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Surgery


These indicators include various complication rates and death rates, and they summarize how well we follow recommended surgical practices. We also show the number of surgical procedures performed for certain high-risk procedures. Data for cardiovascular procedures are in a separate section. Norton Healthcare performance represents the performance of all the hospitals combined.

SCIP indicators - percent of selected surgical inpatients
% of SCIP measure opportunities met (composite). This indicator also monitors the composite score on all SCIP accountability measures defined by Joint Commission. Accountability measures are quality measures that meet four criteria designed to identify measures that produce the greatest positive impact on patient outcomes when hospitals demonstrate improvement: Research (strong scientific evidence exists demonstrating that compliance with a given process of care improves health outcomes), Proximity (the process being measured is closely connected to the outcome it impacts; there are relatively few clinical processes that occur after the one that is measured and before the improved outcome occurs), Accuracy (the measure accurately assesses whether the evidence-based process has actually been provided), and Adverse Effects (the measure construct is designed to minimize or eliminate unintended adverse effects). (elements: scipinf1a, scipinf2a, scipinf3a, scipinf9, scipvte2, scipinf4, scip inf6, scipcard2). % of SCIP measure opportunities met (accountability composite) high 98 99 98 98 # 98 96 99
Number of select surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with open heart, colon, hip and knee procedures, abdominal and vaginal hysterectomies, or vascular surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37 / JC / CMS SCIPINF 1a) given preop. antibiotic on time high 97 99 98 97 # 98 99 99
Number of select surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with open heart, colon, hip and knee procedures, abdominal and vaginal hysterectomies, or vascular surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38 / JC / CMS SCIPINF 2a) given recommended preop. antibiotic high 100 99 99 100 # 99 99 99
Number of select surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with open heart, colon, hip and knee procedures, abdominal and vaginal hysterectomies, or vascular surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or greater than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, those who did not receive antibiotics during hospitalization, and those who were diagnosed and treated for infection within two days after surgery.(NQF surgical 39 / JC / CMS SCIPINF 3a) with antibiotic discontinued on time high 98 99 97 98 # 98 98 98
Number of cardiac surgical patients per 100, whose 6 A.M. serum glucose on postoperative day one (POD1) and postoperative day two (POD2) were within controlled range of < 200 mg/dL. Studies have been shown that the risk of infection was significantly higher for patients undergoing coronary artery bypass graft (CABG) if blood glucose levels were elevated. Includes cardiac surgical patients. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery.(JC / CMS SCIPINF 4) cardiac surg. w/ controlled 6am post-op serum glucose high 96 # 92 # # 94 97 97
Number of select surgical patients per 100, whose surgical site hair removal was performed with clippers or depilatory only OR who had no hair removal. Studies have shown that shaving causes skin abrasions that may become infected later. Includes patients with open heart, colon, hip and knee procedures, abdominal and vaginal hysterectomies, vascular and other major surgical procedures. Excludes patients who performed their own hair removal and patients whose methods of hair removal cannot be determined.(JC / CMS SCIPINF 6) w/ approp. surg. site hair removal high 100Quality Ribbon 100 100 100 # 100 100 100
Number of select surgical patients per 100, who were on beta blocker therapy prior to admission and received a beta blocker during the perioperative period. Beta blockers have been shown to reduce the risk of cardiovascular complications. Includes patients with open heart, colon, hip and knee procedures, abdominal and vaginal hysterectomies, vascular and other major surgical procedures. Excludes patients who did not receive beta blockers due to contraindications as documented in the medical record and patients who die during the perioperative period.(JC / CMS SCIPCARD 2) given beta blocker during peri-op period high 97 97 99 99 # 98 98 98
Number of select surgical patients per 100, who received appropriate venous thromboembolism (VTE) prophylaxis within 24 hours prior to surgery to 24 hours after surgery. Includes patients with open heart, colon, hip and knee procedures, abdominal and vaginal hysterectomies, vascular and other major surgical procedures. Excludes patients who had procedure performed entirely by laparoscope, patients whose total surgery time is less than or equal to 30 minutes, patients who stayed less than or equal to 24 hours postop, and patients who are on warfarin prior to admission, patients with contraindications to both mechanical and pharmacological prophylaxis.(JC / CMS SCIPVTE 2) given approp. VTE prophylaxis high 99 99 99 98 # 99 98 98
