOMYELIT-L/LEG
CHR OSTEOMYELIT-ANKLE
CHR OSTEOMYELIT NEC
CHR OSTEOMYELIT-MULT
OSTEOMYELITIS NOS-UNSPEC
OSTEOMYELITIS NOS-SHLDER
OSTEOMYELITIS NOS-UP/ARM
OSTEOMYELIT NOS-FOREARM
OSTEOMYELITIS NOS-HAND
OSTEOMYELITIS NOS-PELVIS
OSTEOMYELITIS NOS-L/LEG
OSTEOMYELITIS NOS-ANKLE
OSTEOMYELIT NOS-OTH SITE
OSTEOMYELITIS NOS-MULT
PERIOSTITIS-UNSPEC
PERIOSTITIS-SHLDER
PERIOSTITIS-UP/ARM
PERIOSTITIS-FOREARM
PERIOSTITIS-HAND
PERIOSTITIS-PELVIS
POLIO OSTEOPATHY-UNSPEC
POLIO OSTEOPATHY-SHLDER
POLIO OSTEOPATHY-UP/ARM
POLIO OSTEOPATHY-FOREARM
POLIO OSTEOPATHY-HAND
POLIO OSTEOPATHY-PELVIS
POLIO OSTEOPATHY-L/LEG
POLIO OSTEOPATHY-ANKLE
POLIO OSTEOPATHY NEC
POLIO OSTEOPATHY-MULT
BONE INFECT NEC-UNSPEC
BONE INFECT NEC-SHLDER
BONE INFECT NEC-UP/ARM
BONE INFECT NEC-FOREARM
BONE INFECT NEC-HAND
BONE INFECT NEC-PELVIS
BONE INFECT NEC-L/LEG
BONE INFECT NEC-ANKLE
BONE INFECT NEC-OTH SITE

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ICD-8
Code

ICD-9
Code

ICD-10
Code

ICD-9CMCode
730.89
730.90
730.91
730.92
730.93
730.94
730.95
730.96
730.97
730.98
730.99
785.52
790.7
996.60
996.61
996.62
996.63
996.64
996.65
996.66
996.67
996.68
996.69
997.31
998.51
998.59

Shortened Description
BONE INFECT NEC-MULT
BONE INFEC NOS-UNSP SITE
BONE INFECT NOS-SHLDER
BONE INFECT NOS-UP/ARM
BONE INFECT NOS-FOREARM
BONE INFECT NOS-HAND
BONE INFECT NOS-PELVIS
BONE INFECT NOS-L/LEG
BONE INFECT NOS-ANKLE
BONE INFECT NOS-OTH SITE
BONE INFECT NOS-MULT
SEPTIC SHOCK
BACTEREMIA
REACTION-UNSP DEVIC/GRFT
REACT-CARDIAC DEV/GRAFT
REACT-OTH VASC DEV/GRAFT
REACT-NERV SYS DEV/GRAFT
REACT-INDWELL URIN CATH
REACT-OTH GENITOURIN DEV
REACT-INTER JOINT PROST
REACT-OTH INT ORTHO DEV
REACT- PERITON DIALY CATH
REACT-INT PROS DEVIC NEC
VENTLTR ASSOC PNEUMONIA
INFECTED POSTOP SEROMA
OTHER POSTOP INFECTION

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Venous
Thromboembolism
(VTE) Measure Set

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Measure
Code
Measure Description

Venous Thromboembolism (VTE)


Originally developed through a collaborative effort between The Joint Commission and the
Centers for Medicare and Medicaid Services (CMS)

I-VTE-1

Patients who received VTE prophylaxis (or reasons of why this was not
done) on the day of or day after hospital admission or
surgery.<BR>Note: This measure applies to medical and surgical cases
that are not included in the SCIP measure population

I-VTE-2

ICU patients who received VTE prophylaxis (or reasons of why this was
not done) on the day of or day after hospital admission or
surgery.<BR>Note: This measure applies to all ICU cases except those
included in the SCIP measure population (knee/hip arthroplasty) who
had surgery on the day of or the day after ICU admission or transfer

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I-VTE-1
Venous Thromboembolism Prophylaxis
Measure Overview
I-VTE 1 Patients who received VTE prophylaxis (or reasons of why this was not
done) on the day of or day after hospital admission or surgery.
Note: This measure applies to medical and surgical cases that are not included
in the SCIP measure population.
Overview/Details:
VTE prophylaxis given on the day of or the day after hospital admission or surgery or a
reason documented of why VTE prophylaxis was not given.
See Appendix A.
Rationale:
Hospitalized patients at high-risk for VTE may develop an asymptomatic deep vein
thrombosis (DVT), and die from pulmonary embolism (PE) even before the diagnosis is
suspected. Therefore, the best approach is for every patient to be evaluated for primary
prophylaxis since preventing DVT is essential to reducing morbidity and mortality.
There is clinical evidence that appropriately used thromboprophylaxis has a desirable
risk/benefit ratio and is cost effective. Thromboprophylaxis provides an opportunity to
improve patient outcomes and reduce hospital costs.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services: Medical/surgical units
Measure Name: Venous Thromboembolism Prophylaxis

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Numerator: Patients who received VTE prophylaxis or have documentation of why no


VTE prophylaxis was given:
x
x

the day of or the day after hospital admission


the day of or day after surgery end date for surgeries that start the day of or day
after hospital admission

Denominator: All patients who are >=18 years.


Domains of Performance
$SSURSULDWHQHVV
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QPS Standards
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assessments

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I-VTE-1
Measure Details
Reasons and Implications: Hospitalized patients at high-risk for VTE may develop an
asymptomatic deep vein thrombosis (DVT), and die from pulmonary embolism (PE)
even before the diagnosis is suspected. There is clinical evidence that appropriately
used thromboprophylaxis has a desirable risk/benefit ratio and is cost effective.
Thromboprophylaxis provides an opportunity to improve patient outcomes and reduce
hospital costs.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Patients who received VTE prophylaxis or have documentation of why no
VTE prophylaxis was given:
x
x

the day of or the day after hospital admission


the day of or day after surgery end date for surgeries that start the day of or day
after hospital admission

Inclusions to the population: Not Applicable


Exclusions to the population: None
Data elements:
x
x
x
x
x

Reason for No VTE Prophylaxis Hospital admission


Surgery end date
Surgical procedure
VTE Prophylaxis
VTE Prophylaxis date

Denominator: All patients who are > = 18 years.


