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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.

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 0.53 0.28 0.49 0.49   0.48   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 0.15 0.07 0.11 0.17   0.12   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 1.3 1.3 1.0 1.6   1.2   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 0.5 0.4 0.7 0.5   0.6   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 0.5 1.0 0.8 1.2   0.8   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 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon 0Quality Ribbon   0Quality Ribbon   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 0.35 0Quality Ribbon 0.20 0.34   0.26   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 0.10 0.07 0.17 0.22   0.15   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 0.01 0.02 0.03 0.06   0.03   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 0Quality Ribbon 0Quality Ribbon   0Quality Ribbon    
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 2.4 3.9 #   2.7   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 2   9   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     3.0   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 7 2 57 0   66   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 93 94 84 96   93   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 0.6 0.9 0.4 0.7   0.6   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 97 93 96 98 # 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 99 100Quality Ribbon 98 100Quality Ribbon # 99 98 98

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