National Healthcare Quality Institute (NHQI), Inc. Qualified Clinical Data Registry 2016 Measure Specification Document 4.14.16 Page 1
MEASURE NAME: THPSO Measure #1: Perioperative Aspiration Pneumonia rate NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients, independent of age, who receive a general anesthetic, and have an aspiration pneumonia identified within 48 hours. Patients who undergo emergent general anesthesia are excluded from this measure. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per general anesthetic performed during the reporting year. It is anticipated that clinicians who provide general anesthesia will submit this measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo general anesthesia. NUMERAT: Denominator Criteria (Eligible Cases): Patient encounter(s) during reporting period where patients underwent a general anesthesia. THPSO1: DN 4.14.16 Page 2
Patients with evidence of aspiration or aspiration pneumonia within 48 hours of completion of anesthesia. This may be from clinical observation, physical findings, or a new infiltrate identified on CXR by an anesthesia provider or radiologist within 48 hours of completion of anesthesia, which is consistent with aspiration pneumonia. Numerator Criteria: Performance Met: Evidence of aspiration or aspiration pneumonia within 48 hours of completion of anesthesia. THPSO1-PM Denominator Exclusions: Emergent modifier to ASA classification or other indication of an emergency. THPSO1-DE Denominator Exceptions: Performance Not Met: No evidence of aspiration or aspiration pneumonia within 48 hours of completion of anesthesia. THPSO1- PNM RATIONALE: Pulmonary aspiration is a serious cause of anesthesia-related morbidity and mortality, and is a leading cause of death from pulmonary complications. Aspiration occurs in approximately three per 10,000 anesthetic procedures with higher incidences in special patient populations and emergency situations. 1 The goal of perioperative pulmonary management is to identify patients at high risk of significant postoperative pulmonary complications, and to provide appropriate interventions to minimize that risk. In most cases, even in high-risk patients, the procedure can be performed safely. Occasionally postponement, procedural modification, or cancellation is warranted. 1 Abdulla S. Pulmonary aspiration in perioperative medicine. Acta Anaesthesiol Belg. 2013;64(1):1 13. 4.14.16 Page 3
MEASURE NAME: THPSO Measure #2: Post-dural puncture headache rate NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, independent of age, who are identified as having a post-dural puncture headache within 48 hours of placement of a spinal or epidural anesthesia MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Effective Clinical Care RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per spinal or epidural anesthetic performed in hospital locations excluding the emergency department and emergent bedside procedures during the reporting year. It is anticipated that clinicians who provide spinal or epidural anesthesia will submit this measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo spinal or epidural anesthesia. Denominator Criteria (Eligible Cases): Patient encounter(s) during reporting period where patients underwent spinal or epidural anesthetic. THPSO2-DN 4.14.16 Page 4
NUMERAT: The diagnosis of a post-dural puncture headache after an attempt at or placement of an epidural or spinal anesthesia. Numerator Criteria: Performance Met: Clinical evidence of a post-dural puncture headache within 48 hours of completion of anesthesia. THPSO2- PM Denominator Exclusions: Denominator Exceptions: Performance Not Met: No clinical evidence of a post-dural puncture headache within 48 hours of completion of anesthesia. THPSO2- PNM RATIONALE: Post-dural puncture headache is a known and common complication following dural puncture. Research has demonstrated that procedural methods, including the use of small-gauge needles, and needles of the pencil-point design, can lower the risk of this complication. Post-dural puncture headaches are diagnosed by history and physical exam. A strong postural component of the headache, along with a recent dural puncture, is an indicator of a post-dural puncture headache. 2 2 Ghaleb A, Khorasani A, Mangar D. Post-dural puncture headache. Int J Gen Med. 2012;5:45 51 4.14.16 Page 5