Data elements:
x
x
x
x
x

Admission Date
Birthdate
ICD diagnosis code
ICU admission date
ICU admission/transfer

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Inclusions to the population: Not applicable


Exclusions to the population:
x
x
x
x

Patients less than 18 years of age


Patients who are direct admits to the intensive care unit (ICU)
Patients with an ICD Principal diagnosis code of Mental disorders
Patients with an ICD Principal or other diagnosis code of Obstetrics or VTE

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I-VTE-1
References

x
x
x
x
x

Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism:
the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
Kucher N, Koo S, Quiroz R, Cooper JM, et al. Electronic alerts to prevent venous
thromboembolism among hospitalized patients. New England Journal of
Medicine. 2005, 352(10), 969-1036.
Caprini JA, Arcelus JI. State of the art venous thromboembolism prophylaxis.
SCOPE on Phlebology & Lymphology 1:2005, 228-240.
Michota FA. Venous thromboembolism prophylaxis in medical patients. Curr
Opin Cardiol. 2004 Nov;19(6):570-4.

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I-VTE-2
ICU Venous Thromboembolism Prophylaxis
Measure Overview
I-VTE 2 ICU patients who received VTE prophylaxis (or reasons of why this was
not done) on the day of or day after hospital admission or surgery.
Note: This measure applies to all ICU cases except those included in the SCIP measure
population (knee/hip arthroplasty) who had surgery on the day of or the day after ICU admission
or transfer.

Overview/Details:
ICU VTE prophylaxis given on the day of or the day after ICU hospital admission or
surgery or a reason documented of why VTE prophylaxis was not given.
See Appendix A.
Rationale:
The vast majority of patients admitted to a critical care unit (CCU) have a major risk
factor for VTE, and many may have multiple risk factors including advanced age,
serious medical illness or recent surgical procedures or trauma. The use of
thromboprophylaxis has been clinically demonstrated to be efficacious in preventing
deep venous thrombosis in these patients.
Measure Related Outcomes:
Mortality: Decreased mortality
Readmissions within 30 days: Decreased
Reliability: Increased delivery of evidence based care
Improvement noted as: An increase in rate
Patient Settings/Services: Intensive Care Units
Measure Name: Intensive Care Unit Venous Thromboembolism Prophylaxis
Numerator: Patients who received VTE prophylaxis or have documentation of why no
VTE prophylaxis was given:
x

the day of or the day after ICU admission (or transfer)

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the day of or day after surgery end date for surgeries that start the day of or day
after ICU admission (or transfer)

Denominator: Patients directly admitted or transferred to ICU who are >= 18 years

Domains of
Performance

QPS Standards

CCPC

IPSG

$SSURSULDWHQHVV

QPS.3 patient
assessments

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I-VTE-2
Measure Details
Reasons and Implications: The vast majority of patients admitted to a critical care
unit (CCU) have a major risk factor for VTE, and many may have multiple risk factors
including advanced age, serious medical illness or recent surgical procedures or
trauma. The use of thromboprophylaxis has been clinically demonstrated to be
efficacious in preventing deep venous thrombosis in these patients.
Data Collection: Retrospective data sources for the required data elements include
administrative data and medical records.
Numerator: Patients who received VTE prophylaxis or have documentation of why no
VTE prophylaxis was given:
x
x

the day of or the day after ICU admission (or transfer)


the day of or day after surgery end date for surgeries that start the day of or day
after ICU admission (or transfer)

Inclusions to the population: Not Applicable


Exclusions to the population: None
Data elements:
x
x
x
x
x
x

Anesthesia start date


ICU VTE Prophylaxis
ICU VTE Prophylaxis date
Reason for No VTE Prophylaxis ICU admission
Surgery end date ICU admit or transfer
Surgical procedure- ICU admit or transfer

Denominator: All patients who are > = to 18 years.


Data elements:
x
x
x
x
x
x

Admission Date
Birthdate
ICD diagnosis code
ICU discharge date
ICU admission date
ICU admission or Transfer

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Inclusions to the population: Not applicable


Exclusions to the population:
x
x

Patients less than 18 years of age


Patients with an ICD Principal or other diagnosis code of Obstetrics or VTE

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I-VTE-2
References
x
x
x
x

Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell
CW. Prevention of venous thromboembolism. The Eighth ACCP Conference on
antithrombotic and thrombolytic therapy. Chest. 2008; 133:381S-453S.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism:
the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.
Chest. 2004 Sep;126(3 Suppl):338S-400S.
Attia J, Ray JG, Cook DJ, Douketis J, Ginsberg JS, Geerts WH. Deep vein
thrombosis and its prevention in critically ill adults. Arch Intern Med. 2001 May
28;161(10):1268-79.
Geerts WH, Selby R. Prevention of venous thromboembolism in the ICU. Chest.
2003 Dec;124(6 Suppl):357S-363S.

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Appendix A
VTE Prophylaxis Inclusion Table
Table 2.1 VTE Prophylaxis Inclusion Table
VTE Prophylaxis

Inclusion/Synonyms

Coumadin/ Warfarin

Coumadin
Jantoven
Warfarin
Warfarin Sodium
Anti-Embolism stockings
Anti-thrombosis stockings
Elastic support hose
Graduated compression elastic stockings
Jobst stockings
Surgical hose
TED hose (TEDs)
White hose
Thrombosis stockings
Arixtra
Fonda-parinux sodium

Graduated Compression
Stockings (GCS)
- Knee or thigh high

Factor Xa Inhibitor
Oral Factor Xa Inhibitor
Low Dose Unfractionated
Heparin (LDUH)
- Include only Heparin given
by the subcutaneous (SQ,
Subcu, SC, SubQ) route

Rivaroxaban (Oral)
Calciparine
Calcilean
HEP
Hepalean
Heparin
Heparin Calcium
Heparin Leo
Heparin Na
Heparin Sod
Heparin Sodium
Heparin Sodium Inj.
Heparin Sodium Inj. Pork
Heparin Subcu/SQ/SC/SubQ
Liquaemin