Number of surgical patients per 100, with urinary catheter removed on Postoperative Day 1 or Day 2. Includes selected surgical patients with a catheter placed postoperatively.(JC / CMS SCIPINF 9) with urinary catheter removed on postop day 1 or day 2 high 97 99 96 95 # 97 97 98
SCIP inf-1 (percent of surgical inpatients given preop antibiotic on time)
Number of coronary artery bypass graft (CABG) surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with coronary artery bypass graft surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37b / JC / CMS SCIPINF 1b) CABG surgical inpatients high 97   100Quality Ribbon   # 98 99 99
Number of other cardiac surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with open heart surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37c / JC / CMS SCIPINF 1c) cardiac surgical inpatients high 95 # 88 # # 92 99 99
Number of hip arthroplasty surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with hip surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37d / JC / CMS SCIPINF 1d) hip surgical inpatients high 96 99 97 100Quality Ribbon # 98 98 99
Number of knee arthroplasty surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with knee surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37e / JC / CMS SCIPINF 1e) knee surgical inpatients high 100Quality Ribbon 99 100 100Quality Ribbon # 100 99 99
Number of colon surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with colon surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37f / JC / CMS SCIPINF 1f) colon surgical inpatients high 98 # 100Quality Ribbon 100Quality Ribbon # 99 98 98
Number of hysterectomy surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with abdominal and vaginal hysterectomy procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37g / JC / CMS SCIPINF 1g) hysterectomy surgical inpatients high # 100Quality Ribbon 97 95 # 96 99 99
Number of vascular surgical patients per 100, who received antibiotics for infection prevention within the recommended time before surgical incision (one hour for most antibiotics). This recommended time is most effective for preventing surgical infections. Includes patients with vascular surgical procedures performed. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at the time of admission or greater than 24 hours prior to surgery.(NQF surgical 37h / JC / CMS SCIPINF 1h) vascular surgical inpatients high 96 # 100Quality Ribbon # # 98 98 98
SCIP inf-2 (percent of surgical inpatients given recommended preop antibiotic)
Number of coronary artery bypass graft (CABG) surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with coronary artery bypass graft (CABG) surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38b / JC / CMS SCIPINF 2b) CABG surgical inpatients high 100Quality Ribbon   100Quality Ribbon   # 100Quality Ribbon 100 100
Number of cardiac surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with open heart surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38c / JC / CMS SCIPINF 2c) cardiac surgical inpatients high 100Quality Ribbon # 98 # # 99 100 100
Number of hip arthroplasty surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients hip surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38d / JC / CMS SCIPINF 2d) hip surgical inpatients high 100Quality Ribbon 100Quality Ribbon 100Quality Ribbon 100Quality Ribbon # 100Quality Ribbon 100 100
Number of knee arthroplasty surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with knee surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38e / JC / CMS SCIPINF 2e) knee surgical inpatients high 100Quality Ribbon 100Quality Ribbon 100Quality Ribbon 100Quality Ribbon # 100Quality Ribbon 100 100
Number of colon surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with colon surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38f / JC / CMS SCIPINF 2f) colon surgical inpatients high 98 # 97 97 # 96 96 96
Number of hysterectomy surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with abdominal and vaginal hysterectomy .surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38g / JC / CMS SCIPINF 2g) hysterectomy surgical inpatients high # 100Quality Ribbon 100Quality Ribbon 100Quality Ribbon # 100Quality Ribbon 98 98
Number of vascular surgical patients per 100, who received antibiotics for infection prevention consistent with current guidelines specific to each surgical procedure. The recommended antibiotics are most effective for preventing surgical infections. Includes patients with vascular surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 38h / JC / CMS SCIPINF 2h) vascular surgical inpatients high 100Quality Ribbon # 97 # # 99 99 99