MEASURE NAME: THPSO Measure #3: Perioperative Peripheral Nerve Injury rate NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, independent of age, who develop a new peripheral nerve injury within 48 hours of the operative period following a spinal, epidural, regional, or general anesthetic. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Effective Clinical Care RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per spinal, epidural, regional or general anesthetic performed during the reporting year. It is anticipated that clinicians who provide spinal, epidural, regional or general anesthesia will submit this measure. Each case of spinal, epidural, regional or general anesthetic are in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo spinal, epidural, regional or general anesthesia. 4.14.16 Page 6
Denominator Criteria (Eligible Cases): Each case of spinal, epidural, regional or general anesthetic during the reporting year. THPSO3- DN NUMERAT: The diagnosis of a new peripheral nerve injury within 48 hours of anesthetic procedure. Numerator Criteria: Performance Met: Clinical evidence of a new peripheral nerve injury within 48 hours of completion of anesthesia. THPSO3-PM Denominator Exclusions: Denominator Exceptions: Peripheral nerve injuries that are demonstrated to be secondary to surgical intervention, as evidenced by EMG or anatomical location (i.e. the common peroneal division of the sciatic nerve may be injured after total knee replacement due to its anatomical location, with a reported incidence ranging from 0.3% to 4%). Various surgical and post-surgical etiological factors may exist including mechanical stretching of the nerve, disruption of blood supply, prolonged tourniquet use, excessive blood loss, hypotension and direct compression of nerve sometimes caused by post-op wound dressings. THPSO3-DX Performance Not Met: No clinical evidence of a new peripheral nerve injury within 48 hours of completion of anesthesia. THPSO3- PNM RATIONALE: Peripheral nerve injuries that occur peri-operatively are largely preventable. These injuries commonly result from incorrect patient positioning during surgery. Patient specific risks include diabetics, being extremely thin or obese, tobacco use, or prolonged surgery. Appropriate preoperative assessment to identify at-risk patients, patient positioning, and monitoring can help prevent peripheral nerve injuries. 3 3 Bouyer-Ferullo, S. Preventing Perioperative Peripheral Nerve Injuries. AN Journal. 2013;97(1):110-124.e9 4.14.16 Page 7
MEASURE NAME: THPSO Measure #4: Pneumothorax rate as a complication of central line placement NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, independent of age, who develop a pneumothorax as a complication of central line placement. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per central line placement performed during the reporting year. It is anticipated that clinicians who perform central line placements will submit this measure. All central line procedures occurring in hospital locations excluding the emergency department, ICU, and emergent bedside procedures are included in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patient, independent of age, who undergo central line placement in hospital locations excluding the emergency department, ICU, and emergent bedside procedures by an anesthesia provider. 4.14.16 Page 8
Denominator Criteria (Eligible Cases): Central line placement procedures during reporting period. THPSO4-DN NUMERAT: The new onset of a pneumothorax in the perioperative period, requiring intervention, arising from an attempt at securing vascular access by an anesthesia provider. Intervention is defined as application of increased F io 2, needle decompression, tube thoracostomy, or other procedures designed to treat a pneumothorax. Numerator Criteria: Performance Met: Pneumothorax within the 48 hours of completion of anesthesia, arising from central line placement, and requiring intervention. THPSO4-PM Denominator Exclusions: Denominator Exceptions: Performance Not Met: No pneumothorax within the 48 hours of completion of anesthesia, arising from central line placement, and requiring intervention. THPSO4-PNM RATIONALE: Central venous catheters allow measurement of hemodynamic variables in hospital locations excluding the emergency department and emergent bedside procedures, as well as access for fluids and medications. The use of central venous catheters, however, is associated with hazardous and expensive adverse events. Mechanical complications, such as vascular injury and pneumothorax are amenable to interventions related to selection of the appropriate site, as well as the use of imaging for placement guidance. 4 4 David C. McGee, D. and Gould, M. Preventing Complications of Central Venous Catheterization. N Engl J Med 2003; 348:1123-1133 4.14.16 Page 9