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Table 2.1 VTE Prophylaxis Inclusion Table


VTE Prophylaxis

Inclusion/Synonyms

Low Molecular Weight


Heparin (LMWH)

Ardeparin
Dalteparin
Danaparoid
Enoxaparin
Fragmin
Innohep
Lovenox
Normiflo
Orgaran
Tinzaparin
AE pumps (anti-embolic pumps)-calf/thigh
Alternating Leg Pressure (ALP)
Athrombic pumps-calf/thigh
Continuous Enhanced Circulation Therapy (CECT)
DVT boots-calf/thigh
EPC cuffs/ stockings-External pneumatic compressioncalf/thigh
Flotron/Flotron DVT system-thigh
Impulse pump-thigh
Intermittent pneumatic compression stockings
Intermittent compression device (ICD)
KCI stockings
Leg pumpers
PAS (Pulsatile anti-embolic stockings)
Plexipulse-calf/thigh
Pneumatic intermittent impulse compression device
Rapid inflation asymmetrical compression (RIAC) devices
Sequential compression device
Sequential pneumatic hose
Thromboguard
Thrombus pumps-calf/thigh
Vascutherm
VasoPress DVT System

Intermittent Pneumatic
Compression Device (IPC)

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Table 2.1 VTE Prophylaxis Inclusion Table


VTE Prophylaxis

Inclusion/Synonyms
Venodyne boots-calf/thigh

Venous Foot Pump (VFP)

AE pumps-foot only
A-V impulse system
Foot pump
Kendall AV impulse (foot)
Kendall boots
Plantar venous plexus pump-foot only
Plexiboots-foot only
Pneumoboots-foot only
SC boots-foot only
SCD boots-foot only
Venous foot pump

Note: This table is not meant to be an inclusive list of all available mechanical
prophylaxis; rather it represents current information available at the time of
publication.
Table 2.3 VTE Parenteral Therapy Table
Inclusion/Synonyms
VTE Prophylaxis
Direct Thrombin Inhibitors

Argatroban (Acova)

- argatroban
- bivalirudin
- lepirudin

Bivalirudin (Angiomax)

Factor Xa Inhibitor

Arixtra

Lepirudin (recombinant hirudin)(Refludan)

Fondaparinux sodium
Unfractionated Heparin
(UFH)
- intravenous (IV)
- subcutaneous (fixed dose
or monitored)

Calciparine
Calcilean
HEP
Hepalean

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Heparin
Heparin Calcium
Heparin Leo
Heparin Na
Heparin Sod
Heparin Sodium
Heparin Sodium Inj.
Heparin Sodium Inj. Pork
Heparin Subcu/SQ/SC
Liquaemin
Low Molecular Weight
Heparin (LMWH)

Ardeparin
Dalteparin
Danaparoid
Enoxaparin
Fragmin
Innohep
Lovenox
Normiflo
Orgaran
Tinzaparin

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Appendix B
ICD Codes
VTE
Please Note : Due to the various ICD Code versions used by different countries,
ICD-8, ICD-9, and ICD-10 spaces have been left intentionally blank. Please fill in
the specific code utilized by your country to correspond to the ICD-9-CM code
description for the following diagnoses.
Table 7.03 VTE
ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM
Code