SCIP inf-3 (percent surgical inpatients with antibiotic discontinued on time)
Number of coronary artery bypass graft (CABG) surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with coronary artery bypass graft (CABG) surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or greater than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, those who did not receive antibiotics during hospitalization, and those who were diagnosed and treated for infection within two days after surgery.(NQF surgical 39b / JC/ CMS SCIPINF 3b) CABG surgical inpatients high 97   100Quality Ribbon   # 98 99 99
Number of cardiac surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with open heart surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or greater than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, those who did not receive antibiotics during hospitalization, and those who were diagnosed and treated for infection within two days after surgery.(NQF surgical 39c / JC / CMS SCIPINF 3c) cardiac surgical inpatients high 95 # 92 # # 94 99 99
Number of hip arthroplasty surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with hip surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or greater than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, those who did not receive antibiotics during hospitalization, and those who were diagnosed and treated for infection within two days after surgery.(NQF surgical 39d / JC / CMS SCIPINF 3d) hip surgical inpatients high 100Quality Ribbon 99 98 98 # 99 98 98
Number of knee arthroplasty surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with knee surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or greater than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, those who did not receive antibiotics during hospitalization, and those who were diagnosed and treated for infection within two days after surgery.(NQF surgical 39e / JC/ CMS SCIPINF 3e) knee surgical inpatients high 100Quality Ribbon 100Quality Ribbon 98 96 # 99 99 98
Number of colon surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with colon surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 3f / JC/ CMS SCIPINF 3f) colon surgical inpatients high 100Quality Ribbon # 88 97 # 95 96 96
Number of hysterectomy surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with abdominal and vaginal hysterectomy surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 3g / JC / CMS SCIPINF 3g) hysterectomy surgical inpatients high # 100Quality Ribbon 97 99 # 99 98 98
Number of vascular surgical patients per 100, whose antibiotics to prevent infection were discontinued within 24 hours after surgery end time. A brief course of prophylactic antibiotics is as effective as longer courses, and earlier discontinuation helps to reduce antibiotic resistance. Includes patients with vascular surgical procedures. Excludes patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients receiving antibiotics at time of admission or great than 24 hours prior to surgery, patients who did not receive any antibiotics before, during, or within 24 hours after surgery end time, and those who did not receive antibiotics during hospitalization.(NQF surgical 3h / JC / CMS SCIPINF 3h) vascular surgical inpatients high 98 # 83 # # 93 96 96
Postoperative complications - percent of surgical inpatients with
Number of surgery patients per 100 with a postoperative hemorrhage (surgical site bleeding) or hematoma (abnormal collection of blood). Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients discharged with a surgical DRG and an operating room procedure. Excludes patients with principal diagnosis of postoperative hemorrhage or postoperative hematoma, patients whose only OR procedure is postoperative control of hemorrhage or drainage of hematoma, patients where a procedure for control of hemorrhage or drainage of hematoma occurs before the first OR procedure, and obstetrical patients.(AHRQ PSI 9) bleeding low 0.25 0.45 0.10 0.41   0.25   0.24
Number of elective surgery patients per 100 with postoperative physiologic and metabolic imbalance (for example, diabetic coma, acute renal failure). Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients with an admit type of elective, and discharged with a surgical DRG. Excludes patients with a principal diagnosis of physiologic and metabolic derangement and patients with a secondary diagnosis of acute renal failure and a principal diagnosis of AMI, cardiac arrhythmia, cardiac arrest, shock, hemorrhage, or GI hemorrhage. Other exclusion criteria may apply.(AHRQ PSI 10) physiologic derangement low 0.06 0.09 0.03 0Quality Ribbon   0.04   0.05
Number of elective surgery patients per 100 with postoperative respiratory failure. Respiratory failure occurs when the body is unable to rid itself of carbon dioxide and cannot provide adequate oxygen to the body?s cells. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients with an admit type of elective, and discharged with a surgical DRG. Excludes patients with a principal diagnosis of acute respiratory failure, patients where tracheostomy is the only OR procedure, patients where a tracheostomy procedure occurs before the first OR procedure, patients with respiratory or circulatory disease, and OB patients.(AHRQ PSI 11) respiratory failure low 1.1 1.3 0.8 1.3   1.0   0.9