MEASURE NAME: THPSO Measure #5: Ultrasound guidance for central line placement NQF NUMBER: Not applicable DESCRIPTION: The percentage of central line placement procedures that use ultrasound guidance MEASURE TYPE: Process NATIONAL QUALITY DOMAIN: Effective Clinical Care RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per central line placement performed during the reporting year. It is anticipated that clinicians who perform central line placement will submit this measure. All central line procedures occurring in hospital locations excluding the emergency department and emergent bedside procedures are included in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: All central line placement procedures in hospital locations excluding the emergency department and emergent bedside procedures. Denominator Criteria (Eligible Cases): Central line placement procedures during reporting period. THPSO5-DN 4.14.16 Page 10
NUMERAT: The use of ultrasonographic guidance for placement of a central line. Numerator Criteria: Performance Met: Ultrasound was used for central line placement guidance. THPSO5-PM Denominator Exclusions: Denominator Exceptions: Performance Not Met: Documentation of a medical, patient or system reason that ultrasound was not used by the provider for central line placement guidance, the central line placement was emergent. THPSO5-DX Ultrasound guidance was not used for central line placement. THPSO5-PNM RATIONALE: Central venous catheters allow measurement of hemodynamic variables in hospital locations excluding the emergency department and emergent bedside procedures, as well as access for fluids and medications. The use of central venous catheters, however, is associated with hazardous and expensive adverse events. Mechanical complications, such as vascular injury and pneumothorax are amenable to interventions related to selection of the appropriate site, as well as the use of imaging for placement guidance. 5 5 Troianos CA1, Hartman GS, Glas KE, Skubas NJ, Eberhardt RT, Walker JD, Reeves ST; Councils on Intraoperative Echocardiography and Vascular Ultrasound of the American Society of Echocardiography. J Am Soc Echocardiogr. Guidelines for performing ultrasound guided vascular cannulation: recommendations of the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. 2011 Dec;24(12):1291-318. 4.14.16 Page 11
MEASURE NAME: THPSO Measure #6: Perioperative Myocardial Infarction rate in low risk patients NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, age 18 years and above, who are low risk as identified by their ASA class, who have a myocardial infarction within 48 hours of undergoing general anesthesia. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per general anesthetic performed during the reporting year. It is anticipated that clinicians who perform general anesthesia will submit this measure. Each case of general anesthetic is in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo general anesthesia. Denominator Criteria (Eligible Cases): Each case of general anesthesia occurring during reporting period. THPSO6-DN AND 4.14.16 Page 12
Age: 18 years or older NUMERAT: The diagnosis of a new myocardial infarction within 48 hours of undergoing general anesthesia. Diagnosis of a myocardial infarction may be made by enzymes and/or diagnostic EKG changes within 48 hours of discharge from PACU. Numerator Criteria: Performance Met: Perioperative myocardial infarction. THPSO6-PM Denominator Exclusions: Patients with known pre-existing coronary artery disease or myocardial infarction, or ASA class III, IV or V. THPSO6-DE Denominator Exceptions: Performance Not Met: No perioperative myocardial infarction. THPSO6-PNM RATIONALE: Perioperative myocardial infarction can occur for a number of reasons. The risk for perioperative myocardial injury can be increased by a failure to appropriately screen patients for underlying preoperative disease, as well as failure to use protective modalities during anesthesia. Perioperative monitoring for ischemia, as well as detecting, treating, and preventing tachycardia, while avoiding hypotension or decreased cardiac output can help prevent perioperative myocardial infarction. 6 6 Landesberg G1, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009 Jun 9;119(22):2936-44. 4.14.16 Page 13
MEASURE NAME: THPSO Measure #7: Perioperative Myocardial Infarction rate in high risk patients NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, age 18 years and above, who are high risk as identified by their ASA class, who have a myocardial infarction within 48 hours of undergoing general anesthesia. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per general anesthetic performed during the reporting year. It is anticipated that clinicians who perform general anesthesia will submit this measure. Each case of general anesthetic is in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo general anesthesia. 4.14.16 Page 14