Shortened Description

415.11

IATROGEN PULM EMB/INFARC

415.19

PULM EMBOL/INFARCT NEC

451.11

FEMORAL VEIN PHLEBITIS

451.19

DEEP PHLEBITIS-LEG NEC

451.2

THROMBOPHLEBITIS LEG NOS

451.81

ILIAC THROMBOPHLEBITIS

451.9

THROMBOPHLEBITIS NOS

453.40

DVT/EMBLSM LOWER EXT NOS

453.41

DVT/EMB PROX LOWER EXT

453.87

AC EMBL THORAC VEIN NEC

453.89

AC EMBOLISM VEINS NEC

453.9

VENOUS THROMBOSIS NOS

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Table 7.04 VTE Obstetrics


ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM
Code

Shortened Description

634.60

SPON ABORT W EMBOL-UNSPEC

634.61

SPON ABORT W EMBOL-INC

634.62

SPON ABORT W EMBOL-COMP

635.60

LEGAL ABORT W EMBOL-UNSPEC

635.61

LEGAL ABORT W EMBOL-INC

635.62

LEGAL ABORT W EMBOL-COMP

636.60

ILLEG AB W EMBOLISM-UNSPEC

636.61

ILLEG AB W EMBOLISM-INC

636.62

ILLEG AB W EMBOLISM-COMP

637.60

AB NOS W EMBOLISM-UNSP

637.61

AB NOS W EMBOLISM-INC

637.62

AB NOS W EMBOLISM-COMP

638.6

ATTEMP ABORT W EMBOLISM

639.6

POSTABORTION EMBOLISM

671.30

DEEP THROMB ANTEPAR-UNSPEC

671.31

DEEP THROM ANTEPAR-DELIV

671.33

DEEP VEIN THROMB-ANTEPAR

671.40

DEEP THROMB POSTPAR-UNSPEC

671.42

THROMB POSTPAR-DEL W P/P

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ICD-8

ICD-9

ICD-10

Code

Code

Code

ICD-9CM
Code

Shortened Description

671.44

DEEP VEIN THROMB-POSTPAR

671.50

THROMBOSIS NEC PREG-UNSPEC

671.51

THROMBOSIS NEC-DELIV

671.52

THROMB NEC-DELIV W P/P

671.53

THROMBOSIS NEC-ANTEPART

671.54

THROMBOSIS NEC-POSTPART

671.90

VEN COMPL PREG NOS-UNSPEC

671.91

VENOUS COMPL NOS-DELIVER

671.92

VEN COMP NOS-DELIV W P/P

671.93

VENOUS COMPL NOS-ANTEPAR

671.94

VENOUS COMPL NOS-POSTPAR

673.20

OB PULM EMBOL NOS-UNSPEC

673.21

PULM EMBOL NOS-DELIV

673.22

PULM EMBOL NOS-DELIV W P/P

673.23

PULM EMBOL NOS-ANTEPART

673.24

PULM EMBOL NOS-POSTPART

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Glossary

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Glossary
A
Accreditation
Determination by Joint Commission International (JCI) accrediting body that an eligible
health care organization complies with applicable JCI standards (JCI)
Accreditation process
A continuous process whereby health care organizations are required to demonstrate to
JCI that they are providing safe, high-quality care, as determined by compliance with
JCI standards and International Patient Safety Goals recommendations. The key
component of this process is an on-site evaluation of an organization by JCI surveyors.
(JCI)
Accuracy of data
The extent to which data are free of identifiable errors.
Acute Hemorrhagic Stroke
A non-traumatic intracerebral hemorrhage, subarachnoid hemorrhage or hemorrhagic
infarction
Acute Ischemic Stroke
A measurable neurological deficit of sudden onset, presumed secondary to focal
cerebral ischemia, and not otherwise attributable to intracerebral hemorrhage (ICH) or
another disease process. Cerebrovascular disorder caused by deprivation of blood flow
to an area of the brain, generally as a result of thrombosis, embolism, or reduced blood
pressure
Acute Myocardial Infarction (AMI)
Death of heart muscle resulting from insufficient blood supply to the heart. For
purposes of this measure set, acute myocardial infarction is identified by the ICD codes
in Appendix A, Table 1.1.
Allowable value
A list of acceptable responses for a data element.
Administrative/financial performance measures
Measures that address the organizational structure for coordinating and integrating
services, functions, or activities across operational components, including financial
management (for example, financial stability, utilization, credentialing.) (CCPC)
Ambulatory care
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Types of health care services provided to individuals on an outpatient basis.


Ambulatory care services are provided in many settings ranging from freestanding
surgical facilities to cardiac catheterization centers. (JCI)
Antithrombotic Therapy
Pharmacologic agents (oral or parenteral) preventing or interfering with the formation of
a thrombus or blood coagulation.
Appropriateness
7KHGHJUHHWRZKLFKWKHFDUHSURYLGHGLVUHOHYDQWWRWKHSDWLHQWVFOLQLFDOQHHGVJLYHQ
the current state of knowledge
Assisted Fall
A fall in which any staff member (whether nursing service employee or not) was with the
patient and DWWHPSWHGWRPLQLPL]HWKHLPSDFWRIWKHIDOOE\HDVLQJWKHSDWLHQWVGHVFHQW
WRWKHIORRURULQVRPHPDQQHUDWWHPSWLQJWREUHDNWKHSDWLHQWVIDOO$VVLVWLQJWKH
patient back into bed or chair after a fall is not an assisted fall. A fall that is reported to
have been assisted by a family member or visitor also does not count as an assisted
fall.
Atrial Fibrillation
Cardiac arrhythmia characterized by disorganized electrical activity in the atria
accompanied by an irregular ventricular response that is usually rapid. The atria quiver
instead of pumping in an organized fashion, resulting in compromised ventricular filling
and reduced stroke volume. Stasis of left atrial flow increases the risk of stroke.
Atrial Flutter
Type of atrial tachycardia characterized by contraction rates between 230/min and
380/min.
Availability
The degree to which the appropriate care is available to meet the patientVQHHGV
Best practice
Clinical, scientific, or professional technique, method, or process that is recognized by a
majority of professionals in a particular field as more effective at delivering a particular
outcome than any other practice. These practicHVDOVRVRPHWLPHVUHIHUUHGWRDVJRRG
SUDFWLFHRUEHWWHUSUDFWLFHDUHW\SLFDOO\HYLGHQFHEDVHGDQGFRQVHQVXVGULYHQ -&,
Cardiac Module
A set of evidence-based process measures designed to prevent cardiac complications
in surgical patients.

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Certification
1.

2.

The procedure and action by which an organization evaluates and


certifies that an individual, institution, or program meets requirements
such as standards. Certification differs from accreditation in that
certification can also be applied to individuals (for example, a medical
specialist). (CCPC)
The process by which a nongovernment agency or association certifies
that an individual has met predetermined qualifications specified by
that agency or association.

Certification review
An evaluation of a clinical care program to assess its level of compliance with
applicable Joint Commission International standards and to make determination about
its certification status. The evaluation includes assessing documentation, reviewing
performance measurement reports, gathering verbal information, making on-site
observations, and educating and consulting with the program about standards
compliance and performance improvement. (CCPC)
Cesarean Section
Surgical delivery of a fetus through incision in the abdominal wall and the uterine wall,
Does not include removal of the fetus from the abdominal cavity in case of rupture of the
uterus or abdominal pregnancy.
&KLOGUHQV$VWKPD&DUH &$&
Asthma is defined as a lung disorder marked by breathing difficulty, wheezing, or
coughing. For purposes of this measure set, the population is defined as children equal
or greater than 2 through 17 years of age.
Clinical Care of Patients
The clinical care of patients includes medications, laboratory and diagnostic imaging
services, surgery, anesthesia, and many types of treatments that place patients at risk.
These risks may results in the mix-up of test results between patients, delays in
diagnosis and treatment, wrong side or wrong patient surgical procedures, incorrect
medications or doses, and many other harmful outcomes which for the most part are
preventable.
Clinical Care Program Certification (CCPC)
An interdisciplinary, continuum-based approach to health care delivery that prevents,
minimizes, or delays exacerbations or complications of an illness or condition by
6XSSRUWLQJWKHSDUWLFLSDQWVVHOI-management activities
Supporting the ongoing patient/practitioner relationship
Using a standardized method or process for delivering or facilitating the delivery
of clinical care based on clinical practice guidelines or evidence-based practice
7DLORULQJWUHDWPHQWVDQGLQWHUYHQWLRQVWRWKHSDUWLFLSDQWVQHHG
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Promoting the flow of patient information across settings and providers while
protecting patient rights, security and privacy
Analyzing and using data to continually revise treatment plans
Continuously evaluating ways to improve performance and clinical practice,
thereby improving participant care.