Number of surgery patients per 100 with postoperative blood clots (i.e., pulmonary embolism (PE) or deep vein thrombosis (DVT)). Preventive measures can lower the risk of these events. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients discharged with a surgical DRG. Excludes patients with a principal diagnosis of DVT or PE, patients where interruption of vena cava is the only OR procedure, patients where interruption of vena cava occurs before or on the same day as the first OR procedure, and OB patients.(AHRQ PSI 12) PE or DVT low 0.4 0.4 0.6 0.2   0.5   0.6
Number of elective surgery patients per 100 with postoperative sepsis. Sepsis is the presence of bacteria in the blood or other tissues of the body. To fit AHRQ, we left all patients in the data, even though we found that many did not truly have postoperative sepsis. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients with an admit type of elective and discharged with a surgical DRG. Excludes patients with a principal diagnosis of sepsis, patients with a principal diagnosis of sepsis or infection, patients with a diagnosis code for immunocompromised state or cancer, patients with a length of stay less than 4 days, and OB patients.(AHRQ PSI 13) sepsis low 0.3 0Quality Ribbon 1.2 0.7   0.7   1.1
Number of surgery patients per 100 with a postoperative hip fracture. The indicator was originally intended to capture falls with a hip fracture after surgery. To fit AHRQ, we left all patients in the data, even though we found that many did not truly have postoperative hip fractures. In fact, we had several patients who are labeled ?postoperative hip fractures? by this indicator whose hip fracture occurred before they came to the hospital. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes inpatients 18 years or older discharged with a surgical DRG and an operating room procedure. Excludes patients with a hip fracture as a principal diagnosis, cases where the only procedure is hip fracture repair, and patients with diseases and disorders of the musculoskeletal system and connective tissue.(AHRQ PSI 8) hip fracture low 0.04 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon   0.01   0.00
Number of abdominopelvic surgery patients per 100 with reclosure of postoperative disruption of abdominal wall. This indicator identifies patients who have had abdominal or pelvic surgery and then experience a rupture of the surgical wound. Risk-adjusted for age, sex, DRG, and comorbidity categories. Excludes patients where a reclosure of postoperative disruption of abdominal wall occurs before or on the same day as the first abdominopelvic surgery procedure, and OB patients.(AHRQ PSI 14) abdominal surgeries w/ postop wound dehiscence low 0.12 0Quality Ribbon 0.10 0Quality Ribbon   0.07   0.20
Other surgical complications - percent of
Number of medical and surgical patients per 100 with accidental puncture or laceration during a procedure. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes medical and surgical discharges defined by specific DRGs. Excludes patients with a principal diagnosis indicating technical difficulty, and OB patients.(AHRQ PSI 15) select surgeries encountering technical difficulties low 0.11 0.08 0.15 0.16   0.13   0.22
Number of medical and surgical patients per 100 with pneumothorax caused by medical care. Pneumothorax is the abnormal presence of air in the area containing the lungs. Risk-adjusted for age, sex, DRG, and comorbidity categories. Includes medical and surgical discharges defined by specific DRGs. Excludes patients with iatrogenic pneumothorax as a principal diagnosis, patients with a diagnosis of trauma, patients with a thoracic or cardiac surgery, patients with lung or pleural biopsy, or obstetrical patients.(AHRQ PSI 6) patients w/ pneumothorax resulting from medical care low 0.02 0.02 0.04 0Quality Ribbon   0.02   0.04
Mortality and volume indicators
Number of medical and surgical patients with a foreign body accidentally left in during procedure. Includes medical and surgical discharges defined by specific DRGs. Excludes patients with a principal diagnosis of foreign body accidentally left in during a procedure.(AHRQ PSI 5) # surgeries when foreign body was unintentionally left low 0Quality Ribbon 0Quality Ribbon 1 1   2    
Number of hip replacement patients per 100, who died in the hospital. Risk-adjusted using patient age, severity of illness, and risk of mortality (APR-DRG version 20). Includes inpatients discharged with a procedure of partial or full hip replacement and a diagnosis of osteoarthrosis. Excludes patients with missing discharge dispositions or patients transferred to an acute care hospital.(AHRQ IQI 14) % hip replacement patients who die (AHRQ risk-adjusted) low 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon   0Quality Ribbon   0.12