Denominator Criteria (Eligible Cases): Each case of general anesthesia occurring during reporting period. THPSO7-DN AND Age: 18 years or older NUMERAT: The diagnosis of a new myocardial infarction within 48 hours of undergoing general anesthesia. Diagnosis of a myocardial infarction may be made by enzymes and/or diagnostic EKG changes within 48 hours of discharge from PACU. Numerator Criteria: Performance Met: Perioperative myocardial infarction. THPSO7-PM Denominator Exclusions: Patients with known pre-existing coronary artery disease or myocardial infarction, or ASA Classification: I or II. THPSO7-DE Denominator Exceptions: Performance Not Met: No perioperative myocardial infarction. THPSO7-PNM RATIONALE: Perioperative myocardial infarction can occur for a number of reasons. The risk for perioperative myocardial injury can be increased by a failure to appropriately screen patients for underlying preoperative disease, as well as failure to use protective modalities during anesthesia. Perioperative monitoring for ischemia, as well as detecting, treating, and preventing tachycardia, while avoiding hypotension or decreased cardiac output can help prevent perioperative myocardial infarction. 7 7 Landesberg G1, Beattie WS, Mosseri M, Jaffe AS, Alpert JS. Perioperative myocardial infarction. Circulation. 2009 Jun 9;119(22):2936-44. 4.14.16 Page 15
MEASURE NAME: THPSO Measure #8: New perioperative central neurologic deficit NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients, independent of age, with new central neurologic deficits within 48 hours of undergoing non-emergent general anesthesia for surgeries not involving the central nervous system. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once general anesthetic performed during the reporting year. It is anticipated that clinicians who perform general anesthesia will submit this measure. Each case of general anesthetic is in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo general anesthesia. 4.14.16 Page 16
Denominator Criteria (Eligible Cases): Each case of general anesthesia occurring during reporting period. THPSO8-DN NUMERAT: The new onset of a CNS deficit within 48 hours of operation. Numerator Criteria: Performance Met: New CNS deficit within 48 hours of operation. THPSO8- PM Denominator Exclusions: Patients undergoing general and regional anesthesia for procedures that involve the central nervous system or spine. THPSO8-DE Denominator Exceptions: Performance Not Met: No new CNS deficit within 48 hours of operation. THPSO8-PNM RATIONALE: Neurological injury is a complication of both anesthesia and surgery, and may result in longer lengths of stay, increased costs, increased probability of death, and increased morbidity. These injuries may affect any level of the central nervous system, with outcomes ranging from neurocognitive dysfunction to frank stroke. Perioperative CNS deficits are responsive to prevention through proper risk screening of patients, intraoperative monitoring, and therapeutic interventions. 4.14.16 Page 17
MEASURE NAME: THPSO Measure #9: Postoperative nausea and vomiting rate Adults NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, age 18 years and above, who develop post-operative nausea or vomiting requiring anti-emetic administration in the PACU. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per general anesthetic performed during the reporting year. It is anticipated that clinicians who perform general anesthesia will submit this measure. Each case of general anesthetic for patients 18 years old and older are in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients who undergo general anesthesia. Denominator Criteria (Eligible Cases): Each case of general anesthesia occurring during reporting period. THPSO9-DN 4.14.16 Page 18
NUMERAT: Patients, age 18 years and above, who develop post-operative nausea or vomiting requiring anti-emetic administration in the PACU. Numerator Criteria: Performance Met: Anti-emetic administration required in the PACU. THPSO9-PM Denominator Exclusions: Patient age less than 18 years old. THPSO9-DE Denominator Exceptions: Performance Not Met: Anti-emetics not required in the PACU. THPSO9-PNM RATIONALE: Postoperative nausea and vomiting (PONV) is a preventable adverse outcome of anesthesia and surgery. PONV is a common complication in the ambulatory care population, with an incidence ranging from 30% to 50%. This complication can lead to unexpected hospital admission, as well as patient morbidity such as electrolyte abnormalities and dehydration. PONV has been noted as one of the most common causes of patient dissatisfaction after anesthesia, with reported incidences of 30% to 80% depending upon venue and patient risk. PONV is responsive to pre-treatment, with appropriate risk assessment including patient attributes and operative risks. 8 8 Sébastien Pierre, S. and Whelan, R. Nausea and Vomiting After Surgery. Cont Edu Anaesth Crit Care and Pain. 2013;13(1):28-32. 4.14.16 Page 19