Clinical Measures
Measures designed to evaluate the processes or outcomes of care associated with the
delivery of clinical services; may focus on the appropriateness of clinical decision
making and implementation of these decisions; must be condition specific, procedure
specific, or address function of patient care (e.g., medication use, infection control,
patient assessment, etc.)
Clinical practice guidelines
Statements that help practitioners and patients choose appropriate health care for
specific clinical conditions (for example, recommendations on the case management of
diarrhea in children under the age of 5). The practitioner is guided through all steps of
consultation (questions to ask, physical signs to look for, tests to perform, assessment
of the situation and treatment to prescribe). JCI
Community Acquired Pressure Ulcer
Any pressure ulcer discovered/documented at the time of hospitalization. An ulcer
observed within the first 24 hours from the time of inpatient admission should be
considered community acquired for this measure set.
Competent and Capable Workforce
Patients assume that the health care professionals providing their care and treatment
are competent and capable. Furthermore, even though health care professionals may
intend to provide quality and safe patient care every day, they are frequently not
supported by consistent and low-risk processes and systems, thus placing patients at
risk.
Contraindication
A factor or condition that may render the administration of a drug or agent or the
performance of a procedure or other practice inadvisable, improper, and/or undesirable.
Continuity
The degree to which the care for the patient is coordinated among practitioners, among
organizations and over time.
Controllers
Controllers are long term control medication for asthma. Controllers reduce airway
inflammation and prevent asthma exacerbations. Inhaled corticosteroids are the
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preferred medications for controlling mild, moderate, and severe persistent asthma.
Refer to Appendix C, Table 6.1 for a listing of controller medications.
Corticosteroids Any of the hormones produced by the adrenal cortex or their synthetic
equivalents, used to achieve quick relief of asthma exacerbations or long term control of
the swelling, inflammation and mucus production that occurs when the airway are
irritated. Corticosteroids are available in inhaled, topical, oral, and intravenous forms.
Data Collection
The act or process of capturing raw or primary data from a single or number of sources.
$OVRFDOOHGGDWDJDWKHULQJ
Data Collection Effort
The availability and accessibility of the required data elements, the effort required to
abstract or collect data.
Data Element
$GLVFUHWHSLHFHRIGDWDVXFKDVSDWLHQWVGDWHRIELUWKRUSULQFLSDOGLDJQRVLV
Data Quality
The accuracy and completeness of measure data on performance in the context of the
analytical purposes for which they will be used.
Data Source
The data source for specific data elements refers to the primary source document(s)
used for data collection (for example, billing or administrative data, encounter form,
medical records).
Defined measure
A structured measure with defined populations that measures specific events or values;
such as may have numerators and denominators, take the form of a continuous
variable, or result from review questions. (CCPC)
Denominator
The lower portion of a fraction used to calculate a rate, proportion, or ratio. Also the
population for a rate-based measure.
Denominator Specifications
An explanation of the denominator description that consists of included population,
excluded populations, data elements, and corresponding data sources.
Denominator Statement
A statement that depicts the population evaluated by the performance measure.
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Denominator Verification
The extent to which the population of interest is identified through data collection.
Discriminatory Capability
The extent to which an indicator demonstrates variation in performance across health
care organizations.
Domains of Performance
$WWULEXWHVRIRUJDQL]DWLRQSHUIRUPDQFHWKDWDUHUHODWHGWRRUJDQL]DWLRQVGRLQJWKHUight
WKLQJV VXFKDVDSSURSULDWHQHVVDYDLODELOLW\DQGHIILFDF\ DQGGRLQJWKLQJVZHOO VXFK
as, continuity, effectiveness, efficiency, respect and caring, safety, and timeliness).
Performance domains are definable, measurable and improvable.
'RQRW XVHOLVW
A written catalog of abbreviations, acronyms, and symbols that are not to be used
throughout an organizationwhether handwritten or entered as free text into a
computerdue to their potentially confusing nature. (JCI)
Effective
Evidence-based practice that produces better outcomes than its alternative
Effectiveness
The degree to which care is provided in the correct manner, given the current state of
knowledge, to achieve the desired or projected outcome(s) for the patient.
Efficient
The appropriate use of resources at the least expense to the patient, provider, and care
setting.
Efficiency
The degree to which the care of the patient has been shown to accomplish the desired
or projected outcomes.
Elective Carotid Endarterectomy
Surgical procedure performed by choice, involving excision of atheromatous segments
of the endothelium and tunica media of the carotid artery, leaving a smooth tissue lining
and facilitating blood flow through the vessel; surgery done to prevent stroke.
Elective Carotid Intervention
Surgery (e.g., carotid endarterectomy) and othe procedures (e.g., carotid angioplasty,
VWHQWLQJ LQYROYLQJWKHFDURWLGDUWHU\SHUIRUPHGGXHWRWKHSDWLHQWVFKRLFH

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Elective Delivery
Delivery of a newborn(s) when the mother was not in active labor or presented with
spontaneous ruptured membranes prior to medical induction and/or cesarean section.
Episode of Care (EOC)
A patient or case-level record submitted to the database.
Equitable
Care delivered fairly with consideration to need and no other discriminatory factors
Evidence-based practice
Patient care and treatment grounded in science or published clinical studies over a
longitudinal and progressively rigorous empirical evidence. (CCPC)
Face validity
The preliminary expert-based judgment on the usefulness and relevance of a
performance measure for the purpose for which it is intended.
Fall
An unplanned descent to the floor (or extension of the floor, e.g., trash can or other
equipment) with or without injury to the patient.
Focus of indicator
The activity or area that the measure addresses. For example, the focus of an indicator
PLJKWEHPRQLWRULQJSDWLHQWUHVSRQVHRUXULQDU\FDWKHWHUXVDJH
General Data Elements
Data elements that must be collected by hospitals for each patient record. These data
are patient demographic data, hospital identifiers, and patient identifiers.
Health care-associated infections (HAI)
Any infection(s) acquired by an individual while receiving care or services in a health
care organization. CoPPRQ+$,VDUHXULQDU\LQIHFWLRQVVXUJLFDOZRXQGLQIHFWLRQV
pneumonia, and blood stream infections. (JCI)
Health care professional
Any person who has completed a course of study and is skilled in a field of health. This
includes a physician, dentist, nurse, or allied health professional. Health care
professionals are often licensed by a government agency or certified by a professional
organization. (JCI)