Number of craniotomy patients per 100, who died in the hospital. A craniotomy is the surgical opening of a section of the skull for the purpose of operating on the tissue underneath. This procedure is often performed for the treatment of a brain hemorrhage (bleeding) or aneurysm. Risk-adjusted using patient age, severity of illness, and risk of mortality (APR-DRG version 20). Includes inpatients 18 years and older discharged with a DRG code for craniotomy. Excludes patients with missing discharge dispositions, patients transferred to an acute care hospital, and patients with a principal diagnosis of head trauma.(AHRQ IQI 13) % craniotomy patients who die (AHRQ risk-adjusted) low 0Quality Ribbon 2.3 1.2 #   2.1   5.8
Number of esophageal resection surgery patients per 100, who died in the hospital. This procedure involves the removal of part of the esophagus, usually due to cancer. Risk-adjusted using patient age, severity of illness, and risk of mortality (APR-DRG version 20). Includes inpatients discharged with a diagnosis of esophageal cancer and a procedure of esophageal resection. Excludes patients with missing discharge dispositions, and patients transferred to an acute care hospital.(AHRQ IQI 8) % esophageal resection patients who die (AHRQ risk-adj) low #   # #   #   4.6
Number of esophageal resection procedures per year. This procedure involves the removal of part of the esophagus, usually due to cancer. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients discharged with a diagnosis of esophageal cancer and any procedure of esophageal resection.(AHRQ IQI 1) # esophageal resection surgical procedures (AHRQ defn.) high 2 0 5 1   8   6
Number of pancreatic resection surgery patients per 100, who died in the hospital. This procedure involves the removal of part of the pancreas. Risk-adjusted using patient age, severity of illness, and risk of mortality (APR-DRG version 20). Includes inpatients discharged with a diagnosis of pancreatic cancer and a procedure of pancreatic resection. Excludes patients with missing discharge dispositions, or patients transferred to an acute care hospital.(AHRQ IQI 9) % pancreatic resection patients who die (AHRQ risk-adj) low     0Quality Ribbon     0Quality Ribbon   5.4
Number of pancreatic resection procedures per year. This procedure involves the removal of part of the pancreas. Some research suggests higher volumes are associated with better patient outcomes, but it is controversial whether volume alone has any role as a useful quality indicator. Includes inpatients discharged with a diagnosis of pancreatic cancer and a procedure of pancreatic resection.(AHRQ IQI 2) # pancreatic resection surgical procedures (AHRQ defn.) high 2 0 37 0   39   10
Miscellaneous
Number of gall bladder surgeries per 100 that were performed laparoscopically. A laparoscopic removal of the gall bladder is performed through several small incisions in the abdomen. Laparoscopic removal of the gall bladder has been associated with lower risks than an open removal of the gall bladder, which requires a much larger incision in the abdomen. Risk-adjusted for age and sex. Includes discharges with procedure of uncomplicated gall bladder removal, both inpatient and outpatient.(AHRQ IQI 23) % gall bladder surgery done laparoscopically high 90 96 81 96   91   84
Number of patients 65 or older with intra-abdominal procedures per 100, who had an appendectomy incidental to the procedure. Due to increased risk to the patient, incidental appendectomies are not recommended in elderly patients unless medical reasons are present. Risk-adjusted using patient age, severity of illness, and risk of mortality (APR-DRG version 20).(AHRQ IQI 24) % incidental appendectomy in those over 64 years old low 2.9 2.2 0Quality Ribbon 4.1   2.0   1.2
Hospital outpatient surgery
Number of surgical patients per 100 with prophylactic antibiotics initiated within one hour prior to surgical incision. Includes patients with select surgical CPT codes. Excludes patients enrolled in a clinical trial, patients who had a principal or admission diagnosis suggestive of infection prior to surgery and patients who receive oral antibiotics only.(CMS/OP 6) % surgical patients given preop antibiotic on time high 98 96 96 99 # 97 97 98
Number of surgical patients per 100 who received prophylactic antibiotics recommended for their specific surgical procedure. Includes patients with select surgical CPT codes. Excludes patients enrolled in a clinical trial, patients who had a principal or admission diagnosis suggestive of infection prior to surgery, patients who do not receive any antibiotics during the encounter, patients with procedures that include transrectal biopsy of prostate, penile prosthesis insertion, removal or revision.(CMS/OP 7) % patients given recommended prophylactic antibiotic high 98 99 99 99 # 99 97 98

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