MEASURE NAME: THPSO Measure #10: Postoperative nausea and vomiting rate Pediatrics NQF NUMBER: Not applicable DESCRIPTION: The percentage of patients, less than 18 years of age, who develop post-operative nausea or vomiting requiring anti-emetic administration in the PACU. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per general anesthetic performed during the reporting year. It is anticipated that clinicians who perform general anesthesia will submit this measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients who undergo general anesthesia. Denominator Criteria (Eligible Cases): Each case of general anesthesia occurring during reporting period. THPSO10-DN 4.14.16 Page 20
NUMERAT: Patients, less than 18 years of age, who develop post-operative nausea or vomiting requiring anti-emetic administration in the PACU. Numerator Criteria: Performance Met: Anti-emetic administration required in the PACU. THPSO10-PM Denominator Exclusions: Patient age 18 years or older. THPSO10-DE Denominator Exceptions: Performance Not Met: Anti-emetics not required in the PACU. THPSO10-PNM RATIONALE: Postoperative nausea and vomiting (PONV) is a preventable adverse outcome of anesthesia and surgery. PONV is a common complication in the ambulatory care population, with an incidence ranging from 30% to 50%. This complication can lead to unexpected hospital admission, as well as patient morbidity such as electrolyte abnormalities and dehydration. PONV has been noted as one of the most common causes of patient dissatisfaction after anesthesia, with reported incidences of 30% to 80% depending upon venue and patient risk. PONV is responsive to pre-treatment, with appropriate risk assessment including patient attributes and operative risks. 9 9 Sébastien Pierre, S. and Whelan, R. Nausea and Vomiting After Surgery. Cont Edu Anaesth Crit Care and Pain. 2013;13(1):28-32. 4.14.16 Page 21
MEASURE NAME: THPSO Measure #11: Post-obstructive Pulmonary Edema rate following endotracheal intubation NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients, independent of age, who develop post-obstructive pulmonary edema following extubation in the or PACU. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per endotracheal intubation performed in hospital locations excluding the emergency department and emergent bedside procedures during the reporting year. It is anticipated that clinicians who perform endotracheal intubation will submit this measure. Each case of intubation in hospital locations excluding the emergency department and emergent bedside procedures. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo general anesthetic with endotracheal intubation in hospital locations excluding the emergency department and emergent bedside procedures. 4.14.16 Page 22
Denominator Criteria (Eligible Cases): All patient encounter(s) during reporting period where the patient underwent general anesthetic with endotracheal intubation in the operating room. THPSO11-DN NUMERAT: Patients with signs or symptoms of post obstructive pulmonary edema following extubation in the or PACU. Post-obstructive pulmonary edema may be a clinical diagnosis, and does not require the administration of a treatment, nor radiographic confirmation, to be counted in the numerator. Numerator Criteria: Performance Met: Post-obstructive pulmonary edema following extubation in the or PACU. THPSO11-PM Denominator Exclusions: Denominator Exceptions: Performance Not Met: No post-obstructive pulmonary edema following extubation in the or PACU. THPSO11-PNM RATIONALE: Post-obstruction pulmonary edema is a recognized complication of general anesthesia. The majority of cases are known to be preventable through recognition of risk factors and modification of anesthesia technique. 10 10 Singh Bajwa, SJ. and Kulshrestha, A. Diagnosis, Prevention and Management of Postoperative Pulmonary Edema Ann Med Health Sci Res. 2012 Jul-Dec; 2(2): 180 185. 4.14.16 Page 23
MEASURE NAME: THPSO Measure #12: Respiratory Arrest in PACU rate NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients, independent of age, who develop respiratory arrest in the PACU. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once for each anesthesia event performed in the operating room during the reporting year. It is anticipated that clinicians who perform anesthesia will submit this measure. Each case of anesthesia for patients, independent of age, is in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo an anesthetic procedure. Denominator Criteria (Eligible Cases): Patient encounter(s) for an anesthetic procedure in the operating room. THPSO12-DN 4.14.16 Page 24