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Health status performance measures


Measures that address the functional well-being of specific populations, both in general
and in relation to specific conditions, demonstrating change over time (for example,
physical functioning, bodily pain, social functioning, mental health.) (CCPC)
Heart Failure (HF)
A clinical syndrome characterized by signs and symptoms resulting from disturbances in
cardiac output or from increased venous pressure, including fatigue, shortness of
breath, or leg swelling. For purposes of this measure set, heart failure is identified by
the ICD codes in Appendix A, Table 2.1.
Hospital Acquired Pressure Ulcer (Nosocomial)
An ulcer observed after the first 24 hours from the time of inpatient admission AND for
which there is no documentation in the record indicating the date of first discovery;
should be considered as hospital acquired.
Hospital-Based Inpatient Psychiatric Services (HBIPS)
A measure set focused on improving quality and performance in inpatient psychiatric
settings through performance measurement.
ICD Codes
A two-part classification system in current use for coding patient medical information
used in abstracting systems and for classifying patients. The first part is a
comprehensive list of diseases with corresponding codes compatible with the World
+HDOWK2UJDQL]DWLRQVOLVWRIGLVHDVHFRGHV7KHVHFRQGSDUW contains procedure codes
independent of the disease codes.
Improvement of Quality and Safety
Health care organizations, and their patients, remain at risk from poor quality and
unsafe practices if organizations do not learn from their good and bad experiences and
take actions to continually improve. Data are at the core of this learning. Organizations
need to understand and value data collection and analysis in process improvement.
Organizations must gain experience in setting improvement priorities, collecting data,
displaying data for better analysis, and finally, planning and implementing improvement
strategies.
Infection module
A set of evidence-based process indicators designed to prevent postoperative infection
in the surgery patient.
Intensive Care Unit (ICU)
A nursing care area that provides intensive observation, diagnosis, and therapeutic
procedures for adults and/or children who are critically ill. An ICU excludes nursing
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areas that provide step-down, intermediate care or telemetry only. Specialty care areas
are also excluded.
Intermittent Pneumatic Compression Device
Device that uses sequential and/or intermittent compression to counteract blood flow
stasis by increasing peak blood flow velocity. As a result, less blood is allowed to pool
in veins thus decreasing chances for thrombus formation.
International Essentials
7KHILYHDUHDVRIULVNRQZKLFKWRIRFXVLQLWLDOTXDOLW\DQGVDIHW\LPSURYHPHQWHIIRUWV
These five areas were developed from an extensive international literature search on
health care quality and safety. Criteria for each Risk Area provides clear and achievable
risk-reduction strategies. Levels of effort are identified for each criterion to provide a
means for evaluating progress in reducing risk and improving quality.
Intracerebral Hemorrhage (ICH)
Non-traumatic abrupt onset of headache or altered level of consciousness and/or focal
neurological deficit that is associated with a focal collection of blood within the brain
parenchyma on CT scan and is not due to trauma or hemorrhagic conversion of a
cerebral infarction.
Leadership Process and Accountability
Experience around the world has shown that in large and small health care
organizations, in general and specialty care facilities, in rural and urban settings, and in
public and private settings, the most essential factor in improving quality and patient
safety is leadership support at the highest level of the organization
Measure Information Form
Tool used to provide specific clinical and technical information on a measure. The
information contained includes: performance measure name, description, rationale,
numerator/denominator statements, included populations, excluded populations, data
elements, risk adjustment, sampling, data accuracy and selected references.
Measure set
A unique grouping of carefully selected measures, that when reviewed together, provide
DFRPSUHKHQVLYHXQGHUVWDQGLQJRUDVVHVVPHQWRIDXQLWVGHSDUWPHQWVRU
RUJDQL]DWLRQVSHUIRUPDQFH &&3&
Measure-specific data elements
Data elements used by one specific measure or several measures in one specific
measure set, such as acute myocardial infarction (AMI).

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Medical record (data source)


Data obtained from the records or documentation maintained on a patient in any health
care setting. Includes both automated and paper medical record systems.
Nosocomial Infection
An infection acquired by a patient in a health care organization, especially a hospital.
This infection is not present or incubating before admission to a hospital.
Numerator
The upper portion of a fraction used to calculate a rate, proportion or ratio.
Numerator specifications
An explanation of the numerator description that consists of included populations,
excluded populations, data elements, and corresponding data sources.
Numerator Statement
A statement that depicts the portion of the denominator population that satisfies the
conditions of the performance measure to be an indicator event.
Nursing-Sensitive, Nursing-Sensitive Processes and Outcomes (NSC)
Processes and outcomes (and structural proxies for theses processes and outcomes,
e.g., skill mix, nurse staffing hours) are affected, provided, and/or influenced by nursing
personnel, but nursing is not exclusively responsible for them. Nursing-sensitive
measures must be quantifiably influenced by nursing personnel, but the relationship is
not necessarily causal.
Observed rate
7KHREVHUYHGUDWHLVWKHLQGLFDWRUUDWHWKDWLVEDVHGRQWKHKRVSLWDOVDJJUHJDWHGDWDIRU
a reporting period. This is calculated as the number of indicator numerator cases for
the reporting period divided by the number of denominator cases. Observed rates are
used to measure hospital performances.
Outcome
The result of the performance of a function or a process(es). The effect(s) that an
intervention has on a specific health problem. It reflects the purpose of the intervention.
For example, the outcome(s) or a rural health program on safe drinking water could be
fewer diarrhea episodes in children under five or a decreased child mortality rate by
diarrhea. (JCI)
Outpatient
Generally, persons who do not need the level of care associated with the more
structured environment of an inpatient or a residential program. In many countries,
RXWSDWLHQWFDUHLVDOVRNQRZQDVDPEXODWRU\FDUH,QVRPHFRXQWULHVRXWSDWLHQWVDUH
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FRQVLGHUHGDGPLWWHGWRDKHDOWKFDUHRUJDQL]DWLRQLQRWKHUVRXWSDWLHQWDUHFRQVLGHUHG
UHJLVWHUHG -&,
Parenteral
Not through the alimentary canal but rather by injection through some other route, such
as subcutaneous, intramuscular, intraorbital, intracapsular, intraspinal, intravenous, etc.
Patient Centered
&DUHWKURXJKRXWDSDWLHQWVH[SHULHQFHVKRXOGEHFRRUGLQDWHGDQGJURXQGHGLQ
respectful interactions with care providers that is consistent ZLWKWKHSDWLHQWVYDOXHV
expectations and care decisions.
Patient Days
Conceptually, a patient day is 24 hours, beginning the hour of admission
as measured by daily or period censuses. Facilities should use all data available to
them to represent a complete count of the total number of patients per unit, including
"days" of care provided to short stay patients.
Patient Level Data
Collection of data elements that depict the health care services provided to an individual
(patient). Patient level data are aggregated to generate hospital level data and
comparison group data.
Perception of care quality performance measures
Satisfaction measures that focus on the delivery of clinical care from the
SDWLHQWVSDUWLFLSDQWVSHUVSHFWLYHLQFOXGLQJEXWQRWOLmited to, patient safety and
education, medication use, pain management, communication about plans and
outcomes of care, prevention and illness, improvement in health status, and so forth. A
measure may address one or more aspects of care. (CCPC)
Performance measure
A quantitative tool (for example, rate, ratio, index, percentage) that provides an
LQGLFDWLRQRIDQRUJDQL]DWLRQVSHUIRUPDQFHLQUHODWLRQWRDVSHFLILHGSURFHVVRU
outcome.
Performance measurement
The use of quantitative tools (for example rates, ratios, indices, percentages) to provide
DQLQGLFDWLRQRIDQRUJDQL]DWLRQVSHUIRUPDQFHLQUHODWLRQWRDVSHFLILHGSURFHVVRU
outcome. (CCPC)
Perinatal Care (PC)
The care and management of the fetus and newborn infant in the perinatal period,
before, during and after delivery.
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Physical Restraint
Any manual method, physical or mechanical device, material, or equipment that
immobilizes or reduces the ability of a patient to move his or her arms, legs, body or
head freely.
Pneumonia (PN)
Pneumonia is defined as an acute infection of the pulmonary parenchyma that is
associated with at least some of the symptoms of acute infection, accompanied by
presence of acute infiltrate on chest radiograph or auscultatory findings consistent with
pneumonia (such as altered breath sounds and/or localized rales.
Pressure Ulcer
A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a
bony prominence, as a result of pressure, or pressure in combination with shear. A
number of contributing or confounding factors are also associated with pressure ulcers;
the significance of these factors is yet to be elucidated.
Prevention/Early Detection
The degree to which appropriate services are provided for promotion preservation, and
restoration of health and for the early detection of disease.
Prophylactic Antibiotic
An antibiotic used to prevent, rather than treat or cure, disease. For the purposed of
SCIP-Inf-1 through 3, antibiotics given to prevent postoperative infection will be
collected. Because the overuse of antibiotics can lead to resistance, antibiotics taken to
prevent infarction should be used only for a short time.
Process measure
A measure used to assess a goal directed, interrelated series of actions, events,
mechanisms or steps. For example, a performance measure describing what is done
to, for or by patients, as in performance of a procedure.
Quality of Care
The degree to which health services for individuals and populations increase the
likelihood of desired health outcomes and are consistent with current professional
knowledge. Dimensions of performance include the following: patient perspective
issues, safety of the care environment; and accessibility, appropriateness, continuity,
effectiveness, efficacy, efficiency, and timeliness of care.
Quality Improvement
An approach to the continuous study and improvement of the processes of providing
health care services to meet the needs of individuals and others. Synonyms include
continuous quality improvement, continuous improvement, organizationwide
performance improvement, and total quality management. (CCPC)
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Rate-based (measure)
An aggregate data measure in which the value of each measurement is expressed as a
proportion or as a ratio. In a proportion, the numerator is expressed as a subset of the
denominator (for example, AMI patients who received aspirin within 24 hours before or
after hospital arrival over all AMI patients). In a ratio, the numerator and denominator
measure different phenomena (for example, the number of patients with central lines
who develop infections divided by the number of central line days).
Reliability
The ability of the indicator to accurately and consistently identify the events it was
designed to identify across multiple health settings.
Relevance
The applicability and/or pertinence of the indicator to its users and customers.
Repeat Fall
More than one fall by the same patient in the same month may be
classified as a repeat fall.
Respect and Caring
The degree to which the patient or a designee is involved in his or her own care
decisions, and to which those providing services do so with sensitivity and respect for
WKHSDWLHQWVQHHGVH[SHFWDWLRQVDQGLQGLYLGXDOGLIIHUHQFHV
Safe
Delivery of care in a manner that minimizes any risk of harm to the patient.
Safe Environment for Staff and Patients
Health care organizations are very complex places which house a significant amount of
equipment, hazardous materials, and many types of patient supplies. Health care
practitioners may be proficient in using equipment, but may often lack the expertise to
inspect and maintain equipment. Those inspecting and maintaining equipment may not
have the required skills and knowledge to ensure that equipment if functional and safe.
Safety
The degree to which the risk of an intervention and the risk in the care environment are
reduced for the patient and others, including the health care provider.
Sampling Method
Describes the process used to select a sample. Sampling approaches for national
hospital inpatient quality measures are simple random sampling and systematic
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VDPSOLQJ5HIHUWRWKH6DPSOLQJ$SSURDFKHVGLVFXVVLRQLQWKH3RSXODWLRQDQG
Sampling Specifications section for further information.
Sample Size
The number of individuals or particular patients included in a study. Usually chosen so
that the study has a particular statistical power of detecting an effect of a particular size.
Seclusion
Seclusion is the involuntary confinement of a patient alone in a room or an area where
the patient is physically prevented from leaving.
Standard
A statement that defines the performance expectations, structures, or processes that
must be in place for an organization to provide safe and high-quality care, treatment,
and service. (JCI)
Standardized measure
A performance measure that has precisely defined specifications, standardized data
collection protocols, meets established evaluation criteria, and can be uniformly adopted
for use. (CCPC)
Stratification
A form of risk adjustment which involves classifying data into strata based on one or
more characteristics, variables, or other categories.
Stratified Measure
A performance measure that is classified into a number of strata to assist in analysis
and interpretation. The overall or un-stratified measure evaluates all of the strata
together. The stratified measure or each stratum consists of a subset of the overall
measure. For example, surgical patients who received a prophylactic antibiotic within
one hour prior to surgical incision is reported as all surgical patients with the appropriate
ICDPrincipal Procedure Code, who received the prophylactic antibiotic within one hour
prior to surgical incision; however, the stratified measure(s) for SCIP-Inf-1 is reported by
the specific ICD Principal Procedure, such as hip arthroplasty (SCIP-Inf-1d).
Stroke (STK)
See definitions for Acute Ischemic Stroke and Acute Hemorrhagic Stroke.
Structure measure
A measure of whether organizational resources and arrangements are in place to
deliver health care (for example, the number of facilities providing a service). (CCPC)