NUMERAT: Patients who develop respiratory arrest in PACU requiring intervention (bag/mask ventilation or intubation). Numerator Criteria: Performance Met: Respiratory arrest requiring intervention in the PACU. THPSO12-PM Denominator Exclusions: Denominator Exceptions: Performance Not Met: No respiratory arrest requiring intervention in the PACU. THPSO12-PNM RATIONALE: Respiratory arrests in the PACU result from a myriad of causes, including post-operative changes in the respiratory system coupled with underlying patient conditions and co-morbities. Many respiratory arrests may be avoidable through early recognition and intervention by anesthesia providers. A high rate of respiratory arrest in the PACU may be due to inadequate monitoring of the extubated patient, or the use of non-standardized criteria for post-operative extubation. 11 11 Rock P. and Rich PB. Post-operative pulmonary complications. Curr Opin Anaesthesiol. 2003 Apr;16(2):123-31 4.14.16 Page 25
MEASURE NAME: THPSO Measure #13: Dental Injury Rate following airway management NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients, independent of age, who develop dental injury from airway manipulation by the anesthesia provider in non-emergent operative cases. MEASURE TYPE: Outcome Inverse Measure NATIONAL QUALITY DOMAIN: Patient Safety RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per anesthesia performed during the reporting year. It is anticipated that clinicians who perform anesthesia will submit this measure. Each case of general anesthetic is in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Patients, independent of age, who undergo general anesthesia. This includes all general anesthetic cases using endo-tracheal intubation, laryngeal mask airways, and other intra-oral airway tools. 4.14.16 Page 26
Denominator Criteria (Eligible Cases): Each case of general anesthesia occurring during reporting period. THPSO13-DN NUMERAT: A change in the patient's preoperative dental status resulting from airway manipulation or instrumentation from endotracheal intubation, as well as the use of intra-oral airway devices such as laryngeal mask airways. Numerator Criteria: Performance Met: Change in preoperative dental status resulting from airway manipulation or instrumentation for endotracheal intubation or use of intra-oral airway devices. THPSO13-PM Denominator Exclusions: General anesthetics solely using mask airway devices, and emergent cases.. THPSO13-DE Denominator Exceptions: A change in preoperative dental status, but not resulting from anesthesia airway manipulation (i.e. resulting from operative procedure) THPSO13-DX Performance Not Met: No change in preoperative dental status. THPSO13- PNM RATIONALE: Dental injuries result in common claims against anesthesiologists. This is a reflection of the fact that dental injuries are common complications of oro-tracheal intubation. Both patient and anesthesiology provider factors can be causative, including poor dentition, aggressive laryngoscopy, insufficient anesthesia, emergent procedures, inadequate paralysis, and inexperience. 12 12 Gaudio RM1, Feltracco P, Barbieri S, Tiano L, Alberti M, Delantone M, Ori C, Avato FM.Dent Traumatol. Traumatic dental injuries during anaesthesia: part I: clinical evaluation. 2010 Dec;26(6):459-65. 4.14.16 Page 27
MEASURE NAME: THPSO Measure #14: Patient Experience: Post-anesthesia follow-up NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients, age 18 years and above, who undergo a standardized patient experience survey. MEASURE TYPE: Process NATIONAL QUALITY DOMAIN: Person and Caregiver-Centered Experience and Outcomes RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per daily anesthesia episode performed during the reporting year. It is anticipated that clinicians who perform anesthesia will submit this measure. Each daily anesthesia episode for a patient who is 18 years of age or older is in the denominator. For a patient who has two or more anesthesia cases during a day (i.e. a surgery and anesthesia followed be recovery, and then a return to the operating room with another anesthesia in the same day will be considered a single daily anesthesia episode). The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (THPSO codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Once per patient per daily anesthesia episode for patients, age 18 years and above, who undergo anesthetic cases in the operating room. 4.14.16 Page 28