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Subarachnoid Hemorrhage (SAH)


Non-traumatic abrupt onset of headache or altered level of consciousness that is
associated with blood in the subarachnoid space on CT or a clinical history and exam
consistent with SAH (sudden onset of severe headache or altered level of
consciousness) with xanthochromia and many red blood cells in the cerebrospinal fluid.
Surgical Care Improvement Project (SCIP)
The Surgical Care Improvement Project (SCIP) is a national quality partnership of
organizations focused on improving surgical care by significantly reducing surgical
complications through performance measurement. Utilizing ten process measures in
three separate modules (infection, cardiac, and VTE), the goal is to reduce the
incidence of surgical complications nationally by 25 percent by the year 2010.
Structure measure
A measure of whether organizational resources and arrangements are in place to
deliver health care (for example, the number of facilities providing a service). (CCPC)
Systemic Corticosteroids
Corticosteroids are hormones produced by the adrenal cortex or their synthetic
equivalents and are administered orally or intravenous. Corticosteroids are used to
achieve quick relief of acute or moderate to severe asthma exacerbations. Oral
corticosteroids are also used for long term control of the swelling, inflammation and
mucus production in the airways. Refer to Appendix C, Table 2.15 for a listing of PN
systemic corticosteroid medications or Table 6.3 for a listing of CAC systemic
corticosteroid medications.
Timely
Care delivery that is prompt and provided without delay to mitigate the risk of harm to a
patient.
Timeliness
The degree to which the care is provided to the patient at the most beneficial or
necessary time.
Type of indicator
$QH[SODQDWLRQRIWKHSHUIRUPDQFHLQGLFDWRUVIRUPDWDVWRLWVVWUXFWXUHSURFHVVRU
outcome.
Unable to Determine (UTD)
Each data element that is applicable per the algorithm for each of the measures within a
PHDVXUHVHWPXVWEHWRXFKHGE\WKHDEVWUDFWRU:KLOHWKHUHLVDQH[SHFWDWLRQWKDWDOO
data elements are collected, it is recognized that in certain situations information may
not be available (e.g., dates, times, codes, etc.). If, after due diligence, the abstractor
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determines that a value is not documented or is not able to determine the answer value,
WKHDEVWUDFWRUPXVWVHOHFW8QDEOHWR'HWHUPLQH 87' DVWKHDQVZHU
Vaccine
A vaccine is a suspension of an attenuated (weakened) or killed microorganism, such
as bacteria or virus, administered for the prevention, amelioration, or treatment of
infectious diseases.
Validation
The process by which the integrity and correctness of data are established. Validation
process can occur immediately after a data item is collected or after a complete set of
data are collected.
Validity
Ability to identify opportunities for improvement in the quality of care; demonstration that
the indicator use results in improvements in outcomes and/or quality of care.
Variation
The differences in results obtained in measuring the same event more than once. The
sources of variations can be grouped into two major classes: common causes and
special causes. Too much variation often leads to waste and loss, such as the
occurrence of undesirable patient health outcomes and increased cost of health
services. (JCI)
Venous Thromboembolism (VTE)
A term that includes deep vein thrombosis and/or pulmonary embolism.

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Selected References:
x
x
x
x
x

x
x

x
x
x
x
x

Babbie, ER, The Practice of Social Research, 2nd edition, Belmont, CA:
Wadsworth Publishing Company, 1979.
Disease-Specific Care Certification Manual, 2nd Edition. Joint Commission on
Accreditation of Healthcare Organizations, Oakbrook Terrace, IL. 2005.
Everitt, BS, The Cambridge Dictionary of Statistics, Cambridge University Press,
1998.
Joint Commission International Accreditation Standards for Hospitals, 4th Edition,
Joint Commission International, Aokbrook Terrace, Il 2010.
Iezonni, LI, Foley, SM, Heeran, T, Daley, J, Duncan, CC, Fisher, ES, Hughes, J,
$0HWKRGIRU6FUHHQLQJWKH4XDOLW\RI+RVSLWDO&DUHUsing Administrative Data:
3UHOLPLQDU\9DOLGDWLRQ5HVXOWVQuality Review Bulletin, November, 1992, 361370.
Lexikon Second Edition, Oakbrook Terrace, IL: Joint Commission on
Accreditation of Healthcare Organizations, 1998.
McHorney, CA, Kosinski, M, and :DUH-U-(&RPSDULVRQVRIWKH&RVWDQG
Quality of Norms for the SF-36 Health Survey Collected by Mail Versus
7HOHSKRQH,QWHUYLHZ5HVXOWV)URPD1DWLRQDO6XUYH\Medical Care, 32, (1994),
551-567.
0RVE\V'LFWLRQDU\RI0HGLFLQH1XUVLQJ +HDOWK3URfessions, 7th Edition. Mosby
Elsevier, St. Louis, MO. 2006.
Nichols, T and Earl, L, Basic ICD-9-CM Coding Handbook, Chicago, IL:
American Health Information Management Association, 1992.
ORYX Technical Implementation Guide, The Joint Commission, Oakbrook
Terrace, Illinois, current.
2009 Comprehensive Accreditation Manual for Hospitals; The Joint Commission,
Oakbrook Terrace, Illinois, 2008.
7DEHUV&\FORSHGLF0HGLFDO'LFWLRQDU\)$'DYLV&RPSDQ\3KLODGHOSKLD3$
1997.

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