Denominator Criteria (Eligible Cases): THPSO14-DN Patient encounter(s) for an anesthetic procedure in the operating room. AND Age: 18 years or above NUMERAT: Patients who undergo standardized survey regarding their patient experience. Survey questions must be specific to the anesthesia care experience and must include 1) presence of significant nausea/vomiting since anesthetic, 2) ability to tolerate their diet, 3) adequate post-operative discomfort control, 4) general satisfaction with the anesthesia experience, 5) pain at locations other than the surgical site, 6) presence of a significant sore throat, cough or hoarseness, and 7) the adequacy of postoperative discharge instructions. Numerator Criteria: Performance Met: Completion of a standardized post-anesthetic survey. THPSO14-PM Denominator Exclusions: Documentation of patient reason(s) or medical reason(s) for not completing survey (i.e. patients who are non-verbal, who are unable to be surveyed due to a medical or psychiatric reason, who are unable to be surveyed due to a language barrier, or who decline to be surveyed) THPSO14-DE Denominator Exceptions: Performance Not Met: Failure to complete a standardized post-anesthetic survey, reason not given. THPSO14-PNM RATIONALE: Current survey methodology is frequently lacking in specificity with respect to the anesthesia experience. The development of data collection allowing for the analysis of patients perspectives of anesthesia care with the provisions of objective and meaningful comparisons that will allow for expectations by patients is necessary in order to improve patient outcomes. 4.14.16 Page 29
MEASURE NAME: NHQI Measure #24: Patient Experience: Did the Patient Receive Adequate Instructions NQF NUMBER: Not applicable DESCRIPTION: Percentage of patients age 18 years and above, who undergo a post-anesthesia evaluation, who report receiving adequate post-anesthesia instructions. MEASURE TYPE: Outcome NATIONAL QUALITY DOMAIN: Communication and Care Coordination RISK ADJUSTMENT: Risk adjustment is not applicable for this measure. INSTRUCTIONS: Measure Reporting via QCDR Registry: This measure is to be reported once per patient per post-anesthesia survey evaluation performed during the reporting year. It is anticipated that clinicians who perform anesthesia will submit this measure. Each post-anesthesia survey evaluation for a patient who is 18 years of age or older is in the denominator. The listed numerator options are used to report the numerator for the measure. CPT codes, SNOMED-CT codes, other normalized taxonomies, patient demographics, and other discrete data from data collection forms and/or systems may be used to identify patients who are included in the measure s denominator and numerator. The listed denominator and numerator options (NHQI codes) are used to report denominator and numerator eligible instances for the measure to the QCDR. Submitting providers and/or data sources must provide a crosswalk to, and receive approval from, the QCDR demonstrating how they have mapped internal normalized data to the QCDR numerator and denominator criteria. Codes clearly identifying all denominator eligible cases, as well as Performance Met, Denominator Exclusions, Denominator Exceptions, and Performance Not Met must be submitted to the registry. The below listed specific codes may be submitted to the registry. Alternatives may be used with prior approval, as long as the submitting provider provides the registry with data that clearly delineates the below categories. DENOMINAT: Once per patient for post-anesthesia evaluation for patients, age 18 years and above, who undergo anesthetic cases in the operating room. Denominator Criteria (Eligible Cases): NHQI24-DN Patient post-anesthesia survey evaluations. 4.14.16 Page 30
AND Age: 18 years or above NUMERAT: Per standardized survey regarding the adequacy of the post-anesthesia instructions received by the patient. Numerator Criteria: Performance Met: Patient received adequate post-anesthesia discharge instructions. NHQI24PM Denominator Exclusions: Denominator Exceptions: Performance Not Met: Patient did not receive adequate post-anesthesia discharge instructions. NHQI24-PNM RATIONALE: Patients who are more satisfied with the quality of their post-discharge instructions are thought to be better informed regarding both post-operative expectations, including what activities they should and should not be participating in, as well as their medication and pain control regimen. Patient satisfaction has been correlated with improved surgical care in at least one study 13, and patients perception of their care is part of the triple aim as described by the Institute for Healthcare Improvement. 14 13 Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Patient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362-367. 14 Institute for Healthcare Improvement. The IHI triple aim. http://www.ihi.org/engage/initiatives/tripleaim/pages/default.aspx. Last accessed December 9, 2015. 4.14.16 Page 31